EPA 520/4-77-003
Considerations of
Health Benefit-Cost Analysis
for Activities Involving
Ionizing Radiation Exposure
and Alternatives
A Report of
Advisory Committee
on the
Biological Effects of Ionizing Radiations
Assembly of Life Sciences
National Research Council
National Academy of Sciences
\vX
U.S. ENVIRONMENTAL PROTECTION AGENCY
Office of Radiation Programs
Criteria and Standards Division
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This Report was prepared for the U.S. Environmental
Protection Agency under Contract No. 68-01-2230 with
the National Research Council, National Academy of
Sciences. The information contained therein is the
sole responsibility of the National Academy of Sciences
and the U.S. Environmental Protection Agency assumes no
responsibility for the accuracy and completeness of the
Report.
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CONSIDERATIONS OF HEALTH BENEFIT-COST ANALYSIS FOR ACTIVITIES
INVOLVING IONIZING RADIATION EXPOSURE AND ALTERNATIVES
A Report of
Advisory Comnittee
on the
Biological Effects of Ionizing Radiations
Assembly of Life Sciences
National Research Council
NATIONAL ACADEMY OF SCIENCES
Washington, D.C.
1977
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NOTICE
The project that is the subject of this report was approved by the
Governing Board of the National Research Council, whose members are drawn
from the Councils of the National Academy of Sciences, the National Academy
of Engineering, and the Institute of Medicine. The members of the Committee
responsible for the report were chosen for their special competences and
with regard for appropriate balance.
This report has been reviewed by a group other than the authors
according to procedures approved by a Report Review Conmittee consisting
of members of the National Academy of Sciences, the National Academy of
Engineering, and the Institute of Medicine.
The work presented in this report was supported by the Office of
Radiation Programs, Environmental Protection Agency, under Contract No.
68-01-2230.
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PREFACE
This report of the health benefit-cost analysis of exposure to low levels
of ionizing radiation and the application of various methods of such analysis
was done under the auspices of the National Academy of Sciences (NAS) at the
request of the Environmental Protection Agency (EPA). The report defines the
over-all problems of such an analysis of benefit-cost, describes the need for
such analysis and applies methods described to illustrative examples.
The Conmittee has endeavored to ensure that no sources of pertinent knowl-
edge or expertise were overlooked in its study. During the course of its de-
liberations, the Conmittee solicited the opinions and counsel of several
individual scientists and others with information needed for a complete over-
view of the problem.
The subcommittees or individuals chiefly responsible for the preparation
of the more specialized chapters in this report are as follows:
Chapter III. Subcommittee on Concepts
Joseph E. Rail (Chairman), Michael S. Baram, J. Martin
Brown, George W. Casarett, Murray Eden, Anthony C.
Fisher, John V. Rrutilla, Edward B. Lewis, and R. Talbot
Page.
Chapter IV. Michael S. Baram, with the assistance of Eric Petraske,
and Frederic Mettier
Chapter V. Subcomnittee on Energy Production
Bruce C. Netschert (Chairman), Seymour Abrahamson,
Edward L. Alpen, Michael S. Baram, Cyril L. Comar,
Hans L. Falk, John V. Rrutilla, Oliver Smithies, and
Arnold Zellner
Chapter VI. Subconmittee on Medical Applications
Jacob I. Fabrikant (Chairman), Seymour Abrahamson,
Murray Eden, Earle C. Gregg, and George B. Hutchison
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ABVISORY COMMITTEE ON THE
BIOLOGICAL EFFECTS OF IONIZING RADIATIONS
George W. Casarett - Chairman
Univ. of Rochester Medical Center
Rochester, New York
Seymour Abrahamson
University of Wisconsin
Edison, Wisconsin
Edward L. Alpen
University of California
Berkeley, California
Michael S. Baram
Massachusetts Inst. of Technology
Cambridge, Massachusetts
J. Martin Brown
Stanford Univ. School of Medicine
Stanford, California
Cyril L. Comar
Electric Power Research Institute
Palo Alto, California
Murray Eden
Massachusetts Inst. of Technology
Cambridge, Massachusetts
Hans L. Falk
Natl. Inst. of Environnental
Health Sciences
Research Triangle Pk., N.Carolina
Earle C. Gregg
University Hospitals
Cleveland, Ohio
George B. Hutchison
Harvard School of Public Health
Boston, Massachusetts
Jacob I. Fabrikant -Vice Chairman
McGill University Faculty of
Medicine
Montreal, Canada
John V. Krutilla
Resources for the Future, Inc.
Washington, B.C.
Edward B. Lewis
California Inst. of Technology
Pasadena, California
Bruce C. Netschert
Natl. Economic Research Associates,
Inc.
Washington, B.C.
Bavid P. Rail
Natl. Inst. of Environmental
Health Sciences
Research Triangle Pk., N.Carolina
Joseph E. Rail
National Institutes of Health
Bethesda, Maryland
William L. Russell
Oak Ridge National Laboratory
Oak Ridge, Tennessee
Oliver Smithies
University of Wisconsin
Madison, Wisconsin
Arthur C. Upton
State Univ. of New York at
Stony Brook
Stony Brook, New York
Albert W. Hilberg
Senior Staff Officer
Bivision of Medical Sciences
Assembly of Life Sciences
National Research Council
National Academy of Sciences
Washington, B.C.
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CONTENTS
SUMMARY AND RECOMMENDATIONS 5
CHAPTER I - INTRODUCTION 12
CHAPTER II - NEEDS, PROBLEMS, AND APPROACHES OF THE TIMES 19
CHAPTER III - CONCEPTS OF BENEFIT-COST ANALYSIS 30
CHAPTER IV - LEGAL AND INSTITUTIONAL ASPECTS OF USING BENEFIT-COST. . . 73
ANALYSIS TO CONTROL IONIZING RADIATION
CHAPTER V - BENEFIT-COST ANALYSIS FOR ENERGY PRODUCTION 123
CHAPTER VI - BENEFIT-COST ANALYSIS FOR MEDICAL RADIATION 144
GLOSSARY I 188
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SUMMARY AND RECOMMENDATIONS
SUMMARY
It must be recognized that in discussing the possible usefulness of
benefit/cost analysis for radiation regulation, we are dealing with data
ranging from the known to the nebulous, of issues ranging from the practical
to the purely ethical, and of problems ranging from local to global and from
the recent past to the indefinite future.
For some questions, benefit/cost analysis can provide unequivocal an-
swers. For instance, if it were determined, statistically or theoretically,
that mass mammography screening programs induce more cancers than they de-
tect, then such programs should be halted. On the other hand, if studies
show that they detect twice as many cancers as they induce, but that the
dollar cost of the program, applied elsewhere, would result in a greater
number of cancer detections, the problem becomes more complicated but still
solvable. Again, if a non-radiation technique, such as ultrasonography or
thermography, were shown to be as effective as x-rays in detecting cancer
and to have no deleterious side effects, this would clearly be the preferred
technique.
In the middle ground are problems for which benefit/cost analysis may
provide information essential to informed decision-making, but can provide
no final answers. A hypothetical example might be that of airport x-ray
inspection devices. Analysis can yield data on the possible harm, to pas-
sengers and attendants, of such devices, on the dollar costs of the program,
and on the frequency and costs of airplane hijacking before and after the
program was instituted; but the value judgment must be a political-ethical
decision.
Perhaps the most important problems are those for which there are no
data—the effect of today's radiation ten generations hence, the probability
of a nuclear meltdown, the future buildup of nuclear wastes—but, at best,
only guesses which may be off by several orders of magnitude. Here, benefit-
cost analysis cannot be done in terms of dollars or other cannon units but,
with a different focus, it can identify issues which must be recognized if
rational decisions are to be made. The questions of who pays (rural people,
future generations) vs. who benefits (city people, present generation); of
maximum and minimum possible harm from a given course of action; of alternative
courses of action, can be spelled out.
This suggests a three-fold responsibility of federal regulatory agencies:
1) to promulgate regulations based on benefit/cost analysis, when such analysis
can provide clear answers; 2) to provide legislators with all relevant benefit/
cost data in areas where such data alone do not resolve the question; and
13) to bring to public attention the social and ethical benefit/cost consider-
ations, for which quantification is impossible.
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Benefit/cost analysis need not be undertaken if: 1) of two equally
beneficial alternatives, one is clearly less costly in both health effects
and money; 2) there is, in fact, no measurable alternative; or 3) society
has determined either that a given risk, e.g., nuclear meltdown, is unaccept-
able, however slight the odds or great the benefit, or, conversely, that the
benefits of nuclear power outweigh the costs, however great.
Clearly, a basic question arises in any attempt to apply benefit/cost
analysis to problems where data are largely conjectural or where ethical
considerations are paramount: will such an analysis help by contributing some
light to hitherto obscure areas, or will it hurt by focusing attention on
quantifiable parameters at the expense of less easily definable but more
important areas? For instance, is the attempt, which many have made, to
assign a monetary value to a human life helpful in at least providing an
economic baseline for analysis, or harmful in making an insoluble problem
seem manageable?
It seems unlikely that a benefit/cost analysis based on translation of
death and disability into lost work-years, or aesthetics into real estate
prices, which resulted in a ratio of one or greater would be generally con-
vincing given the necessarily arbitrary and narrow nature of the assigned
values. However, if by even such analysis the benefit/cost ratio comes to
less than one, it would suggest that, in fact, the aggregate of quantifiable
and unquantifiable costs must, to a greater degree than indicated by the
ratio, outweigh the benefits.
Nonetheless, there are cogent reasons for society to attempt health
benefit/cost analysis for major technological applications involving radiation
exposure of the population in comparison with feasible alternatives which
involve less or no radiation exposure. Such analyses could facilitate ra-
tional and cost-effective safety and control procedures and the avoidance of
health hazards and economic dislocations associated with excessive or inade-
quate expenditures in relation to risk. Health benefit/cost assessments,
even though present data are incomplete, can provide some guidance to decision-
makers, direct attention to gaps in knowledge, indicate priorities for research
and stimulate the accumulation of needed data and analysis, and contribute to
public understanding of the relevant issues and problems.
Although there are great benefits to be derived from the use of various
radiation technologies, there are also costs. In one form, these costs arise
as a risk of adverse health effects to members of the population. This risk
can be stated as a probability which, when applied to the population at risk,
gives the number of adversely affected persons. This adverse effect is a
social cost and, in principle, can be expressed as the monetary cost of the
adverse health effect. Additional private resource costs incurred in the pro-
vision of these benefits from the various radiation technologies are, of course,
also included in the total social costs. These are the terms defining health
benefits and health costs in this report.
This report deals with health benefit/cost analysis in terms of the needs,
problems and methodological approaches of the times, the concepts and param-
eters, ethical considerations, and regulations governing the deleterious agents
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involved. It illustrates application of methodology, but does not attempt a
definitive analysis. This report is not concerned with the reassessment of
risks from radiation exposure.
The goals of this report are to frame the problems, communicate the
elements of the complex technical processes and methods of analysis, and pro-
vide a basis for more informed governmental decision-making and public par-
ticipation in the issues.
The need to measure benefits, risks, and costs that include subjective
values and are subject to pluralistic social values adds greatly to the dif-
ficulties of health benefit/cost analysis.
Many investigators have made monetary estimates of the value of life, of
the biological damage caused by radiation exposure, of the expenditure justified
to avoid a given radiation exposure, of the value of a man-rad, or of the value
of a unit of risk to a life. There has been no internally consistent, theo-
retically justified conceptual basis for these studies, and although there has
been some consistency among the estimates based on various premises, they must
be viewed with some skepticism. Whether the method is acceptable is a ques-
tion for consideration along with the question of alternative approaches.
Chapter III of this report presents an exposition of conventional economic
benefit/cost analysis on the assumption that data are available where required.
This exposition brings to light many problems in an analysis of activities in
which radiation is produced. Radiation is considered in three major contexts:
1) its use in medical and dental diagnosis; 2) its use in medical therapy; and
3) its production in various stages of the nuclear fuel cycle. Each of these
situations is different, and examples from all of them are utilized in illus-
trating basic concepts of benefit/cost analysis.
In some situations, one economic strategy may so dominate all others that
there may be no need for valuing health or illness in monetary terms. However,
more extensive analysis is usually required, leading to the need to find a
comnon unit, e.g., monetization, for very elusive values. Also, inequities
may arise, e.g., the cost may be borne by a segment of the population which
does not share equally in the benefits. Another serious distributional prob-
lem relates to intergeneration effects: oil used today for the benefit of the
present population may impose increased cost on unborn generations; dangerous
long-lived radiomuclides produced today for a present benefit will be a cost
to future generations. When standard discounting procedures are used, future
generations and their welfare are largely ignored.
A special problem, is irreversibility. In conventional benefit-cost
analysis, decisions are assumed to be reversible. Such is not the case in
many aspects of benefit-cost analyses involving radiation and alternative
modalities. For example, this occurs both in the case of production of long-
lived dangerous nuclides by nuclear reactors and in the burning of irreplaceable
fossil fuels.
Improbable but serious accidental events pose another problem in analysis.
Melt-down of a nuclear reactor would be an example of this, and it is shown
that a special type of analysis is required for this situation.
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It is also shown that when the costs of a new program are very high and
when its benefits are uncertain, conventional benefit-cost analysis may under-
value the health and social costs.
A fundamental assumption of conventional benefit-cost analysis is that
human welfare (which benefit-cost analysis seeks to maximize) may be mea-
sured in monetary or materialistic terms. This assumption has fundamental
problems. The materialistic system may not be the best one; for instance, it
cannot handle the situations in which the risks and benefits do not accrue to
the same people.
Benefit-cost analyses in the health field tend to be filled with many
uncertainties and intangibles and to raise moral issues. Some people feel
that such analyses should not be attempted at all since they appear to equate
dollars with human lives. Other people feel that benefit-cost analyses, in
spite of their obvious shortcomings, can assist governmental agencies and
other public institutions in arriving at a rational allocation of resources
and personnel.
Irreversible processes, quality of life, risk avoidance, distributional
effects, incomnensurability, and ethical considerations are not adequately
addressed in conventional benefit-cost analysis. Therefore, under these con-
ditions, conventional benefit-cost analysis cannot provide an exclusive basis
for decision-making.
Chapter IV of this report reviews and assesses the efficacy of benefit-
cost analysis for purposes of decision-making in the regulatory agencies,
i.e., in the context of administrative and judicial decision-making on the
control of the harmful externalities of such regulated activities as energy
production.
The regulatory process is a relatively obscure one for most citizens.
It is remote in spatial and emotional terms, is. complicated and is not readily
amenable to public understanding and participation.
The questions about the uses of benefit-cost analysis in the regulatory
process which have been raised in this report are significant in that they
relate to societal capacity to protect human health and welfare now and for
the future generations which will bear the risks resulting from contemporary
decisions on radioactivity and other harmful substances.
In the regulatory process, the only apparent alternative to conventional
benefit-cost analysis has been cost-effectiveness analysis. As discussed in
this report, cost-effectiveness analysis requires the articulation of objec-
tives, the weighing of the alternative means to achieve the various articulated
objectives, and the selection of the least costly approach. For regulation of
nuclear energy sources of radioactivity, use of the cost-effectiveness approach
would entail the establishment of societal health objectives and risk param-
eters (e.g., carcinogenic risks) by legislative or other institutional processes
which are deaned acceptable as being socially representative.
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The task of making such decisions on health objectives is certainly a
difficult one but, once accomplished, the results may serve to ensure that
regulatory decision-making on energy production and other activities in-
volving harmful externalities is accountable with respect to articulated
societal objectives for environmental health. This process would additionally
force consideration of our stewardship for future generations. Consideration
of alternatives to conventional benefit-cost and cost-effectiveness analyses
for regulatory decision-making is perhaps the most critical need of the times
from the .standpoint of human health and survival.
One of the purposes of benefit-cost analysis of radiation uses is the
practical one of providing a rational basis for decision-making in the field
of radiation protection. It is hoped that this report may assist regulatory
agencies in carrying out missions in the environmental protection field. It
may assist agencies in decisions as to how best to allocate resources and
personnel in order to keep unnecessary exposure of the public to ionizing
radiation to a minimum.
A key element in the benefit-cost analysis of alternative strategies for
energy development or for other applications of radiation must include the
Immediate and long-term costs of regulation and compliance, as well as the
research costs underlying the development of standards and protection guides.
Another element of cost underlying various energy development strategies,
not often explicitly examined nor generally equivalent for all options, is
the cost of research and development assumed by all levels of government.
When these costs are not distributed to the users, a subsidy exists for that
option which must be accounted for in the benefit-cost analyses.
Benefit-cost analysis in nuclear power production is discussed in Chapter
V. In applying benefit-cost analysis to nuclear power production, the proper
comparison is with an alternative, such as fossil-fuel power production. The
externalities associated with both technologies must be included in the analysis,
in relation to all stages of both the nuclear and fossil fuel cycles.
Benefit-cost analysis can be applied effectively to nuclear power pro-
duction at the level of technical decisions. However, where national policy
is involved, decisions must inevitably be made on the basis of value judg-
ments, to which economics, including benefit-cost analysis, can make only a
limited contribution.
Models for benefit-cost analysis for medical and dental uses of radiation
are developed in Chapter VI. The ethical considerations relating to radiation
protection are placed in the perspective of current patterns of medical prac-
tice in the united States. The models developed are based primarily on the
economic cost of illness and are designed to achieve a benefit-cost relation-
ship. The models are general and imprecise, unifying simplicity is achieved
by monetization of benefits and costs and by relating the costs to the benefits
to be derived by the individual and society as a whole. The prevention of
disease and the failure to cure existing ill-health are considered in terms of
the gain or loss of human resources. The reduction of radiation risk is con-
sidered as a means to achieve improvement in the benefit-cost ratio. The
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reduction-of-risk model is developed using a reduction-of-dose method; means
to achieve this without impairing potential benefits of medical radiation are
described. An approach to the development of alternative technologies and
methodologies is considered briefly.
RECCtMENDATIONS
1. Development of national policies and strategies involving such activ-
ities as nuclear power production and medical uses of radiation and
their alternatives, should be guided to the extent possible by health
benefit-cost analyses. It should be recognized, however, that such
analyses can only determine choices at technical levels where the
technical information is available and cannot dictate choices or
replace the ultimate responsibility of the decision-maker at higher
levels where policy decisions mist inevitably include more value
judgments.
