Sage Journals: Discover world-class research

Abstract

In spite of ongoing globalisation in many fields, the ethics of radiological protection have long been discussed almost exclusively in terms of ‘Western’ moral philosophy concepts such as utilitarianism or deontology. A cross-cultural discourse in this field is only just beginning. In ‘Principles of Biomedical Ethics’, Beauchamp and Childress suggested that there exists a ‘common morality’ which is ‘not relative to cultures or individuals, because it transcends both’. They proposed four cross-culturally valid principles for decision making in medicine: respect for autonomy, non-maleficence, beneficence, and justice. A similar approach is being developed by the International Commission on Radiological Protection Task Group 94 on the ethics of radiological protection. Here, the core values are: human dignity, beneficence/non-maleficence, prudence, and justice. Other values could be added, such as consideration for the interests of society as a whole or the interests of future generations, or procedural values such as transparency and accountability; this paper will include a brief discussion on how they relate to the four basic principles. The main question to be addressed here, however, is whether the proposed core values are indeed part of a ‘common morality’. This, as it will be argued, cannot be decided by a global opinion poll, but has to be based on an analysis of the written and oral traditions that have provided ethical orientation throughout history, and are still considered seminal by the majority of people. It turns out that there are indeed many commonalities across cultures, and that the concept of globally shared core values for the radiological protection system is not hopelessly idealistic.

Keywords

Globalisation Biomedical ethics Core values Procedural values Balancing principles

1. GLOBAL ETHICAL BASIS FOR RADIOLOGICAL PROTECTION

1.1. Ethical basis of radiological protection as seen until now

The 2007 Recommendations of the International Commission on Radiological Protection (ICRP, 2007) obviously presuppose certain elements of ethics, but these are not always made explicit (Clarke and Valentin, 2009). Individual authors, including members of the Commission (Clarke, 2003; Streffer et al., 2005; González, 2011), have identified arguments from utilitarian, deontological, and other types of ethics.

Thus, for instance, the principle of justification (‘any decision that alters the radiation exposure situation should do more good than harm’) calls for a weighing of positive and negative consequences of radiation exposures, and is therefore often thought to be based on utilitarian thinking. However, alternative interpretations have been offered, ranging from Aristotelianism (Hansson, 2007) to Machiavellianism (González, 2011). Without going into any detail, this fact alone shows that the ethical basis of the first principle is not unambiguous.

Somewhat less controversial is the assignment of the principle of optimisation (‘the likelihood of exposure, the number of people exposed, and the magnitude of their individual doses shall be kept as low as reasonably achievable, taking into account economic and societal factors’). As it aims to minimise risk, while leaving room for other aspects of human well-being, it is generally considered to be utilitarian in nature. Whereas the justification principle is only looking for a net positive outcome, this second principle is to ensure the widest possible margin between cost and benefit. ICRP (1973) has even explicitly recommended cost–benefit analysis as a tool for optimisation.

In contrast, the principle of dose limitation (‘the total dose to any individual from regulated sources in planned exposure situations … should not exceed the limits specified’) stems from the consideration that doing good to some people cannot justify doing harm to others. It is not acceptable, for instance, to expose one individual to a relatively high risk in order to save many individuals from a relatively low risk, even if this would lead to a reduction in the collective risk. In the third principle, a deontological argument is at work, where the emphasis is on the rights of individuals rather than on overall usefulness.

The problem with all this is that in moral philosophy, utilitarian and deontological theories are considered to be mutually exclusive because they have different priorities. For the utilitarian, all that counts is the ‘greatest happiness for the greatest number’ (Bentham, 1776), whereas the deontologist will insist that you should ‘treat humanity, whether in your own person or in the person of any other, never merely as a means to an end’ (Kant, 1795). It is not clear how a combination of these two is supposed to work, as there are many situations where one would be completely incompatible with the other. The current philosophical foundation of radiological protection is therefore rather problematic (Shrader-Frechette and Persson, 1997; Persson and Shrader-Frechette, 2001; Gardiner, 2008).

1.2. Global perspective of ethics

Beyond the role of utilitarian and deontological arguments in the evolution of the ICRP recommendations, the question can be raised regarding whether it is at all appropriate in a globalising world to base the recommendations of an international advisory body mainly on ethical theories developed in Europe during the era of enlightenment. Less than 30% of the world’s population is living in Europe and the Americas, but over 50% in Asia and another 20% in Africa and the Middle East. Is it reasonable to expect the majority of mankind to adopt principles of radiological protection developed in a context largely alien to them?

It is true that population numbers do not reflect the relative use of radioactive materials or radiation around the globe, but this situation is gradually changing. According to the World Nuclear Association (WNA, 2015), there are currently 436 nuclear power reactors in operation, and only 120 of them (28%) are in Asia, Africa, and the Middle East. However, of the 67 reactors worldwide under construction and the 166 reactors planned, 43 and 104 (64% and 63%, respectively) will be operating outside Europe and the Americas. As for medical radiology, a statistical survey for 2011 showed that, on average, 131 computer tomography examinations were performed per 1000 inhabitants of the Organisation for Economic Co-operation and Development countries. Figures close to this average were reported for Israel (n = 127), Korea (n = 119), and Turkey (n = 112) (Statista, 2015). These examples indicate that radiological procedures with relatively high exposures are not restricted to countries with a ‘Western’ tradition of thought, and countries in Asia, Africa, and the Middle East are catching up.

