Core ethical values of radiological protection applied to Fukushima case: reflecting common morality and cultural diversities

The predecessor of the ICRP was established in 1928 [4], resulting from a series of reports of severe skin burns found in medical professionals conducting x-ray examinations. ICRP's recommendations during this period focused on 'tissue reaction' effects due to cell killing, i.e. those effects for which scientific findings suggest there is a dose threshold below which no deleterious effects are seen. To avoid harmful effects then, it was considered sufficiently protective to keep radiation doses to medical workers below some defined level. This avoidance of harm is the ethical value of 'non-maleficence'.

After World War II, through the 1950s to 1970s, the expanding use of radiation in medical and industrial fields, along with the consequences of the bombings of Hiroshima and Nagasaki and nuclear weapons testing, caused concern among experts and the public regarding risks of stochastic effects (such as cancer or genetic effects) from radiation exposure. Stochastic effects are named as such because their occurrence is considered to be probabilistic in nature, with their probability of occurrence (but not their severity) increasing with the level of exposure. In terms of radiological exposure, high-dose data supports a linear risk model for solid cancer development. Meanwhile, there are controversies how to quantify the risk of low doses, which are generally considered to be doses up to about 30–50 times that of natural background. Additionally, no clear evidence for a threshold for this type of effect exists, so in 1965 ICRP recommended a prudent attitude with respect to radiation risk and adopted a risk model with no threshold where the magnitude of the risk is linearly proportional to the exposure level. This concept is known as the linear, non-threshold (LNT) model, and forms the cornerstone of the ICRP's radiological protection system, directed toward the goal of not only preventing tissue reaction effects but also minimizing stochastic effects. The ethical basis supporting this LNT model is 'prudence', which was later connected to the 'precautionary principle' [5].

Following the adoption of the LNT model, ICRP recommended that 'exposure to radiation be kept at the lowest practicable level in all cases' (1955). However, recognizing that this recommendation conflicted with the potential benefits of radiation use, the Commission modified its initial recommendations by introducing the ALARA principle stating that: all exposure should be kept as low as reasonably achievable, taking into account economic and societal factors (1975). This ALARA principle was equivalently referred to as the optimization principle. This reflected the recognition of the importance of 'reasonable' consideration and decision making that balances not only risk and benefit but also societal and economic factors [6]. Through substantial debates on radiation risks spanning many decades, in 1977 the ICRP established its triad of fundamental radiological protection principles:

• Justification: any decision that alters the exposure situation should do more good than harm;
• Optimisation: all exposure should be kept as low as reasonably achievable, taking into account economic and societal factors (ALARA principle); and
• Limitation: individual exposures should not exceed the dose limits recommended by the Commission. This principle is applied only in planned exposure situations i.e. exposure situations for which sources are deliberately introduced and fully controlled. Dose limits do not apply to medical exposure of patients because of the benefit of radiation, nor to emergency exposure situations in case of loss of control of sources, nor in existing exposure situations when the sources of exposure already exists before the decisions to control them is taken, e.g. radon or contaminated areas after an accident.

These principles are central to the radiological protection system today and apply to the protection of workers, the public, patients and also the environment (fauna and flora), with the aim 'to contribute to an appropriate level of protection for people and the environment against the detrimental effects of radiation exposure without unduly limiting the desirable human actions that may be associated with such exposure' [7].

To bring these principles into practice, ICRP has been seeking more definitive descriptions of 'reasonableness' (the wisdom of 'reasonable' decision-making, needed in the optimization process) and 'tolerability' (to set a boundary between 'unacceptable' and 'tolerable' risk levels in order to set appropriate dose limits for protecting workers or members of the public.) [8].

During the above mentioned elaboration of the system, it was in 1990 that the ICRP recommendations explicitly included avoiding inequity among individual exposures in a population, suggesting attention be paid to the protection of each person [9], as opposed to only considering the group as a whole. This requisite can be related to the ethical value of 'justice', that is, to achieve equitable distribution of risk and benefit derived from actions taken to protect people from radiation exposures.

