Potential Radiation Exposure in
Protecting the Soldier Before,
During, and After
Committee on Battlefield Radiation Exposure Criteria
Fred A. Mettler, Jr., Chairman
Susan Thaul and Heather OMaonaigh, Editors
Medical Follow-up Agency
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Notice | Committee | Reviewers | Preface | Acknowledgments
Conversion Chart | Acronyms | Contents | Summary
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COMMITTEE ON BATTLEFIELD RADIATION
FRED A. METTLER, JR. (Chairman), Professor and Chair, Department of Radiology, University of New Mexico School of Medicine
JOHN F. AHEARNE, Director, Sigma Xi Center, Research Triangle Park, North Carolina, and Adjunct Professor of Civil and Environmental Engineering, Duke University
GEORGE J. ANNAS, Professor and Chair, Health Law Department, Boston University School of Public Health
WILLIAM J BAIR, Radiation Biologist (retired, Senior Advisor for Health Protection Research, Pacific Northwest National Laboratory), Richland, Washington
RUTH R. FADEN, Philip Franklin Wagley Professor of Biomedical Ethics and Director, The Bioethics Institute, Johns Hopkins University
SHIRLEY A. FRY, Senior Advisor, Environmental and Health Sciences Division, Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
LAWRENCE O. GOSTIN, Professor of Law and Codirector, Georgetown/ Johns Hopkins University Program on Law and Public Health, Washington, D.C.
RAYMOND H. JOHNSON, JR., President, CSI-Radiation Safety Training and Communication Sciences Institute, Inc., Kensington, Maryland
LEONARD D. MILLER, Brigadier General, U.S. Army, Retired, Fairfax, Virginia
WILLIAM A. MILLS, Consultant, Radiation Safety, Olney, Maryland
BERNHARD T. MITTEMEYER, Lieutenant General/Surgeon General, U.S. Army, Retired, and Professor of Urological Surgery, Texas Tech University School of Medicine
THEODORE L. PHILLIPS, Wun-kon Fu Distinguished Professor, Department of Radiation Oncology, University of California at San Francisco
GENEVIEVE S. ROESSLER, Associate Professor Emerita (Nuclear Engineering and Radiology, University of Florida), Elysian, Minnesota
RAYMOND L. SPHAR, Captain, Medical Corps, U.S. Navy, Retired, and
U.S. Department of Veterans Affairs, Retired, Washington, D.C.
SUSAN THAUL, Study Director (since October 1997)
J. CHRISTOPHER JOHNSON, Study Director (through October 1997)
STEVEN L. SIMON, Senior Program Officer (Board on Radiation Effects Research, Commission on Life Sciences, National Research Council)
HEATHER OMAONAIGH, Research Associate
PAMELA C. RAMEY-McCRAY, Administrative Assistant
RICHARD N. MILLER, Director, Medical Follow-up Agency
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Councils Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the review of this report:
ROBERT ARTER, Lieutenant General, U.S. Army (retired);
THOMAS BURKE, Department of Health Policy and Management, and Risk Sciences and Public Policy Institute, Johns Hopkins University School of Public Health;
DAVID CHALLONER, Institute for Science and Health Policy, University of Florida;
CARON CHESS, Center for Environmental Communication, Rutgers University;
KENNETH GOODMAN, Forum for Bioethics and Philosophy, University of Miami;
JEFFERY KAHN, Center for Biomedical Ethics, University of Minnesota;
DADE MOELLER, Dade Moeller & Associates, Inc., New Bern, North Carolina;
PHILIP RUSSELL, Major General, U.S. Army (retired), Department of International Health, Johns Hopkins University School of Public Health; and
RICHARD SETLOW, Department of Biology, Brookhaven National Laboratory, Upton, New York.
While the individuals listed above have provided constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests entirely with the authoring committee and the Institute of Medicine.
In 1996, NATO issued guidance for the exposure of military personnel to radiation doses different from occupational dose levels, but not high enough to cause acute health effectsand in doing so set policy in a new arena. Scientific and technological developments now permit small groups or individuals to use, or threaten to use, destructive devices (nuclear, biological, chemical, and cyberbased weaponry, among others) targeted anywhere in the world. Political developments, such as the loss of political balance once afforded by competing superpowers, have increased the focus on regional and subregional disputes. What doctrine should guide decisionmaking regarding the potential exposure of troops to radiation in this changed theater of military operations? In 1995, the Office of the U.S. Army Surgeon General asked the Medical Follow-up Agency of the Institute of Medicine to provide advice.
