PRINCIPLE OF ETHICS IN RADIOLOGY

Task Subjects of Law and Professional Ethics

Author:

Arinal Hanifan
Nur Efriza Romadhoni
Firdha Adlia Syuhada
Muslimah Putri Utami

DIAGNOSTIC IMAGING ENGINEERING STUDY

MASTER OF APPLIED HEALTH POLYTECHNIC OF HEALTH
MINISTRY OF HEALTH SEMARANG
2019
 PREFACE

Thank God we say to Allah SWT on His grace and guidance, so that we can

finish the task subjects of law and professional ethics with the theme etical

principles in radiology.

This task is done as part of the process of completing education courses in the

diagnostic imaging techniques applied polytechnic master programs MoH

Semarang.

May Allah give mercy unto all those who have helped in completing this

final task. The author realizes that this thesis are still many shortcomings and

mistakes. Therefore, the authors expect corrections and suggestions for improving

the final project further.

End the authors hope that this task can be useful for readers, especially

students of applied master program. Thank you.

Semarang, September 2019

Author

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 TABLE OF CONTENTS

COVER............................................................................................................. i
PREAMBLE .................................................................................................... ii
TABLE OF CONTENTS ................................................................................. iii
CHAPTER I INTRODUCTION ...................................................................... 4
A. Background ........................................................................................ 4
B. Problem Formulation ......................................................................... 4
CHAPTER 2 REVIEW PUSTAKA ................................................................. 5
A. Duty Radiografer ............................................................................... 5
B. Principle of Protection Radiasi .......................................................... 6
C. Principle of Protection Radiasi .......................................................... 8
D. Code technologist Indonesia ............................................................. 8
E. Code technologist (ISSRT)................................................................. 10
F. Principles of Conduct Based ESR ...................................................... 14
G. Consideration of use of X-ray is not to medis ................................... 19
H. Ethical Principles of Radiation Protection Radiology Diagnostik .... 26
CHAPTER III CLOSING ................................................................................ 29
A. Conclusion ......................................................................................... 29
BIBLIOGRAPHY ............................................................................................ 30

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 CHAPTER I

INTRODUCTION

A. Background of the paper

Radiographer are healtcare professional who specialist in the imaging of

human anatomy for the diagnostic and treatment of pathology. Radiographers
are medical personnel who are competent in conducting medical examinations
using ionizing and non-ionizing radiation, in its application in the field
radiographer can also serve as a Radiation Protection Officer (PPR) and the
dark room attendant.

Technologist Indonesia has proesi organization Radiographers

Association of Indonesia (PARI) and Internatioal Society Of radiographers and
Radiological Technologist (ISSRT) as a forum for professional aspirations. As
a professional organization also includes a code of conduct to be followed by
each member.
Principles of Ethics in radiology may include various aspects, especially
the problem of patient privacy, and security of radiation.
In the use of radiation for radiography in radiodiagnostic radiation will
contribute to many parties. Radiation will be accepted by the operator, animals
and the environment. There are three principles that have been recommended
by the International Commission on Radiological Protection (ICRP) to be
followed, namely: Justification, Limitations, and Optimization.
This paper will discuss what course covering ethics, and principles in the
world of radiology.

B. Problem Formulation

How the principal application of ethics in the world of radiology?

4
 CHAPTER II

THEORY AND DISCUSION

A. Main Duties Technologist

1.Radiographers
a. Preparing patients, medicines and equipment for radiology
examinations and making pictures.
b. Positioning the patient in accordance with the technical examination.
c. Operationalize radiology equipment according to the SOP. Especially
for examinations with contrast and fluoroscopic examination was done
with specialist radiology.
d. Conducting the film processing (dark room and work station).
e. Doing assurance and quality control.
f. Provide protection to patients, themselves and the communities
surrounding air space of X-rays.
g. Applying the proper techniques and procedures to minimize exposure
received by the patient as needed.
h. Caring for and maintaining routine radiological examination tool.
2.Power PPR
a. Creating Protection and Radiation Safety program.
b. Monitor the operational aspects Protection and Radiation Safety
program.
c. Ensuring the availability and feasibility of the Radiation Protection
equipment, and monitor usage.
d. Systematic and periodic review, monitoring programs in all places
where the X-rays used aircraft.
e. Provide consultation related to Protection and Radiation Safety.
f. Participate in the design of Radiology facilities.
g. Maintain Records.
h. Identify needs and organize training activities.

