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John W. Gofman, M.D., Ph.D., Professor Emeritus,
Molecular and Cell Biology, Univ. Calif. Berkeley
and Egan O'Connor, Exec. Director, CNR and XaHP.
XaHP Document 105, September 2000
XaHP: The X-rays and Health Project.
An educational project of the
Committee for Nuclear Responsibility.
Part 1. The Viewpoint of One Radiologist
The goal of the X-Rays and Health Project (XaHP) is to reduce the x-ray dose per x-ray procedure, to the minimum level consistent with obtaining the medical and dental benefits. The reason for dose-reduction is that x-rays increase the risk of consequential mutations, even when each x-ray exposure occurs at low doses.
Moreover, a massive amount of new evidence (Gofman 1999) indicates that the accumulated mutations from medical x-rays are a major cause of human cancers, and a major cause also of coronary heart disease. No peer-reviewer has yet refuted any part of the analysis; indeed, the new findings are consistent with independent evidence (cited in Gofman 1999).
As we launch XaHP, two radiologists --- who have not examined the new monograph at all --- have claimed that it is wrong. One of them also makes an assertion which deserves a response, because he claims that XaHP will do harm:
"If you scare physicians and patients into rejecting the benefits of medical x-rays, you will do a lot of harm -- in exchange for a benefit which is only hypothetical."
He does not claim that there is any harm to health from reducing x-ray dosage per procedure. That point deserves emphasis. Instead, he claims harm will occur because information about x-rays will increase the fear of x-rays, and the fear (in his opinion) will stop some referring physicians from ordering x-rays and will stop some patients from taking x-rays.
Part 2. Benefit-versus-Risk Decisions in Medicine
In healthcare, physicians and patients continuously accept risks in return for benefits. It would be a giant step backwards to take the position that they both are too stupid to make such choices. For example, patients know that general anesthesia carries risks, and they accept the risks in return for the benefits of the surgery. Indeed, many kinds of surgery, pharmaceuticals, and therapies, carry considerable risks.
There is no denial that some patients are more easily frightened than others. But the special fearfulness of some patients about medical procedures --- not just about x-rays --does not wipe out the right of everyone else to full information about the risks of such procedures.
In late November 1999, the federal Institute of Medicine issued a report estimating that medical mistakes in U.S. hospitals kill 44,000 to 98,000 patients per year. Should this information have been kept hidden from patients, because it might cause some fear about hospitals? Denying information to the public --- allegedly "for its own good" --is a very grave insult to human dignity.
We doubt that x-ray practitioners would want to assert that x-rays are the one agent, in all of medicine, where referring physicians and patients must be told about only the benefits, and must be kept uninformed about dosage and risk.
Part 3. A Rational Way to Diminish a Rational Fear
Among experts, there is consensus that x-rays are a proven cause of human cancer and mutations. That is just not in dispute. By contrast, there is quite a range of expert opinion on the magnitude of the health risks from accumulated exposures. The full range of informed opinion, not just the relatively soothing segment, should be presented to patients, rather than hidden from them.
With respect to risks, our viewpoint is that a medical degree obligates x-ray practitioners to be well acquainted with at least the recent evidence (not from Gofman alone) which demonstrates that the health risk, from accumulated exposures to low-dose ionizing radiation, is not hypothetical.
Whenever a patient contemplates exposure to a proven cause of cancer and mutations, such as x-rays, of course there will be some fear. It is rational.
And one of the rational ways to reduce the fear would be for x-ray practitioners to take a leadership role in proudly demonstrating and certifying that they use the lowest possible x-ray doses, consistent with obtaining good images.
Part 4. A Serious Matter of Medical Duty
Part 1, above, presents the viewpoint that increased fear of x-rays could do a lot of harm in exchange for a benefit which is "only hypothetical." This view came from an influential radiologist who had not examined the new evidence at all. Another radiologist, who also had not examined the new monograph at all, went on television to tell the public that its conclusions must be wrong.
In our opinion, a medical degree confers an especially strong duty to examine evidence bearing on life and death very carefully, before urging anyone to ignore it.
Imagine that persons with such a degree hear about a new study whose conclusion is that millions of future cases of cancer and coronary heart disease could be prevented by reducing x-ray dosage per x-ray procedure. Such a benefit would hardly be trivial! Without examining and refuting the new evidence, can physicians ethically urge anyone to ignore it? What about the very great harm that such advice may cause?
Our viewpoint is that the best outcome for health, with respect to x-rays, will occur only if both patients and physicians are aware of the full range of informed medical opinion. Our informed opinion is that reducing x-ray dosage per x-ray procedure will prevent significant shares of future cases of cancer and coronary heart disease. That would be an immense health benefit. The evidence is so strong that we would feel ashamed if we did nothing about it.
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- Gofman 1999, John W. Radiation from Medical Procedures in the Pathogenesis of Cancer and Ischemic Heart Disease: Dose-Response Studies with Physicians per 100,000 Population. 699 pages. San Francisco: Committee for Nuclear Responsibility Books. ISBN 0-932682-97-9.
and can always be found at http://www.ratical.org/radiation/CNR/XHP/PatientsRtK.html