This report is the final product of the Committee on Battlefield Radiation Exposure Criteria convened for that purpose. In its 1997 interim report, Evaluation of Radiation Exposure Guidance for Military Operations, the committee addressed the technical aspects of the NATO directive. In this final report, the committee reiterates that discussion and places it in an ethical context.
Focusing on potential exposure of military personnel to radiation doses up to 700 millisievert, the committee addresses details of dosimetry, radiation physics, and the medical follow-up of potential, subsequent tumor development. The ethical framework presented in this report applies to potential harms beyond those posed by radiation alone. Soldiers face bullets, explosive devices, climatic and weather extremes, and endemic infections, as well as nuclear, chemical, and biological agents. On a daily basis, commanders in the Pentagon and in the field face decisions that affect the safety of the troops in their charge. This committee lays out a framework for those decisions, be they at a missions planning stage, during its operation, or in its immediate or long-term aftermath. In weighing the risks of a mission that may involve radiation doses to its participants, a commander must somehow quantify not only the immediate and long-term effects of radiation, but also the risks of alternative, radiation-free, approaches to the same mission. To do this, a commander must have information that is understandable and useful. The components of the committees framework should apply, therefore, in all instances of exposure of military personnel to hazards, during times of war and during times of peace.
The committee commends the Office of the U.S. Army Surgeon General for the steps it has taken to protect American soldiers. The committee offers a framework to help ensure that soldiers are not put in harms way without adequate justification; that, when such exposure is deemed necessary, commanders have the information and training necessary to act to limit its extent; and that government agencies work together in a committed, appropriate way to follow up the health status of those individuals who are at risk of related long-term consequences. These tasks certainly are not easy; without appropriate training and information, they are impossible.
Fred A. Mettler, Jr., Chairman
The committee and staff are once again grateful to LTC Carl A. Curling (Medical, Nuclear, Biological, and Chemical Staff Officer), program officer at the Office of the U.S. Army Surgeon General, for his support of the project.
Many individuals participated in the committee-organized briefings and a workshop. During these sessions, representatives from the Departments of Veterans Affairs and Defense, veterans groups, and others learned how we, as a committee, perceived the scope of our task. In turn, we learned facts, history, and what others hoped to gain from our work. We thank them all (see Appendix B for a full listing) for their contributions to the committees work and for their efforts to protect military personnel from harm of all kinds.
In addition to the staff who worked directly on this project, others at the Institute of Medicine and the National Research Council contributed to this report. We thank Sue Barron, Claudia Carl, Mike Edington, Sharon Galloway, and Linda Kilroy for their efforts. Thank you, also, to consulting editor Michael Hayes and James G. Hodge, Jr., Adjunct Professor of Law, Georgetown University, for assistance with this report.
It is difficult to know where to place the next acknowledgment and what exactly to say. We wish that Christopher Johnson could have continued his excellent work with us through to the completion of the project. A little over a year ago, Chris left the Institute of Medicine upon learning that he had a brain tumor. He is at home with his family. We miss him.
Radiation Unit Conversion Chart
|0.001 rem||=||1 mrem||=||0.01 mSv|
|0.01 rem||=||10 mrem||=||0.1 mSv|
|0.1 rem||=||100 mrem||=||1 mSv||=||0.001 Sv|
|1 rem||=||1,000 mrem||=||10 mSv||=||0.01 Sv|
|10 rem||=||=||100 mSv||=||0.1 Sv|
|100 rem||=||=||1,000 mSv||=||1 Sv|
|1,000 rem||=||=||10 Sv|
|0.001 rad||=||1 mrad||=||0.01 mGy|
|0.01 rad||=||10 mrad||=||0.1 mGy|
|0.1 rad||=||100 mrad||=||1 mGy||=||0.001 Gy|
|1 rad||=||1,000 mrad||=||10 mGy||=||0.01 Gy|
|10 rad||=||=||100 mGy||=||0.1 Gy|
|100 rad||=||=||1,000 mGy||=||1 Gy|
|1,000 rad||=||=||10 Gy|
NOTE: Sievert is equivalent to rem; gray is equivalent to rad. (Radiation units are discussed in Chapter 2.)