2. Regulation of radiation emissions from a source (e.g., nuclear power
plant) based on benefit-cost analysis should include consideration
of foreseeable and estimatable environmental and health effects of
the pollutant off-site and over time.
3. The health and environmental effects of such pollutants should be
considered by all interests including non-developmental or non-
promotional interests, and limitations or parameters publicly estab-
lished as to the permissible levels of such effects. Such limitations
or parameters should be used in the benefit-cost analysis guiding the
setting of control standards.
4. Conventional benefit-cost analysis, when extended along the lines we
suggest in this report, would prove of some value, though limited, in
assessing the relative merits of specific uses of radiation and alter-
native options, particularly at the technical level; for example,
nuclear vs. fossil fuel cycles for energy production. Other factors,
such as ethical considerations, will also need to be taken into
account in the decision-making process.
5. Research efforts leading to the assignment of weighting factors to
the elements of benefit-cost analysis which currently may be under-
valued by marketplace economics, in comparison with societal value
judgments, are recommended as an approach toward overcoming short-
comings of conventional benefit-cost analysis.
6. Careful study and appraisal of the benefits, risks, and costs to
society and the individual of medical applications of radiation should
be undertaken to provide the data required for the extensive benefit-
cost analyses which could serve to guide the process of decision-making
in diagnostic applications of radiation.
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7. Careful benefit-cost analysis should be conducted to the extent
possible as a guide in decisions as to whether or not to undertake
mass x-ray screening programs of large populations in comparison
wLth other alternatives.
The Committee urges that there should be a concerted effort to improve
the benefit-cost ratio in medical applications of radiation, without limiting
the benefits derived from modem radiological services. The largest current
source of controllable man-made radiation exposure, by a factor greater than
10, is medical x-rays. Some exposures are of doubtful or no value to the
individuals exposed. It would appear that the most significant and cost-
effective reduction in the radiation exposure of the population as a whole
is likely to be achieved by the development of methods of eliminating medically
unproductive x-ray exposures.
To improve the benefit-cost ratio in relation to radiation exposure from
nuclear energy production and to improve the data base for benefit-cost analysis
of alternative technologies, the Committee urges the following activities:
(a) Improved training of protection personnel;
(b) Education of operators and users of energy sources and medical
devices in sound personnel protection practices;
(c) Animal research directed toward investigation of dose-response
relationships for genetic and somatic effects of various types of
energy-production pollutants as a basis for rational comparison of
all pollutants and the setting of standards;
(d) Epidemiological studies of people exposed to various levels and
kinds of energy-production pollutants; and
(e) Continuing research in the development of improved protection
methodology and procedures.
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CHAPTER I
INTRDDUCTION
Contents
A. BEIR Report of 1972 13
B. Task of the Present NAS-NRC Advisory Comnittee 15
C. General Approach in the Present Report 16
References 17
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Chapter I
ZNTRODUCTION
A. The BEIR Report Of 1972
In its Report (The BEIR Report) of 1972, on "The Effects on Populations
of Exposure to Low Levels of Ionizing Radiation1 (1), the NAS-NRC Advisory
Committee on the Biological Effects of Ionizing Radiations estimated radiation
risks, but did not deal with the methodology of benefit-cost analysis. That
Report stated: "We need standards for the major categories of radiation ex-
posure, based insofar as possible on risk estimates and on benefit-cost
analyses which compare the activity involving radiation with the alternative
options. Such analyses, crude though they must be at this time, are needed
to provide a better public understanding of the issues and a sound basis for
decision. These analyses should seek to clarify such matters as: (a) the
environmental and biological risks of given developments, (b) a comparison
of these risks with the benefits to be gained, (c) the feasibility and worth
of reducing these environmental and biological risks, (d) the net benefit to
society of a given development as compared to the alternative options."
"In the foreseeable future, the major contributors to radiation exposure
of the population will continue to be natural background with an average whole-
body dose of about 100 mrem/year, and medical applications which now contri-
bute comparable exposures to various tissues of the body." (See Table I.I
for sources and amounts of radiation exposure.) "Medical exposures are not
under control or guidance by regulation or law at present. The use of
ionizing radiation in medicine is of tremendous value but it is essential
to reduce exposures since this can be accomplished without loss of benefit
and at relatively low cost. The aim is not only to reduce the radiation
exposure to the individual but also to have procedures carried out with
maximum efficiency so that there can be a continuing increase in medical
benefits accompanied by a minimum radiation exposure."
"Concern about the nuclear power industry arises because of its potential
magnitude and widespread distribution. Based on experience to date and pre-
sent engineering judgment, the contribution to radiation exposure averaged
over the U.S. population from the developing nuclear power industry can remain
less than about 1 mrem per year (about 1% of natural background) and the ex-
posure of any individual kept to a small fraction of background provided that
there is: (a) attainment and long-term maintenance of anticipated engineering
performance, (b) adequate management of radioactive wastes, (c) control of
sabotage and diversion-of fissionable material, (d) avoidance of catastrophic
accidents."
The BEIR Report indicated that to the extent that existing guidelines
and medical radiation exposures can be reduced without impairing benefits,
the exposures are unnecessarily high. As recommended by the NCRP (2), such
radiation exposures should be kept "as low as practicable" below recommended
numerical limits.
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TABLE I.I.
Sinmary of Estimates of Annual Whole-Body
Dose Rates in the United States (1970)
Source
Environmental
Natural
Global Fallout
Nuclear Power
Subtotal
Average Dose Rate*
(mrem/yr)
102
4
0.003
106
Annual Person-Reins
(in millions)
20.91
0.82
0.0007
21.73
Medical
Diagnostic
Radiopharmaceuticals
Subtotal
72**
1
•i^^^HB
73
14.8
0.2
15.0
Occupational
Miscellaneous
TOTAL
0.8
2
182
0.16
0.5
37.4
* Note: The numbers shown are average values only. For given segments of
the population, dose rates considerably greater than these may be experienced.
** Based on the abdominal dose.
From the BEIR Report (1972). (Ref. 1)
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Some of the reconrnendations of the BEIR Report are concerned directly
with the task of the present Committee, i.e., benefit-cost analysis. In this
regard the Report stated: "It is not within the scope of this Committee to
propose numerical limits of radiation exposure. It is apparent that sound
decisions require technical, economic and sociological considerations of a
complex nature. However, we can state some general principles, many of which
are well-recognized and in use, and some of which may represent a departure
from present practice." (Quoted below are those "principles" closely con-
cerned with benefit-cost assessment.)
"a) No exposure to ionizing radiation should be permitted without the
expectation of a conmensurate benefit.
b) The public must be protected from radiation but not to the extent
that the degree of protection provided results in the substitution
of a worse hazard for die radiation avoided. Additionally there
should not be attempted the reduction of small risks even further
at the cost of large sums of money that spent otherwise, would
clearly produce a greater benefit.
c) There should be an upper limit of man-made non-medical exposure for
individuals in the general population such that the risk of serious
injury from somatic effects in such individuals is very small rela-
tive to risks that are normally accepted. Exceptions to this limit
in specific cases should be allowable only if it can be demonstrated
that meeting it would cause individuals to be exposed to other risks
greater than those from the radiation avoided.
d) Medical radiation exposure can and should be reduced considerably
by limiting its use to clinically indicated procedures utilizing
efficient exposure techniques and optimal operation of the radiation
equipment. Consideration should be given to the following:
1) Restriction of the use of radiation for public health
survey purposes, unless there is a reasonable probability
of significant detection of disease.
2) Inspection and licensing of radiation and ancillary
equipment.
3) Appropriate training and certification of involved personnel.
e) Guidance for the nuclear power industry should be established on the
basis of benefit-cost analysis, particularly taking into account the
total biological and environmental risks of the various options avail-
able and die cost-effectiveness of reducing these risks. The quan-
tifying of die 'as low as practicable1 concept and consideration of
die net effect on die welfare of society should be encouraged.
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f) In addition to normal operating conditions in the nuclear power
industry, careful consideration should be given to the probabilities
and estimated effects of uncontrolled releases. It has been esti-
mated that a catastrophic accident leading to melting of the core
of a large nuclear reactor could result in mortality comparable to
that of a severe natural disaster. Hence extraordinary efforts to
minimize this risk are clearly called for."
B. The Task Of The Present NAS-NRC Advisory Comnittee
The task proposed by the Environmental Protection Agency (EPA) and
accepted in principle by the present NAS-NRC Advisory Committee on October 18,
1973, is specified below in detail.
"The Director, Criteria and Standards Division, Office of Radiation Pro-
grams, Environmental Protection Agency, has requested that the National Academy
of Sciences investigate the problem of evaluation of the total benefits derived
from exposure to ionizing radiations for comparison with the total risks. This
study is intended to complement the recently completed study on reassessment
of biologic risks associated with low level exposure to ionizing radiation.
This study will include considerations of benefits and risks of options alter-
native to radiation exposure, as well as any benefits and risks associated
with radiation exposure, especially as they place the benefits and risks of
radiation exposure in perspective for guidance and for public understanding."
"To perform the comparative evaluation of benefits and risks the Advisory
Committee on the Biological Effects of Ionizing Radiations would:
1) Review and evaluate benefit assessment techniques that may be
available.
2) Develop benefit/risk assessment methods which will be useful in
performing comparative studies of benefits and risks from activities
involving exposure to ionizing radiations.
3) Apply the techniques where possible.
4) Evaluate associated factors of benefits and risks in ways that could
be used in the establishment of reasonable protection guides."
"The BEIR Committee would include in its membership for this purpose
persons from social, economic, legal, technological fields, etc., as well as
persons from the more directly related areas of sciences."
"The categories of benefits which might be considered, among others, are:
1) survival and health, 2) security, and 3) self-gratification or other life
quality factors, i.e., any factors which could provide a framework for arriving
at measures of benefits relative to risks or costs."
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"The end-point or goal of such a study would be primarily the devising
of methods of balancing benefits and risks, which could and would then be
applied to various categories of radiation usage."
To carry out the required review and analysis, three subcoranittees were
formed to deal with the following subject areas: 1) concepts, 2) energy pro-
duction, and 3) medical applications.
C. General Approach In The Present Report
The main categories of radiation exposure or usage considered in this
report in regard to the principles of benefit-cost analysis are energy pro-
duction and medical applications of radiation. These are the most important
with respect to peaceful man-made radiation exposure of the population cur-
rently (medical radiation) or potentially (nuclear power generation), and
with respect to their potential benefits. They also represent situations
requiring substantial differences in modeling, benefit-cost alternative
factors, and analytical problems.
The general approach in this report includes consideration of the fol-
lowing: concepts of benefit-cost analysis; available assessment techniques
and processes; conditions and agents positive and negative to health, life
expectancy, and quality of life in regard to radiation usage or exposure and
to feasible alternatives; distribution of these positive and negative con-
ditions and agents and their effects spatially and temporally with respect
to population; regulations governing deleterious agents; ethical principles;
effects in terms of benefit versus risk; conversion of quantified benefit
parameters and risk parameters into cannon units, e.g., monetary units, for
overall analysis and comparisons of benefit and risk; and risk perception
and acceptability.
The goals of the report are to frame the problems, conmunicate the elements
of the complex technical processes, and provide a basis for more informed public
participation in related issues. In the present state of severely limited quan-
titative knowledge pertinent to many of the essential elements or this highly
complex problem, it is not now possible to provide a comprehensive and de-
finitive, and therefore completely persuasive, analysis in this Report.
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CHAPTER I
1. National Academy of Sciences Advisory Committee on the Biological Effects
of Ionizing Radiations (the BEIR ConraLttee). The Effects on Pop-
ulations of Exposure to Low Levels of Ionizing Radiation. National
Academy of Sciences—National Research Council, Washington, D.C.,
(1972).
2. National Council on Radiation Protection and Measurements (NCRP). Basic
Radiation Protection Criteria. Report No. 39. NCRP, Washington,
B.C., (1971).
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CHAPTER II
J, PROBLEMS, AND APPROACHES OF THE TIMES
Contents
A. Needs and Associated General Problems 20
B. Problems of Risk Estimation, Perception, and Acceptance 24
References 29
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CHAPTER II
!, PROBLEMS, AND APPROACHES OF THE TIMES
A. Needs and Associated General Problems
In discussing needs of the times, the BEIR Report (1) states: "When
the risk from radiation exposure from a given technological development
has been estimated, it is then logical for the decision-making process that
comparisons be made and consideration given to a) benefits to be attained,
b) costs of reducing the risks, or c) risks of the alternative options in-
cluding abandonment of the development. The concept of always balancing the
risk of radiation exposure against the expected benefit has been well-
recognized and accepted, but no serious attempt has been made to evaluate
both sides of the equation in any way that could lead to operational guidance.
Official recommendations call for radiation exposure to be kept at a level
'as low as practicable,' a policy that emphasizes and encourages sound prac-
tice. However, risk estimates and cost-benefit analysis are needed for
decision-making. An additional important point, often overlooked, is that
even if the benefit outweighs the biological cost, it is in the public
interest that the latter must still be reduced to the extent possible pro-
viding the health gains achieved per unit of expenditure are compatible with
the cost-effectiveness of other societal efforts."
"It appears logical to attempt to express both risks and benefits in
comparable terms—dollars. To a limited degree risks can be estimated in
such terms. For example, the statement of risk can be expressed in terms
of cost to an individual or to his family and society since there are spec-
ific expenses attributable to an effect. Similarly, estimates can be made
of expenses required to effect given reductions of exposure to harmful agents.
In some instances, it may not be necessary to use absolute dollar costs:
that is, one can compare the cost of different ways of producing the same
desired objective. Given the need for additional electrical power, one might
compare nuclear plants and fossil fuel plants directly in terms of total
biological and environmental costs per unit of electricity produced. Often,
however, there will be need for information on absolute costs. This will
occur when decisions have to be made on whether the public interest is bet-
ter served by spending our limited resources on health gains from reducing
contamination or by spending for other societal needs."
"It must be emphasized that there are many inherent problems in cost-
benefit analysis that will prevent rigorous application in the very complex
systems of present concern to society. These include the implication of
assigning a monetary value to human life, suffering or productivity; the dif-
ficulty in assessment of factors related to the quality of life such as recre-
ational water and land resources; the fact that the costs and benefits may
not accrue to the same members of the population, or even to the same generation
and the virtual impossibility of establishing a single cost-system that would
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be socially acceptable and still take into account differences in individual
willingness to accept various types of risks. An illustration of the latter
points is the observation that health and envirortnental effects from power
plants would be reduced by their location in relatively unpopulated areas.
Yet the people in such areas generally are not the ones who need the additional
electrical energy."
"Despite these uncertainties, there are important advantages in attesting
cost-benefit analyses. There is a focus on the biological and enviroimental
cost from technological developments and the need for specific information
becomes apparent. Thus, for example, we find relatively little data available
on the health risks of effluents from the combustion of fossil fuels. Further,
it is becoming increasingly important that society not expend enormously
large resources to reduce very small risks still further, at the expense of
greater risks that go unattended; such imbalances may pass unnoticed unless
a cost-benefit analysis is attempted. If these matters are not explored,
the decisions will still be made and the complex issues resolved either
arbitrarily or by default since the setting and implementation of standards
represent such a resolution."
"We now come to an important area that requires newer approaches. It is
suggested that numerical radiation standards be considered for each major type
of radiation exposure based upon the results of cost-benefit analysis. As a
start, consideration should be given to exposures from medical practice be-
cause of present relatively high levels of exposure and from nuclear power
development because of future problems of energy production and the need for
public understanding."
"With the development of modern health care programs in the Western
world, there has been a marked increase in the use of radiation in the healing
arts—medical diagnostic radiology, clinical nuclear medicine, and radio-
therapy. This has resulted in the recognition that medical radiation now
contributes the largest fraction, by one or two orders of magnitude, of the
dose from man-made radiation to the united States public." "The significance
of this lies in the absolute reduction of exposure that could be brought about
at relatively low cost with no reduction in medical benefit...."
"The difficulties in attaining a useful cost-benefit analysis for nuclear
power are formidable and will require interdisciplinary approaches well beyond
those that have yet been attempted. Areas that require evaluation include:
a) projection of energy demands, b) availability of fuel resources, c) techno-
logical developments (clean combustion techniques, coal gasification, breeder
reactors, fusion processes, magnetohydrodynamics, etc.), d) public health and
enviroranental costs of electrical energy production from both nuclear and fossil
fuel including aspects of fuel extraction, conversion to electrical energy,
and transmission and distribution."
Society now has. the task of reducing the population exposure to hazardous
agents, such as radiation and the pollutants from fossil-fuel combustion, to
levels as low as practicable or readily achievable, and must know where to
stop and where and how to allocate its limited resources for health protection
and safety to obtain the best yield in reduced risk from activities providing
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public needs and benefits. The further the process of risk reduction goes
the higher the cost per unit of risk reduced, and eventually a level is
reached where a further reduction is prohibitive and unjustified.
Implicit in the attempts of society to eliminate unnecessary exposures
or risks is the application of some form of cost-benefit analysis. Partic-
ularly in the area of health and safety, the government is making, and the
public is demanding, an increasing nunber of preemptive decisions that in-
volve, or should involve, an analytical process for decision-making capable
of evaluating immediate and potential risks and costs and of balancing social
benefits.
In attempting to establish an analytical methodology of decision-making,
some of the most basic questions and problems are concerned with how people
would measure and make judgments of the utility or attractiveness of various
activities, how people would measure and judge the probability of events that
can affect them, how judged probabilities would be changed in accordance with
the arrival of new information, and how measured and judged utilities and
probabilities could be quantified in comparable or cannon units and combined
for input to decisions.
A major philosophical question for decision is whether or not there exists
an unacceptable risk, in the sense that when the hazardous consequences of a
particular event stemming from a development or activity reaches a certain
magnitude it becomes unthinkable to allow even the most remote possibility of
that event occurring. If a risk were determined to be unacceptable, it would
be necessary either to design the development to make the event impossible,
or to forego the benefits and abandon the development or activity. This con-
cept places an infinite value on risks of the size under consideration. On
the general question of risks that may be regarded as unacceptable regardless
of the probability of occurrence, a Committee on Public Engineering Policy
(COPEP) Report (2) indicates that COPEP "believes that risks and benefits
must be regarded as a continuim, and incremental changes across the whole
range must be part of the analysis."