5
 i. Implement countermeasures exercise and retrieval in case of
emergency.
j. Reporting to the license holder any potential operation failure event
Radiation accident.
k. Prepare a written report on the implementation of Protection and
Radiation Safety, and the verification of safety which is known by the
license holder to be reported to the Head BAPETEN.
l. Conduct an inventory of radioactive substances.
3.Power Darkroom
a. Preparing tapes and films.
b. Doing film processing.
c. Changing the processing liquid (liquid developer and fixer).
d. Responsible for the cleanliness of the room dark room.
B. Principles of Radiation Protection
In the use of radiation for radiography in radiodiagnostic radiation will
contribute to many parties. Radiation will be accepted by the operator,
animals and the environment. There are three principles that have been
recommended by the International Commission on Radiological Protection
(ICRP) to be followed, namely:
1. Justification, each use of radioactive substances or other sources should
be based on a principle such benefits. An activity that includes exposure
or potential exposure is only approved if it will turn a bigger profit for
the individual or society compared with a loss or a possible danger to
health. Animals that really require a further test by radiographic
consideration the principle of benefit more to do radiography.
2. Limitation, equivalent radiation received by workers or the public
should not be melalmpaui Dose Limit Values (NBD) has been
determined. Dose limits for radiation workers is intended to prevent the
appearance of deterministic effects (non-stochastic) and reduce the
chances of occurrence of stochastic effects.

6
3. Optimization, radiation should be kept as low (as low as reasonably
achieveable - ALARA), taking into account economic and social
factors. The activities should be planned utilization of nuclear energy
and radiation sources should be designed and operated to ensure that
radiation exposure that occurs can be suppressed as low as possible.
4. Dose Limit Values, Limitation of radiation dose was unknown in 1928,
ie since the establishment of an international organization for radiation
protection (International Commission on Radiological Protection /
ICRP). Renowned pioneer in radiation protection is a scientist from
Sweden named Rolf Sievert. He was born in 1896 when Henri
Becquerel discovered natural radioactive substances. Sievert later
immortalized as a unit dose radiation exposure in the system of
International Units (SI). 1 sievert (Sv) showed how much radiation
exposure dose from radioactive sources which are absorbed by the body
per unit of mass (weight), resulting in damage to the cell biological /
jaringan.Menurut ICRP recommendations, radiation workers who were
exposed to radiation at work should not receive radiation doses of more
than 50 mSv per year and an annual average of 5 years should not be
more than 20 mSv. The maximum value is called Dose Limit Value
(NBD). If pregnant women who were exposed to radiation at work,
applied a more stringent radiation limits. The highest radiation dose
permitted during pregnancy is 2 mSv.

7
C. Principles of Radiation Protection
1. Using Protector (Shielding)
The use of shield / protector in the form of Pb plated apron, glove Pb,
Pb glasses etc which is a means of individual radiation protection. Not
directly handle the animal, the animal can be sedated or anesthetized when
necessary. Protection of the environment against radiation can be done by
coating the radiography room using Pb to absorb radiation that occurs
when the process of radiography.
2. Keep the distance
Radiation emitted from the radiation source in all directions. The
closer your body with radiation sumer the radiation exposure that we
receive will be even greater. Radiation in part will be emitted when
mengenahi scattering material. This scattering radiation will increase the
amount of radiation dose received. To prevent the radiation exposure we
can maintain a safe distance at the level of the radiation source.
3. Shorten Time Exposure
Wherever possible strived to not stay too long near the radiation source
during the process of radiography. This is to prevent a large radiation
exposure. MAs setting the right, with the exposure time 0.0 seconds ..
better than 1 second. KVp value used is high enough so that the penetrating
power in radiography pretty good. thus the radiographic repetition can be
prevented.

D. Code technologist Indonesia

1. General obligations
a. Every technologist profession in carrying out the work is not justified
distinction of nationality, ethnicity, skin color, sex, religion, political and
social status of his client
b.Every technologist profession in carrying out the work always wear
professional standards

8
 c. Every technologist Indonesia in carrying out the work of the profession, is
not justified to act influenced consideration of personal gain
d.Every technologist Indonesia in carrying out professional work, always
sticking to the oath of office and code of ethics and professional standards
technologist
2. Liabilities to profession
a. Technologist must maintain and uphold the good name of the profession.
b.Radiographer radiology service work only at the written request of the
Doctor, Dentist, Specialist Physician and Dental Specialist Physician,
with a clear clinical and does not leave the established procedure.
c. Radiographers not justified to have someone else who is not
d.An expert to do the job Radiological Services.
e. Radiographers are not justified diagnose Radiology.
3. Liabilities to Patients
a.Every technologist in carrying out their profession work always maintains
the atmosphere and environment to live the values of the culture, customs,
and religions of patients, patient families and society in general.
b.Every profession technologist in performing work required by the genuine
and sincere towards the patients by providing the best service. If he is
unable or find it difficult, he is obliged to consult with the expert
colleagues or other experts.
c.Every technologist must keep everything that is known to both the work
of the profession as well as from other areas of the patient's condition,
because of the trust patients have been willing herself to be examined
d.Every technologist shall implement the regulations outlined by the policy
of the Government in the field of health
e.Every technologist in the interest of patients at all times cooperate with
other relevant experts and carry out tasks quickly, precisely and
respectable and confidence in the ability of the profession
f. Every technologist required to foster a good working relationship between
the profession with other professions in the interest of public service

