3.57.Human imaging for artistic or publicity purposes (para. 3.17(c) of GSR Part 3 [1]) or human imaging for theft detection purposes (para. 3.19 of GSR Part 3 [1]) are considered to be not justified.
3.58.The application of the justification principle to non-medical human imaging for other purposes requires a special approach, as required by para. 3.61 of GSR Part 3 [1], which states:
“The justification process shall include the consideration of:
The benefits and detriments of implementing the type of human imaging procedure;
The benefits and detriments of not implementing the type of human imaging procedure;
Any legal or ethical issues associated with the introduction of the type of human imaging procedure;
The effectiveness and suitability of the type of human imaging procedure, including the appropriateness of the radiation equipment for the intended use;
The availability of sufficient resources to conduct the human imaging procedure safely throughout the intended period of the practice.”
3.59.The government has the responsibility to ensure that these considerations are taken into account in the justification process for any non-medical human imaging practice. Such considerations need to be taken into account because, unlike medical uses of radiation, non-medical human imaging practices do not yield a direct health benefit to the exposed individual. For such practices, there may be benefits to the exposed individual, but there are also wider benefits to society that should be considered. The onus is on the government to ensure that, as a result of the process in para. 3.61 of GSR Part 3 [1], the proposed nonmedical human imaging practice is indeed justified in the wider context; that is, on the basis that it produces a positive net benefit either to the exposed individuals or to society [4].
3.60.As noted in para. 5.16 of GSG-5 [4], if a particular type of practice involving non-medical human imaging is considered to be justified, separate ‘levels’ of justification should be applied in respect of particular applications of the technique. For example, the generic justification of the use of X ray imaging for the detection of concealed objects that could be used for criminal acts that pose a national security threat may be regarded as the first level of justification. Approving the use of such imaging procedures in specific facilities (or types of facility) represents a second level of justification, although often levels one and two will be considered together. Proposals for application of the technique in other types of facility or situation, such as access control to buildings, should necessitate separate considerations of justification. In this way, the undue proliferation of non-medical imaging can be avoided.
3.61.As noted in para. 5.17 of GSG-5 [4], a further level of justification relates to the selection of particular individuals to undergo a specific non-medical imaging procedure. Criteria for the selection of individuals should be part of the initial application for justification and should be reviewed as part of the overall justification process. Particular consideration should be given to the application of non-medical human imaging procedures to children, pregnant women and other sensitive population groups.
3.62.Paragraph 3.66 of GSR Part 3 [1] states:
“Registrants and licensees shall ensure that all persons who are to undergo procedures with inspection imaging devices in which ionizing radiation is used are informed of the possibility of requesting the use of an alternative inspection technique that does not use ionizing radiation, where available.”
3.63.Where no alternative inspection technique is available, it should be stated in the application for justification whether the intention is for the procedure using ionizing radiation to be made mandatory or whether it should be subject to the informed consent of the persons who undergo the inspection.
3.64.The justification process should also give consideration to what are acceptable imaging procedures for the proposed practice. For example, the imaging procedure may be limited to a particular modality or part of the body, such as a CT scan of the abdomen, or there may be several options to choose from, or the choice of imaging procedures for an individual case depends on what is required for that case. In the latter two cases, the selection of the appropriate imaging procedure should be subject to a further justification for the individual.
3.65.When a particular practice of non-medical human imaging has been determined to be justified, it will normally be subject to conditions that will need to be fulfilled in the implementation of the practice. For Category 1 non-medical human imaging practices, these conditions should include the requirement that the performance of an individually justified non-medical human imaging procedure should take place in a medical radiation facility that is authorized to use radiation for medical diagnosis.
Justification of Category 1 practices
3.66.The following paragraphs provide a list of possible Category 1 non-medical human imaging practices, and a description of some of the issues that should be considered in the justification process. Listing these practices, together with the associated descriptions, should not be interpreted as indicating that the practices are justified by a State.
3.67.Some of the information below is taken from GSG-5 [4], which also provides additional guidance on the justification process.
Legal purposes: Obtaining legal evidence
3.68.This practice relates to human images being obtained to establish the presence or absence of diseases or injuries to be used in official court proceedings.