Global approaches to questions of values and norms are becoming more and more common. A first milestone in this development was certainly the ‘Universal Declaration of Human Rights’ (United Nations General Assembly, 1948). In the second half of the 20^th Century and especially around the turn to the 21^st Century, a number of other international statements on human rights followed, such as the ‘Declaration of the Rights of the Child’ (United Nations General Assembly, 1959), the ‘Declaration on Human Environment’ (United Nations Conference on the Human Environment, 1972), the ‘Declaration on Environment and Development’ (United Nations Conference on Environment and Development, 1992), the ‘Universal Declaration on the Human Genome and Human Rights’ (UNESCO, 1997), and the ‘Universal Declaration on Bioethics and Human Rights’ (UNESCO, 2005).

Of course, the idea of human rights (i.e. inalienable rights that belong to every human being) goes further back in the history of philosophy. Usually, the Stoic school of philosophy (3^rd–6^th Century B.C.) is considered to be the first to have developed the thought. Bartolomé de las Casas (early 16^th Century) was nevertheless still ahead of his time when he advocated the universality of human rights, stating that ‘all peoples of the world are humans … The entire human race is one’ (Carozza, 2003). The idea gained prominence in the era of enlightenment, mainly with John Locke (1689) arguing that ‘by nature’ human beings have a right to ‘life, liberty, and property’. Immanuel Kant (1795) emphasised the interconnectedness of human rights and human dignity, and their fundamental importance for the international context, as ‘the community of nations of the earth has now gone so far that a violation of right on one place of the earth is felt in all’.

With the rise of globalisation over the last few decades, philosophers have addressed the need for, and possibility of, global ethics from various points of departure. A few examples may suffice here. Habermas (1998) spoke of a ‘post-national constellation’ in which we find ourselves, and claims that ‘world citizenship … is already taking shape today in worldwide political communications’. Interested in human flourishing and its global dimension, Sen (2009) wrote extensively about the ‘idea of justice’, which he shows to be central to various cultures around the world, past and present. One of his close associates, Nussbaum (2004) identified a number of ‘core capabilities’ to which all individuals in all societies should be entitled, thus constituting the base of her account of ‘global justice’. Appiah (2006) explored the reasonability of cosmopolitanism, which he defined as ‘universality plus difference’. While emphasising ‘respect for diversity of culture’, he suggested that there is also ‘universal truth, though we are less certain that we have it all already’. Bok (1995) suggested that ‘certain basic values [are] necessary to collective survival’ and therefore constitute a ‘minimalist set of such values [which] can be recognised across societal and other boundaries’. That does not preclude the existence of ‘maximalist’ values, usually more culture-specific, nor the possibility that they can ‘enrich’ the debate, but there is a ‘need to pursue the enquiry about which basic values can be shared across cultural boundaries’.

One area in which cross-culturally shared ethical principles, values, and norms are actively discussed is interfaith dialogue. One outcome of such activities was the ‘Declaration towards a Global Ethic’ signed at the Parliament of the World’s Religions 1993 in Chicago by the representatives of more than 40 different religious traditions. It proceeded from the assumption that ‘there already exist ancient guidelines for human behaviour which are found in the teachings of the religions of the world and which are the condition for a sustainable world order’ (Küng and Kuschel, 1993). Interfaith declarations on more specific topics such as business ethics and environmental ethics have followed (Webley, 1996; Orth, 2002).

1.3. Biomedical ethics as a model

The most widely applied framework of biomedical ethics is probably the framework developed by Beauchamp and Childress (1979) which, although not originally conceived as a cross-cultural type of ethics, turned out to be compatible with such an approach. It is based not on one overall conceptual framework (as is the case with utilitarianism or deontology), but on four somewhat less general principles (respect for autonomy, non-maleficence, beneficence, and justice). In the more recent editions of their book, the authors assumed that these principles are rooted in ‘common morality’, which is ‘not relative to cultures or individuals, because it transcends both’ (Beauchamp and Childress, 2013).

Beauchamp and Childress are not really interested in the question of where and how ‘common morality’ can be found. When they introduced the term, they just claimed that ‘all morally serious persons’ (Beauchamp and Childress, 1994) or, in the current edition, ‘all persons committed to morality’ (Beauchamp and Childress, 2013), would agree with their four principles. The present author does not find this convincing. More effort is needed to show that these principles have cross-cultural validity, or to find others that are more widely acceptable.

The possibility exists, of course, that empirical research could be used to test the assumption that the underlying principles are right, but the author is not convinced that anthropological or cultural studies alone would be meaningful. A universal ‘opinion poll’, which would find out what people around the globe are thinking about the pertinent questions, would just reflect current dispositions and would be very much subject to fluctuations. Something with greater long-term validity is needed.