9
4. Duty towards Yourself
a. Every technologist must keep his good health and safety against the
danger of radiation as well as against disease.
b. Every technologist constantly trying to improve his profession either
individually or together with the road to follow the development of
science and technology, improve the skills and experience that will
benefit community service
E. The Code is based Internatioal Society Of radiographers and Radiological
Technologist (ISSRT)
ISRRT Code has been developed by members and approved by the
Management Board to articulate ethical conduct and responsible behavior
expected of members ISRRT. Each member has a personal responsibility to
understand, adopt, and promote the values and behaviors that are articulated in
this code.
1. Each member has a responsibility to always be alert to and comply with laws,
regulations, standards and codes of conduct governing the practice of
radiography in certain jurisdictions. Ethics can be defined as a process,
rules or principles that govern the behavior.
2. Ethics've learned, can be applied to any ethical questions that may arise.
Ethics create a culture of integrity; supportive, positive atmosphere that
builds morale, internal and external drive loyalty and increase reputation.
3. The Code is a guide where technology experts technologist / Radiology
should evaluate professional behavior related to the patient, the health of
consumers, employers, and health professionals. The Code is intended to
help maintain a high level of ethical behavior and in providing protection,
security, and comfort for the patient.
4. Ethics and professionalism are fundamental in providing good radiographic
practice. Technologist / Radiology technologist must develop and maintain
adequate knowledge about the components of the primary elements of the
laws and regulations that affect patients and their practices. The law does
not always set a positive task, namely, what to do, as far as one of

10
 professional ethics. Today's understanding of professional ethics based on
the principle of which provided a positive duty.
5. In accordance with the rights and privileges granted to the radiologist /
technologist Radiology is also a certain ethical obligations. This ethical duty
to patients and the public demanded that the ethics guidelines formulated.
6. Ethical Guidelines in essence, Express tasks. A task refers to an obligation to
do or not do certain things. The task may be legal and / or ethical. A
radiographer / Radiology technologists have a duty to patients, colleagues,
other health professionals, the public, the environment and for yourself.
Duty to patients:
 The best interests of the patient should be of primary importance.
 Perform only the procedures technologist radiographer / Radiology has
gained competence.
 Advocates of the most appropriate treatment for patients.
 The power that is entrusted to expert radiographer / Radiology should not be
misused.
 Personal bias should not affect the professional relationship.
 Practice the principles of justification, optimization and ALARA.
 Respect and Maintain privacy and patient confidentiality at all times.
 Facilitating and supporting free choice and information about the patient,
family, or caregiver, including the decision to refuse or withdraw from the
imaging and / or treatment.
 Ensure that the principle of informed consent is established throughout the
patient experience.
 Treat all people with respect and dignity, provide care regardless of race,
national or ethnic origin, color, gender, sexual orientation, religion or
political affiliation, age, illness, mental or physical ability.
 Educate patients, family, and caregivers by providing information that can
be understood and used to make decisions about their care.

11
 Answering questions from patients and families fully and honestly in the
frontiers of knowledge, authority and responsibility of the radiologist
technologist / Radiology. Technologist radiographer / Radiology may be
required to seek additional information or refer the patient to a health care
provider is most appropriate.
 Respect the rights of patients.
 Collaborate and consult with the patient, the right decision makers, and
health care providers to facilitate optimal patient care.
 Maintain current knowledge of safety standards associated with this
radiographer / Radiology Technologists practice and perform all procedures
and examinations in accordance with this standard.
 Intervene in a state of abuse or unsafe practices, incompetent or unethical.
 The task for health professionals:
 Respect other health professionals.
 Abstain from making unsubstantiated comments about colleagues and
institutions to the patient or others

Duties to society:
 Respect for all human rights.
 Dealing responsibly with radiation; guided by the principle of ALARA.
 Treat all people with respect, dignity, and without discrimination, provide
care regardless of race, culture, national, ethnic or social origin, color,
gender, status martial and family, sexual orientation, religion or political
affiliation, language, age, illness, mental or physical ability.