Allied Command Europe
Advisory Committee on Human Radiation Experiments
Acquired immunodeficiency syndrome
As low as reasonably achievable
Army Materiel Command
Army National Guard of the United States
Agency for Toxic Substances and Disease Registry
Biological Effects of Ionizing Radiation
Coulombs per kilogram
Code of Federal Regulations
U.S. Department of the Army
U.S. Defense Logistics Agency
U.S. Department of Defense
U.S. Department of Defense Instruction
U.S. Department of Energy
Defense Special Weapons Agency (now the Defense Threat Reduction Agency)
U.S. Environmental Protection Agency
Federal Torts Claims Act
Human immunodeficiency virus
Headquarters, Department of the Army
International Advisory Committee, International Atomic Energy Agency
International Atomic Energy Agency
International Agency for Research on Cancer
International Commission on Radiological Protection
Institute of Medicine
Institutional review boards
Linear energy transfer
Low level radiation
Medical Follow-up Agency
Millisievert per year
North Atlantic Treaty Organization
Nuclear, biological, and chemical
National Cancer Institute
National Council on Radiation Protection and Measurements
U.S. Nuclear Regulatory Commission
Office for Protection from Research Risks, National Institutes of Health
Office of the U.S. Army Surgeon General
Posttraumatic stress disorder
Radiation Exposure State
Supreme Headquarers, Allied Powers Europe
International System of Units
United Nations Scientific Committee on the Effects of Atomic Radiation
U.S. Army Ionizing Radiation Dosimetry Center
U.S. Army Nuclear and Chemical Agency
U.S. Army Reserve
United States Code
U.S. Department of Veterans Affairs
Radiation weighting factor
Weighting factors for tissue
Radiation Units and Measurements
Sources of Radiation Exposure
Radiation Dose Reduction
Assessment of Radiogenic Tumor Risk
Radiation Safety Training for Occupational Exposures
Records and Recordkeeping
Non-Occupational Exposures up to 700 Millisievert
High-Level Exposures in Nuclear War
Summary of Existing Army Programs
Review of This Committees Interim Report
Guidance on Radiation Protection
Psychological Effects and Their Management
Balancing Future and Present Harm
Philosophy of Radiation Protection
Radiation Dosimetry, Records, and Reporting
APPENDIX A: The ACE Directive
APPENDIX B: Participants in Committee Meetings and Workshop
APPENDIX C: Biographical Summaries
Table S-1. Report Recommendations
Table S-2. Draft (August 2, 1996) Operational Exposure Guidance for Low Level Radiation
Table 2-1. Comparison of Three Expressions of Dose in Biological Tissue
Table 2-2. Distribution of Annual Doses (1996) for Army Personnel (military and civilian) Monitored for Occupational Exposure to Radiation
Table 2-3. Estimated Threshold Doses for Deterministic Effects of Acute Radiation Exposure
Table 2-4. Excess Cancer Mortality Estimates: Lifetime Risks per 100,000 Exposed Persons
Table 2-5. Comparative Susceptibilities (based on percent increases in background incidence) of Different Tissues to Radiation-Induced Cancer
Table 2-6. Lifetime Mortality from Specific Fatal Cancer After Exposure to Low Doses at a Low Dose Rate for a Population of All Ages
Table 3-1. Examples of Typical Radiation Doses and Dose Limits or Reference Levels (mSv)
Table 4-1. Draft (August 2, 1996) Operational Exposure Guidance for Low Level Radiation
Table 4-2. Revised, Low Level Radiation Guidance for Military Operations (Draft, Received May 1998)
Table 4-3. Nuclear Radiation Exposure Status and Degree of Risk Exposure
This is the final report of the Committee on Battlefield Radiation Exposure Criteria, produced under the auspices of the Medical Follow-up Agency of the Institute of Medicine, National Academy of Sciences. In it, the committee addresses technical and ethical aspects of military radiation protection and safety policies applicable in instances of the potential exposure of military personnel to radiation doses that are less than those that cause acute effects but that are associated with a long-term risk of subsequent cancers. At the request of the Surgeon General of the U.S. Army, the projects sponsor, the committee focused its interim report (IOM, 1997) on the scientific merit of proposed North Atlantic Treaty Organization (NATO) guidelines for this category of military operations. This final report summarizes the general technical points of the interim report and expands the committees discussion of the ethical considerations, education, training, and the decisionmaking process involved in initiating appropriate actions when military personnel may be at risk of exposure to radiation doses up to 700 millisievert (mSv). The committee also includes consideration of the evaluation of the long-term health effects of radiation.
