by Javier Betancourt
Source: Government of Chiapas, via European Pressphoto Agency. (no copyrights violation intended)
This article introduces the reader to the debate on the ethical use of X-ray imaging by the authorities in various situations. I hope that the reader will be able to think, analyse and criticise the current situation about the politics surrounding x-rays, that everyone has been subjected at some point of their lives.
The debate on the ethical use of X-ray imaging is an issue of increasing concern among the public and the media the last couple of years and can be traced back to the terrorist attacks in the United States in 2001. It became clear then a different approach on airport security was urgent. In order to understand these developments and how x-ray imaging is relevant, it is necessary to differentiate the two basic types that x-ray imaging can be divided: Medical and legal. We could argue that the medical use of the x-ray imaging is not too controversial, since the benefits of its use surpass the dangers of ionizing radiation exposure; however, this has not always been the case on its legal application.
Increased security measures? concerns by the Homeland Security in the US and its British counterpart, the Home Office, have exposed some serious gaps on the ethical use of ionizing radiation for legal purposes. Despite the fact that this technology has been widely available long time ago in order to scan luggage for explosive devices, weapons and illegal substances, after the terrorist attacks in 2001, new utilities for x-rays have been developed including the highly controversial ?whole body x-ray scan?[1]. This device caught the attention of the general public for ?modesty? and privacy concerns of exposing the ?naked body? on this backscattered x-rays imaging technique. Unfortunately the data that are presented to the general public in order to survey the public opinion are based merely on their immediate concerns (privacy) and not on the health risks associated with exposure to ionizing radiation. The above is clearly a case of mislead and uninformed consent; even the fact that this kind of polls are from reliable sources, they usually come after a security concern or terrorist attack that is fresh on the mind of the lay person, therefore giving a highly biased data.
?The majority, 67%, say they would not personally be uncomfortable in undergoing such a scan, with close to half (48%) saying they would not be uncomfortable at all[2]. (January 11, 2010)?
???????????? The public concern is such that a year after this survey was published the European Union banned the ?whole body scanner? due to cancer concerns as this Scientific American article denotes with, what I assume, a tone of biased sarcasm:
?Europe Bans X-Ray Body Scanners Used at U.S. Airports: A small number of cancer cases would result from scanning hundreds of millions of passengers a year. For some, that?s a health issue[3]?
It is possible to conclude by this brief introduction to the legal use of x-ray imaging that, governments, security agencies, health institutions, scientists and the general public have divided opinions in this matter. So it would be worthy to analyze some cases.
?When police ran X-ray scanners over two cargo trucks at a checkpoint in south-eastern Mexico on Tuesday, they made a surprising discovery: Inside the trailer were the ghostly shadows of 513 migrants ? some suffering from dehydration ? packed together in near-suffocating conditions.[4]?
This is a very representative example of how X-Ray scanning can be used to patrol and safeguard the borders to prevent drug smuggling, human trafficking, and rightfully be used on situations that people are endangered.? However, with the decline of illegal immigration through the Mexican-United States border,[5] is the use of aggressive scanning methods still justifiable?
It is rumored that Israel uses widely ?whole body scans? and X-rays on Palestinian checkpoints including children. These claims come from sources such as the Palestinian Centre for Human Rights, arguing health concerns and describing it as ?unidentified naked spy machine of enhanced x-rays?[6]. The aforementioned sources should be taken with discretion since their scientific base is ambiguous; however, it should not be ignored since public health might be in risk. Similar case of ambiguous information is the United Nations Relief and Works Agency for Palestine Refugees: ?Refugees endure x-ray screening to return home? not specifying if this screening is on their property or on their person[7]. This subject is extremely interesting in terms of research and can enlighten the international community on the reality of the procedures and human rights in the Middle East.
Another example of gaps on legislation, and ethical use of the ionizing radiation on children is the case of the Home Office proposal of routine use of X-rays to determine the age of young asylum seekers.[8]
The legal determination of age is an important matter because ?A medical or? educational? assessment? of? a? child? will? include? an assessment of the child?s true age as this will ensure that they? have? the? correct? vaccinations,? are? taught? at? a? suitable? educational level and are appropriately served by government? institutions such as schools and hospitals, and dentists.? Correct age? is? also? important? as? a? means? of? determining? potential? emotional? resources? for? dealing? with? stressful? life? events? and the? attainment? of? developmental? milestones.? Age determines the time at which a young adult can drive a motor vehicle, vote, and receive centre link payments. Accurate? age? estimation? is also vital to ensure that local authorities fulfill their obligations in providing support and services to vulnerable groups such as unaccompanied? minors? less? than? 18? years? of? age.?[9]
But are these benefits enough to justify the nonclinical exposure of children to ionizing radiation? The Home Office was right on its proposal of using X-ray imaging of bones to determine legal age, since it is a method that will provide sufficient information on bone growth by imaging the stages of endochondral ossification of the epiphysis and development of the articular cartilage providing somehow accurate age determination. Nevertheless the estimation and the method will provide a subjective non-absolute timeline. The most reliable method would be to apply X-rays to get an insight of dental sequence of formation and eruption of teeth[10]. Nevertheless these methods have their own limitations since these processes vary depending on ethnic origin and socio-cultural factors such as alimentation which is not be expected to be adequate on economic immigrants or asylum seekers[11], especially among the most susceptible population: Children.