Duty to the environment:

 Limit exposure to unnecessary radiation.
 Protecting the environment by ensuring the correct disposal of medical
waste.

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 Ensuring a safe environment and take steps to minimize exposure to
potential risks (eg, exposure to radiation, a strong magnetic field, the risk of
infection)

Duty towards yourself:

 Professional practice. Uphold the professional standing of the profession.
 Raising the standards of evidence-based professional with documentation
related to the continuing professional development (CPD). Develop
professional role with the proper education and training
 Engage in lifelong learning to maintain a consistent level of competence in
the discipline of practice.
 Stay current on the radiographer / Radiology technologist trends, basing
selection on the practice of evidence, and apply this knowledge to clinical
and research environments that are considered appropriate
 Aspire to a high level of professional effectiveness at all times.
 Maintain and improve personal well-being and never made liable when
under the influence of or affected by conditions that can hamper the quality
or safety of care.
 Responsible for the actions and decisions of professionals, including errors.
 Make sure all verbal and written statements to be honest, clear, and concise.
 Ensure all appropriate professional activities and no conflict of interest.
 Upholding the profession by doing all professional activities in a manner
that will maintain public trust and confidence.
 Take advantage of professional mechanisms, institutional, or regulations that
correspond to intervene when witnessing abuse or unsafe practice,
incompetent or unethical while supporting colleagues appropriately notify
the relevant authorities.
 Promoting a culture of research in the field of radiography which will
improve the quality of evidence-based recommendations in the future.

13
 Confidentiality and consent information must be clear in studies that include
patients and or their records.
 Acting under the law relating to the maintenance of registration or license to
practice.
 It is impossible to create guidelines that will include every possible real life
situations. Technologist radiographer / Radiology requires ethical reasoning
to navigate through everyday actions by professional ethical guidelines.

F. Principles of Conduct by the European Society of Radiology

Over the last decade, the provision of health services has evolved into a
complex system of services provided by a professional team, usually in
institutions using advanced technology. At the same time, the financial pressure
on health services has increased, weaknesses in the health care system translates
into substandard patient outcomes and physician practices have become subject
to a complex set of financial arrangements and incentives. As a result,
physicians find it increasingly difficult to meet their responsibilities to patients
and society. In recognition of ethical challenges are exacerbated or created by
this change, the European Society of Radiology has formulated a set of
principles of ethics and professional responsibility to guide the behavior of
radiologists in their relationships with patients, colleagues, entrepreneurs,
industry, authorities and the public. While the main focus of health care should
be the welfare and interests of each patient, physicians should be aware that the
interrelationships inherent in the health care system makes it impossible to
separate the actions taken on behalf of individual patients on the overall
performance of the system and its impact on society. responsibility of
radiologists' is not limited to what the law requires. Code does not represent a
set of legal but ethical framework intended to guide radiologists with the highest
standards of professional conduct. physicians should be aware that the
interrelationships inherent in the health care system makes it impossible to
separate the actions taken on behalf of individual patients on the overall
performance of the system and its impact on society. responsibility of

14
radiologists' is not limited to what the law requires. Code does not represent a
set of legal but ethical framework intended to guide radiologists with the highest
standards of professional conduct. physicians should be aware that the
interrelationships inherent in the health care system makes it impossible to
separate the actions taken on behalf of individual patients on the overall
performance of the system and its impact on society. responsibility of
radiologists' is not limited to what the law requires.
Ethical principles form the first part of the Code of Conduct of the
European Society of Radiology. They are the basis of the underlying ethics of
professional responsibility that members of the European Society for Radiology
have to keep trying.

15
1. The principle of kindness
Physicians have a primary obligation to use the best available diagnostic and
therapeutic interventions to promote the welfare of their patients to prevent
or cure disease, relieve suffering and improve their health status. Altruism
contributes to the trust that is central to the doctor-patient relationship.
2. principle nonmaleficence
While maximizing the welfare of patients, physicians should reduce the
burden and risks for the patient medical intervention. They must provide
services with full respect for human dignity and the best interests of the
patient.
3. The principle of respecting the autonomy of the patient
Doctors should respect the autonomy of their patients. They must be
completely and honestly inform their patients, maintain confidentiality
within the limits of law and empower patients to make informed decisions
about diagnostic and therapeutic interventions. patient decisions about their
care must be important, so long as decisions are in line with ethical practice
and do not lead to demands for inappropriate care. Diagnostic or therapeutic
interventions require the patient's informed consent.
4. The principle of social justice
The medical profession must promote justice in the health care system,
including the distribution of a fair and cost-effective use of limited resources
of health care. Physicians should work actively to eliminate the European
Society of Radiology Code In March 2013 discrimination in healthcare,
whether based on age, gender, sexual orientation, race, religion,
socioeconomic status or other social categories.