Before and after the turn of the 21st century, the system of radiological protection was confronted with many challenges. Affected by global interests in environmental protection, the ICRP system expanded its scope to non-human species [10, 11]. Simultaneously, the Chernobyl nuclear power plant accident in 1986 renewed global concern about radiation risk. Through dedicated activities of radiological protection professionals in the context of the Chernobyl post-accident situation and of contaminated sites resulting from past activities, there was a progressive recognition of the importance of involving stakeholders in the decision-making process related to management of exposure situations particularly from nuclear accidents [12, 13]. This should be noted as the intention to respect the autonomy of the people affected by radiation and the need to empower them to regain control of their own situation. Such autonomy and empowerment are derived from the fundamental ethical value of 'human dignity'.

Although the focus in the development of the system was on its scientific and technical basis some prominent radiological protection experts pointed out the ethical dimensions of the system [14] often linking issues in radiation protection to the three main theoretical systems of Western ethics: teleological/consequentialist ethics (to achieve the best collective outcome, a representative theory of which is 'utilitarianism'); deontological ethics (to follow duties or rules to respect individual's dignity and human rights); and virtue ethics (to achieve the virtues attributed to humans who behave wisely or reasonably) [15].

Reviewing the ICRP publications, relevant literature, and discussions held at a series of workshops worldwide, TG94 found four core ethical values to be the foundation of the system throughout its development [1, 3]. These values are:

• Beneficence and non-maleficence: do more good than harm [16–19]
• Prudence: rational and/or careful judgment [20], without full knowledge of the consequence of actions.
• Justice: distributive justice (equity in distribution of risk or burden and benefit or gain); corrective justice (compensation for loss) [20]; procedural justice (due process, fairness) [21] and
• Dignity: respect for basic human rights and autonomy [22].

These ethical values are widely accepted in Western philosophy and also accepted commonly throughout the world [23]. Of particular note is that (with the exception of 'prudence') they are common to the principles of biomedical ethics: beneficence and non-maleficence (treated sometimes individually); justice; and respect for autonomy of a person, which is derived from human dignity. These principles of biomedical ethics were proposed at the end of 1970s in the well-known work by Beauchamp and Childress [16] and the Belmont Report [17].

Including 'prudence' as a core value can be seen as a characteristic of radiological protection [24]. This is mainly because this value is central to the ICRP's radiological protection system as mentioned above. The origin of the idea of prudence is 'phronesis' ('practical wisdom' or 'rational choice') of Aristotle's Nicomachean Ethics [20]. Phronesis is one of the five status of the human soul (intellectual virtues) needed to reach the truth, along with others: episteme (scientific knowledge), techne (skill and crafts), sophia (reasoning concerning universal truths and nous (intuition). After Aristotle, theoreticians in various disciplines of each era have discussed 'prudence'. For example, in the last half of the 20th century, the concept of prudence in economics and accounting has been discussed in relation to 'cautiousness' and 'risk aversion' [25, 26]. This means that when there is uncertainty in the consequences of an action, one should overestimate the risk of loss and underestimate the possibility of gain. Such bilateral characteristics of 'prudence' (practical wisdom and cautiousness) could be interpreted differently in various cultural contexts, as discussed below.

The above mentioned core ethical values are largely shared worldwide, but it is also important to consider specifically how these values can be described in different cultural contexts. The tonality of this value system is not identical between the Eastern and Western worlds. Here we describe the construction of this set of values from an Asian perspective, specifically focusing on cultures of Confucianism [27] and Buddhism [28, 29], which are popular in Korea and in Japan, cultural backgrounds of the two of the authors.

For example, these four ethical values can be related to the key concepts of Confucianism (a moral philosophy developed in China and spread to Korea, Taiwan, Vietnam, and Japan), each of which is discussed below regarding how it can be connected to the ICRP triad for the radiological protection system, reflecting the previous discussions [30, 31] (figure 1). There is some variability of the implications of these core values in the context of Confucianism and Asian culture.

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It is obvious that 仁(yin, in Korean or jin, in Japanese), i.e. benevolence, is directly connected to beneficence. This can be related to 'justification' in radiological protection, which ensure doing 'more good than harm', as mentioned above. This is the central and highest value in the philosophy of Confucianism. Such a construction of values is related to a paternalistic society where authorities are assumed to provide benefit to the society.

義(ui or gi) in Confucianism is related to justice in the Western sense. This can be related to 'dose limitation' as it requires equitable dose exposure for each individual. It Confucianism it has a stronger meaning of 'responsibility' and 'obligation' of a person, rather than meaning equity.