In performing decision analyses, there is a tendency to concentrate on
those aspects that are easier to treat, such as those involving quantifiable,
commensurable variables, and to neglect the more subtle or subjective variables
involving psychological factors, quality of life, aesthetics, loss or gain in
personal freedom or privacy, etc. Also, it is difficult to represent the con-
cerns of people in a manner compatible with the balance of the analysis.
There are problems of dealing with different ethics and values, problems of
dealing with present versus future generations, problems of ascertaining what
people are willing to pay for certain benefits, problems of dependencies among
different values, the problem of acceptability of alternatives in the context
of possible future shifts in values, and other problems of interaction.
Traditionally, benefit-cost ratios in engineering planning and design
have been the province of economists who dealt with the monetary costs of
projects in relation to expected performance, savings or profits. Benefit-
cost analysis now often refers to an evaluation of all of the benefits and
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the costs of a proposed activity, and includes also benefit-risk analysis in
which risks to life and health are an important component of the consideration
of costs. This greater comprehensiveness makes the analysis more difficult
and perhaps for the time being less definitive.
Starr (3) has pointed out that society's historical empirical approach
to arriving at acceptable balances of technological benefit and social cost,
by trial, error, and subsequent corrective steps, creates in advanced soci-
eties today a critical situation, for two reasons: 1) the difficulty in
changing a technical subsystem once it has been woven into the economic,
political, and cultural structures; and 2) the techniques for societal dif-
fusion of a new technology and its subsequent exploitation are now so highly
developed that widespread use of a new technological development may occur
before its social impact can be properly assessed, and before any empirical
adjustment of the benefit-versus-cost relation is obviously indicated.
Only recently have the administrative and technical tools enabling pos-
sible comprehensive, quantitative and practical benefit-cost analysis become
available. There has been increasing application of benefit-cost analysis
and benefit-risk analysis in assessment of technology. As part of this pro-
cess, the side effects and long-range consequences may be evaluated along
with the more immediate, obvious and direct consequences.
Although such analyses, as they become increasingly more comprehensive
and accurate, will be of increasing usefulness to decision-makers in choosing
between alternative technical approaches to solve societal problems and in
allocation of societal resources, they do not alone determine how much tech-
nology of one or another kind a society can justifiably purchase.
There are many independent factors, ranging from the scientific to the
political, in benefit-cost analysis, in the subsequent decision-making and
in the setting of protective safety standards for technological activities.
Health scientists, acting only in their roles as scientists, are con-
cerned with the development and correctness of knowledge and evaluation of
the health effects of the technological activity. The political represen-
tatives of society receiving scientific, technical, and political information
are concerned with the costs and the extrinsic values that society assigns
to the effects and with the exercise of wisdom in decision-making concerning
a value acceptable for society for the effects in relation to the benefits of
the activity.
Because of the inadequacies of currently available data on certain ef-
fects and their mechanisms, and in some cases the possible existence of as
yet unknown effects, biomedical scientists are currently limited in the
degree to which they can meet public expectations. For this reason, accurate
assessment of health costs for use in setting standards requires a substantial
research effort.
The prime motivation for establishing protection standards for the
public is political, i.e., the general public, through its formal institu-
tions, defines the goals and promulgates the rules. Society's political
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institutions give the authority and responsibility for establishing acceptable
standards to the standards-setters who mist evaluate the costs of pollution
and balance them against the costs of abatement, i.e., translate the biological
effects or risks into societal costs.
Currently, electromagnetic radiations are covered by federal laws either
related to the Atomic Energy Act, as amended, or to the Radiation Protection
Act of 1968. Through these laws, the federal government can regulate ionizing
radiation emissions from nuclear processes and natural radioactive materials,
as well as ionizing and non-ionizing radiation generated by machines. The
National Environmental Policy Act of 1969, as implemented by the Council for
Environmental Quality, specifically requires government agencies to consider
alternatives to proposed actions affecting the environment and requires
environmental impact statements from those proposing developments which may
affect the environment. There is increasing need and awareness of the
government's responsibility to take into account the benefits and risks
associated with program decisions, consumer demands, new regulations con-
cerning efficacy and safety. The National Environmental Policy Act requires
governmental agencies to study and publish evaluative statements prior to
the making of project decisions with significant environmental impact.
B. Problems of Risk Estimation, Perception and Acceptance
The deleterious side effects of technological activities or pollutants
on health may range from the probable occurrence of slight harm to the im-
probable occurrence of severe harm, and range widely from minor discomfort
to violent death, from transitory to permanent, from localized to worldwide.
The deleterious agents may be chemical, physical, or biological, of naturally
occurring types increased above natural concentrations or synthetic types
more easily identified, from obvious or obscure sources. The relationship
between the deleterious agents and their resultant health effects may be
obvious and recognized immediately, especially those effects which follow
soon after exposure (acute effects), or more obscure, such as those effects
occurring long after brief exposure, or as a result of long low-level chronic
or intermittent exposure. Careful epidemiologic analysis may be needed to
reveal increased frequency of an otherwise naturally occurring effect in the
exposed population.
There can be considerable individual variation in response to radiation
and the various other pollutants, such as those from fossil fuel energy pro-
duction, of concern as subjects of this report. The individual variations in
response relate to stage of development or age, clinical condition, sex, and
genetic constitution.
The somatic health effect of exposure to pollutants that is probably
of greatest public concern is cancer. Radiation and various environmental
chemical pollutants are known to be carcinogenic. One of the difficulties
in evaluating carcinogenic potential of low levels of radiation and chemical
environmental pollutants in human beings is the long latent pieriod between
exposure and development of cancer. Another problem is related to the pos-
sibility of additive or synergistic effects among agents which individually
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may be weakly carcinogenic at the environmental levels of concern and
difficult to identify. Ionizing radiations from external sources and radio-
nuclides are used in medical applications and are pollutants from nuclear
energy power production. The classes of carcinogenic agents identified so
far as being present in products of fossil fuel combustion are polycyclic
and other aromatic hydrocarbons, trace metals, and radionuclides.
Genetic effects, i.e., those occurring in the progeny of the exposed
persons, are caused by a class of agents called mutagens. Ionizing radiation
and various chemical pollutants are mutagenic. Mutational changes vary in
severity from subtle changes of negligible consequence for health to lethal
effects. Owing to uncertainty as to how genetic effects of deleterious
agents in the environment will be expressed and recognized, accurate quan-
tification is difficult if not impossible. However, because of the exten-
sive experimental research done on the genetic effects of ionizing radiation,
it is possible to predict roughly by extrapolation the possible types and
numbers of effects that might be caused in human populations from increased
levels of radiation.
There is a dilemma in attempts to assess the health effects of low
levels of a pollutant in large populations when the pollutant is known to
be harmful only at higher levels. After radiation came to be known as
harmful at high levels and, as a result of nuclear weapons testing and
extremely sensitive means of detection of radioactivity, it was found that
many living organisms throughout the world contained detectable amounts of
man-produced radioactivity, such large amounts of money and manpower were
spent for research on this potential source of harm that probably much more
is known about the effects of ionizing radiation than about the effects of
other agents to which man is exposed. More recently, sensitive measures
have been developed for various chemical pollutants, including those from
fossil fuel combustion, in the biosphere that could be potentially harmful,
so that now there is concern and pressure to eliminate completely or greatly
reduce the possible health risks from these agents.
There is a need for better public understanding of the problem, the
relationship between the level of a harmful agent and its potential effects,
and the virtual impossibility of eliminating all potential risk from most
activities.
For any deleterious agent, there is a range of high levels which are
lethal and cause death early in a large proportion of the exposed population.
Below that range is a range of levels causing observable acute signs of ef-
fect but with a lesser incidence of early death, if any. These acute clinical
effects may disappear and not necessarily be long-term contributors to ill
health, or may be indicative of high probability of serious late effects.
At still lower levels of the deleterious agent, early or late effects of
various kinds may be difficult or impossible to detect definitely by current
methods in human populations, either because they are minor or subtle or if
serious occur late and with very low frequency. If the probability or risk
of such serious late effects is suspected or perceived to be high enough,
society may consider the risks intolerable. Enough is known about ionizing
radiation that risktLevels in this range can be specified. Within the present
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guideline levels for radiation protection, no serious health effects have
been observed in exposed populations, clinically or epidemiologically,
although on the basis of radiobiological theory it is postulated that such
effects could occur. At some low levels for any deleterious agent, the
probabilities of effects may be so low that society is willing to accept
them and is justified in this acceptance if the effects are more than com-
pensated by the associated benefits of the activities that produce the agents.
The understanding of risk, and the problem of risk acceptance, in re-
gard to low levels of various pollutants, requires an understanding of the
distinction between two types of agents, those with a dose "threshold'' for
effect and those with no dose threshold for effect ("non-threshold"). For
"threshold" agents, there is some level below which the agents do not cause
a specified effect. For "non-threshold" agents, there are certain specified
effects which occur in some incidence as a consequence of any level of the
agent. Regulatory procedures and standards that presumably guarantee absence
of risk can be set for threshold agents. However, for non-threshold agents,
there must be acceptance of some level of risk unless the agent can be
eliminated completely. To obtain the benefit of an activity which produces
a deleterious agent, and at the same time minimize the risk to the public
as much as possible in relation to the worth of the benefit, it is desirable
to establish regulations limiting population exposure to the agent at some
appropriately low level. For this purpose, it is important to gain knowl-
edge of the mathematical relationship between level of exposure and incidence
of serious effects, and the actual or at least the probable nature and slope
of this relationship in the range of exposure levels of interest, so that
public acceptance of certain levels of risk commensurate with associated
benefits can be recommended.
In considerations of health risks of technological activities, severe
disability and premature death have been emphasized because they are the
most important effects and because it is difficult to quantify and evaluate
meaningfully many of the less serious effects. Even these serious effects
are variable in their impact on individuals and society, e.g., in regard to
age at the time of occurrence, societal responsibilities, productivity, etc.
At present, it is not possible in the formulation of risks and costs to
estimate the number of person-years lost because of exposure to the agent
or to weigh them to account for societal and personal impacts.
On the other hand, it is possible that morbidity and disability may
have even greater impact on societal welfare than premature death in some
respects. Although mortality data are most readily available and quanti-
fiable, they are at best only indicative of the total risk, such that the
total social cost would be better approximated by application of a factor
for associated disabilities. Furthermore, mortality or disability expressed
as incidence alone, unless converted to amount of life-time lost or duration
of disability, by accounting for age at occurrence, are not fully indicative
of individual loss or societal cost. The time required for disability and
death to occur as a result of exposure to various pollutants may vary greatly
depending upon the pollutant, the degree and intensity of exposure, and the
age at exposure. The factors of age-related incidence of mortality, life-
time lost, age-related incidence and degree and duration of morbidity or
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disability, age at exposure, changing social values as a function of age,
and other like public health parameters are parts of the full evaluation of
social costs theoretically and practically. However, owing to the current
inadequacy or uncertainty of relevant data for such complete analysis, eval-
uations in terms of orders of magnitude are usually the best that can be
expected.
Historically, there are many examples of benefit-cost analyses that
have been determined empirically; for example, society has evidently decided
that the benefits of automobile and airplane travel outweigh the risks and
economic costs. The fact that the social benefits from these and some other
voluntary activities of the public can be estimated and that there are readily
available historical data on accidents and health hazards for some of these
types of public activities, has prompted various attempts at quantitative
evaluation of such types of social cost.
A complication in assigning risk or cost values statistically is that
risks may be borne by some persons disproportionately in relation to their
share of the associated benefits. However, in situations involving allocation
of risks involuntarily to the public, in which a relatively large proportion
of the population is affected by the proposed activity and the maximum risk
to any population subgroup or individual is sufficiently small, the risk-
cost distribution may reasonably be regarded statistically, even when risks
and benefits are assuned disproportionately by different groups of people.
The values that have been least well considered, defined or quantified
in benefit-cost evaluations are those for human life (e.g., mortality, dis-
ability, discomfort) and aesthetics. The quantitative benefit-cost evaluation
implies the willingness to accept a certain level of risk of death or injury
in exchange for a sufficiently large benefit, biological or financial or
other. This also implies willingness to place a tangible value on human
life. Such value judgments are routine in our society. Directly or indi-
rectly, society is constantly setting and adjusting monetary values for human
life, disability and discomfort, for example, jury or court awards of finan-
cial settlements, in actuarial or insurance measures and in premium pay for
hazardous occupations. This concept is needed and useful practically as a
tool and common comparable unit in benefit-cost analyses and as a reflection
of a method society already uses, with the understanding that this use of
monetary values only indicates rather than summates some values of human
life and does not imply insensitivity to the concept that individual life
is priceless.
Data and estimates on deaths from induced cancer could be converted to
figures reflecting life-span lost. The economic costs to society, both in
terms of increased cost of medical services and loss of productivity, as well
as the economic losses of those persons more directly affected could be esti-
mated for cured and non-cured induced cancers. Also, estimates on increases
in ill-health due to genetic effects could be converted into economic costs.
Such conversion of the risk estimates to dollar figures would make possible
the adding of genetic and somatic effects in a common unit to facilitate a
general benefit-coat analysis.
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Several Investigators have made monetary estimates of the biological
damage caused by exposure to ionizing radiation or the expenditure justified
to avoid a given radiation exposure: these estimates range from less than
$100 to many hundreds of dollars per man-rad of radiation dose. The con-
sistency of such estimates from various sources suggests that, in the broadest
area of making benefit-cost analyses, the formulation of these difficult value
judgments is within the realm of possibility. Whether this method is accept-
able is a different question which must be faced along with the question of
alternatives.
The actual cost to society of a radiation-induced illness or death goes
beyond the monetary payments made to survivors, hospitals, etc., since the
value of life and health is also involved. The value of life and health to
the individual who is the potential victim is different from its value to
his relatives or to society. The dollar value of life and health is dependent
in some way on the possible outcomes and probabilities associated with the
level of risk. As an example of one aspect of this dependence, the value to
society but not to the individual of an expected life from 30 to 70 years of
age may be many orders of magnitude greater than that of living from 70 to
71 years.
The rational approach to dealing with risks is to measure risks and
associated benefits and costs of options and to develop a method for making
decisions on the optimal balance. It seems reasonable to anticipate that
some readily quantifiable aspects of risk and benefit may be determined with
increasing accuracy as more knowledge of relevant effects and their mechanisms
accumulates. On the other hand, where important aspects of risk and benefit
are highly subjective and cannot be readily quantified or evaluated, fully
meaningful benefit-cost analysis or balance is impossible to achieve. To
compare the presently subjective areas of benefit and risk would require
establishment of a system of criteria of judgment and weighting.
Risk evaluation and risk-acceptability evaluation are two distinct prob-
lems. It is relatively easy to perform retrospective risk-acceptability eval-
uation by examining examples of public acceptance of levels of risk for various
activities in relation to associated levels of benefits. Prospective risk-
acceptability evaluation, i.e., to estimate the subjective values placed on
future risks, is much more difficult.
The evident fact that the risk perspective of an individual may differ
from that of a social group creates a problem in a democratic political sys-
tem. Rational decision-making on a societal level may thus require an inten-
sive public education and public discussion of the issues and trade-offs.
This is particularly difficult in emotion-laden areas, and perhaps especially
so when death, disability and discomfort of human beings are involved.
In regard to the psychological factors to be taken into account in dealing
with the public and with the news media, one question is concerned with the use
of absolute versus qualified statements on risk. In general, scientific state-
ments require qualification, whereas there is a tendency for the news media, and
the public also, to perfer categorical statements, usually in fairly extreme form.
What may begin as well qualified simple and safe pragmatic assumptions by sci-
entists for interpretation of human data may become transformed into unqualified
dogma in communication to the public.
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CHAPTER II
1. National Academy of Sciences Advisory Comnittee on the Biological Effects
of Ionizing Radiations (the BEIR Comnittee). The Effects on Popu-
lations of Exposure to Low Levels of Ionizing Radiation. National
Academy of Sciences - National Research Council, Washington, B.C.,
(1972).
2. Comnittee on Public Engineering Policy (COPEP), National Academy of
Engineering. Perspectives on Benefit-Risk Decision-Making. Sum-
mary and Recommendations. National Academy of Engineering, Washington,
B.C., (1972).
3. Starr, C. Social benefit versus technological risk. Science 165:1232
(1969).
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CHAPTER III
CONCEPTS OF BENEFIT-COST ANALYSIS
Contents
A. Introduction 34
B. Scope 35
C. Process of Identification and Quantification of Positive and. ... 37
Negative Factors Associated with Health Benefit-Cost
Analysis
D. The Methodology for Benefit-Cost Evaluation of Biological 38
Effects of Ionizing Radiation
1. Surnnary 38
2. Introduction 40
3. Consideration of Benefit-Cost Analysis for Achieving 41
Lowest Practicable Levels of Ionizing Radiations
4. Structuring the Benefit-Cost Analysis of Ionizing 41
Radiation
a. Costs: Inputs and Outputs 42
b. Radiation as a Pollutant 46
c. Subsuming the Intermediate Product 51
5. Estimation and Measurability 51
a. Processes of Power Production 53
b. Diagnostic Radiology 54
c. Therapeutic Radiology 56
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Contents - continued
6. Complications Due to Uncertainties 56
a. Incremental Uncertainties 57
b. Major Uncertainties 59
7. Radiation Protection as a Factor in Benefit-Cost Analysis ... 61
8. Risk Avoidance, Irreversibility and the Distribution 62
of Costs
E. Ethics and Benefit-Cost Analysis 68
References 71
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Chapter III was prepared for this report by a subcomnittee consisting of the
following:
Joseph E. Rail - Chairman
National Institutes of Health
Bethesda, Maryland
Michael S. Baram
Massachusetts Institute of Technology
Canbridge, Massachusetts
J. Martin Brown
Stanford University School of Medicine
Standard, California
George W. Casarett
University of Rochester Medical Center
Rochester, New York
Murray Eden
Massachusetts Institute of Technology
Canbridge, Massachusetts
Anthony C. Fisher
University of Maryland
College Park, Maryland
John V. Krutilla
Resources for the Future, Inc.