16
5. Professional Responsibility
Professional Responsibilities form the second part of the Code of
Conduct of the European Society of Radiology. They set standards of
professional conduct for all members of the European Society of
Radiology. In order to provide high quality health care, radiologists must
maintain clinical independence and professional integrity of the
increasing demand from the public, third parties, the individual patient
and the government. The radiologist should be advocates for their
patients or the populations they serve but do not have to manipulate the
system to obtain benefits for them to harm others. The radiologist must
build relationships with their patients that allows them to interpret the
images and decide on interventions in the context of the patient's overall
medical situation. They must ensure that all relevant information about a
patient's medical history and previous findings correctly transmitted to
them. The radiologist must commit to protect patient confidentiality.
They do not have to spend a patient's medical information without the
explicit consent of the patient and only access the images needed to meet
the medical needs of the patient. Exceptions can only be justified if there
is a serious risk of harm to the patient or others or if required by law.
Given the inherent vulnerability and dependency of patients, radiologists
must be committed to maintaining a proper relationship to their patients.
In particular, the radiologist must not exploit patients for private
purposes, including personal financial gain and sexual advantage. The
radiologist must strive continuously to improve their professional
knowledge and skills and do this repair is available for patients and their
colleagues. The radiologist must always be aware of their limitations and
are willing to seek consultation if necessary. This limitation should be
appropriately disclosed to patients and referring physicians. The
radiologist must be committed to continuous improvement in service
quality. This requires working collaboratively with other professionals to
reduce medical errors, improve patient safety, avoid overuse of health

17
 care resources, minimizing inappropriate practice variation and optimize
the treatment results. Radiologists have a duty to ensure the safety of
their patients and their personnel, especially regarding radiation
protection, safety and use of MR contrast media. Each time the patient
injury as a result of medical treatment, the patient must be informed
immediately in order to avoid serious compromises patient and public
confidence. Failure radiologist to disclose medical errors (eg, missed
diagnosis) is an unethical behavior. However, reports of errors should be
brief and non-judgmental. European Society of Radiology Code In
March 2013 while meeting the needs of the individual patient, the
radiologist must provide health care based on the best available evidence
from research and management of appropriate and cost-efficient finite
resources. The radiologist will be related to other health care
professionals with respect and collaborate with each other for the benefit
of patients. If a radiologist working in practice or institution, he / she
must place his / her professional duties and responsibilities for his / her
patients over the commercial interests of the owners or other people who
work in these practices. The radiologist should never enter into
arrangements which prohibits the provision of necessary medical care or
in need of care below acceptable standards. When referring patients to
the institution or service in which he / she has a direct financial interest,
radiologists must provide full disclosure of the interest. Paying doctors to
refer patients to the radiologist is unethical.

G. Ethical Considerations When using X-ray examination for Medical

Purposes photo
Before considering the benefits of age assessment using radiological
methods, it is important to first consider the context in which the assessment
takes place and any age ethical issues with which they are associated. Of
course, the ethical issues raised by the assessment method used age and can
not be separated from the framework of the principles of medical ethics.

18
 Bioethics, a branch of moral philosophy, consists of four principles:
autonomy respect, kindness, and fairness nonmaleficence (UNICEF, 2012).
These principles can be given varying weight and the corresponding
application will be subjective values in certain clinical situations. However,
the principles can serve as a tool to assist in the handling of the situation,
reaching any decision and subsequent analysis of previous decisions made
1. Radiation exposure Objectives for Non-Medical
Exposure to radiation for non-medical purposes is ethically
problematic important as listed in the latest publication of the ratings ages
immigration controls in the United Kingdom (Aynsley et al., 2012), which
asserts that it is necessary to weigh up the benefits of the actual to the
potential damage that may be caused to a group of children and young
people who are potentially vulnerable as a consequence not only of their
age, but also their background and experience (Aynsley et al., 2012). In this
case, there is no doubt that the amount of radiation exposure involved in
chest X-rays is very low.
But even at low doses, the increase statistically significant at the level
of cancer has been observed (Sodickson et al., 2009), and the difficulty in
obtaining reliable data as of the cancer rate is due to one decisive reason:
most of the radiation induced cancer, has a latency period of more than 40
years between exposure and illness.
While this may be true, a number of recent studies have also been
published on the specific cancer risk children may suffer from diagnostic
X-rays in the last few years (Adelstein, 2014). Children and adolescents
who are many cases in forensic age estimation process that is much more
sensitive to the carcinogenic risk of ionizing radiation than adults. As a
result, the International Commission on Radiological Protection (ICRP)
approved new recommendations for protection against ionizing radiation in
2007, which takes into account the biological and medical information of
patients exposed to radiation (Christner et al., 2010).

