Radioactivity in the environment chapter 4 a cross cultural approach to radiation ethicsa

Radioactivity in the environment chapter 4 a cross cultural approach to radiation ethicsa Radioactivity in the environment chapter 4 a cross cultural approach to radiation ethicsa Radioactivity in the environment chapter 4 a cross cultural approach to radiation ethicsa Radioactivity in the environment chapter 4 a cross cultural approach to radiation ethicsa Radioactivity in the environment chapter 4 a cross cultural approach to radiation ethicsa

Radioactivity in the Environment, Volume 19

ISSN 1569-4860, http://dx.doi.org/10.1016/B978-0-08-045015-5.00004-6

A Cross-Cultural Approach to

Friedo Zölzer

Department of Radiology, Toxicology and Civil Protection, University of South Bohemia, České Bud ějovice, Czech Republic

E-mail: zoelzer@zsf.jcu.cz

4.1 BACKGROUND

The recommendations of the International Commission on Radiological Pro-tection (ICRP, Clarke & Valentin, 2009; ICRP, 2007a) obviously presuppose

a This article is based on a presentation at the Symposium on Ethics of Environmental Health in Prague, September 2011.

Chapter Outline

4.1 Background 53

4.2 Ethics of Radiation

Protection in a

Globalizing World 55

4.3 “Principles of Biomedical

Ethics” as an Example 56

4.4 Possible Sources of

Cross-Cultural Ethics 57

4.5 The Need for

Cross-cultural Discourse 58

4.6 The Relevance of the

“Four Principles” for

Cross-Cultural Radiation

Protection Ethics 59

4.6.1 Respect for

4.6.2 Non-Maleficence

4.7 Further Cross-Culturally Accepted Principles with Relevance for Radiation

4.7.1 Concern for the Underprivileged 63 4.7.5 Intergenerational

4.8 Conclusion 66

certain elements of moral philosophy, but these are not always made explicit Individual authors, among them members of the commission itself (Clarke,

2003; González, 2011; Streffer, Witt, Gethmann, Heinloth, and Rumpff, 2005), have identified arguments from utilitarian and deontological, sometimes other kinds 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 moral basis of the first principle is not unambiguous—to say the least

Somewhat less controversial is the assignment of the principle of optimiza-tion (“The likelihood of exposure, the number of people exposed, and the mag-nitude of their individual doses shall be kept as low as reasonably achievable, taking into account economic and societal factors”) As it aims to minimize 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 wid-est possible margin between cost and benefit ICRP has even explicitly recom-mended cost-benefit analysis as a tool for optimization (ICRP, 1973)

By contrast, the principle of dose limitation (“The total dose to any individ-ual 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 from a relatively low one, even if this would lead to a reduction of the collective risk

In the third principle, we therefore see a deontological argument 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 deon-tological 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, 1744), 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, 1785) It is not clear how

a combination of these two is supposed to work, as we can easily think of situ-ations where one would be completely incompatible with the other The current philosophical foundation of radiation protection is therefore rather problematic (For further discussion, see Clarke, 2003; Gardiner, 2008; Hansson, 2007;

Persson, & Shader-Frechette, 2001; Shrader-Frechette & Persson, 1997) How this heterogeneous system of principles developed historically is an inter-esting question as well, but will not be pursued here (Clarke & Valentin, 2009) Suffice it to say that ICRP proposed the ALARA principle (“as low as reasonably

achievable”) as early as 1958 in its Publication 1 (ICRP, 1959)b The other two principles made their first appearance in Publication 26, which came out in

1977 (ICRP, 1977) Neither at that point nor later, however, has there been much

of a critical reflection on the principles’ philosophical background, and on what

it might mean to combine elements of opposing ethical approaches

4.2 ETHICS OF RADIATION PROTECTION IN A GLOBALIZING WORLD

My question here goes beyond the incompatibility between utilitarian and deontological arguments I should like to ask if it is at all appropriate in a globalizing world to base the recommendations of an international advisory body such as ICRP 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 Can we really expect the majority of mankind to adopt prin-ciples of radiation 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, there are currently 434 nuclear power reactors in operation, only 115 of them, or 26%, in Asia, Africa, and the Middle East (http://www.world-nuclear.org/info/reactors.html) However, of the 64 reac-tors worldwide under construction and the 160 reacreac-tors planned, 43 and 102, or 67% and 64%, respectively, will be operating outside Europe and the Americas