Washington, B.C.
Edward B. Lewis
California Institute of Technology
Pasadena, California
R. Talbot Page
Resources for the Future, Inc.
Washington, D.C.
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CHAPTER III
CONCEPTS OF BENEFIT-COST ANALYSIS
Sunnary
In this chapter is presented an exposition of classical economic
benefit-cost analysis assuming that data are available where required. This
illuminates many problems in an analysis of activities in which radiation is
produced. Radiation arises in three major contexts: it is used for medical
diagnosis; it is used for medical therapy; and it is produced during power
production in atomic reactors. Each of these situations is different and
examples from all of them are utilized in structuring a benefit-cost analysis,
It is shown that in certain cases a given strategy dominates, e.g., if
both market-incurred costs and external costs (such as health effects or
landscape degradation) are less than for an alternative, then the need for
monetizing health or illness can be avoided.
In many cases, however, certain special problems arise. One of these
is inequality in distribution of effects. The costs may be incurred by a
segment of the population which does not enjoy the benefits. Another serious
distributional problem relates to intergenerational effects. The oil used
today for the benefit of the present population may mean an increased cost
is distributed to unborn generations. Entirely analogous is the problem of
dangerous long-lived radionuclides produced today for a present benefit
which are a cost to future generations. If standard discounting procedures
are used, the welfare of our grandchildren is largely ignored. Another
special problem is irreversibility. This occurs both in the positive sense
when long-lived dangerous nuclides such as plutonium are produced by atomic
reactions, and in the negative manner when fossil fuels are burned since
they cannot be replaced. In general, in classical benefit-cost analysis,
decisions are assumed to be reversible from a societal standpoint. Such is
not the case in many aspects of benefit-cost analyses involving radiation
and alternative modalities.
Improbable but serious events pose another problem in analysis. Melt-
down of a reactor is an example of this and it is shown that a different
type of analysis is required for this situation.
Finally, it is shown that when the costs of a new program are very high
and when its benefits are uncertain, standard benefit-cost analysis under-
values the health and social costs.
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CHAPIER III
CONCEPTS OF BENEFIT-COST ANALYSIS
A. Introduction
Comparison of costs and benefits is as old as human comprehension. The
decision of primitive man whether to go hunting or sleep when the larder is
full is basically a weighing of the costs versus the benefits accruing to
alternative actions. Msdern industry is constantly involved in benefit-cost
analyses and upon, their accuracy depends the company's future. Mast societies
have sporadically made intuitive judgments in which costs have been balanced
against benefits for alternative actions, where such actions may be war or
negotiation, public benefit or private prosperity, present expenditure or
present austerity. In the last few centuries some societies have been
governed in part on the principle that the sun of the multitudinous indi-
vidual assessments of personal benefits-costs will automatically yield a
rational national welfare maximum. This more or less implicit assumption
has usually been embedded in an economic system generally agreed upon in the
culture. There is a tendency, however, for individual benefit-cost analyses
to underestimate total costs by externalizing them. Production which allows
pollution of air, water, or land transfers some costs to society at large,
so that pollution is profitable for some individual businesses. Some soci-
eties have attempted centralized decision-making in which the general pop-
ulation has had (usually) a relatively small input into the analyses and
subsequent decisions. General ideologies have frequently been of overriding
consideration in such decisions.
Society, and in particular the united States, must now make difficult
choices concerning the standard of living which we and our children and their
heirs may achieve. The health and safety of the general population and the
amenities of life including especially the physical and biological condition
of the country and city, the land and water, also require decisions which
are to a great extent dependent on our choice for the standard of living we
expect. A society may have, and usually has had, the apparent opportunity
to defer decisions. It is obvious that postponing a decision is in itself
a decision and one that has as important and far reaching effects as making
a decision. Nonetheless, there is a human tendency to avoid those decisions
which leave a large fraction of the population dissatisfied no matter which
alternative is chosen. Hence, in the past^ deferral of difficult decisions
has, perhaps, been more common than decisive action. Several circumstances
have now converged to make societal decisions in the United States inevitable.
These are: 1) the increased role of the government in regulation of industry.
It is now not possible for many large industries unilaterally to make decisions
unconstrained by governmental regulations; 2) the realization by the majority
of the citizenry that the world's resources are finite and that consequences
flow from this; 3) an increasingly informed and vocal population which has a
certain amount of political influence and which is concerned with environmental
protection, public safety, etc.
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B. Scope
Given that decisions are required and that rationality demands analysis
before decision, this section will be concerned with an examination of the
process of benefit-cost analysis as it relates to ionizing radiation. This
radiation affects society in a variety of ways. The effects of the radiation
on living organisms are deleterious. It may kill, it may cause cancer, and
it may cause genetic damage. An important feature of the radiation at low-
dose levels is that the effects are random and are predictable only in a
statistical sense. If 1,000,000 adults receive 100 rads of general body
radiation, we can predict on the basis of certain assumptions that over a
period of 10 years duration of risk about 2,000 of them will develop leu-
kemia (1). We cannot, however, predict who will get leukemia and who will *
be spared. In special instances, therapeutic radiation can be used to destroy
cancerous tissue and per se_ have a beneficial effect. In other instances,
where radiation is used to visualize parts of the body for the purpose of
diagnosis, the radiation although deleterious is required for the process
of image formation. In still other situations, radiation is produced inci-
dental to but inevitably as a result of some process. The prime example of
this is radiation produced by atomic reactors. Each of these uses and sources
of radiation has such different and special features that they will be dealt
with separately. Moreover, some radiation is impossible to escape; everyone
received from naturally occurring radioisotopes and cosmic rays and about
0.1 rad/year. For comparison, in the United States each person on the average
receives about 0.07 -cadi-year from all medical use.
Increasing relative scarcity of traditional sources of energy is prob-
able within the coming decades. Nuclear energy has the potential for pro-
viding civilization with energy for several centuries but with attendant
unwanted radiation exposure. Hence, a document which deals with benefit-
cost analysis for activities involving radiation exposure must consider
energy sources and power production.
As seems evident from the foregoing and as will become clear later in
this discussion as various problems are considered in greater detail, it is
not possible, using the tools of benefit-cost analysis, to arrive at a for-
mula which will describe the exact amounts of oil, coal, and nuclear fuels
to be used each year. Nor will it be possible to have another formula which
will advise us how much to spend for research in the various actual and
potential energy supply systems such as coal, solar, geothermal, fusion,
etc. However, economic and benefit-cost analyses, although difficult, could
give guidelines for the optimal mix of different power sources for the United
States for the next several decades, given certain assumptions. These as-
sumptions fall into four categories and any attempt to formulate benefit-
cost calculation must begin with assumptions derived from each of these
categories.
The first category of assumption is concerned with irreversible
processes. These are of two types which have certain symmetrical
features. Depletion of oil is not only irreversible but given the
fact that United States oil production reached its peak several
years agb, the exhaustibility of oil resources is a problem of
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inmediate concern. Equally irreversible is the accumulation of
radioactive wastes from nuclear power stations. This generates
problems in handling and in storage which can only be a burden on
future generations. This special feature of irreversibility is
of critical importance and different qualitatively from most
parameters usually considered in benefit-cost analyses. Although
science and technology can offer some guidance, value judgments
are required as to the relative importance of depleting one re-
source versus providing an unwanted burden of radiation exposure
from radioactive wastes.
2. The time frame of the analyses is an important assumption. Does
one 6pHmizI~"the proportional share of different energy sources
for ten years or for 100 years? Clearly the results will differ
if we wish to spend energy profligately now or conserve it. An
ancillary but important consideration in this regard is the rela-
tionship between discoveries or inventions and the level of energy
availability in an economy. It seems likely that a technologically
advanced society will require mere energy but will also be more
likely to discover new ways of \ roducing substitutes for oil or
using or rendering less dangerous the radioactive wastes.
3. Another vital assumption necessary for any calculation is the
assumed level of energy consumption over whatever time span is
decided in the second assumption! An energy intensive economy
will produce more wastes and deplete more oil than will an
economy with a static or decreasing consumption of energy.
4. A final assumption involves a value judgment about the quality
of life, a term difficult to define precisely and subject to dif-
ference of opinion; for example, can the value of the energy pro-
duced from coal or nuclear power plants be weighed against the
ecological and aesthetic qualities? Naturally, there is no uni-
formity of opinion as to even what is aesthetically pleasing and
what is not.
These general considerations will be discussed in various parts of this
document.
In this chapter, we shall consider certain general mathematical state-
ments which are required for benefit-cost analysis. In this exercise, we
shall examine some unusual problems which arise. Paramount among these are
incannensurability among variables and inequalities in both temporal effects
and between those individuals who receive benefit and those who suffer damage.
These inequalities must be identified and segregated so that comparisons may
be made of functions or numbers having the same dimensions. In most analyses,
political and human factors enter into the construction of a method of benefit-
cost analysis. The difficulties, ambiguities and frequently almost arbitrary
assumptions inherent in most complex benefit-cost analyses concerning radi-
ation are so large that in a democratic society, public input into some of
these assumptions would appear to be required. It is conceivable that an
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analysis could be performed in such a way that assumptions are hidden and
arbitrary decisions about the value of human life and suffering concealed, so
that the results of an arcane formulation are presented to both decision -
makers and the public as an unarguable conclusion. The basic tenets of a
democratic society preclude this manner of decision making. Hence, we pro-
pose to consider those aspects of benefit-cost analysis in which judgments
of both an ethical and political nature are involved. Additionally, we hope
to examine from an historical or precedental aspect how these judgments may
properly be exposed to public appraisal and possible preliminary decisions
made, this review of analysis will demonstrate that in a certain sense
benefit-cost analysis which involves radiation is a stepwise process in which
various sectors of public opinion may be involved at several discrete points.
This implies that there is not one analysis to be presented to one decision-
making body, but that during the process there are multiple stages at which
decisions of a non-scientific nature are required.
Finally, we explore and make as explicit as possible the moral and
ethical considerations involved in benefit-cost analysis of this type. This
is in no sense an attempt to formulate moral judgments but is, rather, an
attempt to show at what steps in the analytic process ethical and moral
values are implicit.
C. Process of Identification and Quantification of Positive and Negative
Factors Associated with Health Benefit-Cost Analysis
In an effort to evaluate the benefits and costs of radiation regulation,
it is important to obtain the best data possible on the physical and biolog-
ical factors, i.e., distribution of radiation exposure and dose in the ex-
posed population and the biological effects of the radiation, before the
effort is made to transform such data into some comnon unit of account, say,
a value expressed in monetary units.
The process of health benefit-cost analysis for any of the various
activities resulting in radiation exposure of people or alternative activities
to the same ends which result in less or no radiation exposure (see Figure
III.l) involves: a) identification of the agent(s) or factor(s) affecting
health in a positive (beneficial) direction and in a negative (deleterious)
direction; b) determination of the spatial and temporal distribution of these
positive and negative agents or factors in the population; c) determination
or estimation of the probabilities and/or degrees and incidence of beneficial
effect and of deleterious effects of these positive and negative agents or
factors in the study population samples yielding the data; d) calculation of
the beneficial or deleterious impacts of these agents or factors on the total
population expected to be exposed on the basis of the determined or estimated
incidence values in study populations and assumptions concerning dose-response
relationships; and e) transformation of health impact values into common units
of account for comparison of health benefits and health detriments (costs),
e.g., dollars.
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Figure 111.1
Identification of
Health Benefit
Factors
B,
Benefits
Identification of
Health Cost
Factors
C,
Identificaition
of Population
Benefitted
Pi
Determination of
Probability of
Event BI
Occurring
Determination
of Probability
of Event Ci
Occurring (pCi)
Identification of
Population at Risk
Ni
Expected Value
for Number
Benefitted (Nb1)
Determination of
Unit Value
$B,
Determination of
Unit Cost
Expected Value
for Number (Me,)
Affected
CO
9°
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Qne property of ionizing radiation is that it is differentially absorbed
by various tissues of the body. This property is the basis of diagnostic
radiology. Another property of radiation, that it can cause reproductive
sterilization or destruction of cells, is exploited in radiotherapy. Although
these medical uses of radiation have positive effects (benefits) on health,
there may also be some undesired side effects that are negative or deleterious.
Accordingly, it is necessary to detail both positive and negative effects,
their impact and their transformation into some common unit of account, if
possible. The radiation that is produced in nuclear power production is a
natural consequence of nuclear transformations. Where a population is ir-
radiated coincidentally with achieving another purpose, as in the generation
of nuclear power, only the negative effects of the radiation need be evaluated.
Radiation protection may imply the substitution of a non-radiation for
a radiation related technology in some cases; for example, the substitution
of fossil fuel for nuclear in generating electricity. But there are health
and non-health related environmental effects not reflected in the market costs
associated with the alternative which also must be evaluated in a corresponding,
conceptually consistent, manner.
In Figure III.l is given a schematic block diagram that represents the
steps in the process of research and analysis associated with the evaluation
of the health effects—benefits and costs—of alternative technologies or
strategies involving different amounts of radiation exposure.
If the dollar costs of the resource or factor services used to carry on
an activity represent the total social costs, it is not necessary to under-
take extra-market benefit and cost analyses at each of the many stages at
which the various factors supplying services to the activity are produced.
On the other hand, if there are extra-market social costs, i.e., adverse
health and environmental effects not somehow incorporated into the dollar
costs of the services used in a given activity, it is then necessary to
analyze the extra-market, or external, costs associated with each activity
that feeds into the activity of primary concern. For example, it is known
that the externalities associated with the generation of electrical energy,
whether by combustion of fossil fuel or nuclear reaction, are not confined
to the power plant. Accordingly, non-market compensated adverse effects
associated with such activities as mining (whether coal or uranium), fuel
processing, waste disposal, etc., require the analytic and research treatment
implied by the schematic diagram in Figure III.l. Non-health related environ-
mental effects may also be involved depending on the nature of the activity.
D. The Methodology of Health Benefit-Cost Evaluation for Ionizing Radiation
1. Summary
In this section is presented a deterministic analytical model employing
production functions to illustrate the procedures which can be used in benefit-
cost analysis once the conceptual difficulties associated with a given social
goal have been resolved and when complete information is available. Discussed
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briefly are the ways in which the parameters—inputs and outputs—of the
production function are estimated. For elements determined by an uncon-
strained market the estimation is straightforward. However, in certain
important instances, the market price may be distorted, and thus require
an adjustment if it is to be used as a measure of benefit. Alternate
methods for estimating costs or benefits are treated briefly.
Other parameters are not ordinarily measured in monetary units. The
problems of incommensurability and the ways in which parameters measured
by different units can be reduced to a cannon unit are considered. It is
indicated that these procedures always involve implicit or explicit value
judgments. The concept of dominance is described as a technique for avoiding
the necessity for reducing all terms to the same unit.
The problem of incomplete information is subdivided into two parts.
When the range of uncertainty in the estimates is narrow the analytic pro-
cedures can still be used to good effect. However, it is argued that when
the estimate of the probability of occurrence of a grave event is itself
uncertain then a different mode of analysis is needed.
The final part of this section deals with social values affecting the
benefit-cost analysis. Discussed are distributional affects, that is, the
fact that the people who stand to gain from the introduction of a process
may be different from the people who will bear the cost or health burden.
Another factor discussed is the relation between uncertainty as to benefits
and costs prior to the establishment of a new process and the cost of ter-
minating the process if the actual experience shows the initial estimates
were seriously in error. In the case of a nuclear power source with a high
capital cost, the price of reversing the initial decisions may be so high
that the decision is virtually irreversible. These ideas are brought to-
gether within the concept of risk avoidance. It is shown that if standard
benefit-cost estimation practices are followed, the monetary equivalent of
a health or social cost will invariably be undervalued.
2. Introduction
The International Commission on Radiological Protection (ICRP) has recom-
mended (2) that the total benefits (B) from activities involving radiation
must be demonstrated to be greater than total (private and social) costs (C),
and that regulating, moderating, or controlling radiation doses must be car-
ried to the point where the gain from dose reduction achieved no longer war-
rants the increment in costs of control. This, of course, is a simple
representation of the standard criteria used in benefit-cost analysis, i.e.,
that Ab/Ac - 1 and that B- C > 0. It should be pointed out that procedurally,
it is necessary to equate the incremental benefits and costs to determine the
levels of radiation doses and costs of control that maximize the total net
benefit—or minimize the total net cost—a condition that should be realized
prior to the determination of whether or not the benefits from the radiation
exceed the costs.
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The ICRP has assumed that the conditions required to give normative
significance to results of benefit-cost analysis hold in situations concerning
biological effects of ionizing radiation. It is conceivable that either in
general or special cases this assumption is unwarranted, and this matter will
need to be examined in due course. For the moment, however, it may be in-
structive to determine what procedures should be followed in order to apply
ICRP's summary criteria for determining the "as low as practicable" dose
levels.
3. Consideration of Benefit-Cost Analysis for Achieving Lowest
Practicable Levels of Ionizing Radiations'
Many quantitative procedures have been devised to help decision-makers
choose from among several courses of action. However in order to carry out
a quantitative evaluation for a complex social undertaking, one must make a
large number of assumptions, although some of them may be of dubious validity.
The apparent objectivity of a numerical calculation tends to obscure the
weaknesses in the reasoning upon which the computation may be based. For
this reason it is preferable to regard benefit-cost analysis as part of the
process of dissecting the intricacies of a problem rather than as the only
tool for generating definitive answers.
We proceed in four steps. First, we consider a mathematical framework
for benefit-cost analysis. We illustrate its use by considering processes
in which ionizing radiation is an intrinsic, useful product (diagnostic
radiology) and in which the radiation is an unwanted by-product (nuclear
power generation). In particular, in Section 4, we proceed as though all
the necessary information were freely available and entirely accurate. As
an expositional device, we put aside the complications of reality. Once
we show how the various costs and benefits fit together conceptually we turn
to the difficulties in establishing the validity of the values of cost and
benefit that are needed for the analysis.
In Section 5, we consider the problems of estimation and measurability.
We discuss the ways in which costs and benefits can be estimated. We will
consider in particular strategies to be followed when the available data are
in different units of measure; money, life expectancy, quality of life,
environmental change, etc. In Section 6, we discuss the complications in
estimation that arise when the available information is incomplete or uncer-
tain. In Sections 7 and 8, we return to the question of risk and the prob-
lems associated with the long- lived nature of some of the health and non-health
environmental costs.