禮(yei or rei) means courtesy and respect for persons as well as social rules. This with the sense of restriction may evoke the notion of 'dose constraint', which is source-related restrictions on individual dose in optimization process to limit inequity. However, yei in Confucianism refers to respect for the elderly or persons of higher hierarchy for reaching harmony with others rather than for assuring equal human rights of self-determination and freedom, which means to respect human dignity. Human dignity is agreed upon as the foundation of human rights in modern Asian society, but it is not originally included in a set of core values of Confucianism, in precisely the same meaning.

智(zhi or chi: wisdom) is related to 'prudence' but has a wider meaning in Confucianism, as the basis of autonomy and self-determination. 'Zhi' is a specific type of wisdom, a high-ranked ability of humans to lead to decision making considering various kinds of values. Among the two typical interpretations of 'prudence', practical wisdom and cautiousness, the former is more related to 'zhi' in Confucianism.

信(shin, both in Korean and Japanese) means 'trust', which can be achieved as a result of 'stakeholders participation' respecting each stakeholder's autonomy, which is derived from 'human dignity'.

In Buddhism, 慈悲 (jihi in Japanese) means 'compassion', which is obviously related to beneficence, as well as to benevolence, mercy, or clemency. People are seen in 'reincarnation', a cycle of rebirth from a past being, which might have been non-human, under the law of 'karma'. Buddhism expands the idea of non-maleficence to all sentient beings, not limited to humans, and sometimes even flora and fauna. Hence, justice can be achieved by an obligation of the well-off to be generous to others rather than by distributive justice in the fair allocation of goods.

In Buddhism, our mental and physical states arise from and depend on conditions(縁起engi, 'dependent origination'), and individual or social goodness is interrelated and interdependent with others (other people, including ancestors and the deceased, as well as other living creatures, 'living' land, or natural things in the world). Buddhism denies the idea of an autonomous person (無我muga, 'no-self') and regards an existence of a person to be empty (空ku). Extinction of 'self' is one of the paths to the spiritual enlightenment (悟りsatori or 涅槃 nehan, 'nirvana'), the status of wisdom, which is attained through meditation, rather than through intellectual inquiry, logical thinking or democratic deliberation.

This idea of 'an empty individual which exists in relationship to others' is closely related to Japanese culture where the value of 和 (wa, peaceful harmony) outweighs the autonomous decision-making of an individual, which can be interpreted as both negative (obedient to others) and positive (keeping harmony with others) [32]. In Japanese culture people learn that it is a prudent attitude not to argue their own opinions and to keep harmony with others. The first article of the 17-article constitution, Japan's first written ancient code of laws by Shotoku Taishi defined that 'Harmony should be valued and quarrels should be avoided'. It also says, that 'Decisions on important matters should not be made by one person alone. They should be discussed with many people' [33]. In this context, 'wa' is related both to prudence and stakeholder participation.

As described above, 'beneficence' is commonly respected as a value both in Western and Eastern worlds, whereas the Western concepts of 'dignity' for individual rights and 'justice' for equity are established also in the Eastern world, but still weak in their implementation. 'Prudence' has more various implications in different cultural contexts. Considering these variations, we reflect how these core values can be applied to actual issues that arose in the Fukushima case.

In the inevitably confusing and intimidating situation following a nuclear accident, people are faced with crucial decisions and dilemmas with no obvious solution. In the case of Fukushima, this was exacerbated by political conflicts and a profound social distrust of authorities and experts who caused a 'man-made' [34] disaster and failed to ensure their previous promise derived from 'safety myth' [35].

Based on exploration of the experience of the Chernobyl accident, ICRP issued in 2008 two important publications to provide guidance both for the emergency phase (Publication 109) [12] and the post-accident recovery phase which is considered by the Commission as an existing exposure situation (Publication 111) [13]. The evacuation directive in Fukushima following the event and lifting of living restrictions later on raised ethical questions that are difficult to answer. These publications and related literature have provided suggestions for how to analyze such dilemmas; however, it was only after the Fukushima accident that Japanese society could widely share the knowledge learned from the past experiences.

Here we reflect upon what happened in Fukushima, focusing on the evacuation during the early emergency phase and the issue of where to live during the post-accident recovery phase to find how ethical values can be applied in such complex situations.