19
 Australia's protection Radiation Firm and Nuclear Safety (ARPANSA)
stating that the radiation exposure associated with chest X-ray and wrist
minimal and that there is a wide acceptance in the scientific community
that the radiation dose of a chest X-rays pose a negligible risk to one's
health (ARPANSA 2013) , ARPANSA estimates that the X-ray examination
of the epiphyses of the proximal clavicle standard is 0.1 microsievert
(μSv), while CT ranged between 600-800 μSv (microsievert). This makes
the exposure to radiation through a conventional X-ray is very low
compared to other medical procedures (Table 11), x-ray of the hand is 0.1
microsievert (μSv), and in the case of Orthopantomograms 220 μSv
effective dose whereas in the case of full thorax TC is 6.6 mSv (Ramsthaler
et al., 2009).
When doses above compared to the risk category and the appropriate
level of benefit to the public is expected from exposure to radiation (Table
1), it is clear that the level of exposure is minimal risk as shown in Table 1,
which has been modified from those published by the ICRP (ICRP, 2007)
and incorporate risk terminology recommended by the Calman (1996) .the
sievert (symbol: Sv) is a unit derived from ionizing radiation dose in units
of the International System (SI). It is a measure of the health effects of low
levels of radiation on the human body (1000 μSv = 1mSv). The quantity
measured in Sieverts is intended to represent a health risk stochastic, which
for the assessment of the radiation dose is defined as the probability of
cancer induction and genetic damage.

20
 Table 1: Categories of risk, appropriate dosage levels and appropriate
levels of benefit to the community (et Einstein 2007)

2. Safe dose of radiation

Schmeling et al. (2011) argues that while there is some level of
exposure to ionizing radiation associated with the process of radiography,
but when radiographs are taken to estimate the age of doses implicated in
the acceptable limits' in relation to natural environmental radiation
exposure. According to the Scientific Committee of the United Nations on
the effects of atomic radiation and the International Commission on
Radiological Protection (ICRP), the radiation exposure of the population in
western countries has steadily increased in the last decade (Morgan and
Bair, 2013), this rise has been calculated as the average in Africa at 0,, 85
mSv / y, Germanyatabout1.2mSvper years and in the Netherlands in
about2.0mSv (Morgan and Bair, 2013).
The average dose of radiation from a single radiograph in the UK is
0.01 mSv, while the average annual radiation exposure in the UK per year
is 2.7mSv (Allison, 2009). Chest X-ray is therefore equivalent to about 25
minutes of exposure to natural radiation. However, any exposure to

21
 radiation is not without risks and the use of X-rays and their potential for
danger is still controversial (Allison, 2009; Walker, 2000).
But because of the high radiation dose, the use of CT is limited to the
question of whether an individual has completed the 18th or 21st. A
sternoclavicular joint CT produces a dose of about 600-800 μSv per
examination (Bromberg and Covarrubias, 2012), accounting for a
disproportionate radiation dose higher than with other diagnostic X-ray.
However, surveys show that the particular radiation exposure from CT is
very dependent on the parameter settings.
3. radiation risk
Until now, many of the estimated risk for X-rays based on the linear
no-threshold model (LNT) which states that the extrapolation of the health
risks of radiation from the observed high low doses is very linear and that
this effect holds even down to zero dose (Martin , 2014), therefore (LNT)
assumes that long-term biological damage caused by ionizing radiation
(essentially the risk of cancer) is proportional to dose.
Martin (2014) reviewed the evidence and oppose the LNT hypothesis
and explain that, at present, the scientific community favors LNT
philosophy as the most obvious risk model. However, data from patients
undergoing much-ray examination during their childhood because they are
suffering from tuberculosis or scoliosis showed a significant increase in the
incidence of cancer in their future life (Cohen et al., 2012).
Nevertheless, the risk of cancer may be due to ionizing radiation from
X-ray dose below 1 mSv (millisievert) was too small to be calculated
directly from epidemiological data, and this is the case for almost all of the
methods used to estimate the age of the forensic (Schmeling et al. 2008).
As a comparison obvious from general radiography radiation dose used and
the estimation of the risk associated with age are shown in Table 11
Several authors have stressed the lack of the usual dose compared with
naturallyoccurring FAE examination and radiation exposure even cultivate
and diagnostic procedures (Table 11) aircraft .Flight staff received an