4. Structuring the Benefit-Cost Analysis^ of Ionizing Radiation
For a program involving radiation, e.g., an X-ray program for diagnostic
purposes, benefit-cost analysis is useful in helping to formulate and answer
two questions: 1) what is the best scale of the program? and 2) what is the
best mix of inputs for the scale? To answer these two questions, it is necessary
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to perform two optimizations. A program to achieve the "lowest practicable
level of radiation" in accordance with the two optimizations would provide
the desired result in the following sense: it would indicate the point
beyond which lowering of the radiation from this level, for example, by
adding shielding, would entail more costs than benefits.
a. Costs: Inputs and Outputs
To fix ideas, consider a hospital planning a diagnostic X-ray program.
It can buy an expensive machine which economizes on the technician's time
if it decides on a large-scale program, or a less expensive machine if the
program scale is to be smaller. It can buy a machine with more safety
features, but only at a greater cost in the machine or in the technician's
time. The output of the machine is measured in units corresponding, say,
to the number of X-ray exposures for patients per month. The inputs to the
program include the capital cost of the machine to be amortized over some
period of time, electricity, and the technician's time. These are costs
measured by markets and we can use interest payment, wage payments, prices
of electricity, as measures of cost. (These costs are sometimes called
internal or private) . But there are other costs, just as real and not
directly measured in monetary units. There is the cost entailed because
the radiation dose required for the diagnostic procedure can induce a
malignancy in the patient. There is also the undesired radiation to the
patient. In the process of generating a desired X-ray of teeth, for ex-
ample, the gums and other parts of the face are also irradiated. These
latter doses are unwanted and represent costs that may be reduced by in-
creasing the shielding or by other ways that may raise the cost of the
X-ray procedure. Similarly, the technician may be irradiated, and this,
too, represents a cost. (These latter costs are sometimes called external
and represent elements of total social cost.)
We shall first assume that all the costs and benefits have been esti-
mated correctly. One way to schematize these interrelationships is by a
production function:
(1) Xx = f (Ylf Y2, Y3,
where X. is the output, number of desired X-ray exposures,
Y-, is the capital input of the machine,
^2 is the technician's time,
Y~ is the amount of electricity used,
is the unwanted X-ray dose to the patient, and
is the unwanted X-ray dose to the technician.
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Often X? and Xg are thought of as unwanted outputs; here they are treated
as unwanted inputs, which may at first seem a little strange, but Xo and X3
are costs like the other inputs and it is convenient to treat X2 and X3 sym-
metrically with the other costs. The production function incorporates the
idea of trade-off. For the same output Xn , we can decrease the technician's
time (Yo) at the price of a bigger capital input (Y^) ; we can economize on
the technician's time at the cost of exposing him to a little more unwanted
dosage (X^) ; we can cut down on Xo with a more expensive machine (Y^) which
more precisely directs the X-ray beam.
Even though the X-ray exposure, 2^, is a necessary product, it is not
desired for its own sake but as an intermediate product. Output X^ is used
in turn as an input for another production activity. (Xi considered from
the point of view of an output is a benefit, but X^ considered from the point
of view of an input is a cost.) In this second activity, the X-ray dosage,
film, technician's time, and doctor's time are turned into diagnoses. Thus,
we write down another production function, incorporating another round of
trade-offs :
(2) D = gfclf Z2,
where D is the output, the number of diagnoses,
Zi is the doctor's time in interpreting the X-ray,
Z2 is the film, and
X-L is the X-ray dosage.
(Other inputs of the productive activity are neglected for convenience.)
As indicated earlier, more sensitive equipment can cut down the dosage per
patient which enters into the estimation of X^ There are obviously many
other trade-offs but one example is enough for the idea.
We could go further and consider D also an intermediate product, again
not valued for its own sake, but valued as an input in another productive
activity which produces cures or increases life span. But for this illus-
tration, we can stop here and consider D a final product. When it is viewed
as a desired final product D is a benefit.
We can imagine that somehow, by direct market measured or by indirect
estimates, the total benefits attributable to each number of diagnoses is
calculated. We plot this information as curve B(D) in Figure III. 2. On the
horizontal axis, D measures the scale of the number of diagnoses.
We are now ready to illustrate how the two optimizations are performed.
For any particular output level of diagnoses, for example D*, there are many
possible input mixes which could produce that level. Suppose
input mix 1 input mix 2
-------
,B(D)
Figure III.2
C2
C(D)
Figure 111.3
-D
Figure 111.4
C'(D)
B'(D)
Rgure III.5
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are two such input mixes capable of achieving D*. For each input, we have
an estimate of its unit cost, by direct market measurement or by indirect
estimation. As a practical matter, the estimation of the health costs of
KI, of the costs of the unwanted radiation to the patient (X2>, and the
costs of the unwanted radiation to the technician $3) is very difficult.
Setting aside for the moment this very difficult practical matter, we
imagine that the cost of X2 and X3 are estimable for each level of X2 and X3
radiation exposures. The total cost of all the inputs can now be calculated
for each input mix. Suppose for input mix 1, this total cost (including both
internal and external costs) is GI, and for input mix 2, it is C?, and we
plot these two costs associated with output level D* in Figure III.3. We can
imagine calculating the total of all costs for all input mixes capable of
achieving D*. There would be some lowest total cost and an input mix asso-
ciated with it. (To be mathematically precise, there would be a greatest
lower bound.) We plot this lowest cost C* on Figure III.3. In like manner
for each possible output level, we find that input mix capable of achieving
it with the lowest cost and plot that cost against the corresponding output
level. The graph of such least cost points is C(D) in Figure III.3. The
process of finding the least cost combination for each output level is the first
optimization. This optimization specifies the best input mix for each pos-
sible output level. In this calculation, the external cost of unwanted
radiation is included along with the cost of defensive measures and the
least cost combination achieves the "lowest practicable level" of radiation
for any given program size.I/
The second optimization is much simpler, given B(D) and C(D). We plot
B(D) and C(D) together on Figure III.4 and ask what is the best scale of
program size? The answer is determined by the largest gap between the two
curves; here the net benefits (the benefits B(D) minus the costs C(D)) are
greatest. This is shown at DP in Figure III.4. If we compute the marginal
benefits B'(E>) and marginal costs C'(D) in Figure III.5, DP is also the point
under which the marginal benefits are equal to the marginal costs (B1 (D)=
dB(D)/dD and C'(D)=dC(D)/dD). At point D°, an expansion of the program by
one unit (arranging the inputs in the appropriate least cost way) leads to
incremental (marginal) benefits just equal to incremental (marginal) costs.
Thus at D°, there is no gain by expansion by one unit. A similar argument
— Just as in microeconomic theory with private factors of production, these
least cost combinations have the following mathematical property: Suppose
X2* and YI* are part of the least cost mix of achieving D* number of diag-
noses. Suppose, also, that T is the marginal damage of radiation exposure to
patients while r is the marginal rental cost of capital. Then
3f 3f = r/T
3X2
The marginal trading off of a little more shielding for a little more
capital cost is an important part of searching for the best defensive
strategies.
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goes for contraction by a unit. By the second optimization, the best scale
for the program is where the net benefits are largest, or equivalently where
the marginal benefits are equal to the marginal costs.V (Of course this
second optimization rule should not be applied blindly. In Figure III.6,
the biggest gap is at D^ but the net benefits are negative and no program
is better than E)2; at D3 in Figure III. 7, the marginal costs are equal to
the marginal benefits but here the net benefits are being minimized.) To
perform a proper benefit-cost analysis of an optimal program, both optimi-
zations must be performed simultaneously. It is not sufficient to first
pick the optimal program size and then choose the optimal level of safety.
b. Radiation as a Pollutant
In some processes radiation emission is a wholly undesired product; an
unwanted "side effect." In such cases, we can use the same framework as
before. Consider a nuclear power plant: its desired output is electricity
and its conventional inputs are capital, labor, nuclear fuel, and so on.
Besides these costs, there is also radioactive emission which we treat as
we did above as an input or factor of production. Again there are trade-
offs in the inputs. For the same output level of electricity, we can de-
crease the radioactive emission by increasing the capital cost, with more
shielding or by more carefully training the operating personnel. We write
the production function
E = f (Y!,Y2,X)
where
E is the output, electricity,
YI is the capital input, or factor of production,
Y2 is the labor input, or factor of production, and
X is the radioactive emission, also an "input" or
factor of production.
Setting aside the practical problems of benefit measurement, we can posit
the existence of a benefit curve B(E), just as in Figure III.2, but with E
in place of D. For each level of output E, we find the least cost mix of
inputs to achieve it.
— Consider a mass screening program where the incidence of the disease for
which the diagnostic radiology is undertaken is not uniformly distributed
among all age cohorts. Reducing the scale of the program by eliminating
progressively portions of the tail of the probability distribution would
be one way in which to alter the scale of the program incrementally.
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C(D)
B(D)
Figure 111.6
D
B(D)
C(D)
Figure 111.7
D3
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There are great difficulties in achieving this. What is needed is the
marginal damage of X. That is, for the levels of E, Y]_, Ą2, and X in ques-
tion (and any other variables which might affect the marginal damage), we
need to estimate the damage caused by increasing X by one unit. To make
this estimate, we need to estimate its three underlying components: 1) The
"source term." For a given amount of radiation generated in a particular
plant with capital structure Y^ and personnel Yo, how much of this radiation
is released into the environment? Radiation releases to the atmosphere are
easy to measure under normal operation conditions. It is not possible, how-
ever, to measure releases of radiation subsequent to accidents which have
not (or not yet) occurred. Estimates must be made of the probability of
occurrences of releases and of the magnitude of the releases from accidents.
These are difficult estimates to make. Furthermore, the magnitude of these
probabilities is still subject to much debate. 2) The environmental transfer
function. How is the radiation released from the plant dispersed throughout
the environment? In particular, what are the incremental "doses" received
by the population from an incremental release? 3) The health effect. For a
given dose distributed over the population what are the health effects attri-
butable to the incremental generation of X? (EPA's ''Environmental Radiation
Dose Commitment; An Application to the Nuclear Power Industry" (3) is an
example of the methodology required.) The problem of estimating the marginal
cost appears to be simpler for the X-ray machine than for the nuclear plant.
For the X-ray machine, the environmental transfer function can be estimated
with little difficulty.
Unfortunately, there is no alternative to facing these difficulties and
dealing with them as best we can if we are to estimate efficient levels of
radiation, safety effort, and program scale in economic terms. For the moment,
we imagine that these difficulties are surmounted; for each level of output E,
we have found the least cost mix of inputs to achieve it; the graph of these least
cost amounts plotted against E is C(E), as in Figure III.3, but with E in
place of D. And, as before, the largest net benefit, where B(E)-C(E) is
maximized, is the best scale of the plant.
In practical applications, a nuclear plant may be in competition with a
fossil fuel plant. In this case, we have a second production function to
generate the same final output E:
E = g(Z1,Z2,S)
where
Z;L is the capital input of the coal-fired station,
Z2 is the labor input, and
S is stack emissions, another factor of production
and "input."
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Conibining the two possible productive activities, we have the aggregate
production function:
E = h(Y1,Y2,X,Z1,Z2,S), where h is defined by
h = f(Yl,Y2,X) + g(Z!,Z2,S).
As before, for each E we choose that mix of (Y1,Y2,X,Z^,Z2,S) which mini-
mizes the total cost (internal cost plus external cost, or social cost) of
providing E. The plot of these least costs against E defines a new cost
function C(E). Suppose for some E* the least cost mix of achieving it is
(Yi*,Y2*,X*,Zi*,Z2*,S*). This input mix defines the best mix of input factors
for each productive activity, fossil and nuclear, to achieve E*. By sub-
stituting (Y]*,Y2*,X*) into f and (Zi*,Z2*,S*) into g, we also find the best
scale of the nuclear effort balanced against the fossil effort, for that level
of electricity production E*.
The new cost function C(E) can also be defined in terms of the individual
cost functions Gust as supply functions are derived from individual cost
functions in microeconomic theory). Prom the nuclear production function
E = f (Yi,Y2,X) there can be derived, by the first optimization, the cost
function Ci(E); and similarly from the fossil production function E = g(Zi,Z2,S)
the associated cost function C2(E). Suppose that the best balance to achieve
aggregate E* electricity generation is EI* nuclear and E2* fossil. For these
two to be in balance, a unit decrease in the production by nuclear should save
in costs just what a unit increase in production by fossil would entail (this
neglects corner solutions and problems with smoothness of the functions).
In other words, at EI* production by nuclear and E2* by fossil, the marginal
costs of production should be equal, or GI' (El*) = C2'(E2*). At this level
of marginal cost, the total industry output is EI* + E2* = E*, the amount
supplied by the two programs together.
In general, the "industry supply function" is defined by adding hori-
zontally the two marginal cost curves, as in Figure III.8, panels B and C.
For any given output, in this case E*, we can trace the marginal cost asso-
ciated with this output, the best balance of nuclear and fossil effort (El*
and E2* in Figure III.8B), and from the underlying total cost functions the
best input mixes (Y}*,Y2*,X*) and (Zi*,Z2*,S*) to achieve these efforts (asso-
ciated with Figure III.8A).
The new cost function, C(E) of the above paragraphs, equals /. C'(x)dx,
for the C1 defined in panel 8C, so that the notation is consistently defined.
The benefit function B(E) has not changed from the previous example
where there was just one method of generating electricity, nuclear. Again
the optimum scale for electricity generation is defined by the biggest gap
between the new cost curve and the old benefit curve, or where the old mar-
ginal benefit B' (E) and new marginal cost curves cross, at E° in panel 8C.
Optimal aggregate scale E° of panel 8C also specifies optimal individual
program efforts EI° and E2o of panel B, and from the least cost input mix
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Figure 111.8
/
Ei"
/
E2'
C2(E)
C'(E)
B
C2'(E)
new cost function
C(E)
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associated with each point on the individual cost curves GI and C2, we also
have specified the optimal input mixes (Yl°,Y2o>X°) for nuclear and (Zi°,
Z2°,S°) for fossil power production.
c. Subsuming the Intermediate Product
In the last example, there were no intermediate products. It is also
possible to formulate the first example of the x-ray diagnosis program without
an intermediate product. All that is needed is to substitute equation (1)
into equation (2) to yield
D=g(Z1,Z2, fCyLY2.Y3.X2.X3)).
Now we have a single production function of diagnoses specified by inputs of
capital to the x-ray machine, technician's time, unwanted dosage to the tech-
nician, unwanted dosage to the patient, the film, and the doctor's time.
Minimization over these variables to define least cost combinations will lead
to the same cost curve as C(D) in Figure III.3. If there is concern about
the right amount of lead shielding for the patient, we do not need to talk
explicitly about the intermediate product Xj_, at all. In some applications,
it is useful to aggregate intermediate production functions (eliminating
intermediate products from explicit analysis) to use final product functions
by themselves. In this way, it is shown that the two cases, the X-ray machine
with its wanted radiation, and the nuclear power plant, with its unwanted
radiation, can be treated by the same mathematical formalism.
5. Estimation and Measurability
The production function discussed in Section 4 above can contain many
terms that represent a variety of costs and benefits. Some are measured in
the market, that is, by their actual or expected cost in money or by the price
which the user will pay for the product. Others are not directly measured in
monetary units. For those measured in the market, we can take the current
market price, wage scale, etc., as the basis for calculations. Costs and
benefits which are not measured in the market but are measured in other cur-
rency, for example, years of life lost, must be estimated in other ways.
Further, in many analyses it will be essential to arrive at a conversion
factor from each measure to a single common measure before the benefit-cost
calculation can be made.
Let us consider the problem of a hospital planning a diagnostic radiology
program. Inputs such as the capital cost of the X-ray equipment, film, elec-
tricity, technicians' and physicians' salaries, rent, amortization, etc. are
measured by the market. We can use price lists, wage scales, interest rates,
power rates, etc., to estimate these costs.
The value of the benefits may be estimated in the same way. The desired
final product is the diagnosis. If there is an unconstrained medical market,
we could take the market price—the fee for a diagnostic X-ray exanriniation—to
be the measure of this benefit. The major virtue of this estimate is that it
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is rather easy to make; otherwise, it has little to recomnend it. The price
of a diagnosis will vary over a wide range—free for some patients, 'partially
subsidized for others. The price is subject to change by doctors as a sub-
jective response to inflation or the effect of health insurance on the behavior
of physician and patient. What is perhaps the most important complication is
that almost all patients lack the information by which to calculate the worth
of the diagnosis to them.
In such cases, economists might try to make their own estimates of the
health benefits attributable to the diagnoses by—for example—calculating the
expected increase in the total wages earned by the patient as a consequence of
the cure and to the extent that the cure was attributable to the diagnosis.
Since many patients and many different wage scales will be involved, some kind
of average must be computed. But a simple average carries the implication that
the same benefit in years of productive life saved is greater for the higher
paid person than the lower, all other things being equal. Not all people con-
cerned will agree upon this value system.
In like manner estimates need to be made of the years of life lost by
exposure to unwanted radiation. Two estimation steps are needed. First,
there is a cost computation in health units, for example. The expected value
for the years of productive life lost is computed from the expected level of
unwanted exposure. Second, a monetary value is placed on the lost time by
estimating the expected present value of the lost wages. The complications
of making plausible estimates of the likelihood of cancer or the decrement
in length of life that can result from exposure has been treated in detail
in the BEIR report (1). As with the dollar estimates of the benefits of
diagnostic radiology, the costs of exposure may be estimated from the expected
present value of the lost wages from the increased probability of morbidity
and mortality. It is worth noting that the present value may be a very un-
reliable estimator because the overt onset of cancer will, in many instances,
be a decade or more after the time of exposure.
Another problem in estimation has to do with the variation in physician
performance. Since the end benefit is increased years of life or decreased
morbidity, this variable needs to be evaluated.
Similar difficulties arise in estimating the benefits accruing to power
generation. The value of the benefits of electricity generation can in
principle be measured by consumers1 willingness to pay for it. But while
there are markets for electricity and market prices for it, care must be
taken in using these prices as the measure of benefit. Electric utilities
are franchised monopolies and prices are regulated. Before using electricity
prices as a measure of benefit, we may want to make adjustments in our cal-
culations that take into account the ways in which price is distorted from
being an appropriate indicator of benefit value.