3.69.If such imaging is being considered, the State should have a legal mechanism to allow the acquisition of images for the purposes of obtaining legal evidence. The criteria for selection or eligibility of individuals to undergo such imaging would also need to be considered in the justification process, as would the specification of acceptable imaging procedures.
3.70.The parties involved in the justification process for non-medical human imaging for the purpose of obtaining legal evidence would typically include the authorities for justice and police, medical professional bodies and the regulatory body.
Legal purposes: Age determination
3.71.The reason for examinations to determine age usually originates from some legal circumstance in which there is no valid proof of date of birth. The reason may concern adoption, refugees seeking asylum or be in support of a decision on whether to apply an adult criminal law. Two types of examination are usually carried out: dental and skeletal. A skeletal examination is normally of a selected part of the body, such as the hand and wrist, iliac crest or clavicle.
3.72.The justification process should consider the reasons for undertaking the practice. The main benefit of such examinations is to the authorities in the State where the examinations are performed, to enable a sound basis for a legal decision to be established. There may or may not be a direct benefit to the person being examined.
3.73.Radiological scanning for age determination is not always accurate and should be justified in each case (see paras 3.60 and 3.61). There are many reasons (e.g. socioeconomic) for differences in dental and skeletal development, and the validity of the method to be used should be established for each individual case [42]. Many methods are less accurate for adolescents than for children, and even less accurate for adults. As such, this practice might not be sufficiently accurate for determining whether a persons is, for example, over 18 years of age [42].
3.74.The parties involved in the justification process for non-medical human imaging for the purpose of age determination would typically include the authorities for justice, border control and immigration, medical professional bodies and the regulatory body.
Legal purposes: Immigration or emigration
3.75.X ray examinations can be used to check for active or past disease. The most common example is the use of chest radiographs to determine whether immigrants or emigrants have active or past tuberculosis. This type of practice involves the examination of individuals without medical symptoms. As indicated in paragraph 3.18 of GSR Part 3 [1], automatic examinations without reference to clinical indications are normally deemed not to be justified. However, issues in relation to the protection of the public health and vulnerable individuals within society may result in the consideration of such practices as necessary for ensuring public health, and hence whether immigration or emigration can take place for an individual.
3.76.If non-medical human imaging procedures for immigration or emigration purposes are being considered by a State, the justification process should also involve a review of the proposed referral or selection criteria to be applied as part of the proposed practice. The onus is on the State to pursue alternative and equivalent means, where available, for achieving the desired outcome. For example, rather than requiring a chest X ray for all immigrants, the immigration requirements could instead require a medical examination, with the need for a chest X ray being determined as a result of the medical examination. Such chest X rays would then be medical exposure and outside the scope of this Safety Guide.
3.77.Non-medical human imaging for immigration purposes poses additional legal issues. If a State has decided that such a practice is justified, it will involve the exposure of persons who are not yet (and who may never become) citizens of that State. Similarly, for any exposures that are undertaken for the purposes of emigration, the justification process should consider how any requirements of the State of destination will be met and the justification for such exposures in that State.
3.78.The consequences of a positive identification of disease should also be considered as part of the justification process. For example, a justification decision may be required in relation to a proposal that all immigrants from States in which tuberculosis is endemic are X rayed to determine whether they have active or past tuberculosis. One possible outcome is that they are treated if a positive diagnosis is made. Another possible outcome is that a positive identification of disease is regarded as a barrier to entry or acts as a trigger for deportation. These are two very different outcomes for the individual who will be X rayed and need to be factored into the decision making process for justification of the procedure.
3.79.The parties involved in the justification process for non-medical human imaging for immigration or emigration purposes would typically include the authorities for immigration and emigration, justice and border control, medical professional bodies and the regulatory body.
Legal purposes: Detection of drugs within a person
3.80.This practice relates to the use of X ray imaging to detect drugs that are concealed within a person entering a State. Packages containing drugs may have been swallowed or otherwise concealed internally by a drug courier transporting them. Non-medical human imaging procedures should be used only when there is a high degree of suspicion that the individual has swallowed a package containing drugs, and particularly when there are concerns for the health of the individual (see para. 3.61). Criteria for identifying suspected drug couriers should be developed.