22
average 0,008mSv per hour of exposure to radiation from the
intercontinental flight at an altitude of12000meters, translated into
2000mSv per year as a result of staying up in the air (cosmic radiation), is
considered a moderate level of risk by the ICRP (Table 11), but the benefits
of air travel is considered substantial in the world to cultivate (Schmeling
et al., 2008).
It also follows that the effective radiation dose in the case of an
intercontinental flight equivalent to CT of the sternoclavicular
joints are equivalentto3.5months of natural radiation exposure. On the basis
of this comparison a health risk
as a result of regular X-ray examination for age determination
Forensic (FAE) is ignored (Schmeling et al., 2008). However, exposure to
radiation produces not only a stochastic (random) but non-stochastic
damage physicians should be aware. non-stochastic effects appear in the
top 100 mSv and therefore irrelevant inusual radiological diagnosis. But
non-stochastic effects do not have a threshold like that and not dose-
related, so that they finally appearance in the case of Xrays examination
should be carefully considered. Several other authors minimize and
maximize the inherent dangers for non-stochastic effects (Garamendi et al.,
2011).

23
4. Radiation Exam Guide Techniques in the Field of Age Estimation
Because of the restrictions imposed by the German X-ray regulations,
the use of radiological examinations without medical indications are not
permitted in almost all circumstances, except in the cases (criminal
proceedings) provided by law for this purpose (Schulz et al., 2008). As a
result of that, the accuracy of age estimation procedures for civil
proceedings and asylum has been reduced. Thus, the attention of the
modern group of scientists has been withdrawn for use free of radiation
bone assessment techniques in this context. Only conventional radiology
and computed tomography was used successfully to study the hardening
phase of the medial clavicular epiphysis until 2006.
Schmidt et al. (2013a) conducted a study on Magnetic Resonance
Imaging (MRI) of the sternoclavicular joint so as to establish whether the
level of hardening of the epiphyseal cartilage can be assessed on an MRI
scan, this is the first attempt for their knowledge to learn ossification
clavicular using MRI but he learned only 56 bodies , His team (Schmidt et
al., 2013b) recommended that the results achieved should be examined
with a large number of cases, and a modified protocol MRI exam required

24
for checking medial clavicular epiphyseal cartilage for diagnostic purposes
forensic age from living people.
It is also important to note that MRI is very expensive and less
accessible, it also requires more skill than the conventional digital X-rays.
Hillewig (2011) also noticed that the difference between the stages 4 and 5
when using MRI seems unlikely as the epiphyseal scar never seen (stage 4)
in the MRI image (Figure 27), this is due to low sensitivity to very thin scar
calcification. In the literature, stage 4 was first observed on radiographs at
the age of 26 who are not in the age of 14-22 variety is most often used in
cases of expected life (Schmeling et al., 2004). In the case where the
threshold age of 21 is important, the identification stage 5 is of no
consequence, and because this technique is of little or no benefit in this
case. Although visualization of epiphyseal scars can be important in cases
where age should be formed, for example, a few years after the crime has
been committed, it is not an important parameter in most cases the
estimated life year later, Schulz et al. (2008) conducted a study of
ultrasound in the field when clavicular ossification for forensic age
estimation in living subjects over 18 years. This study was conducted to
establish radiation-free imaging technique, uses Pro Focus 2202 Ultrasound
System (BK Medical, Herlev, Denmark) equipped with a linear transducer
and pad 8MHz deadlock. Right clavicle 84 test subjects, aged between 12-
30 years were evaluated, prospectively by ultrasonography.
The authors suggested to confirm their findings in a larger sample size
and the observer variability analysis. Evaluation medial clavicular
epiphyseal ossification with ultrasound could eventually become a
diagnostic modality rapid economic and non-ionizing for forensic age
estimation.
Apart from being free of radiation technique, sonography has the added
advantage of an economical and fast, easy to use and can be applied as a
mobile unit. But the main drawback for application in the diagnosis of age
forensics is that until recently, the limited number of cases have been