As for medical radiology equipment, data published by the World Health Orga-nization suggest a similar trend Computer tomography, for instance, is currently almost exclusively a matter of high income countries, with typically 10–30 units per million population, whereas in low-income countries this figure is 0–2 units per million population (http://www.who.int/gho/publications/world_health_statistics/ EN_WHS2012_Full.pdf) Again, in spite of their economical difficulties, many countries in Asia, Africa, and the Middle East are on their way to catching up

So, is it appropriate to carry on as we have done for the last 50 years? Currently, nobody seems to be complaining But this may well change and our system of radi-ation protection may be considered unacceptable in parts of the world What would

we do in such a situation? Would we give up the idea of international recommenda-tions for radiation protection and accept a situation where different principles were applied in different places around the globe? What if there was disagreement on issues that would affect people beyond the local or regional context?

I think that both the geographical distribution of mankind and the changes

in the use of radioactive materials and radiation to be expected over the coming

b In 1958, the exact wording was “as low as practicable” (Publication 1, ICRP, 1959), later, in 1966,“as low as readily achievable, economic and social consequences being taken into account” (Publication 9, ICRP, 1966)

years suggest that our system of radiation protection should not be based exclusively

on certain theories of “Western” ethics It seems to me that the discourse needs to

be raised to another level Instead of proceeding from concepts developed in one particular cultural context, we should acquire a truly global perspective, developing arguments that are acceptable to people of different backgrounds My proposal is therefore to work toward “cross-cultural” ethics of radiation protection (For exam-ples of similar approaches in other areas, see Veatch, 2000) This of course immedi-ately leads to another question: Do different cultures have fundamentally different approaches to moral issues, or is there something like a “common morality” that

we can draw upon? (For a sceptical viewpoint on this question, see Turner, 2003)

4.3 “PRINCIPLES OF BIOMEDICAL ETHICS” AS AN EXAMPLE

One of the most widely used frameworks of biomedical ethics is the one devel-oped by Beauchamp and Childress (Beauchamp & Childress, 1979) It is based

on four principles:

1 Respect for autonomy,

2 Nonmaleficence,

3 Beneficence, and

4 Justice.

and these are assumed to be rooted in a “common morality”, which is “not relative to cultures or individuals, because it transcends both” (Beauchamp & Childress, 2009d)

Initially, Beauchamp and Childress were not speaking about different cul-tures They were just trying to find middle-level principles that the former as

a utilitarian and the latter as a deontologist could agree to without referring to one single, more fundamental principle, such as usefulness or individual rights

It is not that the utilitarian and the deontologist each contributed one or more principles which the other had to accept in exchange of getting some of his own ideas through Rather both could fully agree with all four principles, albeit for different reasons (Beauchamp & Childress, 2009f)

The four principles have 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 has to be weighed in each case at hand The principles also need “specification”, i.e concrete rules or guidelines have to be derived for different areas of application, which can to a certain extent vary between cultural contexts How exactly to “balance” and to “specify” is the matter of long discus-sions in Beauchamp and Childress’ book (Beauchamp and Childress, 2009e)

My main proposition in the following is that the approach of Beauchamp and Childress could become a model for the ethics of radiation protection, in that we could try to identify relevant principles in the “common morality”, and thus avoid the “Western” bias, which has prevailed so far However, my approach differs from the one proposed by Beauchamp and Childress in two aspects, namely on

l how we find the underlying principles of the “common morality”, and

l how we “balance” the principles and “specify” them in different contexts

4.4 POSSIBLE SOURCES OF CROSS-CULTURAL ETHICS

Beauchamp and Childress are not really interested in the question of where and how the “common morality” can be found When they introduced the term, they just claimed that “all morally serious persons” (Beauchamp & Childress, 1994),

or in the current version “all persons committed to morality”, would agree with their four principles I do not find this convincing More effort is needed to show that these principles have cross-cultural validity—or to look for other, more widely acceptable ones