In this summary, the committee presents a synopsis of its recommendations in Table S-1; it then proceeds to lay out the studys history and a brief outline of material in the interim report. The committee divides the rest of this Summary into three parts. The first section reprints the list of recommendations from the interim report. For discussion of those points, refer to Chapter 5 of the full report. Next, the committee highlights the concepts of justification for imposing risk on others; procedures for optimizing the risk situation to protect soldiers while also meeting military objectives; policies for recording, maintaining, and using dose information regarding individual soldiers; and programs that may be used to identify potential adverse health effects that become apparent long after the exposure. This summary concludes with the five recommendations that the committee presents in the reports final chapter.
TABLE S-1. Report Recommendations
1. Balancing future and present harm
When making decisions, commanders should consider long-term health effects that any action may have on their troops.
2. Philosophy of radiation protection
The U.S. Department of Defense (DoD) should develop and clearly express an underlying philosophy for radiation protection, including justification and optimization.
3. Communicating risk
Military personnel should receive appropriate training in both radiation effects and protection in a way that neither inappropriately minimizes effects nor creates unwarranted fear.
4. Radiation dosimetry, records, and reporting
Troops expected to be in radiation areas should have individual dosimeters. DoD should also maintain exposure records, with strong privacy assurances, and make these available to the exposed individuals.
Given the tests that are currently available and their limitations, monitoring programs for cancer (whether spontaneous or radiogenic) should be limited to those testing and monitoring programs included in guidelines for the general population.
HISTORICAL PERSPECTIVE AND RATIONALE
During the Cold War era, NATO and the U.S. Army instituted policies involving radiation dose limits and control measures to be used in the event of global nuclear war. The U.S. Army also has in place a radiation safety and protection programcomparable to civilian occupational protection programsfor personnel involved in routine duties involving possible radiation exposure. In the post-Cold War setting, however, military scenarios involving radiation exposure rarely reflect global nuclear war but more often consider limited nuclear exchanges, terrorist actions with improvised nuclear devices, conventional explosives employed as a means of disseminating radioactive materials, or nuclear power plant accidents. Military operations involving such situations are not covered by either the guidelines designed for nuclear war or the programs in effect for occupational duties.
Supreme Headquarters, Allied Powers Europe (SHAPE), recognized a need to plan for potential radiation exposure of military forces in Europe that might occur during the peacekeeping mission in Bosnia. In response, SHAPE staff, with U.S. Army participation, developed the Allied Command Europe (ACE) Directive Number 80-63, "ACE Policy for Defensive Measures against Low Level Radiological Hazards during Military Operations" (NATO, 1996).
The ACE Directive (NATO, 1996) provides general policy for the conduct of operations in the presence of radiation. It seeks to avoid unnecessary radiation exposure whenever possible and to minimize doses when exposure is unavoidable. The Directive touches on planning, coordination, security, dosimetry, recordkeeping, training, equipment, expertise, and commander responsibilities. It includes a chart (excerpted here from the Directive as Table S-2 and as Table 4-1 in Chapter 4 of this report) that defines radiation exposure state categories and outlines actions to be taken when personnel receive (or are at risk of receiving) specified levels of radiation dose. The operational exposure guidance presented in the Directive was the focus of the committees interim report.
TABLE S-2. Draft (August 2, 1996) Operational Exposure Guidance for Low Level Radiation
|Total Cumulative Dose (cGy)a||Radiation Exposure State Category||Stateb||Actions|
|[< 0.5 mGy]
< 0.05 cGy
|0||No risk||� None|
|1A||Normal risk||� Record
individual dose readings
� Initiate periodic monitoring
|1B||Minimal risk||� Record
individual dose readings and continue monitoring
� Initiate rad survey
� Prioritize tasks
� Establish dose control measures as part of operations
|1C||Limited risk||� Record
individual dose readings
� Continue monitoring and update survey
� Continue dose control measures
� Execute priority tasks onlyc
1025 cGy d
|1D||Increased risk||� Record
individual dose readings
� Continue monitoring and update survey
� Continue dose control measures
� Execute critical tasks onlyd
2570 cGy e
|1E||Significant risk||� Record
individual dose readings
� Continue monitoring and update survey
� Continue dose control measures
� Execute critical tasks only
|aDose is uniform to the
entire body due to whole-body irradiation. This table does not consider the intake of
radioactive material. This is assumed because of the employment of effective respiratory
protection and other measures. All doses should be kept as low as reasonably achievable
(ALARA). This will reduce the risk to the individual soldier and will retain maximum
operational flexibility for future employment of exposed soldiers. The use of the
measurement millisievert (mSv) is preferred in all cases. However, due to the fact that
normally the military has only the capability to measure centigray (cGy), as long as the
ability to obtain measurements in millisievert is not possible, ACE forces will use
centigray. For whole-body gamma irradiation, 1 cGy is equal to 10 mSv.