3.81.The benefit of this procedure is the reduction in trafficking of drugs. In some States, it is considered that there is benefit to the person being examined, in that swallowed drug packages may split and release the content into the intestines, resulting in serious injury or death. In that sense, the exposure could be regarded as being undertaken for medical purposes; however, since the primary purpose is to detect trafficking of drugs, the exposure should not be regarded as a medical exposure unless there are clinical indications for the investigation.
3.82.If such imaging is being considered, the implication is that there will be a legal mechanism whereby the State, typically through a court order or an approved process, can request the acquisition of images for the purposes of detection of concealed drugs. It should be noted that alternative techniques not involving the use of radiation are available, such as the administration of emetics or taking the person into custody for a period of time that would allow for suspected concealed packages to pass through the body.
3.83.The criteria for selection or eligibility of suspected couriers to undergo non-medical human imaging should also be considered, as well as the option for such individuals to undergo an alternative process for ascertaining whether or not drugs are present. The specification of acceptable imaging procedures should also take place.
3.84.As noted in para. 5.50 of GSG-5 [4], the detection of drugs within a person can also be carried out using a transmission X ray scanner (i.e. as a Category 2 practice). Such X ray scans are performed and the images viewed by personnel who are not specialists in radiology, for example by law enforcement officers trained to use such equipment. The effective dose to the person being scanned would be much lower than if it were conducted as a Category 1 procedure. The Category 2 procedures can be used, for example, to scan suspected drug couriers to determine whether further medical examination is required at a medical facility. Such an approach is consistent with the application of the principle of optimization of protection and safety as discussed in paras 3.120–3.128.
3.85.The parties involved in the justification process for non-medical human imaging for the purpose of detection of drugs within a person would typically include the authorities for justice, border control and police, radiology professional bodies and the regulatory body.
Occupational purposes: Assessment of fitness for employment
3.86.Non-medical human imaging for the assessment of fitness for employment includes imaging performed prior to employment or periodically during employment, where the imaging occurs solely on the basis of an administrative process within a given company or organization. Any imaging performed with reference to clinical indications of the individual is medical exposure and is outside the scope of this Safety Guide.
3.87.Paragraph 3.18 of GSR Part 3 [1] states (footnote omitted):
“Human imaging using radiation that is performed for occupational, legal or health insurance purposes, and is undertaken without reference to clinical indication, shall normally be deemed to be not justified.”
In exceptional circumstances, the government or regulatory body may decide that the justification of such non-medical human imaging for specific practices is justified.
3.88.The onus should be on the State to pursue alternative and equivalent means, where available, for achieving the desired outcome. For example, rather than an administrative order for a chest X ray to be required in all cases, there could instead be a requirement for a medical examination, with any need for a chest X ray being determined as a result of the medical examination.
3.89.If there are deemed to be exceptional circumstances as indicated in para. 3.87, the justification process should consider the specific types of occupation for which justification might be appropriate and any other conditions that would apply to the use of non-medical human imaging for assessment of fitness for employment. The justification process should also consider the specification of acceptable imaging procedures.
3.90As part of the justification process, it is useful to consider the reasons for undertaking the practice, including any (perceived) benefits. As well as benefits to the employer (which alone should not be a reason for justification), there may also be benefits for workers in terms of general health and safety in the workplace, as well as the early detection of medical problems before symptoms emerge.
3.91.If such imaging is to be allowed, the State should have a legal mechanism whereby individual employers can require employees and prospective employees to undergo X ray examinations for the purpose of assessing fitness for employment without reference to clinical indications.
3.92.The parties involved in the justification process for non-medical human imaging for the purpose of assessment of fitness for employment would typically include the authorities for labour, worker unions and other organizations, medical professional bodies and the regulatory body.