The possibility exists, of course, that we would use empirical research to test the assumption that we have got the underlying principles right (Beauchamp & Childress, 2009a), but I am not convinced that anthropological or cultural stud-ies alone would be meaningful A universal “opinion poll” that 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

We have to look for something with greater long-term validity

Orientation has been provided throughout the ages by the religious and philosophical traditions of the different cultures Although our “Western” soci-ety is largely secularized, and fundamentalism, fanaticism, and extremism have brought religion into discredit, we cannot ignore the fact that these traditions continue to be of great influence for people not versed in “Western” secular philosophy And even in the “West”, the importance of Christianity is probably still much greater than the number of people attending Sunday church service 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 analy-sis of “common morality” can therefore not pretend that religion has no role to play in the twenty-first century

My suggestion then is that the most important documents for the construction

of 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 the Bud-dha 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 consid-ered to be divinely inspired A nonbeliever will of course have some difficulty with this notion, but can instead perhaps take such writings as crystallizations of hundreds or thousands of years of human experience Another category of useful documents for our purpose are those produced by way of intra- and interreli-gious dialogues, because they already reflect a certain cross-cultural agreement

A prominent example would be the “Declaration Toward a Global Ethic” signed

at the Parliament of the World’s Religions in 1993 (Küng & Kuschel, 1993a)

There are also relevant cultural expressions outside the context of ( organized) religion Thus, we should not ignore oral traditions in the form of proverbs, stories, legends, and myths, especially those of indigenous peoples who have no written records We should also take into consideration secular texts of various kinds that have had a formative influence over the centuries 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-honored traditions, some modern doc-uments like the “Universal Declaration of Human Rights” (http://www.un.org/ en/documents/udhr/index.shtml) adopted by the United Nations General Assem-bly in 1948, or the “Universal Declaration on Bioethics and Human Rights” adopted by the UNESCO General Conference in 2005 (http://unesdoc.unesco org/images/0014/001461/146180e.pdf) have been suggested to already constitute

“common heritage of humankind” (ten Have and Gordijn, 2013, Chapter 63)

4.5 THE NEED FOR CROSS-CULTURAL DISCOURSE

Having established certain commonalities across cultural boundaries, however, does not mean the end of our task A mere collection of principles cannot yet

be considered cross-cultural ethics We need to develop what we have identified

as “global ethic” into a coherent system, where in particular it is clear how the principles are to be “balanced” with each other and how they are “specified” in different areas of application Beauchamp and Childress, as mentioned above, have gone a long way to resolving such questions In their work, they rely much

on the concept of a “reflective equilibrium” (Rawls, 1971; Rawls, 1999): one starts with certain firmly held ethical beliefs, proposes some principles that seem to build up on those beliefs, applies these to new questions, looks for consistency between the original beliefs and the new applications, and modifies either component of the system until everything fits together without contradic-tion (Beauchamp & Childress, 2009b)

This is well and good, but I think it underestimates the difficulties of cross-cultural understanding If, as Ludwig Wittgenstein maintains, “the limits of my language mean the limits of my world” (Wittgenstein, 1921), we cannot hope

to develop a cross-culturally acceptable set of principles and work with it if we talk only to people from our own “world” If we really want to know what the meaning of those principles in other cultures is, and how they should be “bal-anced” and “specified”, we have to actually talk to each other across cultural borders The ethic contained in our principles can be developed into real cross-cultural ethics only through a global discoursec In this regard, I even have some

c The doyen of discourse ethics, Jürgen Habermas, who himself claims to be “religiously unmusi-cal”, has nevertheless recently argued that “the liberal state has an interest of its own in unleashing religious voices in the political public sphere, for it cannot know whether secular society would not otherwise cut itself off from key resources for the creation of meaning and identity.” Habermas, 2008

sympathy for opinion polls, only I think they should be accompanying the development of cross-cultural ethics rather than driving it

In the remainder of this paper, I will try to indicate how the established prin-ciples of radiation protection are compatible with, or even follow from those proposed by Beauchamp and Childress and can be anchored more deeply in the above-mentioned written and oral traditions of mankind I will then mention some problematic areas of radiation protection where I see further potential for a cross-cultural approach to provide support for certain positions and against others