Let us consider further the strategies that might be employed when benefits
and costs are of different kinds; e.g., money, years of life, quality of life,
etc., are measured in different units.
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Recognizing that it is difficult to derive unassailable procedures for
putting the various costs and benefits in the same dimensions, for example,
dollars, we suggest that it is useful to see how far it is possible to go
without facing this problem. Wherever possible, we propose to subdivide the
problem so that dollars can be compared with dollars and man-years, say, with
man-years. In an analogous manner, it would be possible to consider the costs
and benefits of different populations separately, deferring as long as pos-
sible the need to average the consequences over the disparate populations.
a. Processes of Power Production
When alternative technologies for processes in this category are com-
pared, the benefits are directly commensurate so that one can compare alter-
native costs against a common denominator, such as megawatt hours. The costs
will be of different kinds: market costs for producing equivalent amounts of
power, environmental degradation costs, social dislocation costs, health
costs, and the like. As indicated above, the costs imposed on different
populations will need to be considered; costs to the plant workers, miners,
people residing near the plant, those living at a greater distance from it,
etc.
The strategy proposed here may be illustrated by a simpler process
(which can be regarded as a sub-problem in the analysis of nuclear power) ;
namely, the transport of nuclear materials. Only the mode of transportation
(that is, by air, ship, motor vehicle, rail) is to be considered. The
benefit is the same in each instance. It is implicit that we are considering
the transport of the same type of radioactive material and hence that the
kind of health risk will be the same. Therefore, in considering health costs,
only the alternative quantitative measures of risk from exposure need to be
evaluated. The probability of accident (or sabotage) will vary among the
modes, as will the population exposed to accidental release of radiation as
well as the expected severity of exposure. As long as expected exposure is
greater for one mode than another, its associated health costs must be greater.
In some comparisons, the health and market costs need not be put in the
same units. Suppose that, when benefits are equated, the health costs for
one mode (X) were lower than for another, Y, and that the market costs were
also lower for mode X than for mode Y. Then mode X dominates Y. Made X is
unambiguously less costly than Y no matter what dollar value is put on the
health costs.
We can formalize this as follows:
Let benefits from either mode be B
Label the different kinds of costs; money, health, social, etc.
Ca» Cb> Cc. . . .and hence we label the cost of mode X
We are interested in comparing B - (C^ + C^x + • • • •) with
B - (Cay + C(jy + ....).
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The ccranon decision rule is: choose X if
[B - (Cax + Cfax+ ....)] > [B - (Cay + Cby+ ....)]
and since the benefits are the same, we can rewrite the decision
rule as follows:
Choose X if ŁC-;V > EC. .
. jj . jx
But if Cjy _> Cjx for every j, that is, for each different kind of
cost—then x dominates Y and the sums of cost need not be computed
in order to apply the decision rule.
Let us explore this strategy further. For any specific adverse effect,
say the occurrence of death, there is an a priori distribution that assigns
a probability of death to each individual in the population at risk. Each
mode may entail as a consequence an increase in this probability for some or
all the members of the population. Call the increase in probability for a
particular individual if mode X is used APjx. In order to compute dollar
cost, we must associate with the increase in probability a valuation function
Cjx = Vj (APjx)
The values Vj will not be the same for all people unless, of course,
insistence on equal value is the first principle of the social theory governing
the assignment of value to a health factor. Thus, C^ = Z Vj(APjx) where C^ is
the total health cost of alternative X. However, as before, we may be able
to use the device of dominance to choose between alternatives X and Y. If
Cjy >_ Cjx for every j then Cy ^ Cx no matter what the values Vj are (as long
as they are finite), and we can use our decision rule to identify X as the
preferred alternative. In the foregoing example, the choice between alter-
natives is based only on the probabilities of adverse events and not on the
explicit health costs.
b. Diagnostic Radiology
There are several ways in which the statement of diagnostic radiology
problems may be simplified. First, the radiological procedures are appro-
priately and readily separable according to the diagnostic problems they are
intended to resolve. In this category, we can in principle estimate both the
health and some of the other extra-economic costs, and the benefits in terms
of increment or decrement in the probability of death. Since these param-
eters are in the same units, their ratios are dimensionless. In the analysis
of at least some diagnostic procedures, the health benefits are so substantial
that one need not consider the financial costs at all. They would be negligible
when a year of life is assigned any reasonable monetary value.
Among the subproblems of diagnostic radiology, there are a number which
can be treated in much the same manner as the problem of nuclear versus fossil
fuel energy; that is, alternative diagnostic procedures can be compared. An
example would be echocardiography versus radiography for the detection of
morphologic cardiac abnormalities. If it can be determined that each procedure
offers equivalent benefits in terms of diagnostic accuracy then^they can be
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compared purely on the basis of costs. In the case of radiography, the costs
contain both a monetary and a health cost, whereas it is currently presumed
that echocardiography entails no health cost. And if the monetary cost of
echocardiography is equal or less than radiography then the decision is
obvious and the only remaining problem is to devise the process whereby
radiology departments acquire the necessary ultrasound equipment and the
expertise to use it.
Unfortunately, the above argument is predicated on the assumption that
the benefits from the alternatives are equivalent. The assumptions need to
be validated. Benefits can be defined in terms such as the reduction in the
probability of death. But what if the correct diagnosis, D, will not improve
longevity? It seems reasonable to assume that a positive diagnosis will
benefit the patient and others in the reduction of pain as well as with
respect to the poorly defined but real effects on the quality of life. The
problem of putting such benefits together with increase in life expectancy
is not easy, but may not always be avoidable.
The paradigm for economic theory would be to value these benefits by
seeking answers to questions such as "What would you be willing to pay for
a decrease in your pain but no increase in life expectancy?" Or, since vir-
tually all information has value, "What would it be worth to dissipate your
uncertainty and to know that you have an incurable cancer?" One may conjec-
ture that if a benefit-cost analysis requires this level of benefit to be
factored in, it is probably the wrong problem to study with this kind of
analysis. It is more appropriately the problem for an ethical philosopher.
In most circumstances, a correct diagnosis at a given time will improve
the prognosis. In this case, the comparison of benefits associated with
alternative diagnostic procedures may be assumed to involve only the diagnosis
and not necessarily treatment if it is assumed that the therapy will be
identical whichever procedure is used for diagnosis. The effect of early
diagnosis on the selection of therapeutic management is a subproblem of this
model.
The usual way to represent benefits is by equations for each procedure
of the following form:
= wi Px(D,d) + w2 Px (D,d) + w3 PX(D,3)
where Px(D,d) is the probability of correct positive diagnosis
PX(D,3) is the probability of correct negative diagnosis
PX(D,3) is the probability of incorrect positive diagnosis
Px(B,d) is the probability of incorrect negative diagnosis
These probabilities are estimated for diagnostic procedure X. The w^
are weights or values that accrue for each possible outcome. One would expect
that an error in diagnosis is of negative value and therefore that W2 and W3
would be negative.
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We can write a similar equation for procedure Y
= W]Py(D,d) + w2Py(I>,d) + w3Py(D,d) +
The decision rule would be choose X if bU >_ b^ ; otherwise choose Y.
Clearly if X is better on purely diagnostic criteria, 'that is if
Px(D,d ) > Py(p,d), PX(S,H) > Py(5,H), Px(D,d) < Py(D,d), PX(D,3) < Py(D,3)
then the values or weights need not be assigned. X must be the better procedure
in terms of benefit to the patient as well as diagnostic accuracy.
c. Therapeutic Radiology
While the theoretical tools for formal decision-making assessments in
therapeutic radiology are the same as for those for diagnostic radiology,
relevant importance of the various costs and benefit terms will be quite
different. For example, the treatment is more costly, the radiation dose
is much larger, and a much higher proportion of patients will be gravely
ill.
To be sure, the health benefits and the health costs can be measured in
the same dimensions, but this may be deceptive. In current practice radiation
therapy for cancer is used only after the diagnosis of malignancy is certain.
This will be true whether radiation is the only therapy of choice or whether
it is used following surgery in order to decrease the likelihood of recur-
rence of the disease process. The probability of adverse effect of the
radiation may be much larger than with the levels of radiation used in
diagnostic radiology. Most adverse effects of the radiation will not be
manifest until years after the exposure. An individual faced with imminent
death from cancer may place a much greater value on a relatively short pro-
longation of life by radiation than on the avoidance of the potential future
health effects of the radiation therapy.
Thus, for therapeutic radiology where changes in probabilities of adverse
effects, APj and Vj, can vary so widely, separate calculations will need to be
made for sub-groups of the population depending on age, sex, disease type, etc.
Potential genetic effects introduce the time dimensions in a more insistent
way. This issue and others of relevance to the foregoing discussion, i.e.,
treatment of uncertainty and irreversibility and measurement of the value of
life or change in the probability of survival, are discussed at some length
in the next two sections.
6. Complications Due to Uncertainties
Theory can be relatively simple and straightforward. But when actual
policy decisions have to be made, it will not be possible to neglect some con-
siderations which enormously complicate the problem of choice. In this section,
we consider complications that arise from varying degrees of uncertainty. For
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the purposes of exposition, we discuss two degrees of uncertainty, "incremental"
uncertainties and ''major" uncertainties. In reality, the uncertainties of the
problem vary from the almost certain to the nearly inestimable.
a. Incremental Uncertainties
In actual applications, we do not, of course, have the benefit and cost
curves, nor the input costs associated with each input mix, nor even the pro-
duction functions. Much has been written on the problem of decision-making
without full information, and little vail be said here except for a few
comnonsense remarks.
The programs we have been discussing by way of illustration are already
in existence. We have both fossil fuel and nuclear power plants producing
electricity. We are not at zero levels. We are already at some point like
D4 in Figure III.10. We do not need to know the whole B(D) and C(D), but we
can content ourselves with incremental questions: should the program be ex-
panded or contracted and should the mix of inputs be adjusted in some direc-
tion? (Again these questions should be handled simultaneously.) In particular,
we need to seek an appropriate balance between unwanted radiation exposure and
defensive expenditures limiting it.
It is generally true that we know most about the case we are currently
experiencing, a fair amount about conditions slightly different from this
status quo, and less and less about conditions more and more different from
the status quo. The situation might be like that illustrated in Figures
III.9 and III. 10. There we have estimates of the costs and benefits and a
spreading band of ignorance as we move away from the present case lA. At
D4, where our knowledge is best, it appears that the total benefits are
greater than the total costs (Figure III.9) so that the program at E>4 is bet-
ter than no program at all. By the corresponding marginal curves in Figure
III. 10, it appears that marginal benefits are greater than marginal costs,
so that some expansion of the program is in order. Just how much is very
uncertain. It might be as little as to D5, or as much as D6. While it would
be preferable to have more knowledge in any direction, it seems clear from
the sketchy situation portrayed in Figure III. 10 that knowledge about mar-
ginal costs and benefits for larger programs would be more useful than knowl-
edge about marginal costs and benefits for smaller programs. Thus, the
analysis provides ways to proceed without complete knowledge; some types of
knowledge are more worth acquiring than other types (or directions), and from
our understanding of the extent of our ignorance, we can sometimes specify
the knowledge it would be most useful to acquire.
The same remarks can be made about the input mix. One changes the input
mix in a particular direction as long as the marginal costs of doing so are
smaller than the marginal benefits (in the final product attributable to the
change). Because there are many uncertainties about the effects of input mix
changes and the costs of input mix changes, the error band around the cost
curves is drawn, larger than the error band around the benefit curves.
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Figure 111.9
benefits somewhere here
costs somewhere here
Figure 111.10
marginal costs somewhere here
\
marginal benefits somewhere here
D4 D5 D6
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b. Major Uncertainties
Virtually all the benefits and costs contain probabilistic components.
Further, they vary with time in ways that are not completely predictable.
The analyst when faced with a parameter which can fluctuate wildly will at-
tempt to describe its behavior as a stochastic process. It is not our
intention to enter into the intricacies of probability theory. However,
the issue of accidents in nuclear power plants which has been a subject of
extensive debate can be considered briefly as illustrative of some of the
difficulties in estimating the consequences of some new activity.
There are basically two strategies applied to this problem. First,
physical theory is applied. Mich of the physics of nuclear power plants is
well understood. Information is available on such factors as radiation
damage to materials, heat stress, mechanism of failure of welds, absorp-
tivity of shielding, etc. Models of the behavior of plants, that is, simu-
lated behavior, have been studied extensively. The model maker will attempt
to make his mathematical model as close to reality as he can. Still, it is
only a model. If the analyst has left out some important factor his model
may well behave quite differently from the behavior of the process it is
modeling. One way to verify the appropriateness of the model is to compare
its performance with real power plants. However, in some instances, for
example, the most drastic of the protective mechanisms in nuclear power
plants, the actual test of performance would be prohibitively expensive
since it would shut down and damage irreparably elements of a functioning
plant.
Thus, the second strategy is to study experience. There are a number of
power plants in operation, accidents have occurred and their severity has been
ascertained. On the basis of experience to date analysts will frequently plot
accidents in 'terms of their severity (see histogram in Figure III.11A).
From this plot (histogram), they will attempt to determine the underlying
distribution (Figure III.11B), i.e., they will try to estimate the probability
assignable to an accident of arbitrary severity. But because experience has
been quite limited, the available data are sparse. As a consequence prob
abilistic estimates of events of catastrophic Drocortians will be hiohlv
unreliable. In this circumstance, analysts will ordinarily form a conservative
(pessimistic) estimate, but the choice of a level of conservatism is a matter
of judgment rather than computation. It is for this reason that some analysts
have chosen to make a worst case analysis, that is, to assume that the worse
conceivable accident will occur sometime. While this may make the cost side
of the equation quite high it will still be finite. For example, such an
argument has been used to suggest that nuclear power plants be sited as far
as possible from centers of population. This will surely minimize the ex-
pected increase in morbidity and mortality, but will entail substantially
increased costs for construction, power distribution, etc. Here, as before,
a value judgment must be made.
However, conservative estimates alone should not be given to those who
will be entrusted with arriving at a final decision. Rather, the role of the
analyst should be to provide the decision-makers with an explicit and objective
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Figure 111.11
I
•5
6
B
x
x
XXX
XXX X
X X X X X X
xxxxxxxxx
severity
I
o
I
severity
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description of the benefits and costs involved including the valuation schemata
on which they are based. Then if they so desire, the decision-makers may make
conservative decisions, but at least their decisions will reflect their atti-
tudes toward risk and not the attitudes of the analyst. In this manner, the
role of the analyst becomes one of presenting the uncertainties involved as
clearly as possible.
If the range of uncertain outcomes is limited, then an "incremental analysis"
of the kind presented earlier in this chapter will be appropriate. Such will be
the case where there is virtually no possibility of catastrophic events—for
example, where we are concerned with small changes in levels of radiation leak-
age in diagnostic radiology as costed against more expensive equipment and
shielding.
However, this form of incremental analysis is not appropriate when we con-
sider the consequences of nuclear power plant accidents or the risk of sabotage
from diverted fissionable materials. In these cases, we are faced with the
consideration of very grave events occurring with very small and uncertain
probability. The seriousness of these events is not easily measurable, as
they involve attributes with different units, e.g., years of life, quality of
life, effect on future generations, etc. The probability that any given
scenario of events will occur is likewise difficult to estimate. Complicating
both the measurability problems and the probability estimation problans is the
additional consideration of inter-temporal effects on later generations. These
inter-temporal effects may be irreversible. A discussion of the problem of
irreversibility and its effect on future options will be given in more detail
in the next sections.
Even if the consequences of any grave event could be measured in some
common terms, and if its probability of occurrence in any given time period
could be estimated, one must eventually address the question of how to recon-
cile events of very serious consequence and very small probability (e.g.,
nuclear power plant accident) with events of marginal consequence which can
be more easily predicted (e.g., the steady state emission levels from those
plants). A strategy for producing a given level of energy output must include
expenditure allocations for both marginally reducing small levels of radio-
active emissions and reducing the small probability that large numbers of
persons will be accidentally and fatally irradiated. Such tradeoffs involving
significant levels of risk can perhaps only be made at the final stage of the
decision process. The analyst should insure that the relevant assessments of
consequences and their probabilities filter through to the decision-makers in
as explicit yet compact form as possible. The techniques found in the area of
statistical decision theory should be helpful in compacting these many-dimensioned
assessments.
7. Radiation Protection as a Factor in the Benefit-Cost Analysis
Benefit-cost analysis for alternate strategies for energy development
or for other applications of radiation must include the immediate and long-
term costs of regulation and compliance, as well as the research costs
underlying the development of standards and protection guides.
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The immediate costs involve such areas as staffing regulatory programs,
monitoring sources of man-made releases of pollutants with attendant instru-
mentation development costs. A technical staff is needed to analyze existing
scientific data and devise programs to develop new scientific bases for reg-
ulatory programs and standards development.
The development of standards and regulations is more advanced for radi-
ation than for most other environmental contaminants. There are, however,
jurisdictional problems in the regulatory application of radiation standards
which can seriously affect the degree to which the public is protected against
radiation hazards. (This is discussed at length in Chapter IV.) These same
jurisdictional problems are now surfacing in the area of regulation of other
environmental pollutants.
It may be desirable to visualize the future and long-term costs associated
with: 1) the training of protection personnel; 2) educating operators and
users of energy sources in sound personnel protection practices; 3) animal re-
search directed towards investigating dose-response relationships for genetic
and somatic effects of various types of pollutants as a basis for the rational
setting of standards; 4) epidemiological studies of persons exposed to varying
levels and kinds of pollutants; and 5) research in the development of improved
protection methodology and procedures.
Another element of costs underlying various energy development strategies
that is not often explicitly examined nor generally equivalent for all options
is the cost of research and development assumed by all levels of government.
When these costs are not distributed to the users, a subsidy exists for that
process which must be taken into account in the benefit-cost analyses.
8. Risk Avoidance, Irreversibility, and the Distribution of Costs
There are two questions concerning the use of benefit cost analysis in
decisions on activities involving the discharge of radiation to the environ-
ment that merit special attention. First, are the conditions for use of the
analysis indicated by theoretical welfare economics likely to be satisfied?