Orientation has been provided throughout the ages by the religious and philosophical traditions of the different cultures. Although ‘Western’ society is largely secularised, and fundamentalism, fanaticism, and extremism have brought religion into discredit, the fact that these traditions continue to be of great influence for people not versed in ‘Western’ secular philosophy cannot be ignored. Even in the ‘West’, the importance of Christianity is probably still much greater than the number of people attending Sunday church services would suggest. The views of Europeans and Americans have been shaped at least as much by Christian values passed on from generation to generation for centuries, as by the philosophical traditions of the enlightenment era. An analysis of ‘common morality’ cannot therefore pretend that religion has no role to play in the 21^st Century.

The author’s suggestion then is that the most important documents for establishing a ‘common morality’ are the sacred scriptures of the world’s great religions, such as the Vedas and the Bhagavadgita for the Hindus, the Sermons of Buddha for the Buddhists, the Torah for the Jews, the Gospels for the Christians, the Quran for the Muslims, the Writings of Bahá’u’lláh for the Bahá’ís, and so on. They provide a framework of orientation for the believers (even though there may be some disagreement regarding their exact meaning), because they are considered to be divinely inspired. A non-believer will, of course, have some difficulty with this notion, but may at least appreciate that these scriptures reflect values deeply rooted in the various cultures. Another category of useful documents for this purpose is those produced by way of intra- and interreligious dialogue, because they already reflect a certain cross-cultural agreement.

There are also relevant cultural expressions outside the context of (organised) religion. Thus, oral traditions in the form of proverbs, stories, legends, and myths, especially those of indigenous people who have no written records, should not be ignored. In addition, secular texts of various types that have had a formative influence over the centuries should be considered. The Hippocratic Oath comes to mind, or the works of certain philosophers of ancient Greece and China (even if Confucius’ writings are perhaps more appropriately classified as sacred scripture). In addition to these time-honoured traditions, some modern documents such as the abovementioned ‘Universal Declaration of Human Rights’ or the ‘Universal Declaration on Bioethics and Human Rights’ have been suggested to already constitute ‘common heritage of humankind’ (ten Have and Gordijn, 2013).

The author has previously attempted to show that the four principles of biomedical ethics are rooted in the written and oral traditions of mankind (Zölzer, 2013). This paper will seek to do the same for the four core values suggested by ICRP Task Group 94 as a basis for the ethics of radiological protection. The Task Group did discuss whether or not it should proceed from the Beauchamp and Childress set of principles, recognised as they are in medical ethics and other contexts, but decided to take a somewhat different approach. It tried to identify the core values that have permeated the system of radiological protection from its beginning. These are similar, but not identical, to the principles suggested by Beauchamp and Childress. In the current draft statement of the Task Group, ‘respect for autonomy’ is replaced by the more comprehensive idea of ‘human dignity’, ‘non-maleficence’ and ‘beneficence’ are presented as two aspects of one single concept, ‘prudence’ is added to the list, and only ‘justice’ is left unchanged. This paper will not discuss the advantages and disadvantages of this deviation from the established theory of principlism, but will be restricted to discussing the extent to which the four core values, as well as the related procedural values, are known and respected in different cultural contexts around the world.

2. THE FOUR CORE VALUES

2.1. Beneficence and non-maleficence

‘To abstain from doing harm’ is one of the central features of the Hippocratic Oath (Edelstein, 1943), which was later adopted by Jewish, Christian, and Muslim physicians (Pelligrino, 2008). The principle is also mentioned, albeit indirectly, in similar texts from ancient China (Tsai, 1999). Of course, it has always been understood that pain sometimes has to be inflicted to achieve healing, and thus non-maleficence has to be balanced with beneficence. To work ‘for the good of the patient’ is also part of the Hippocratic Oath, and it features quite prominently in the mentioned Chinese medical texts.

More generally (i.e. outside the context of medicine), both beneficence and non-maleficence can be seen as core principles in any system of religious ethics. A central concept of both Hinduism and Buddhism is ahimsa, which means kindness and non-violence to all living beings. The Bhagavad Gita praises the ‘gift which is made to one from whom no return is expected’, whereas the Dhammapada states that ‘A man is not great because he is a warrior or kills other men, but because he hurts not any living being’. Both the Torah and the Gospel express the same thought in a different way by exhorting everybody to ‘love your neighbour as yourself’. More concretely, the Talmud observes that ‘to save one life is tantamount to saving a whole world’, while the Apostle Paul suggests that ‘whenever we have the opportunity, let's practice doing good to everyone’. The Quran asserts that ‘Whoever rallies to a good cause shall have a share in its blessings; and whoever rallies to an evil cause shall be answerable for his part in it’. Nevertheless, Islamic jurisprudence has the guideline that ‘if a less substantial instance of harm and an outweighing benefit are in conflict, the harm is forgiven for the sake of the benefit’ (Zölzer, 2013).