Use of non-medical human imaging for employment in sport or the performing arts
3.93.Non-medical human imaging includes assessment of physiological suitability for a career in sport or the performing arts, and assessment of the health status of athletes before selection or transfer. In all of these cases, the imaging is being initiated on the basis of a sports organization or performing arts organization wishing to obtain the desired information for their benefit. There may also be a benefit to the individual, but this is not the primary reason for the assessment.
3.94.The use of imaging in sports medicine, based on clinical indications of the athlete, is well established and is clearly part of medical exposure because the result (either positive or negative) will influence patient management. Such usage is outside the scope of this Safety Guide.
3.95.As noted in para. 3.87, non-medical human imaging for occupational purposes without reference to clinical indication is not normally justified. In between these two scenarios are imaging procedures that are performed in order to exclude physical abnormalities that would contraindicate participation in certain sports, such as neck abnormalities for young people playing contact sports. Such imaging should be on the basis of medical examination, followed by imaging as indicated by medical conditions, in which case the imaging is medical exposure and would be outside the scope of this Safety Guide. However, if such imaging were based solely on non-medical criteria (e.g. age), then it would be non-medical human imaging, and the government or regulatory body should decide whether exceptional circumstances warranted the justification of the practice.
3.96.As part of the justification process, it is useful to consider the reasons for undertaking the procedures and, in particular, which parties benefit from the practice and what are the individual consequences for examined athletes or artists. Ethical issues, such as discrimination, should also be considered.
3.97.The parties involved in the justification process for non-medical human imaging for the purpose of assessment of physiological suitability or fitness for selection or transfer would typically include the authorities for labour, sport and recreation, arts, sports organizations, arts organizations, player or performer associations, medical professional bodies and the regulatory body.
Health insurance purposes
3.98.Non-medical human imaging for health insurance purposes includes preinsurance checks and checks during the lifetime of an insurance policy. Examples could include assessing the significance of pre-existing disorders or checking for the occurrence of subsequent disorders. In all cases, the imaging is being initiated at the request of a health insurance company wishing to obtain information for their own purposes.
3.99.Paragraph 3.18 of GSR Part 3 [1] establishes that non-medical human imaging for health insurance purposes is not justified, except under exceptional circumstances in which the government or regulatory body decides that use of imaging for specific practices can be justified. In such circumstances, the justification process should consider the specific types of health insurance purpose for which justification might be appropriate and any other conditions that would apply to the use of non-medical human imaging for such a purpose. The criteria for selection or eligibility of individuals to undergo imaging for health insurance purposes should also be considered in the justification process. The justification process should also consider the specification of acceptable imaging procedures.
3.100.As part of the justification process, it is useful to consider the reasons for undertaking the procedures and, in particular, which parties benefit from the practice. Non-medical human imaging for health insurance purposes is likely to involve commercial enterprises, with the company accruing the benefit from such exposures. Health insurance is about assessment of risk and non-medical human imaging procedures are intended to provide the insurers with information to manage the risk in favour of the insurers.
3.101.If such imaging is to be allowed, the State should have a legal mechanism whereby individual health insurance companies can require policy holders and prospective policy holders to undergo X ray examinations for the purpose of providing medical information to the health insurer without reference to clinical indications. Consideration should also be given to whether there would be any restrictions on the health insurance companies that would be eligible.
3.102.The parties involved in the justification process for non-medical human imaging for health insurance purposes would typically include the authorities for health, justice and labour, health insurance companies, consumer representatives, medical professional bodies and the regulatory body.
Justification of Category 2 practices
3.103.In the justification process, the government or regulatory body should consider which type of imaging technology might be acceptable for the proposed practice: transmission technology or backscatter technology (see para. 3.2). Consideration should also be given to the way in which the inspection imaging devices are to be deployed in the proposed Category 2 non-medical human imaging practice; that is, as either a general use system or a limited use system (see para. 3.3).
3.104.Specific conditions of use in a proposed Category 2 non-medical human imaging practice should be considered in the justification process and, if the practice is ultimately considered justified, such conditions of use should form part of the conditions of the authorization.
3.105.The person or organization applying for a Category 2 practice to be justified should undertake a radiological assessment that determines the individual dose per inspection or scan as well as the cumulative dose to persons who are likely to be exposed frequently, for example frequent air travellers, flight crew and ground crew, or frequent visitors to prisons.