4.6 THE RELEVANCE OF THE “FOUR PRINCIPLES” FOR CROSS-CULTURAL RADIATION PROTECTION ETHICS

4.6.1 Respect for Autonomy

The first of the four principles is perhaps the most problematic It has been criticized as being “more or less ethno-ethics of American society” (Fox, 1990;

Matsuoka, 2007), 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 (Fagan,

2004; Fan, 1997) In “Principles of biomedical ethics” 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 “informed consent”, which means that neither therapy nor research can be carried out without the agree-ment of a competent patient This understanding of “autonomy” is certainly common in what we call the “West”, but not so much in other parts of the world There is at least anecdotal evidence that in Latin America, in Muslim Countries,

in Africa, in China, and in South East Asia, decision making is not primarily a matter of the individual patient, but very much a matter of the patient’s fam-ily (Justo & Villarreal, 2003) And it does not appear as if that would have to

be considered just a current phenomenon, whereas the written and oral tradi-tions would actually place emphasis on autonomy as it is understood in the

“West” So the question is indeed whether autonomy in the individualistic sense

of Beauchamp and Childress is justifiable as a cross-cultural principle

It may therefore be reasonable for our discussion to rather look at a closely related concept, namely “respect for human dignity” (On the relationship between the two concepts, see Andorno, 2009; van Brussel, 2012) It is expressed in different ways around the world, but as a fundamental principle it is virtually ubiquitous In the Bhagavadgita, Krishna states, “I am the same to all beings…In a Brahma…and

an outcast, the wise see the same thing” (The Bhagavadgita, 1973, 9:29 and 32) Similar statements are reported of the Buddha and Confucius (Lepard, 2005)

In the Bible, the prophet Malachi asks, “Do we not have one father? Has not one God created us?” (Bible, 2012, Malachi 2:10) The same idea is expressed

in the Quranic verse, “We have conferred dignity on the children of Adam…and favoured them far above most of Our creation” (Quran, 1980, 17:70) And a much-cited passage from Bahá’u’lláh’s writings reads: “Ye are all the leaves of one tree and the drops of one ocean” (Tablets of Bahá’u’lláh, 1994, Bishárát 37)

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 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 untouch-able dignity, and everyone, the individual as well as the state, is therefore obliged

to honor this dignity and protect it” (Küng & Kuschel, 1993b)

Human dignity has also for centuries been invoked by secular philosophers This strand of thought begins with Stoicism, continues through the Renaissance, and leads up to Enlightenment (Kretzmer & Klein, 2002) In our time, together with the above-mentioned religious traditions, it has played a very prominent role in the drawing up of the “Universal Declaration of Human Rights” (http:// www.un.org/en/documents/udhr/index.shtml) of 1948 and the “Universal Dec-laration of Bioethics and Human Rights” of 2005 (http://unesdoc.unesco.org/ images/0014/001461/146180e.pdf) Incidentally, the latter document mentions autonomy as well, but it accords the first place to human dignity

There is no space here to discuss in detail what importance “respect for human dignity” could have with regard to radiation protection I would like to suggest, however, that the third principle of radiation protection, the principle

of dose limitation, partly rests on this foundation To expose somebody to high doses in order to spare others is clearly 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

4.6.2 Non-Maleficence and Beneficence

“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, 2005) Of course, it has always been understood that sometimes pain has to be inflicted to achieve healing and thus nonmaleficence has to be balanced with beneficence To work

“for the good of the patient” is part of the Hippocratic Oath as well, and it features quite prominently in the above-mentioned Chinese medical texts ( Edelstein, 1943; Tsai, 1999, 2005)

More generally, i.e outside the context of medicine, both nonmaleficence and beneficence can be seen as core principles in any system of religious

eth-ics A central concept of both Hinduism and Buddhism is ahimsa, which means

kindness and nonviolence to all living beings (Peetush, 2011) The Bhagavadg-ita praises the “gift which is made to one from whom no return is expected” (The Bhagavadgita, 1973, 17:20), whereas the Dhammapada states, “A man is not great because he is a warrior or kills other men, but because he hurts not any living being” (Dhammapada, 1997, 270) Both the Torah and the Gospel express

the same thought in a different way by exhorting everybody to “love your neigh-bour as yourself” (Bible, 2012, Leviticus 19:18 and Matthew 22:39) More concretely, the Talmud observes that to “to save one life is tantamount to saving

a whole world” (Talmud, Sanhedrin 37a, quoted in Rosner, 2001), whereas the apostle Paul suggests that “whenever we have the opportunity, let’s practice doing good to everyone” (Bible, 2012, Galatians 6:10) 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” (Quran, 1980, 4:85) 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” (Fadel, 2010)