In the context of radiological protection, beneficence and non-maleficence together would certainly support the principle of justification, which calls for nothing else than that the former should outweigh the latter. When it comes to the principle of optimisation, the matter may be a bit more complicated, as the wording in the ICRP recommendations suggests ‘taking into account economic and societal factors’. The interest of the general public, the ‘common good’, is certainly one factor that none of the traditions would recommend neglecting, but economic considerations are not usually on the agenda of sacred scriptures. Their emphasis is on the human being, especially his or her spiritual and physical health. However, economic factors cannot be neglected altogether. Resources are limited, and it is simply not possible to invest unlimited money into better living conditions – or better radiological protection, for that matter – when that would mean that other aspects of the common good would not receive attention, or even basic needs would not be satisfied. Therefore, this question becomes a question of justice, which will be discussed below.

2.2. Prudence

In recent decades, there has been much discussion about the ‘precautionary principle’, especially in the context of environmental issues. For instance, the United Nations Conference on Environment and Development in Rio de Janeiro in 1992, also called the ‘Earth Summit’, proposed that ‘where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation’ (United Nations Conference on Environment and Development, 1992). Another important version is the one drawn up by a group of scientists from different disciplines gathered at the Wingspread Conference in 1998: ‘when an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically’ (Wingspread Conference, 1998).

Of course, the principle in its modern form cannot be expected to appear in the written and oral traditions of different cultures. Exhortations to prudence, however, are ubiquitous, and they are generally interpreted, by people referring to these traditions for orientation, as suggesting a precautionary approach. Thus, in the Mahabharata, Krishna advises to ‘act like a person in fear before the cause of fear actually presents itself’, whereas Shotoku Taishi, the first Buddhist regent of Japan, puts it this way: ‘when big things are at stake, the danger of the error is great. Therefore, many should discuss and clarify the matter together, so the correct way may be found.’ Confucius simply says that ‘the cautious seldom err’. The Proverbs include the statement: ‘those who are prudent see danger and take refuge, but the naïve continue on and suffer the consequences’, and Muhammad reportedly counselled one of his followers who complained that God had let his camel escape: ‘tie up your camel first, then put your trust in God.’ For an explicit reference to the precautionary principle, the statement of a representative of the Australian Aboriginals and Torres Strait Islanders is given as an example: ‘over the past 60,000 years we, the indigenous people of the world, have successfully managed our natural environment to provide for our cultural and physical needs. We have no need to study the non-indigenous concepts of the precautionary principle (and others). For us, they are already incorporated within our traditions’ (Zölzer, 2013).

Prudence as a core value of the system of radiological protection is most obvious when it comes to the optimisation principle. To keep exposures ‘as low as reasonably achievable’ means to be cautious about possible risks, but it also means to balance possible radiation risks with risks – and benefits – of a different nature, economic or societal. It therefore seems appropriate that Task Group 94 suggests ‘prudence’ rather than ‘precaution’ as the key term, because it includes awareness of risks as well as consideration of the common good, or the interest of the general public as mentioned above.

In its latest recommendations, ICRP upholds the linear-non-threshold (LNT) model and says that although there are no data to support or reject it in the very low dose range, it ‘remains a prudent basis for radiological protection’ (ICRP, 2007). However, the Commission suggests that ‘the aggregation of very low individual doses over extended time periods is inappropriate, and in particular, the calculation of the number of cancer deaths based on collective effective doses from trivial individual doses should be avoided’ (ICRP, 2007). This is justified by saying that ‘the assumptions implicit in the calculation of collective effective dose … conceal large biological and statistical uncertainties’ (ICRP, 2007). In the author’s opinion, there is an element of inconsistency here, as the calculation of collective dose presupposes the very LNT model that is otherwise considered applicable even in the absence of direct evidence. While it is possible that reasons to disregard ‘trivial doses’ may exist in certain situations, the author does not believe that it is possible to forgo ethically sound arguments if these reasons are to prevail over established principles. In the particular case here, the fact that the Commission’s recommendation is based on ‘uncertainties’ cuts across its own statement that the application of the LNT model is ‘commensurate with the precautionary principle’ (ICRP, 2007).

2.3. Justice

The ‘Golden Rule’ is one of the most common ethical guidelines around the world. It is found in every single tradition one may choose to look at, and even its wording is strikingly uniform. A few examples must suffice: ‘one should never do that to another which one regards as injurious to one’s own self’ (Hindu); ‘Hurt not others in ways that you yourself would find hurtful’ (Buddhist); ‘Never impose on others what you would not choose for yourself’ (Confucian); ‘That which is hateful to you, do not do to your fellow. That is the whole Torah; the rest is the explanation; go and learn’ (Jewish); ‘Therefore whatever you want people to do for you, do the same for them, because this summarises the Law and the Prophets’ (Christian); ‘None of you [truly] believes until he wishes for his brother what he wishes for himself’ (Muslim); and ‘If thine eyes be turned towards justice, choose thou for thy neighbour that which thou choosest for thyself’ (Bahá’í). Due to its general acceptance, this rule is also foundational to the abovementioned ‘Declaration Toward a Global Ethic’ of the Parliament of the World’s Religions (Küng and Kuschel, 1993). It is obvious, at least from some of the versions quoted here, that the Golden Rule can also serve as support for the principles of non-maleficence and beneficence. However, the author believes that its greatest importance is for the idea of justice. It asks everyone to consider the interests of the other as if they were on his or her own, and thus demands reciprocity (Zölzer, 2013).