Second, assuming theoretical objections do not preclude some sort of analysis,
how are the gains and losses in this special case involving human life, to be
evaluated?
With respect to the first question, a major objection to benefit-cost
analysis has been that it does not account for distributional effects. That
is, as Samuelson (4) and others have argued, the fact that the gains to some
individuals from a project outweigh the losses to others, does not in itself
guarantee that the project will result in an improvement in social welfare,
since society may for some reason be particularly concerned about the welfare
of the losers. Of course, where compensation is made, most economists would
agree that a project showing net benefits is socially desirable, and that the
benefit-cost analysis carries implications for public decision. Where compen-
sation is not made, it is probably fair to say that these same economists would
recomoend that planners give some attention to the distribution of gains and
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costs. For example, if it can be shown that most of those affected,
favorably or unfavorably, will come from the same income classes, we are
likely to be a good deal more comfortable with the implications of the
analysis. On the other hand, it is possible to argue as Hicks did (5)
that undertaking projects yielding an excess of benefits over costs re-
gardless of distribution is likely to benefit virtually everyone in the
long run, the idea being that if individual A is a net loser in project I,
today, he may be a gainer in project II, tomorrow, and so on. This idea
of a probabilistic compensation criterion has recently been more formally
developed by Polinsky (6). If valid, it suggests that economists and plan-
ners need not worry too much about the distributional effects of a partic-
ular project, and concentrate instead on the more straightforward task of
simply assessing the benefits and costs.
Without attempting to resolve here the difficult and challenging questions
that have been raised with respect to the treatment of distribution, we wish
to note that they apply with particular force in the study of processes in-
volving radiation exposure. Some of the biological effects of radiation will
be distributed indefinitely into the future, affecting increasing numbers
in future generations. Ordinarily, future costs and benefits of a project
are weighted by an exponentially declining discount factor. This is justified
on various grounds, such as individual preferences for consumption now, rather
than later, and the opportunity cost of capital employed in the project. The
consequence in this case is that much of the damage to health entailed by
operation in the near future of a system of nuclear power plants, occurring
as it will in the relatively distant future, will have its economic cost
washed away by discounting. At normal rates of discount of from five to ten
percent, not many years are required for this effect to take hold. A human
life lost in 1985 because of exposure in 1975 when discounted at 7% is worth,
at present, only half as much as a life lost now. Accordingly, the question
we face is, can the time stream of benefits, and perhaps more importantly,
of costs, be evaluated by means of standard discounting procedures? Or ought
we to give special consideration to the very unusual time distributions?
The question is even more difficult than that faced in the intra-temporal
case, i.e., in attempting to deal with the effects of a project on the dis-
tribution of welfare within a single time period or generation. The reason
is that many, if not most, of those affected by the decision in the former
case, for example on whether to go with the breeder reactor, will not have
participated in the decision. How are their interests to be represented, if
at all? Is it fair for the present generation to impose the associated radi-
ation load on future generations? We certainly do not have definitive answers
to these questions, but they are important, and for this reason, we feel they
ought to be raised, at least (7).
Aside from the problem of distribution across generations of welfare, or
its opposite burdens, that is raised by the very long-lived, virtually irre-
versible effects of a nuclear power program, there are some implications for
the efficiency- of investment in such a program. In particular, it has been
shown that efficiency in the presence of irreversibility requires a more subtle
balancing of benefits and costs than is envisioned in conventional benefit-
cost analysis. A program or project having adverse effects that are for all
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practical purposes impossible to reverse should be developed on a smaller
scale than appears warranted by a comparison of current benefits and costs—
if it is anticipated that the burden of the adverse effects may grow
more onerous in the future (8).
The sacrifice of current gains is a consequence of the restriction on
reversibility. It appears that the conditions required for this result to
apply may be fulfilled by investment in nuclear fission reactors, among other
things.
A second important area to be explored with reference to an appropriate
benefit-cost framework for analysis of radiation hazards is the treatment of
uncertainty and the interaction between uncertainty and irreversibility.
Although we know that the effects of radiation are not certain, all of the
distributional considerations discussed above would remain relevant even if
they were. We now wish to consider how uncertainty about the benefits and
costs of a project involving the release of radiation ought to affect the
calculations. The simplest way to factor in uncertainty, say about project
costs, is to compute the expected value of the costs. For example, suppose
it is known that the cost of a damaging event in the nuclear fuel cycle would
be $100 million, and that its probability of occurring is .01, then the ex-
pected cost is $1 million. Although this simple calculation may be the best
that can be made with the available data, it should be pointed out that it
implies a rather strong assumption: that (social) utility is a linear func-
tion of income, or equivalently, that society is not averse to the risk
associated with the damaging event.
It is ordinarily assumed, on the basis of much evidence, that in their
economic behavior individuals are averse to risk. Yet, as Samuelson (9) and
Arrow and Lind (10) have argued, it does not necessarily follow that a social
choice should be characterized by risk aversion. Instead, because it is pos-
sible to spread the risk from a project among the large number of people who
benefit, it has been suggested that the appropriate social decision criterion
is simply the project's expected value. However, this risk-spreading argu-
ment does not seem to apply to radiation from a nuclear plant (11), since
the amount of the radiation to each individual is not reduced even as the
number of affected individuals is increased.
Let us consider briefly the implications of the proposition that indi-
vidual attitudes toward the risk associated with nuclear radiation release
are relevant to the social choice. In Figure III. 12, benefit B is measured
along the horizontal axis, utility U along the vertical axis. Risk aversion
implies that the utility function is concave, or increasing at a decreasing
rate as indicated in Figure III. 12 (12). Suppose, for simplicity, that there
are just two possible outcomes from the operation of a nuclear power plant:
BQ, the net benefit associated with successful operation of the plant (some
minimal level of radiation output), and B]_, associated with a damaging event,
such as a large scale release of plutonium due to a njalfunctioning of the
transport or storage system. Bi occurs_with probability p, BQ with probability
(1-p). Then expected net benefits are B = pB^+ (l-p)BQ. If the individual's
behavior satisfies a reasonable set of axioms, his utility from this risky
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Figure 111.12
U
U(B0)
U(B»)
B»
BENEFIT
Bo B
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prospect is U = pU(B^) + (l-p)U(Bg), which lies directly above B on the
straight line joining the points U(BI) and U(B0) on the utility function.
The assumed (concave} shape of the utility function, indicates that_this is
just equal to the utility associated with the certain benefit B* > B. In
other words, the individual puts a value on the nuclear project that is less
than its expected net benefit. Finally, for given_B, the greater the spread
in outcomes, the larger the divergence of B* from B. The greater the poten-
tial damage, that is, the less adequate is expected net benefit as an indica-
tion of the value of the project.
There is also a kind of synergism between such uncertainty and irrevers-
ibility mentioned earlier. As one would expect, where the consequences of a
project would be difficult or impossible to reverse, and their magnitude not
certain, there is in effect an extra cost to the project: a loss of "option
value" (14). Option value may be understood in the following way. Suppose
the passage of time will result in new information about the benefits and
costs of, say, a system of nuclear fission plants. The information can, how-
ever, be taken into account in energy planning only if irreversible commit-
ments, for example the storage of radioactive waste, have been avoided.
Since the accumulation of these wastes (we assume) is irreversible, once
the nuclear plants are operating the consequences of a decision to put them
in operation cannot be undone, even by new information which suggests the
decision was a mistake. An option has been lost. Alternatively, when 1011
barrels of oil have been converted to water and carbon dioxide, the option
to use that amount of oil for any reason whatsoever is also lost. But it
should be emphasized that, not the fact, but rather the consequences, of
irreversibility or option loss are important.
We now turn briefly to the question of how to evaluate changes in the
incidence of death, disease, injury, and so on, that might be expected to
accompany a project. As discussed in Section 4, the conceptually appropriate
measure here appears to be the value the individual attaches to the change in
the probability of the adverse event occurring. Information on this value is
not easy to come by. One recent study (15) infers it from the estimated
relationships between occupational wages and safety. Post attempts to mea-
sure the value of loss of life or serious injury or disability have generally
been based on foregone earnings, plus direct medical expenditures. As we
shall suggest, there are problems with this approach. The first, and most
serious, is that it is not derived from the measure we have taken to be cor-
rect in principle, the value (paid or received) associated with full knowledge
of the change in probability. Let us lay aside this objection for the moment,
and explore further this technique and another, based on insurance behavior
of individuals.
If it is known that operation of the project will entail a net change
p, 0
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t, and r is the discount rate. The aggregate expected health cost is the
n «> vj
sum over all members E^c) = p z z t , where the number of members
j=l t=0 .
is n. Refinements allowing the probability of the adverse effect to vary with age,
date of exposure, degree of exposure, and so on, are easily incorporated, as in the
n • D yj
measure I z pj t , which introduces different probabilities for
j=l t-0 -
each individual.
Another measure of the value of life, or avoidance of injury, that has
been suggested (16) is derived from the amount an individual pays to insure
against a loss, say his life. For example, if he is willing to pay a $100
premium in a situation in which the probability of loss of his life is .001,
it is inferred that he values his life at $100,000 (=$100/.001).
As Mishan (17) has demonstrated, there are problems with each of these
measures (and others, essentially refinements of them) apart from their
arbitrariness. First, the foregone earnings measures assume that the only
thing that matters to an individual or to society is the (reduction in) size
of the Gross National Product (GNP) . No allowance is made for the loss of
utility due to pain, injury, or death. This omission is particularly serious
in the case of an elderly or retired person, one for whom all remaining Yt
terms are zero. A somewhat similar problem arises in connection with the
life insurance calculation: a person with no dependents might not be willing
to pay anything for insurance, yet still set a value on his own life.
Second, the treatment of uncertainty is not persuasive. Suppose an indi-
vidual values an object at $X, but believes the probability of loss or de-
struction is p. The expected loss is then $pX. If the individual were neutral
toward risk, he would be willing to pay an insurance premium just equal to the
amount of the expected loss. If, however, he were averse to risk, he would
pay more: the expected loss plus a premium (to the insurance company) for
bearing the risk. The situation is exactly as in Figure III. 12, where the
expected loss (from an initial level of welfare Bo) can be represented by
BQ - B, and the risk premium by "5 - B*. Taking an expected value of foregone
earnings then underestimates the value of the expected loss in earnings.
Similarly, the insurance calculation of the value of life or limb described
above simply reverses the procedure, while retaining the implausible linearity
assumption.
From preliminary discussion, two tentative conclusions might be drawn.
1) Even if we can legitimately accept (or ignore) the distributional effects
of a program involving radiation exposure, including the inter-generational
effects, measurement of the expected value of the costs of the exposure will
not capture the full value of the costs, due to the risk preferences of the
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affected individuals. 2) The unusual time distribution of the costs and
their potential magnitude raise serious questions about the appropriateness
of following standard practice, discounting all benefits and costs and looking
only at their present values.
E. Ethics and Benefit-Cost Analysis
The general thesis in the use of benefit-cost analysis as one of the
bases in the making of decisions affecting the public is that such analysis
provides one of the objective evaluations on which such decisions should be
based, in preference to subjective bases such as those which may derive from
intuition, ideology, or political pressures.
In order to compare costs and benefits adequately in benefit-cost
analysis, it is necessary to express them in common, comparable terms.
MDnetization is virtually the only way to arrive at common, comparable
terms for summation of various kinds of benefits and summation of various
kinds of costs ("costs" including risks to health and life and other usually
non-monetized detriments) . The value of yx>ds or services is usually defined
by "the market" and usually represents the social consensus of the value of
the commodities, except perhaps for governmental or private monopolistic
price regulations or extemalization of costs. Even things which cannot really
be valued adequately in the market place, such as a human life or a scenic
view, can be assigned a monetary value based upon what people normally pay
for them in various ways and circumstances.
Not the least of the arguments in favor of monetization of costs and
benefits in benefit-cost analysis is that it is nearly universally accepted
in our society. However, there have been severe criticisms of benefit-cost
analysis because of the materialistic implications of monetization (18) .
It can be also argued that a problem of using economic principles alone
is that they may not be adequate to ensure future human welfare. This is in
contrast, for example, to most systems in nature which have effective feed-
back mechanisms to prevent excessive growth and its deleterious consequences.
Since our environment is limited, it is desirable that our systems, including
our economic system, have adequate mechanisms of limitation which are suf-
ficiently sensitive to react in f'Tne to avert deleterious consequences.
Another of the problems of simple benefit-cost analysis is the dispro-
portionate or inequitable accrual of benefits and costs among people.
In its present state, the methodology of benefit-cost analysis is not
adequate to guide reasonably equitable distribution of benefits and costs
in major societal activities. The limitations of a purely monetary value
system and of a simplistic benefit-cost analysis for the purpose of equitable
distribution of benefits and costs, indicates that additional factors, mostly
relying on value judgments, are required for societal decision-making. It is
usually not possible to foresee and quantify all future consequences of a
particular major decision of action. The interactions of events, people, and
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institutions are so complex that quantification and formulation of all factors
is beyond currently foreseeable expectations. Furthermore, it appears that
people generally view the near term as more important than the long term, so
that benefit-cost analysis has tended accordingly to focus more on the near-
term and discount the long-term factors.
All of this illustrates that benefit-cost analysis cannot be absolutely
complete, and cannot, except in simple cases, determine what is best for the
whole system. For example, with an issue as complex as the present energy-
environmental problem, the prospect that a simplistic application of benefit-
cost analysis will yield a complete and definitive basis for decision-making
appears to be untenable. One of the main reasons for this is the difficulty
of assessing the impact of the decisions which might be made on future
generations of people.
Thus, it is apparent that we are faced with a dichotomy. On the one hand,
traditional benefit-cost analysis seeks to maximize human welfare primarily
through increasing economic well-being: a process which weights heavily both
material possessions and the current generation. On the other hand, a dif-
ferent method could be constructed upon a value system which places primary
emphasis on future generations. Deciding between these systems, or how
much weight each should receive, is a difficult task, about which honest
people will differ passionately, since human values of an aesthetic and
moral nature are involved.
We believe that both systems are important, and that in many of the com-
plex decisions facing our society both should be used in the decision-making
process. We believe that it is in the interests of the whole system (present
and future) that the two approaches be brought together. This is not to
dilute or modify either side, but to recognize them as partners each capable
of supplying input into the decision-making process.
How can these two systems be brought together? Our philosophy throughout
this volume is that it can be done through a benefit-cost analysis which goes
considerably further than that developed and used in traditional economics.
In decisions that have a component that depends on human values, we propose
the following:
(i) The terms on both sides of the equation be given a monetary value
based on the market place, public survey or other appropriate means.
We acknowledge the problems, discussed above, inherent in this
approach, but feel that if benefit-cost analysis is to be done at
all, money appears to be the only comnon denominator that can be
used.
(ii) Weighing factors should be applied to those terms which may be
undervalued by market place economics. Typically, these are likely
to include the terms which have a component which involves people
not able to take part in the decision-making process.
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(iii) The values of the weighting factors have to be established by
society in general, whether through the political process, public
survey, or other means.
The following is quoted from a recent NAS report (19):
Benefit-cost analysis, at least as we use the term, is not a
rule or formula which would make the decision or predetermine
the choice for the decision-maker. Rather, it refers to the
systematic analysis and evaluation of alternative courses of
action drawing upon the analytical tools and insights provided
by economics and decision theory. It is a framework and a set
of procedures to help organize the available information, dis-
play trade-offs, and point out uncertainties, in this way,
benefit-cost analysis can be a valuable aid; but it does not
dictate choices, nor does it replace the ultimate authority
and responsibility of the decision-maker.
The problem of incorporating both of the traditionally separate value
systems into the decision-making process is perhaps the major question of
the coming decades. The short- versus the long-term trade-offs depend on
the manner of incorporation of the traditionally separate value systens
into the decision-making process.
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GHAPTER III
TCES
1. National Academy of Sciences Advisory Committee on the Biological Effects
of Ionizing Radiations. The Effects on Populations of Exposure to
Low Levels of Ionizing Radiation. National Academy of Sciences-
National Research Council, Washington, D.C. (1972).
2. International Commission on Radiological Protection Report No. 22,
Implications of Commission Recomnendation that Dose be Kept as
Low as Readily Achievable. Pergamon Press Ltd. 1973.
3. Environmental Protection Agency. Environmental Radiation Dose Commit-
ment: An Application to the Nuclear Power Industry, EPA, Washington,
D.C.
4. Sam.ie.lson, P.A. Evaluation of real national income, Oxford Economic
Papers, N. S. 2, 1950.'
5. Hicks, J. R. The rehabilitation of consumers' surplus, Review of
Economic Studies, vol. 9: 1941.
6. Polinsky, A. M. Probabilistic compensation criteria, Quarterly Journal
of Economics, August 1972.
7. Fisher, A. C. and Krutilla, J. V. Valuing long run ecological conse-
quences and irreversibilities, Journal of Environmental Economics
and Management, September 1974.
8. Fisher, A. C., Krutilla, J. V., and CLcchetti, C. J. The economics of
environmental preservation: A theoretical and empirical analysis,
American Economic Review, Septenber 1972.
9. Samuelson, P. A. Principles of efficiency, discussion, American Economic
Review, vol. LIV, no. 3, May 1964.
10. Arrow, K. J. and Lind, R. C. Uncertainty and the evaluation of public
investment decisions, American Economic Review, June 1970.
11. Fisher, A. C. Environmental externalities and the Arrow-Lind public
investment theorem, American Economic Review, Septaxber 1973.
12. Friedman, M., and Savage, L. J. The utility analysis of choices in-
, volving risk, Journal of Political Economy, -vol. LVI, No. 4,
August 1948.
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13. Von Neuman, John and Morgenstern, Oscar, The Theory ^of Games and Economic
Behavior. Princeton University Press, Second Ed. 1942.
14. Arrow, K. J. and Fisher, A. C. Environmental preservation, uncertainty
and irreversiMlity, Quarterly Journal of Economics, May 1974.
15. Thaler and Rosen, Mimeograph report, University of Rochester, 1973.
16. Fronm, G. "Civil Aviation Expenditures" in Dorfman, Ed. Measuring
Benefits from Government Investment, Washington, Brookings
Institute, 1965.