In the context of radiation protection, nonmaleficence and beneficence together would certainly support the principle of justification as they support very similar principles in medicine When it comes to the principle of optimi-zation, the matter may be a bit more complicated, as the wording in the ICRP recommendations suggests “taking into account economic and societal factors” Now, the interests of the wider community are certainly one factor that none of our traditions would recommend neglecting, but economical 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 But then, of course, economical factors cannot be neglected altogether Resources are limited and it

is simply not possible to invest unlimited money into better living conditions—

or better radiation protection, for that matter—when that would mean that other areas of the common weal could not receive attention or even basic needs could not be satisfied So this question becomes a question of justice

4.6.3 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, The Mahabharata, 1975, 13:113) “Hurt not others in ways that you yourself would find hurtful” (Buddhist, Udanavarga, 1946, 5:18) “Never impose on others what you would not choose for yourself” (Confucian, Analects XV:24) “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, Talmud, Shabbat 31a, quoted in Kellner,

1993) “Therefore whatever you want people to do for you, do the same for them, because this summarizes the Law and the Prophets” (Christian, Bible, 2012, Matthew 7:12) “None of you [truly] believes until he wishes for his brother what he wishes for himself” (Muslim, Hadiths of an-Nawawi 13) “If thine eyes

be turned toward justice, choose thou for thy neighbour that which thou choos-est for thyself ” (Bahá’í, Tablets of Bahá’u’lláh, 1994, Kalímát-i-Firdawsíyyih 20) Because of its general acceptance, this rule is also foundational to the

above-mentioned “ Declaration Toward a Global Ethic” of the Parliament of the World’s Religions 1993 (Küng & Kuschel, 1993c) 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 nonmaleficence and beneficence But it seems to me that its greatest importance is for the idea of justice It asks everyone to consider the interests of the other as if they were his or her own, and thus demands reciprocity Justice as such is verifiably an element of “common morality” as well The Bhagavadgita contains the promise that “He who is equal-minded among friends, companions and foes…among saints and sinners, he excels” (The Bhagavadgita,

2012, 6:9) In the Sermons of Buddha a similar statement is found: “He, whose intentions are righteousness and justice, will meet with no failure” (Mahavagga,

quoted in Fozdar, 1973) The Psalms observe that, “He loves righteousness and justice; the world is filled with the gracious love of the Lord,” (Bible, 2012, Psalms 33:5) whereas in the introduction to the Proverbs the reader is assured that here

he will acquire “the discipline that produces wise behavior, righteousness, justice, and upright living” (Bible, 2012, Proverbs 1:3) Muhammad advises his followers,

“whenever you judge between people, to judge with justice” (Quran, 1980, 4:58) And 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” (Bahá’u’lláh, 1988, Epistle to the Son of the Wolf, 53)

Again, a look at secular philosophy will be instructive, as justice has not only been of prime importance since Antiquity, but has also been systematically studied 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 that Beauchamp and Childress are talking about ( Beauchamp & Childress, 2009c), and that 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 But 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 needs to be made the subject not only

of philosophical debate, but also of cross-cultural discourse

For radiation protection the principle of justice would seem to play the role of the second pillar of the dose limitation principle, because it exhorts to a just alloca-tion of burdens But as menalloca-tioned in the last secalloca-tion, its reach is certainly beyond that and it has implications for the optimization principle as well It could help with a better explication of exactly how “economic and societal factor” should be

“taken into account” when determining what is “as low as reasonably achievable.”

4.7 FURTHER CROSS-CULTURALLY ACCEPTED PRINCIPLES WITH RELEVANCE FOR RADIATION PROTECTION

I will discuss only three questions here that have been and are still being dis-cussed in the context of radiation protection ethics, but cannot be solved on the