Justice, as such, is verifiably an element of ‘common morality’. The Bhagavad Gita contains the promise that ‘he who is equal-minded among friends, companions and foes … among saints and sinners, he excels’. In the Sermons of Buddha, a similar statement is found: ‘he, whose intentions are righteousness and justice, will meet with no failure.’ The Psalms observe that ‘he loves righteousness and justice; the world is filled with the gracious love of the Lord’, whereas in the introduction to the Proverbs, the reader is assured that here he will acquire ‘the discipline that produces wise behaviour, righteousness, justice, and upright living’. Muhammad advises his followers to be ‘ever steadfast in upholding equity …, even though it be against your own selves or your parents and kinsfolk’. Finally, Bahá’u’lláh writes that ‘No light can compare with the light of justice. The establishment of order in the world and the tranquillity of the nations depend upon it’ (Zölzer, 2013).

A look at secular philosophy will be instructive here, as justice has not only been of prime importance since Antiquity, but has also been studied systematically early on (Johnston, 2011). Aristotle, for instance, distinguished between different forms of justice, and his analysis has exerted decisive influence on later thought. The form talked about here, and which is certainly also implied by the sacred scriptures quoted above, is ‘distributive justice’. It concerns the allocation of goods and burdens, of rights and duties in a society. However, even this one form can be viewed from different perspectives. Which allocation of goods and burdens is just? An egalitarian one, one that considers merits, one that considers needs, or one that respects historical developments? All this is not clear at the outset, and needs to be made the subject not only of philosophical debate, but also of cross-cultural discourse.

For radiological protection, the principle of justice would seem to be the mainstay of the dose limitation principle because it exhorts to a just allocation of burdens. However, as will be argued in the section on beneficence and non-maleficence, its reach is certainly beyond that, and it also has implications for the optimisation principle. It is needed to better explicate exactly how ‘economic and societal factors’ should be ‘taken into account’ when determining what is ‘as low as reasonably achievable’.

2.4. Human dignity

The last core value to be discussed here is perhaps not what one would first think of when it comes to radiological protection. However, it is probably true to say that very few people would deny its applicability to just about any area of human activity. It is expressed in different ways around the world, but the basic idea is virtually ubiquitous – that of a dignity pertaining equally to all humans. In the Bhagavad Gita, Krishna says, ‘I am the same to all beings … In a Brahma … and an outcast, the wise see the same thing’. Similar statements are reported of Buddha and Confucius. In the Bible, the prophet Malachi asks, ‘Do we not have one father? Has not one God created us?’ The concept is also clearly expressed in the Quranic verse: ‘We have conferred dignity on the children of Adam … and favoured them far above most of Our creation.’ In Bahá’u’lláh’s writings, one finds ‘know ye not why we created you all from the same dust? That no one should exalt himself over the other’ (Zölzer, 2013).

These are just short glimpses from different religious sources, but the broad agreement on the notion that all human beings share the same dignity is also reflected in the ‘Declaration Toward a Global Ethic’ of the Parliament of World’s Religions in 1993 (Küng and Kuschel, 1993). It says that ‘every human being without distinction of age, sex, race, skin colour, physical or mental ability, language, religion, political view, or national or social origin possesses an inalienable and untouchable dignity, and everyone, the individual as well as the state, is therefore obliged to honour this dignity and protect it’ (Küng and Kuschel, 1993).

Moreover, human dignity has been invoked by secular philosophers for centuries. This strand of thought begins with Stoicism, continues through the Renaissance, and leads up to Enlightenment (Kretzmer and Klein, 2002). In our time, together with the abovementioned religious traditions, it has played a very prominent role in the drawing up of the ‘Universal Declaration of Human Rights’ of 1948 (United Nations General Assembly, 1948) and the ‘Universal Declaration of Bioethics and Human Rights’ of 2005 (UNESCO, 2005).

There is no space here for detailed discussion of the importance of respect for ‘human dignity’ with regard to radiological protection. It is clear, however, that the third principle of radiological protection, the principle of dose limitation, partly rests on this foundation. To expose somebody to high doses in order to spare others is using him or her merely as a means to an end, and that is – with or without explicit reference to deontological ethics – not in compliance with human dignity.

The Beauchamp and Childress principle of ‘respect for autonomy’ can be seen as a concretisation or application of the idea of ‘human dignity’. It has been criticised as being ‘more or less ethno-ethics of American society’ (Fox, 1990), but of little relevance elsewhere in the world. In particular, some authors claim that people of Asian background would generally not agree with it, or at least define it differently from Beauchamp and Childress (Fan, 1997; Fagan, 2004; Kimura, 2014). The role of this principle is to ensure that the patient is the main decision maker in his or her own case. An important corollary therefore is the concept of ‘an informed consent’, which means that neither therapy nor research can be performed without the agreement of a competent patient. This understanding of ‘autonomy’ is certainly common in the ‘West’, but not so much in other parts of the world. There is at least anecdotal evidence that decision making is not primarily a matter for the individual patient, but very much a matter for the patient’s family in Latin America, Muslim countries, Africa, China, and South East Asia (Justo and Villareal, 2003). There seems to be some support for such an attitude in the written and oral traditions of these areas, so it is indeed questionable whether autonomy in the individualistic sense of Beauchamp and Childress is justifiable as a cross-cultural principle. Task Group 94 has not included it in its set of core values. It did, however, propose procedural values that are similar to those demanded by respect for autonomy.