bRisk is of long-term health consequences, primarily induction of fatal cancer starting 2 years postexposure. Total lifetime risk is assumed to be 4 to 7 percent per 100 cGy (1,000 mSv). This is in addition to the 20 to 25 percent incidence of fatal cancer among the general population. Additional health risks that may occur are teratogenesis and mutagenesis and their associated psychological and social consequences. It must be noted that higher radiation dose rates produce proportionally more other health risk than the same total dose given over a longer period.
cExamples of priority tasks are those missions required to avert danger to persons or to prevent damage from spreading. Examples of critical tasks are those missions required to save human lives.
dDuring peacetime this dose shall not be exceeded except to save human lives.
eRadiation Exposure State (RES) category 1E covers a wide range of doses and its lower level (25 cGy = 250 mSv) is the peacetime maximum operational dose in many NATO nations. This category is normally applicable only in wartime. Intentional exposures to doses in this category (25 to 70 cGy = 250 to 700 mSv) require additional justification.
|SOURCE: NATO. ACE Policy for Defensive Measures against Low Level Radiological Hazards during Military Operations. ACE Directive Number 80-63. Brussels, Belgium: Supreme Allied Headquarters Europe, August 2, 1996 (with minor editorial revisions).|
RADIATION PHYSICS, RADIATION BIOLOGY, AND
RADIATION SAFETY AND PROTECTION
The first few chapters of this report include basic information about (1) radiation physics and radiation biology, (2) accepted standards of U.S. and international civilian and emergency radiation protection and safety practices, and (3) current U.S. Army radiation program practices. Next, the committee discusses the U.S. Armys approach to addressing issues relating to situations in which troops may be at risk of receiving radiation doses up to as much as 700 mSv in light of standard civilian practices, including the consideration of risk assessment, communication, training, education, commander decisionmaking, reporting, and follow-up. Taken together, these considerations form the building blocks of an ethically based approach to the planning, implementation, and follow-up of operations involving potential radiation exposure.
RECOMMENDATIONS FROM THE INTERIM REPORT*
The committee recommends that the U.S. Army:
1. Provide soldiers the same level of radiation protection as civilians working in similar environments.
2. Develop and state an explicit radiation protection philosophy that defines missions as falling under the framework of either a practice or an intervention.
3. Clearly state in the policy paragraph of the subsequent versions of the ACE Directive the definitions adopted for practices and interventions in the necessary military context.
4. Not use the term low level to describe the radiation dose range of 50 to 700 milligray (mGy) (5 to 70 rads).
5. Use terms other than no risk and normal risk for the risk state categories labeled RES [radiation exposure state] 0 and RES 1A in the table of exposure guidance in Annex A of the ACE Directive.
6. Avoid the term radiological hazard when describing the exposure of soldiers to radiation, unless the hazard refers to a specific detrimental effect.
Prospective Risk Assessments
7. Develop requirements for measuring, interpreting, and responding to airborne and surface contamination (particularly that containing alpha and beta emitters). Guidance should define levels of alpha and beta contamination that would trigger use of protective equipment and actions.
8. Reconsider its absolute requirement that soldiers wear protective equipment within an exclusion zone as defined in the ACE Directive.
9. Make a clear distinction between military intelligence threat estimates and radiation risk estimates.
10. Develop explicit requirements to define when individual radiation monitoring is required in the field.
11. Review its dosimetry capabilities and determine if they are adequate to support the use of the Operational Exposure Guidance in the ACE Directive.
12. Increase the specificity of the dosimetry program guidelines in subsequent versions of the Directive (e.g., provide specific guidance on the capabilities of monitoring devices and equipment).
13. Not assume, as the ACE Directive does, that internal doses will be zero because respiratory protection will be used.
14. Review its capability to measure airborne radioactive contamination.
15. Expand Operational Exposure Guidance to include radiation doses from both internal and external sources of radiation. These should be expressed in terms of effective dose and be consistent with the requirements of the U.S. Nuclear Regulatory Commission.
16. Adopt the millisievert (mSv) as the standard unit of effective dose and milligray (mGy) as the unit of absorbed dose.
17. Clearly define the time over which doses are to be accumulated for assignment of RES levels in the Operational Exposure Guidance in Annex A of the Directive.
18. Review and revise doctrine and procedures on dosimetry to ensure that individual doses are monitored and recorded for all soldiers exposed to radiation, whether from routine occupational exposure or as a consequence of uniquely military missions.