25
 investigated using this technique, and has a lower resolution compared with
CT, X-ray or MRI Since sonography is checking procedures are dynamic,
have difficulty in adequately document the findings in a still image,
indicated by the hazy / cloudy picture above. Furthermore, unlike MDCT,
MRI and X-ray convectional, sound waves can not easily pass through the
bone to show the inner structure (Schulz et al., 2008).
Due to the complete elimination of all risks in these techniques is not
possible, the question arises what type and level of risk people are willing
to bear. Hall has claimed that the risk of loss of one in a million to be
generally ignored (Schmidt et al., 2007). On the basis of general and
unlimited risk to life (ie, pregnant women using air crafts as a means of
transportation), the procedure is applied that can pose a risk equivalent, for
example, through the X-ray exposure of the clavicle, should be considered
justified. Given the higher radiation dose significantly through the use of
CT, it is highly recommended and, indeed, necessary to comply with the
diagnostic reference values (DRV).
H. Ethical Principles for Radiation Protection in Diagnostic Radiology
(Malone, Jim. 2016)
1. Respect for autonomy
Medics should mengormati autonomy of each patient, this value is to
ensure that the patient is the primary decision makers about him in a
case. Consideration of individual viewpoint is part of medical ethics
professionals worldwide. With regard to radiation protection, it is
recommended that wherever possible imposition of a risk to be taken on
the willingness of individuals, it is a prerequisite for justification.
2. No harm and kindness
Not doing harm is one of the Hippocratic oath, and so is the work for
the good of the patient. Of course, should always be understood that
there may be situations where pain, or even damage, should be made to
achieve a cure, and thus do not harm and kindness need to be balanced.
These two principles, and awareness of the fact that it sometimes work

26
 against each other, can be found in Europe, Arab, Indian and Chinese
traditions.
In the context of radiological protection, the principle of no harm
and kindness both support the concept of justification and optimization.
In the latter case, the application may be a bit more complicated, because
the interests of the wider community into consideration. Weighing
economic and social factors on the one hand, and the health of the
individual on the other hand, it does not mean an easy task, but morality
in general requires it should not be overlooked. For radiation protection,
Beauchamp and Childress delivered four main ethical principles are the
foundation of the concept of dose limitation, because it prevents the
inequities between harms and benefits. This also implies a concern for
justice, especially in the field of treatment of the most vulnerable, such
as children, or people who are sensitive to radiation.
3. Justice
There is a golden rule that applies worldwide that is, treat others as
you do yourself is one of the most common ethical guidelines throughout
the world. In fact, the sentence is very similar in different traditions. It
can serve as a support for the principle - the principle of no harm and
kindness, but his greatest interest is to support the values of justice, since
asking everyone to consider the interests of others as if it were his own.
4. Dignity
It could be argued that respect for autonomy is actually based on a
certain understanding of human dignity and thus the latter does not need
to be referred to as an additional value. Human dignity is more easily
demonstrated as a cross-cultural concept rather than autonomy. All the
great tradition and recognize the great philosophical. It comes in a
contemporary at the beginning of the UN Universal Declaration of
Human Rights.

5. Preventive measure

27
 One of the additional value of the most widely discussed for four
ethical principles in the field of public health or the environment is
prudence or precaution. It is found in various writings and oral traditions
throughout the world and embraced by several scientific and public
meetings over the last few decades. Precautions may be paraphrased by
stating that where an action has the potential to cause serious harm that
can not be restored, action to protect should be taken even if the causal
relationships involved are not fully established scientifically.
6. Honesty
Honesty about openness and transparency with regard to the benefits
and risks of a procedure. Justice, intergenerational equity and
inclusiveness requires that people are not fooled. Because of the honesty
and the truth has been suggested as a guideline value for the interaction
between specialists with lay people who were exposed to radiation.
Accountability is also emerging as a result of the honesty that are
relevant in the context of radiation protection.
Prudence (precautions) are taken as a precaution and the code for the
precautionary principle, although generally considered a broader concept
than precautions. Prudence can be seen as an extension of no harm, with
an emphasis on our lack of knowledge about appropriate risk; for
example, the risk of small radiation doses. There is much confusion
about the issue in radiation protection. For the purposes of radiation
protection, which should work out the basis of scientific evidence is not
complete, clear and high-level

28
 CHAPTER III

CONCLUSION

A. Conclusion
1. Radiographer should follow the three principles of radiation protection:
Justification, Limitations, and optimization.
2. Radiographer should follow the three principles of radiation protection:
shielding, distance and time.
3. Technologist must always comply with applicable rules.

29
 BIBLIOGRAPHY

Domnis Marera. 2015. Ethical consideration when using x-ray examination for
none medical purposes.IJSR

https://www.myesr.org/sites/default/files/ESR_2012_ESRCodeofethic-5.pdf

KEPMENKES NO 1014 / Menkes / SK / XI / 2008

International Commission on Radiological Protection (ICRP)

Internatioal Society Of radiographers and Radiological Technologist (ISSRT)

Malone J, F. 2015. Pragmatic Zolzer Ethical Basis For Radiation Protection In

Diagnostic Radiology. Dublin

Technologist Association of Indonesia (PARI)

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