3. PROCEDURAL VALUES

3.1. Transparency

Honesty, sincerity, truthfulness, and trustworthiness are unquestionably virtues that have their place in any religious and philosophical tradition. The Mahabharata states, ‘it is always proper to speak the truth’ (Shanti Parva 329:13), and Buddha describes his true follower as a ‘straightforward person … open and honest’ (Dhammapada 9). Confucius states, ‘Every day I examine myself … In intercourse with my friends, have I always been true to my word?’ (Analects 1:4). Similarly, in the Book of Job, the main character declares, ‘My lips will not speak falsehood, and my tongue will not utter deceit’ (Job 27:4). The Gospel of Matthew contains the following exhortation: ‘But let your communication be, Yea, yea; Nay, nay: for whatsoever is more than these cometh of evil’ (Matthew 5:37). The same terseness is found in the Quran: ‘Have fear of God, and be among the truthful’ (9:119). Finally, the Bahá’í writings contain this observation: ‘Truthfulness is the foundation of all human virtues. Without truthfulness, progress and success are impossible for any soul’ (Advent of Divine Justice).

3.2. Accountability

Given the emphasis placed by all religions and philosophies of the world on proper behaviour, it would be difficult to find any source not referring to the actor’s responsibility for what he or she did or did not do. From Mahatma Gandhi, to quote a modern representative of Hinduism, came the statement, ‘it is wrong and immoral to seek to escape the consequences of one's acts’ (The Diary of Mahadev Desai), and Buddha says, ‘Don’t look at others’ wrongs, done or undone. See what you, yourself, have done or not’ (Dhammapada 50). Confucius expresses it in much the same way: ‘The noble person places demands upon himself, the petty person blames others’ (Analects 15:20). The prophet Jeremiah warns that God will ‘give every man according to his ways, according to the fruit of his deeds’ (Jeremiah 17:10). Similarly, the Apostle Paul emphasises responsibility to a higher authority: ‘So then each of us will give an account of himself to God’ (Romans 14:12). Finally, an oral tradition of Muhammad contains this statement: ‘Each of you is a guardian and is responsible for those whom he is in charge of’ (Al-Bukhari).

3.3. Inclusiveness

Inclusiveness would seem to be the first choice for the main procedural value behind the much-discussed concept of stakeholder involvement. It must be admitted that participatory approaches to decision making have historically played a minor role. However, it is certainly possible to point to traditions that consider it highly desirable to solve questions of general interest by way of consultation, including one of the oldest sacred scriptures, the Rigveda: ‘Meet together, speak together, let your minds be of one accord … May your counsel be common, your assembly common, common the mind, and the thoughts of these united’ (10:191); and one of the newest, the Tablets of Bahá’u’lláh: ‘Take ye counsel together in all matters, inasmuch as consultation is the lamp of guidance which leadeth the way, and is the bestower of understanding’ (11:16). It is well known that the primitive Christian and Muslim communities provided space for open consultation, an ideal which was soon lost from both religions’ mainstream, and has only been revived, to some extent, more recently. A relevant statement of Shotoku Taishi, the first Buddhist ruler of Japan, has already been quoted above: ‘When big things are at stake … many should discuss and clarify the matter together, so the correct way may be found.’ Sen (2006), in ‘Identity and Violence’, presents evidence that the democratic ideas of classical Greece for centuries found no echo anywhere in Europe, while the form of government in some Asian city-states at the same time can be described as democratic. All this must be considered anecdotal evidence, but it shows that it may be worthwhile looking for participatory approaches in different traditions. At least it demonstrates that the value of inclusiveness is not an invention of modern times, and is compatible with traditions.

3.4. Empathy

Although it has not played a significant role in ICRP reports to date, the author suggests that empathy should be included as a fourth procedural value, which is of importance for the implementation of radiological protection and has indeed gained in importance over the last decades, especially with the experience from Chernobyl and Fukushima. The term goes back to the 19^th Century and, as such, cannot be expected to be found in much older written and oral traditions. Compassion, loving kindness, and a caring attitude, however, are mentioned everywhere. In the Bhagavad Gita, Krishna says, ‘who is incapable of hatred toward any being, who is kind and compassionate, free of selfishness … such a devotee of Mine is My beloved’ (12:13–14). Buddha praises ‘loving kindness and compassion’ as two of the most important attitudes that the believer should cultivate (Metta Sutta). ‘Care for all others’ (Analects 12:22) is central to Confucius’ teachings. The Talmud contains this statement: ‘Loving kindness is greater than laws; and the charities of life are more than all ceremonies.’ One of the epistles ascribed to the Apostle Peter is the exhortation: ‘Be of one mind, sympathetic, loving toward one another, compassionate, humble’ (1. Peter 3:8). An Islamic oral tradition relates that Muhammad said to his followers: ‘You won’t be true believers unless you have compassion, and I am not referring to the mercy that one of you would have towards his companion or close friend but I am referring to mercy or compassion to all’ (Al Taberani). Finally, an American Indian Proverb recommends, ‘Never criticise a man until you've walked a mile in his moccasins’.