Reference Levels for Operational Exposure Guidance
19. Include radiation doses from internal sources (e.g., from inhaled airborne radioactivity) in applying reference levels in Operational Exposure Guidance.
20. Clearly specify what actions are recommended at each reference level in the Operational Exposure Guidance.
21. Restructure the table of Operational Exposure Guidance to account for the uncertainty of dose estimates in interventions.
22. Develop separate Operational Exposure Guidance for managing practices (routine tasks involving radiation exposure) in the context of a military operation.
Justifying Placing Individuals at Risk of Harm
There is a general ethical principle that one should not put individuals at risk of harm. Exceptions to this principle require justification.
There are standard, not mutually exclusive, ways of looking at how to ethically justify placing some at risk for the benefit of others: consent and role-related responsibility. In many circumstances it is considered ethically justifiable to place individuals at risk of harm for the benefit of others if they consent to that imposition. To be ethically valid, the consent must be based on an adequate understanding of the nature and implications of the risk, and the person must be free to refuse. Another way of thinking about risk focuses on role responsibility. Certain roles, like soldiering, carry with them an obligation to bear risk for the benefit of others. There are both voluntary and involuntary assumptions of roles; it does not necessarily follow that because a role was not voluntarily assumed that it does not carry with it some socially acceptable and morally justifiable risk. For example, whether they enlist or are conscripted, all soldiers assume the role-related risks of military service.
Justifications of consent and role responsibility do not exhaust the ethical considerations associated with the imposition of risk. Several other ethical conditions must be satisfied.
There must be an analysis that supports, if not demonstrates, that no more risk than is necessary to achieve the goal is being imposed or placed on the individual. This is the optimization principle of radiation protection, implemented by ALARAas low as reasonably achievableprocedures. In addition, the ethical duty to minimize risk includes taking steps to minimize the likelihood that the risk will materialize into harm. In this context, the duty includes the responsibility for appropriate follow-up of exposed and potentially exposed individuals. Dosimetry, recordkeeping, and medical monitoring all support postexposure efforts to minimize harm.
There is the duty to treat with respect the persons being placed at risk. This includes disclosure of the risk to the person both before and after the exposure and maintenance of the privacy of the person who has been put at risk of harm, enabling the individual to have control over access to information about his or her exposure and the uses that others might make of this information. One could provide remedy or compensation for the simple assumption of risk or limit the provision of a remedy only to circumstances when the risk materializes into harm.
Finally, there is the set of considerations having to do with justice. Who is to be exposed? Are any of the individuals or groups particularly vulnerable, particularly open to exploitation, or particularly burdened by preexisting harms or risks? How should one weigh deaths or injuries that will occur in the present against deaths or illness that will occur in the future? Does it matter morally if, in choosing the nonradiation threat, the harm would befall only a small number of identifiable soldiers, while, if the choice were radiation exposure, it cannot be known at the time who among those exposed will subsequently suffer the harm?
A few features of the military context further increase the ethical burden on both commanders and the government with respect to soldiers. Commanders have much more authority over soldiers than civilian employers have over their employees. Members of the military are obligated to follow all lawful orders, even those that put them at risk of death or disability. Medical and related records (including radiation exposure information) are vital to ensuring that ethical consideration of possible radiation injury has been taken into account in addressing the military objective.
Training, Recordkeeping, and Reporting
Throughout the report, the committee discusses the topics of training, recordkeeping, and reporting in sequence. In a good radiation protection program all three must be intricately interwoven. Training should impart some basic understanding of radiation, communicate the risk, help the soldier to understand the ramifications of risk perception, and then place that knowledge in a context whereby the risks associated with radiation exposure can be compared with other radiation- and nonradiation-related risks. These comparisons should be tested both by experts in risk communication and with groups of laypeople to ensure that the information is understandable and not misleading. The soldier then can draw upon this foundation to (1) protect himself or herself and others during an exposure situation, (2) know which pieces of information are important to obtain and record, (3) act to notify whomever should know about exposures or effects, and (4) use his or her own dose report to help guide his or her own future occupational, avocational, and health care activities. In addition, through training, the military attempts to teach commanders how to decide when it is appropriate to put subordinates at risk (justification) and how to do so to minimize short- and long-term harm while also achieving the military mission (optimization).
Therefore, training content includes conveying the value of information (e.g., records are important and notification of personnel is important) and the lesson that recordkeeping and notification procedures are valuable only if the soldier knows (through training) what to measure and how to do so, what to record, and what to do with that information once it is recorded.