On the day and 1 day after the accident at the Fukushima Daiichi Nuclear Power Station (FDNPS), resulting from the great earthquake of March 11, 2011, Japanese prefectural and national authorities first issued evacuation directives according to the distance from the FDNPS; then on April 22, restriction was placed on entrance into dangerous areas based on the standard of 20 mSv yr⁻¹ effective dose [36]. A substantial number of evacuation-related deaths of elderly persons in this period were reported. At least 12 of 27 patients with severe medical problems such as end-stage renal failure or stroke died probably owing to transportation of more than 100 km by March 15, and the accompanying interruption in medical care. It is argued that these deaths could have been prevented and better preparedness for future nuclear crises is needed [37]. Another social issue that emerged was the deaths of elderly patients in a geriatric hospital and related nursing home in Futaba-gun (4.5 km from FDNPS): 50 of 438 elderly patients died in the process of compulsory evacuation or at the evacuation center [38]. These are prime examples of a misapplication of the 'non-maleficence' principle caused by focusing only on radiation risk, and lacking perspectives to minimize the possible negative consequences of the evacuation order.

There is also a compelling argument from ethicists that compulsory evacuation of elderly people cannot be ethically justified in terms of public health and individual liberty [39], which is derived from human dignity. It should be noted that additional protection is required to respect the dignity of these vulnerable populations, whose physical status and decision-making capacity are typically not robust [17]. ICRP's recommendations in 2004 for response to a nuclear attack mention that 'while the physical risks associated with evacuation have generally been shown to be low, ... consideration must be given to special groups such as the ill, the elderly, children, and pregnant women who may be at higher risk'. [40]

According to the Reconstruction Agency [41], the number of earthquake-disaster-related deaths (defined as the deaths due to evacuation-related health problems or overfatigue, but excluding deaths caused by direct effects such as building collapse, fire, or drowning in the tsunami (tidal wave)) through August of 2012 was the highest (761) in Fukushima among 10 affected provinces. Among this 761, the numbers of people under the age of 20 was 0; 20 to 65 was 61; and over 65 was 700 (Table 1). Among this number of deaths, 380 were attributed to the Fukushima accident-related evacuation, which the Reconstruction Agency mentioned. The total number of evacuees was 81 300 and if we assume that 380 per 81 300 was the probability of evacuation-related deaths, this mortality of 0.47% is close to the level of mortality associated with an exposure of 100 mSv (0.5%, nominal risk coefficient by ICRP Pub. 103) [42].

An epidemiological survey of 715 elderly people in five facilities in Minami Soma City comparing mortality between five years before and one year after the earthquake reported that overall relative mortality risk (after/before) was 2.68 (95% CI: 2.04–3.49). There was a substantial variation in mortality risk across the facilities ranging from 0.77 (5% CI: 0.34–1.76) to 2.88 (95% CI: 1.74–4.76) [43]. This group provided another analysis to find that the risk of evacuation was higher than risk of radiation, using an indicator of loss of life expectancy (LLE) of elderly persons in nursing homes [44]. The authors conclude that the risk of compulsory evacuation needs to be better balanced against the radiation risk. Their intention was not to blame evacuation, particularly as there was no predefined emergency response plan; rather, they just demonstrate the importance of emergency preparedness to reduce evacuation-related risks. This kind of risk-benefit assessment is a basic requisite in biomedical ethics, as proposed by the Belmont Report [17].

Furthermore, ICRP has stated that 'It is essential that all aspects of the plan are consulted with relevant stakeholders, otherwise it will be more difficult to implement them during the response [12]'. This publication also states that at the early period of an emergency situation, 'the 'reflex' use of preplanned protection strategy will be necessary with no or very little stakeholder involvement'; therefore, stakeholder involvement is especially needed in the preplanned strategy development process as well as in the process of transiting to the post-accident phase. Due to the time-sensitive and difficult nature of balancing value judgments (with consideration of the relevant community and culture) in an emergency situation, collaboratively developing a proactive strategy for immediate implementation of post-accident protection actions is a necessity.