4. IMPORTANCE OF BALANCING

From the foregoing, it seems clear that the system of principles developed by ICRP is indeed based on values that are shared across cultures. They can be traced back to the religious and philosophical traditions that have provided moral guidance for people around the world over the centuries. That is not to say that secular ethics is wrong and useless, but just that a degree of worldwide consensus already exists and is reflected in those traditions. It is also apparent that the values discussed above are similar, if not identical, to the four principles of biomedical ethics suggested by Beauchamp and Childress, which the authors consider to be rooted in ‘common morality’. Cross-cultural validity can be demonstrated both for the core values of the radiological protection system (beneficence/non-maleficence, prudence, justice, human dignity) and for the procedural values which are to guide its implementation (transparency, accountability, inclusiveness, empathy). Whether radiological protection in practice has always, and everywhere, reflected these values is a different question, but there is certainly a growing awareness of their importance.

In conclusion, one aspect needs to be emphasised. The values discussed above, similar to the principles of biomedical ethics, have only ‘prima facie’ validity, which means that they apply as long as there is no conflict between them. If there is, they need ‘balancing’ (i.e. their relative importance must be weighed). This is where cultural specificity can play a role. Beneficence and human dignity, to give just one example, are held in high esteem everywhere around the world, but it is not possible to implement both of them to the same extent in every situation. If such a conflict arises, not everybody everywhere may give the same answer to the question which of the two is to prevail. Should one ignore a patient’s reluctance to having another x-ray examination and impose it on him or her anyway because this will allow a better assessment of therapy options? The answer to this question may be different in Korea, the USA, and the Czech Republic. Some degree of plurality is certainly acceptable, or even desirable, but there is a need for awareness of the differences, and discussion about whether they should be retained or if a common approach should be developed. Making the core values of radiological protection and the related procedural values explicit, and assessing their cross-cultural validity, will help in this endeavour.

References

Appiah, K.A., 2006. Cosmopolitanism: Ethics in a World of Strangers. W.W. Norton, New York.

Beauchamp, T.L., Childress, J.F., 1979, 1994, 2013. Principles of Biomedical Ethics. Oxford University Press, Oxford.

Bentham, J., 1776. A Fragment on Government. T. Payne, London.

Bok, S., 1995. Common Values. University of Missouri Press, Columbia, MO.

Carozza

P.G.

, 2003. From conquest to constitutions: retrieving a Latin American tradition of the idea of human rights. Human Rights Quart. 25: 281–313.

Clarke

R.H.

, 2003. Changing philosophy in ICRP: the evolution of protection ethics and principles. Int. J. Low Radiat. 1: 39–49.

Clarke

R.H.

Valentin

, 2009. The history of the ICRP and the evolution of its policies. Ann. ICRP 39: 75–110.

Edelstein, L., 1943. The Hippocratic Oath: Text, Translation, and Interpretation. Johns Hopkins University Press, Baltimore, MA.

Fan

, 1997. Self-determination vs. family-determination: two incommensurable principles of autonomy. Bioethics 11: 309–322.

10.

Fagan

, 2004. Challenging the bioethical application of the autonomy principle with multicultural societies. J. Appl. Philos. 21: 15–31.

11.

Fox, R., 1990. The evolution of American bioethics: a sociological perspective. In: Weisz, G. (Ed.), Social Science Perspective on Medical Ethics. University of Pennsylvania Press, Philadelphia, PA, pp. 201–220.

12.

Gardiner, S., 2008. Why we need more than justification in the ethics of nuclear protection: a view from outside. In: Eggermont, G., Feltz, B. (Eds.), Ethics and Radiological Protection. Academia, Louvain-la-Neuve, pp. 97–111.

13.

González

A.J.

, 2011. The Argentine approach to radiation safety: its ethical basis. Sci. Techn. Nucl. Inst. 2011: 69–83.

14.

Habermas, J., 1998. The Postnational Constellation. MIT Press, Cambridge, MA.

15.

Hansson

S.O.

, 2007. Ethics and radiation protection. J. Radiol. Prot. 27: 147–156.

16.

ICRP, 1973. Implications of Commission Recommendations that doses be kept as low as readily achievable. ICRP Publication 22. Pergamon Press, Oxford.

17.

ICRP, 2007. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann. ICRP 37(2–4).

18.

Johnston, D., 2011. A Brief History of Justice. Wiley-Blackwell, Chichester.

19.

Kant, I., 1795. Zum Ewigen Frieden. Ein philosophischer Entwurf (transl. 2003, Perpetual Peace: a Philosophical Sketch. Hackett Publishing Company, Cambridge, MA).

20.