The common thread is communication. Accurate and appropriate information must be maintained so that it is available to be given to the right people at the right time. Furthermore, this communication must be exercised within an ethical framework in which the government seeks to meet its military objectives, protect the health of military personnel, and take responsibility for the health consequences of its decisions.
Information is vital to sustaining protection. When existing technology allows detection of radiation exposures, advance notice of potential radiation exposures is the goal. When feasible, radiation levels should be monitored in settings of suspected exposure. The levels of radiation that may involve short- or long-term risks need to be predetermined. Chains of command should be prepared to disseminate radiation warnings quickly and efficiently. If possible, soldiers should be equipped with devices that detect levels of radiation in the operational field in cases in which significant radiation exposure is expected. They should be fully knowledgeable of the operation of these devices and interpretation of the readings displayed by these devices.
Since the U.S. military is also the employer of the soldier, the military has an independent obligation to the volunteer to minimize the risks as much as reasonably possible. This can be done in a number of ways, including planning, the use of protective equipment, and the exploration of less risky alternatives.
In addition to the requirement that the U.S. Department of Defense (DoD) maintain radiation exposure data on all its potentially exposed personnel, the committee strongly recommends that each military member so exposed be provided annually, and on termination of military service, a written document specifying the magnitude of each exposure (if possible) and the location(s) of such exposure(s) during service. A copy of this information can then be made available to the U.S. Department of Veterans Affairs for future determination of disability connected to service in the military and follow-up medical care if required. If possible, the exposure data notification document should include both a listing of the agents to which the person was exposed (e.g., radiation, chemicals, biological exposures, conventional injuries, and stressful situations) and a general statement of the potential health consequences related to those exposures. The quality of the information provided will vary depending on whether the military operation was during war or peacetime, with more detail expected during peacetime activities.
With current equipment and personnel capabilities, the Army cannot fully implement the recommendations in this report. However, as the Army prepares and implements new policy it should bear in mind the recommendations as well as the broader discussion of issues in this report.
The Surgeon General of the U.S. Army requested guidance on the management of military operations in which radiation effective doses might range up to 700 mSv. The committee has formulated recommendations that cover a number of areas. Some of these areas have already been addressed by the military but are included because they are important and the report would not be complete without their consideration.
Balancing Future and Present Harm
Current doctrine and risk evaluation by military commanders focus on acute injuries and fatalities and those factors which potentially affect the ability to achieve a military objective. The U.S. Department of Veterans Affairs deals with long-term health effects and disability. A focus on acute health effects from any cause is still largely appropriate for hostile situations, but it discounts or ignores long-term detriment and is inappropriate for less emergent situations in which the military may be asked to participate.
The U.S. Army asked the committee to consider doses of less than 700 mSv. Although no significant acute effects are expected to result from such radiation doses, excess risks of many types of cancer and leukemia have statistically significant associations with doses in this range. Although the long-term effects of radiation are relatively well known, the long-term detriment associated with other exposures or potential exposures, such as psychological stress, are less well understood and quantified. The committee thinks that these should not be ignored.
RECOMMENDATION 1: When making decisions, commanders should consider the long-term health effects that any action may have on their troops.
This should become standard operating policy.
In addition, the Department of Defense should attempt to quantify long-term detriment from a number of causes, including radiation, and develop training material and scenarios that address these effects.
The long-term effects to be considered in operational decisions should include not only those from radiation but also those from conventional injuries, chemical and biological agents, and psychological stress.
Philosophy of Radiation Protection
A philosophy for dealing with any potential harm should be clearly stated, widely disseminated, ethically based, practical, and comprehensive. This will allow commanders to make informed decisions and be flexible rather than having to deal with prescribed limits when they may be inappropriate or impractical. This philosophy should be focused on minimizing the risk of harm while allowing the performance of the required military objective. There are clearly situations in which radiation exposure is justified because the risk of radiation-induced harm is less than the risks from other hazards associated with the action. A policy that completely avoids radiation exposure is inappropriate and may expose troops, and perhaps others, to larger risks of harm from other, nonradiation, causes.
RECOMMENDATION 2: The U.S. Department of Defense should develop and clearly express an underlying philosophy for radiation protection.
A. The committee suggests application and adaptation of the system recommended by the International Commission on Radiological Protection.
This system includes practices as well as interventions.
These are required to be initially justified (more benefit than risk) and then optimized (minimization of dose) in the context of the situation.
B. The committee recommends that in peacetime or nonemergent situations soldiers should be accorded the same level of protection accorded civilians.