3.106.Issues relating to privacy, provision of information to individuals to be screened, selection criteria for individuals to be screened and informed consent should be considered in the justification process, while noting that alternative methods not involving the use of radiation can also involve many of the same issues.
3.107.Consideration of alternative methods does not imply that only one method can ultimately be considered as justified. Several methods may indeed be considered acceptable. In particular, the availability of an acceptable alternative that does not use radiation does not necessarily exclude a radiation based technology as also being justified and acceptable.
3.108.When a particular practice of non-medical human imaging has been determined to be justified, it will normally be subject to conditions that will need to be fulfilled in the implementation of the practice. These conditions should include criteria to be met by a facility seeking authorization for the given Category 2 non-medical human imaging practice.
3.109.Paragraphs 3.110–3.119 present some issues that are pertinent to the justification process for two possible examples of Category 2 non-medical human imaging. Listing these practices, together with the associated descriptions, should not be interpreted as indicating that the practices are justified.
Detection of concealed objects that can be used for criminal acts that pose a security threat
3.110.Commonly referred to as ‘security screening’, this Category 2 practice is a non-medical human imaging procedure performed on the basis of security considerations. Many scenarios are conceivable and potential applications include passengers boarding aircraft, persons crossing a national border and visitors to prisons. Concealed objects of interest include explosives, firearms, knives and other weapons. Each of these applications, and any others, should be considered separately if being considered for justification by the government in accordance with para. 3.21 of GSR Part 3 [1].
3.111.As part of the justification process, it is useful to consider the reasons why the proposed practice is to be undertaken and which parties will benefit. For these types of practice, the benefit generally lies in preventing the use of explosives and weapons and improving security overall through a deterrent effect. The benefits will be to society in general, although in the case of airline passengers, each passenger may be considered to directly benefit, as well as individual benefits in terms of increased passenger confidence [4]. In any case, each type of security screening application should be specifically evaluated in terms of the purpose and the environment within which the practice is to be applied.
3.112.An example of detailed guidance on the justification process for security screening is given in Ref. [43], and includes the following steps:
Defining the need;
Evaluating the options, including their effectiveness and their limitations;
Evaluating privacy concerns;
Assessing the radiation risk from the technologies;
Assessing the potential net benefit from implementation of the technologies;
Assessing the cost and availability of resources (regulatory, operational and training), and the viability of sustainable implementation.
3.113.The justification process should involve all relevant government authorities, including, but not limited to, those authorities with responsibility for security, border control, consumer groups and the regulatory body. For practices for which a large number of people might be affected, such as the security screening of airline passengers, the government should carefully consider the need for extensive public consultation.
3.114.In the case of the security screening of airline passengers, the government should also consider liaising with counterparts in other States in view of the international dimension of air travel.
3.115.The benefits from some of these types of practice could be substantial. Nevertheless, proposals to introduce them into a State should be scrutinized very carefully by the government.
3.116.When a particular Category 2 non-medical human imaging practice has been considered as justified for a given security purpose within a specified environment, the justification decision should be reviewed on a regular basis as technologies77 and threat evaluations constantly change.
Detection of concealed objects for anti-smuggling purposes
3.117.This Category 2 practice relates to the use of inspection devices to detect objects that have been deliberately concealed on or in a person because either it is illegal to possess the objects or to avoid paying duties or taxes on the objects. The objects that might be under consideration may differ from State to State, but could include drugs and gemstones. As noted in para. 3.84, in the justification process for drug detection, a State may well consider both Category 1 nonmedical human imaging and Category 2 non-medical human imaging options.
3.118.As part of the justification process, it is useful to consider the reasons for undertaking the procedures and, in particular, which parties benefit from the practice. The introduction of such a practice in a State may bring societal benefits, including a reduction in the availability of contraband through the detection and confiscation of contraband, and through the deterrence of potential smugglers.
3.119.The parties involved in the justification process for Category 2 nonmedical human imaging for anti-smuggling purposes would typically include the authorities for justice, border control, customs, police and the regulatory body.