Even though age cannot be determined with certainty even by forensic experts, it is possible to make a good and close estimation, the question therefore is: Which grade of accuracy is the Home Office expecting?
Since the radiological estimation is of two years on either way[12] there are no benefits of having an inaccurate age for the purposes listed above.
Ionizing radiation is known to cause cancer in humans, and according to the University of California, Berkeley?s School of Public Health October 2010 research, diagnostic X-rays may increase the risk of developing childhood leukaemia.
?Specifically, the researchers found that children with acute lymphoid leukemia (ALL) had almost twice the chance of having been exposed to three or more X-rays compared with children who did not have leukemia. For B-cell ALL, even one X-ray was enough to moderately increase the risk. The results differed slightly by the region of the body imaged, with a modest increase associated with chest X-rays[13].?
This article describes the methodology used for this research and includes an interesting feature:
?Interviews were conducted with mothers within four months of the diagnosis of leukemia, and the mothers were asked to report on the number of X-rays received by the child at least 12 months or more before the leukemia diagnosis. Mothers were also asked about their exposures to X-rays during pregnancy and the year prior to pregnancy.
The researchers noted that dental X-rays were not considered because they are so common and deliver such a low dose of radiation that exposure to those radiographs would not discriminate between individuals with high and low levels of radiation exposure.[14]?
Besides the health effects that exposure to ionizing radiation might cause, there are more factors that must be taken into account: A) The informed consent and B) The X-ray imaging standards.
It is matter of serious concern that children are being exposed to ionizing radiation just for the sake of ?getting out the real age? for legal purposes, or in crude reality: to determine their immigration status, especially if it is not carried out with informed consent. An informed consent can be said to have been based upon a clear appreciation and understanding of the facts, implications, and future consequences of an action, this is usually given by the parent or legal guardian of a minor. Due to the complexity of the issue, in some cases where the life of a minor is in danger as a consequence of child abuse, this consent might be denied by the parent or guardian carrying out the abuse, but as the life of the minor is in danger the use of X-rays is perfectly justifiable. Another more disturbing example is the exploitation of children to engage them in drug trafficking, where they are used to transport capsules containing narcotics in their stomachs[15]. In cases like the above, X-rays should be performed, not just for security reasons but for the immediate health risks that this practice means to the minor. In order to avoid the informed consent, some form of ?informed assent? might be put in place; this term describes the process whereby minors may agree to participate in clinical trials. This is similar to the ?informed consent? in adults and a variation might be used to explain children the procedures that will be taking place.
But how will a proper informed assent take place if the information that should be given is not the appropriate?
The X-ray imaging standards are subject of debate since it was recently discovered (January 2012) that patients are being exposed to unnecessarily high doses of radiation during common X-rays and scans because some hospitals have out-of-date equipment and inadequately trained staff.
?Variations between hospitals are so great that adult patients are exposed up to five times as much radiation for identical procedures. Children face the biggest risk, experiencing much larger variations as outside specialist units there are few clinicians with paediatric expertise or equipment.[16]?
This clearly is a violation to the paragraph 32 section 3 of the Ionizing Radiation Regulations of 1999 that states:
?Every employer in respect of whom a duty is imposed by paragraph (1) shall, to the extent that it is reasonable for him to do so having regard to the extent of his control over the equipment, make arrangements for a suitable quality assurance programme to be provided in respect of the equipment or apparatus for the purpose of ensuring that it remains capable of restricting so far as is reasonably practicable exposure to the extent that this is compatible with the intended clinical purpose or research objective.[17]?.
If in the United Kingdom, patients were being exposed to ionizing radiation without control, what kind of considerations were expected for immigrants or asylum seekers? I would like to close citing the wise words of Lisa Nandy, Labour MP for Wigan regarding the suspension of the Home Office X-ray program: ?This suspension is welcome news, but the question remains as to how Home Office ministers could sign off a pilot involving vulnerable children without ethical approval or discussions with children?s ministers? This issue demonstrates a failure across government[s] to protect the most vulnerable children. In light of the serious concerns raised, these pilots must not be allowed to resume.[18]?
*Bio:?Javier Betancourt is an alumnus of the University of the Aegean, Department of Mediterranean Studies, Greece. He is currently in the final stages of attaining a MSc in Forensic Archaeology and Anthropology at the Defence Academy of the United Kingdom, Cranfield Forensic Institute, UK. You can follow him on Twitter?@Javier_DAUK
[9] House of Lords, House of Commons, and Joint Committee on Human Rights, 2007.
The treatment of asylum seekers, tenth report of session 2006?07, Vol 1. London:
The Stationery Office Limited, p. 60?61. In Family physician Vol. 37, No. 10, October 2008. ?Age determination of Refugee Children? Benson, Jill. http://www.ncbi.nlm.nih.gov/pubmed/19002301 (Accessed on 30/05/2012)
[11] Schmeling A, Reisinger W, Loreck D, Vendura K, Markus W, Geserick G. Effects of
ethnicity on skeletal maturation: consequences for forensic age estimations. Int J
Legal Med 2000;113:253?8. In Family physician Vol. 37, No. 10, October 2008. ?Age determination of Refugee Children? Benson, Jill. http://www.ncbi.nlm.nih.gov/pubmed/19002301 (Accessed on 30/05/2012)
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