Justo

Villarreal

, 2003. Autonomy as a universal expectation: a review and a research proposal. EUBIOS J. Asian Int. Bioethics 13: 53–57.

21.

Kimura, R., 2014. Japan, Bioethics. In: Jennings B. (Ed.), Bioethics. Vol. 4, fourth ed. Macmillan Reference, Farmington Hills, MI, pp. 1757–1766.

22.

Kretzmer, D., Klein, E. (Eds.), 2002. The Concept of Human Dignity in Human Rights Discourse. Kluwer Law International, The Hague.

23.

Küng, H., Kuschel, K.J. (Eds.), 1993. A Global Ethic. The Declaration of the Parliament of the World’s Religions. SCM Press, London.

24.

Locke, J., 1689. Two Treatises of Government. A. Churchill, London.

25.

Nussbaum

, 2004. Beyond the social contract: capabilities and global justice. Oxford Develop. Stud. 32: 3–16.

26.

Orth, G. (Ed.), 2002. Die Erde-lebensfreundlicher Ort für alle. Göttinger Religionsgespräch 2002 zur Umwelt- und Klimapolitik. LIT Verlag, Münster.

27.

Pelligrino

E.D.

, 2008. Some personal reflections on the ‘appearance’ of bioethics today. Stud. Bioet. 1: 52–57.

28.

Persson

Shrader-Frechette

, 2001. An evaluation of the ethical principles of the ICRP’s radiation protection standards for workers. Health Phys. 80: 225–234.

29.

Sen, A., 2006. Identity and Violence: the Illusion of Destiny. W.W. Norton, New York.

30.

Sen, A., 2009. The Idea of Justice. Harvard University Press, Cambridge, MA.

31.

Shrader-Frechette

Persson

, 1997. Ethical problems in radiation protection. Health Phys. 73: 373–382.

32.

Statista, 2015. Number of Examinations with Computer Tomography (CT) in Selected Countries. Statista, Inc., New York. Available at: http://www.statista.com/statistics/283085/computer-tomography-examinations-in-selected-countries/ (accessed 16 September 2015).

33.

Streffer, C., Witt, A., Gethmann, C.F., Heinloth, K., Rumpff, K., 2005. Ethische Probleme einer Langfristigen Globalen Energieversorgung. de Gruyter, Berlin.

34.

ten Have, H., Gordijn, B., 2013. Global Bioethics. In: ten Have, H., Gordijn, B. (Eds.), Compendium and Atlas of Global Bioethics. Springer, Dordrecht, pp. 1–16.

35.

Tsai

D.F.C.

, 1999. Ancient Chinese medical ethics and the four principles of biomedical ethics. J. Med. Ethics 25: 315–321.

36.

United Nations Conference on Environment and Development, 1992. Declaration on Environment and Development. United Nations Environment Programme, Nairobi. Available at: http://www.unep.org/Documents.Multilingual/Default.asp?documentid=78 &articleid=1163 (accessed 16 September 2015).

37.

United Nations Conference on the Human Environment, 1972. Declaration on Human Environment. United Nations Environment Programme, Nairobi. Available at: http://www.unep.org/Documents.Multilingual/Default.asp?documentid=97&articleid=1503 (accessed 16 September 2015).

38.

United Nations General Assembly, 1948. Universal Declaration of Human Rights. United Nations, New York. Available at: http://www.un.org/en/documents/udhr/index.shtml (accessed 16 September 2015).

39.

United Nations General Assembly, 1959. Declaration of the Rights of the Child. United Nations Children's Fund, New York. Available at: http://www.unicef.org/malaysia/1959-Declaration-of-the-Rights-of-the-Child.pdf (accessed 16 September 2015).

40.

UNESCO, 1997. Universal Declaration on the Human Genome and Human Rights. United Nations Educational, Scientific and Cultural Organization. UNESCO, Paris. Available at: http://unesdoc.unesco.org/images/0010/001096/109687eb.pdf (accessed 16 September 2015).

41.

UNESCO, 2005. Universal Declaration on Bioethics and Human Rights. United Nations Educational, Scientific and Cultural Organization. UNESCO, Paris. Available at: http://unesdoc.unesco.org/images/0014/001461/146180e.pdf (accessed 16 September 2015).

42.

Webley

, 1996. The interfaith declaration. Constructing a code of ethics for international business. Bus. Ethics Eur. Rev. 5: 52–54.

43.

Wingspread Conference, 1998. Wingspread Statement on the Precautionary Principle. Environmental Research Foundation, Annapolis. Available at: http://www.psrast.org/precaut.htm (accessed 16 September 2015).

44.

WNA, 2015. World Nuclear Power Reactors and Uranium Requirements. World Nuclear Association, London. Available at: http://www.world-nuclear.org/info/Facts-and-Figures/World-Nuclear-Power-Reactors-and-Uranium-Requirements/ (accessed 16 September 2015).

45.

Zölzer, F., 2013. A cross-cultural approach to radiation ethics. In: Oughton, D., Hansson, S.O. (Eds.), Social and Ethical Aspects of Radiation Risk Management. Elsevier Science, Oxford, pp. 53–70.

Are the core values of the radiological protection system shared across cultures?