The most crucial issue during the transition phase that followed the early phase in Fukushima was the adoption of the 'reference level' to manage the recovery phase. For an emergency exposure situation, ICRP recommends selecting a reference level in the band greater than 20 mSy yr⁻¹ but no more than 100 mSv cumulatively. For existing exposure situations, ICRP recommends selecting a reference level in the 1 to 20 mSv yr⁻¹ range [7]. For the protection of people living in long-term contaminated areas, the Commission points out that the reference level should be selected in the lower part of the 1–20 mSv yr⁻¹ range, taking into account the prevailing circumstances with the long-term objective being to maintain exposure within the range at or below 1 mSv yr⁻¹. The adoption of 20 mSv yr⁻¹ by the Japanese authorities [45, 46], which is the upper value recommended for existing exposure situations and the lower one for emergency exposure situations, introduced a lot of confusion and was difficult to understand and accept for many people. The reference level in post-accident situations is basically to guide the implementation of the ALARA principle, i.e. to help to establish the priorities for action. The objective is to identify the most highly exposed individuals in order to reduce their doses to a tolerable level and ultimately step-by-step to an acceptable one, by means of protective actions like decontamination and careful behavior. In this transition phase, prerequisites for the rehabilitation of living conditions and the reconstruction of communities include fairness in the allocation of resources and informed decisions by the affected communities about what is the tolerable level of risk, reached through stakeholders' deliberations.

However, the actual situation in Fukushima was that people who evacuated were confronted with difficult dilemmas concerning their future, particularly with regard to whether or not to return to their homes. There is a trade-off between the protection of the elderly, who are less vulnerable to radiation exposure, compared to children, who are more sensitive to radiation effects. Even only among the children, trade-off of health risks resulting from actions to avoid radiation risk causes difficulties in reaching a decision. There are some reports of increased risk of obesity or other health problems of children related to a restricted life style in the situation where radiation dose is trivial [47, 48]. Meanwhile, another study suggests caution in interpreting the current prevalence of thyroid cancer in children [49]. Some argue the risk of low doses (e.g. around a few mSv up to 10 mSv yr⁻¹) to be significant but others argue that it is trivial. These opinions are easily connected to political positions on the pros or cons of nuclear power plants. Also the differences in the amount of compensation between the people living in the post-accident areas and those who evacuated according to the directive caused difficult issue of justice and equity. Justice in distribution of compensation and fairness in the decision-making process is extremely important in such a situation. In the Japanese cultural context, there are some difficulties in promoting stakeholder participation, as people generally tend to hesitate to express their explicit will, but rather tend to follow an ambiguously developed consensus of the surrounding people, which is characterized as 'related autonomy', keeping harmony ('wa') with others [32, 50].

However, in such a cultural context, there have been some voluntary activities to support people in the post-accident areas, providing instruments and training to measure their individual radiation doses and discuss the implications of the data obtained [51–54]. People are going to find possible ways to mitigate radiation risk and other health risks. They are gradually finding future perspectives to reconstruct their lives. Knowing their own radiation exposure and how to mitigate the risk is progressively leading them to regain confidence in experts and authorities, mutual trust in the community and finally take autonomous decisions, which fit the cultural context of each community. These activities are fostering the development of the so-called 'practical radiation protection culture' [55], which emerged in Belarus during the nineties in the context of projects aiming at the rehabilitation of living conditions of the population affected by the Chernobyl accident [56]. Especially in the Asian context, courtesy and peaceful harmony with surrounding people may sometimes represent weakness for a democratic deliberation process where people are expected to express their own will [32]. Empowerment of these people with knowledge to manage their risk, along with respect for their culture which influences their decision making process is a prerequisite for reconstruction of their lives. This kind of wisdom with positive perspectives in a serious dilemma will lead to improved well-being of people in reconstructed communities.

It should be noted that a report was released in 2014 by the U.S. National Council on Radiation Protection and Measurements (NCRP) titled 'Decision Making for Late-Phase Recovery from Major Nuclear or Radiological Incidents [57]'. It suggests a process of optimization be applied to select the community-specific actions to be taken for recovery, considering multiple issues such as: possible remediation actions, restoration of infrastructure and economic activities, prioritization of land use, availability of waste disposal sites, acceptable exposure levels, and many others. Stakeholder participation is absolutely necessary in this process, in which various stakeholders are provided with information and invited to express their comments and concerns to decision makers (usually municipal officials). This process should be conducted in a manner that respects the cultural background of society, so it could lead the stakeholders themselves to become conscious decision makers. Thus 'stakeholder engagement' becomes 'stakeholder empowerment', which reduces feelings of helplessness and despair in affected populations, and leads to community resilience. This process should also be consistent with the virtues of justice, equity, autonomy and prudence, well interpreted in the cultural context of the affected society, which facilitates the development of the 'radiation protection culture' of the affected society.