Those soldiers who may be exposed to radiation dose levels similar to those to which civilian radiation workers are exposed should have the same level of training as civilian radiation workers and should be subject to occupational dose limits.
C. In settings in which an intervention is required and specific numerical dose limits are neither applicable nor practical, the committee recommends that commanders justify the mission (there is more benefit than risk), examine competing risks, and optimize the mission (identify ways to minimize dose without jeopardizing the mission).
Examples of these settings include emergent or lifesaving actions, actions to prevent exposure of large populations, and hostile situations.
Training and risk communication are extremely important not only so the troops can adequately achieve their objective but also so they can understand the risks and protect themselves.
RECOMMENDATION 3: Military personnel should receive appropriate training in both radiation effects and protection. Their training will need to vary on the basis of the particular level of potential exposure and upon the task at hand.
Training may range from task-specific operational briefings to full courses, depending upon the situation.
Well-crafted, realistic scenarios should be incorporated into training at all levels.
Potential long-term health consequences from radiation exposure should be included in the discussion of risks.
The training should put radiation effects in perspective in language that the troops can understand but not in a way that inappropriately minimizes the effects or creates unwarranted fear.
When long-term risks of harm from sources other than radiation are largely unknown, this should be stated.
Regardless of current NATO policy, DoD should avoid using the terms low risk or no risk in training and briefings when radiation levels clearly carry a measurable cancer risk.
Radiation Dosimetry, Records, and Reporting
For risk management during and after a mission, it is important to estimate or quantify current and past exposures. This is optimally done through the use of radiation detection devices, environmental sampling, personnel dosimeters, bioassays, and, possibly, whole-body counting. Even in certain hostile situations when all of these may not be possible, estimates of exposure conditions and dose can still be made. Such information should be available to military personnel during active duty and after discharge.
RECOMMENDATION 4: A program of measurement, recording, maintenance, and use of dosimetry and exposure information is essential.
A. Troops expected to be in areas where there is a risk of radiation exposure should have individual dosimeters.
B. Systematic individual radiation dose recordsfor external and internal dosesshould be maintained and should follow the soldier from one operational unit to another should be kept.
C. A system that includes the capability to field monitor, and estimate or measure and then record internal doses needs to be developed.
When appropriate, organ-absorbed doses should be recorded in addition to the effective dose.
D. The U.S. Department of Defense should also maintain exposure records in a confidential manner that contains strong privacy assurances. Records should be kept in a secure form and should be available to the individual.
E. Annually and upon deactivation or discharge, potentially exposed military personnel should be given a written record of their radiation exposures with estimated doses (annual and cumulative), even if they are zero.
This should be separate from any administratively required occupational recording and notification.
There should also be an explanation of the implications of these radiation exposures for future health outcomes.
Even if an operation is classified, there is still a need to provide such information.
The exposure of troops to agents and situations that may have long-term health effects raises the issue of whether there is any appropriate medical monitoring (screening) that will detect such effects before they are evident clinically and that may positively affect disease progression or outcome. The primary effect in the cumulative radiation dose range that the committee considers in this report is an excess risk of certain types of cancer and leukemia. Unfortunately, at this time only a few screening tests are clearly effective; these tests are used to detect breast, cervical, and colon cancers. Physician-directed individual diagnostic testing may be useful in selected situations, particularly when the radiation absorbed doses are extremely high. It should be noted that cancer currently occurs in about 40 percent of the U.S. population (NCI, 1994). For doses in the highest dose range addressed in this report (500700 mSv), the increased risk of cancer attributable to the radiation dose is about 1/10 the normal baseline cancer incidence rate for unexposed individuals. Although this is a low percentage, a large number of troops exposed at these doses could result in a large number of excess cancers.
RECOMMENDATION 5: Given the tests that are currently available and their limitations, testing and monitoring programs for cancer (whether spontaneous or radiogenic) should be limited to those testing and monitoring programs included in guidelines for the general population.
Specific periodic screening or medical monitoring of radiation-exposed populations is not warranted solely on the basis of the radiation exposure in the dose range considered in this report.
If effective tests for other cancer types do become available, screening may be useful on the basis of the normal cancer incidence in the general population.
For persons who have received cumulative effective doses in excess of 50 mSv, the establishment of well-designed and dynamic registries may be helpful in addressing future health-related issues on an individual or population basis.
*An Evaluation of Radiation Exposure Guidance for Military Operations: Interim Report. J.C. Johnson and S. Thaul (eds.). Washington, D.C.: National Academy Press, 1997.
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