17. Mishan, E. J. Cost-Benefit Analysis (New York: Praeger, 1971).
18. Schumacher, E. F. Small is Beautiful. A study of economics as if
people matteredSphere Books, Ltd. London, 1974.
19. NAS Report. Decision-Making in Regulating Chemicals in the Environment.
Washington, B.C., 1975.
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CHAPTER IV
LEGAL AND INSTITUriONAL ASPECTS OF USING
BENEFIT-COST ANALYSIS TO CONTROL IONIZING RADIATION
Contents
SIM1ART. ................................ 75
A. Introduction ............................ 76
1. Purpose and Scope of Chapter ................. 76
2. Nuclear Power Case Study ................... 76
B. Institutions and Authority ..................... 82
1. Nuclear Regulatory CamrLssion ................. 82
2. Environmental Protection Agency ................ 84
3. The States ....... . . .................. 88
C. Decision-Making .......................... 90
1. Concepts ........................... 90
2. Nuclear Regulatory Comnission ................. 92
a. Pre-1975 .................. ....... 92
b. 1975: New System .................... 93
3. Environnfintal Protection Agency and the States ........ 98
D. Basic Legal and Policy Considerations Attending Uses Of ...... 103
Benefit-Cost Analysis
1. Conmon Law ........................ •
2. Legislation and Regulation ............... , . .105
E. Conclusions .............. • ........... . .112
\ Footnotes ............. ............... .113
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This chapter was prepared for this report by Michael S. Baram,
Massachusetts Institute of Technology, Cambridge, Massachusetts,* with
the assistance of Eric Petraske, Boston University School of Law, Boston,
Massachusetts, and Frederic Mettler, Massachusetts General Hospital,
Boston, Massachusetts.
*Bracken, Selig, Padnos, Baram and McGregor, Boston, Massachusetts.
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CHAPTER IV
LEGAL AND INSTITiniONAL ASPECTS OF USING
BENEFIT-COST ANALYSIS TO CONTROL IONIZING RADIATION
Stimiary
This chapter provides an evaluation of the legal and institutional
issues vMch attend the uses of benefit-cost analysis for regulatory
decision-making on ionizing radiation.
In an introductory section, the purpose and scope of the chapter, its
focus on nuclear power, and basic functions of federal and state agencies
are discussed.
This is followed by an analysis of the legal framework for controlling
ionizing radiation from nuclear power plants and other sources in the uranium
fuel cycle. The analysis is focused on the statutory authority and regula-
tory programs of the Nuclear Regulatory Connission, the Environmental Pro-
tection Agency, and various state agencies. Such an analysis must reflect
value judgments made by the authors on the degree to vMch agencies have
used their authorities in carrying out their responsibilities and the
manner in which they have done so.
The third section contains an evaluation of the analytical methods and
decision-processes employed by such regulatory agencies to establish spe-
cific design and performance requirements' for nuclear power plants and
offsite environmental and health standards.
The final sections of the chapter include discussion of basic legal
and institutional considerations arising from uses of benefit-cost analysis
in regulation and conclusions applicable to the formulation of national
policy and federal programs for toxic and carcinogenic pollutants including,
but not limited to, ionizing radiation.
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GHAPTER IV
LEGAL AND INSTITUTIONAL ASPECTS OF USING
BENEFIT-COST ANALYSIS TO CONTROL IONIZING RADIATION
A. Introduction
1. Purpose and Scope of Chapter
As other chapters of this report have indicated, most human exposure to
ionizing radiation from artificial sources is attributable to medical uses.
Nevertheless, in this chapter, assessment of the use of benefit-cost analysis
in the control of ionizing radiation focuses primarily on the nuclear energy
fuel cycle for several reasons:
Regulation of ionizing radiation, employing benefit-cost analysis,
has occurred only within the context of the nuclear energy fuel
cycle.
Regulation of nuclear energy is substantially centralized in a
single federal regulatory agency; therefore, use of benefit-cost
by such agency can be socially assessed by the criteria of admin-
istrative law, which have been designed to ensure accountability
of agency decision-making.
The number of nuclear power reactors in the U.S. is expected to
increase significantly. Regulatory problems should be identified
and addressed immediately, since the pattern of regulation will
become increasingly difficult to change as the commitment grows,
and larger societal and economic interests are threatened by
change.
Each reactor represents a continuing source of long-lived radio-
nuclides which accumulate in the environment, and therefore con-
stitutes an important dose commitment for present and future
generations.
As a result of these considerations, this chapter focuses on the nuclear
energy fuel cycle for purposes of assessing the uses of benefit-cost analysis
in decision-making on ionizing radiation. The balance of this introductory
section briefly describes the nuclear energy fuel system and radiation con-
trol options.
2. Nuclear Power Case Study ';'•
Ionizing radiation, as a form of pollution, can be depictfed by a simple
flow-chart or model to facilitate analysis of the relative roles of various
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regulatory authorities at federal and state levels. A basic model, employing
a nuclear power plant for illustration, can be presented: (Figure IV. 1).
A coherent approach to the regulation of ionizing radiation from nuclear
power sources calls for consideration of the nuclear fuel cycle; and more
detailed flowcharts or models can be developed to depict this cycle and the
array of authorities and their roles in controlling radiation. A more detailed
model is now presented to provide a more complete context for assessing the
regulation of ionizing radiation (Figure IV.2).
The diagrams demonstrate that four primary types of authorities func-
tion to control ionizing radiation arising from the use of nuclear fuel in
the operation of a nuclear power plant.
These authorities (Figure IV.2) are:
(1) Site, Construction and Design Controls: Site—The states and their
local subdivisions control the use of private lands and non-federal,
public lands: and the federal agencies (e.g., Dept. Interior)
similarly control federal lands. Nuclear Regulatory Commission
siting guidelines establish criteria necessary for its approval
of proposed sites.
Construction and Design—Implementation of the National Environ-
mental Policy Act requires broad assessment by federal agencies
and state authorities, with "lead agency" responsibility for
assessment of most nuclear facilities in the U.S. Nuclear Regu-
latory Commission, and statutory responsibilities for review of
assessment in the U.S. Environmental Protection Agency and Council
on Environmental Quality. The Nuclear Regulatory Cornnission has
exclusive authority to establish design standards and to issue
the construction license necessary for power plant realization.
(2) Source Operation and Performance Controls—The U.S. Nuclear Regu-
latory ConnrLssion has exclusive authority to: establish operating
and performance requirements; issue interim and operating permits;
control various activities involving nuclear materials ("Source",
"by product" and "special") and the disposal of wastes; and set
and enforce most regulations for such activities. The U.S. Depart-
ment of Transportation shares authority to control transport
activities with the Nuclear Regulatory Commission (1).
(3) Onsite Receptor Controls—The U.S. Nuclear Regulatory Commission,
Bureau of Mines and various State authorities control the exposure
of employees and materials in the on-site occupational environment
to ionizing radiation (1).
(4) Offsite Receptor Controls—Control functions are widely dispersed:
The Federal Food and Drug Administration has authority over radio-
activity contamination of shellfish and other foods; State and U.S.
Environmental Protection Agencies have advisory and regulatory
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FIGURE IV.1: Radiation Pollution Control
e.g. nuclear
power plant
Radiation
Emissions
and
Transformations
e.g. various life
forms on-site
and off-site
Receptor
Control
Nuclear Regulatory
Commission: control over
design, facility discharges,
etc. by means of standard-
setting, permits and other
regulatory processes governing
source activities.
Environmental Protection Agency
and State Agencies: control b~
means of monitonng and standard
setting regarding different
features of ambient, off-site
environment; and review of
Nuclear Regulatory Commission
environmental impact statements
for off-site effects: State
authorities and the Nuclear
Regulatory Commission regarding
occupational environment.
-------
FIGURE IV.2: Nuclear Fuel Cycle Context for Radiation Pollution Control
Sources
(Steps in Fuel Cycle)
Extraction of Ores
4r
transport
*
^Processing for Fuel
7 *
f transport
/ *
/ Use: e.g. Power Plant
/ *
I transport
/ *
\ I Disposal of Wastes
\ r
Recycling
Controls: Siting, Design and Construction
Source Operation and Performance
(a) Siting: (Federal Lands) U.S. Dept. of
Interior, with U.S. Nuclear Reg. Commission.
(b) Siting: (State and Private Lands) State
and Local Siting Boards, Zoning
Authorities, Energy Commissions, with
U.S. Nuclear Regulatory Commission.
(c) Construction and Design: (Environmental
Impact Assessment) U.S. Nuclear Reg.
Commission, Environmental Protection
Agency, Council on Environemntal Quality;
and other State and Federal agencies
Radiation Emissions and Transformation
Receptors
Onsite
(Occupational)
- Humans
- Materials
(d)
involved in site and facility analyses
and consideration of alternatives under NEPA.
Construction and Design: (Standards) U.S.
Nuclear Regulatory Commission.
(e) U.S. Nuclear Regulatory Commission
(with U.S. Department of Transportation
re transport controls).
Offsite
(Environmental)
- Resources, (air,
water, soil,
ecosystem)
- Foodchain
- Humans (present)
- Humans (future)
Controls: Onsite Receptors, Offsite Receptors
(a) State Occupational Safety and Health
Agencies and U.S. Nuclear Regulatory
Commission
(b) U.S. and State Health, Fish and
Wildlife Authorities
(c) U.S. Environmental Protection Agency,
Public Health Service, Food and Drug
Admin istration
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functions for various features of the ambient environment such as
water, air, soil, animals, and humans (present and future gener-
ations) ; and for public water supply (1).
This chapter focuses primarily on federal agency decision-making related
to Design Controls (1), Source Operation and Performance Controls (2), and
Offsite Receptor Controls (4), as such controls are of most significance to
the direct regulation of radiation, the use of cost-benefit analysis to
establish limitations, and the implementation of the "As Low As Reasonably
Achievable" (ALARA) concept. Site, and Construction Controls (1) and Onsite
Receptor Controls (3) are also important elements of radiation regulation,
and are discussed in this chapter.
Figures IV.1 and IV.2 emphasize the time development of the system they
describe, and illustrate key points in the fuel cycle where various regulatory
agencies and other authorities intervene in order to carry out their statutory
duties. This overall, integrated view will subsequently be disaggregated to
enable more detailed examination of radiation regulation by means of cost-
benefit analysis and the "As Low As Reasonably Achievable" concept.
The following diagram (Figure IV. 3) sunmarizes the relationships between
the three major authorities involved in the nuclear fuel cycle—the U.S.
Environmental Protection Agency (EPA), the U.S. Nuclear Regulatory Commission
(NRC), and the States—and their relationships to the utility or power plant
proprietor.
Two structural issues are now apparent:
(1) EPA does not act directly on the actual source of radioactive emis-
sions, but acts through other agencies that may not understand, or
be able to implement, or may disagree with EPA's goals.
(2) The two paths of authority converging on the utility give rise to
potential difficulties (a) when mutually exclusive and conflicting
orders are given to the utility, and (b) when no agency or inter-
agency mechanism is available or willing to deal with a problem.
In the second part of this chapter, the ability of the present insti-
tutional structure to carry out regulatory responsibilities involving benefit-
cost analysis and the ALARA concept is assessed. This assessment includes
analysis of the authority granted to key agencies by their governing statutes,
the duties and discretion involved in the exercise of agency authority,
judicial decisions construing such statutes, the overlap of various grants
of authority, and gaps that may exist in coverage where no agency presently
can or will act—all with respect to determining the efficacy of this structure
for effectively regulating radiation.
In the third part of this chapter, decision-making that occurs within
this institutional structure is assessed. This analysis includes review of
the uses of benefit-cost analysis and the ALARA concept by the authorities
in their decision-making on standards and other elements of regulation;
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FIGURE IV.3: Regulatory Authority Structure
Conduct of Federal Air and
Water Pollution Control
Programs, through Approved
State Programs.
Review of Environmental Impact Statements
Under NEPA, and Responsibilities for
Ambient Off-site Radiation Levels.
Control of Siting,
Public Health, etc.;
Implementation of
Air and Water Quality
Programs.
Permit Processes
for Construction and
Operation; Application of
Appendix I and other design
and performance regulations;
Development of Env. Impact
Statements.
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whether cost-benefit and ALARA are to be understood as applying on a case-
by-case or generic basis; and measures of accountability imposed on agency
decision-making by judicial review.
This assessment stage is concerned primarily with the adequacy of the
analytical processes employed for decision-making by the agencies in the
context of administrative law. Particular findings or standards that result
from the processes, and the competence and availability of the personnel to
carry out the processes, are beyond the scope of this chapter.
The fourth part of this chapter presents basic legal and policy issues
inherent in the use of benefit-cost analysis for agency regulation and
judicial decision-making.
The fifth and final part of this chapter contains conclusions derived
from the foregoing analyses.
B. Institutions and Authority
1. Nuclear Regulatory Commission
From 1954 to 1970, authority to control nuclear power and its externalities
was concentrated in the Atomic Energy Commission (AEG). The statutory grant
was broad, giving the agency power to impose such conditions on licensees as
it determined to be in the public interest (2). The AEG chose to follow the
recommendations of the Federal Radiation Council (FRC}(5) as a policy decision.
It was not compelled to do so, as FRC authority was limited to providing
"guidance," (3) and the AEG had full authority to act independently (4). The
standard recommended in 1960 by the FRC of 500 mR. to the most exposed member
of the public was adopted by the AEC, included in its regulations, and is still
in effect under the AEC's successor, the Nuclear Regulatory Commission (NRC)
(5). The FRC was abolished and its functions transferred to the Environmental
Protection Agency in 1970 (6).
In 1970, when the Environmental Protection Agency (EPA) was established,
the authority of the AEC to set "generally applicable environmental standards
for the protection of the general environment from radioactive material" was
transferred to EPA by Reorganization Plan No. 3 (7). The term "standards"
as used, was also derinedT
...standards mean limits on radiation exposures or levels, or
concentrations or quantities of radioactive material, in the
general environment outside the boundaries of locations under
the control of persons possessing or using radioactive
material (7).
AEC authority to impose conditions on its licensees was therefore re-
tained but modified, in the sense that conditions which related to offsite
radiation levels and exposures would henceforth have to be consistent with
EPA regulations and guidelines.
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At the time this change occurred, the AEC adopted as its policy another
FRC reccOTDendation for maintaining "radiation exposures and releases of
radioactive materials...as far below,the limits specified...as practicable"
(8). This policy is the conceptual source for significant features of sub-
sequent AEC regulation of its licensees, such as the AEC's Appendix I (9),
which provides "numerical guides for design objectives and limiting~cbn-
ditions for operation to meet the criterion 'as low as is reasonably
achievable1 for radioactive material in light-water-cooled nuclear power
reactor effluents" (10). Following a four and a half year gestation period
in "proposed" regulation status, a final version of Appendix I was promul-
gated by the Nuclear Regulatory Commission on April 30, 1975 (10).
The Nuclear Regulatory Ccranission (NRC), successor to the AEC in most
nuclear power regulation respects, attached a condition to its final decision
on Appendix I: Appendix I does not provide numerical standards or criteria,
but serves to give license applicants "qualitative guidance" as to "one
acceptable method of establishing compliance with the 'as low as is reason-
ably achievable' requirement;" and the applicant is free to persuade the
NRC that some alternative design or method would constitute "as low as is
reasonably achievable" (ALARA)(11). As a practical matter, the high cost
of such a persuasion attempt and the low probability of success make this
an unrealistic option for most applicants. Therefore, the NRC has been
relatively free to develop AIARA standards in its promulgation of Appendix
I (12).
The legal issue in this matter relates to agency accountability when
judicial review of agency rule-making is sought. Judicial review can focus
on procedures used in the promulgation of such rules of general applicability,
and on the substantive msrits of the rule in question. Since judicial review
of a "guidance" is not as rigorous as review of a standard would be, par-
ticularly where the guidance expressly allows the consideration of alter-
natives to be presented by applicants, the NRC is thereby less accountable
on Appendix I than it is on more conventional rules and standards. The
agency has thereby reserved substantial discretion on the matter of numerical
limitations for implementing AIARA, and therefore remains fully accountable
only to the 500 mR. limit it adopted as a standard following the 1960 recom-
mendation of the FRC.
A related legal issue involves the validity of AEC adoption of the AIARA
concept for use in regulating facility design and operation, and thereby the
validity of NRC's Appendix I for quantifying and applying ALARA in practice.
If ALARA and Appendix I could be construed as providing for "generally
applicable environmental standards for the protection of the general environ-
ment from radioactive material," the AEC would lack authority for such adop-
tion, since the transfer of such authority to EPA occurred on December 2,
1970 (13). Consequently, NRC enactment of Appendix I would be beyond the
agency's scope of authority.
The practical effect of the foregoing developments has been the con-
tinued and extensive involvement of the AEC, and now the NRC, with decision-
making and assunptions about off site radiation levels and exposures, and the
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incorporation of such determinations in NRC licensing and other onsite
regulatory decisions—coincident with EPA's substantial silence on offsite
radiation matters, despite the authority it has had since the 1970 Reorgan-
ization Plan.
EPA has agreed to the continued NRC role; has not sought to system-
atically provide data and opinions on offsite radiation levels and exposures
to the NRC and the states; and in 1975 circumscribed its own role to that of
setting the outer boundary or parameter for uranium fuel cycle radiation in
the general environment (14)—within which the NRC could establish new ALARA
numbers and modifications of existing regulatory requirements (15). This
EPA proposed regulation is not restrictive in regard to present plant emis-
sion levels, and would thereby leave to NRC discretion most facility-specific
decisions as to whether and when lower emission levels should be required of
licensees. Thus, the objective of the Reorganization Plan to have EPA develop
ambient and other off site requirements for radiation, and to thereby play a
central role in facility-related decision-making by the NRC, has not been
realized. As a result, the NRC, alone, has determined desirable offsite
levels and exposures, and incorporated them at its discretion in the conditions
it imposes on licensees.
2. Environmental Protection Agency
The transfer of radiation authority from the AEC to EPA was part of a
general plan to consolidate environmental control programs at the federal
level, to establish EPA as the overall coordinator of pollution control
efforts, and to put "...into one agency a variety of research, monitoring,
standard-setting and enforcement activities scattered throughout several
departments and agencies" (15).
Subsequent laws, such as the Clean Air Act (CAA)(16) and the Federal
Water Pollution Control Act Amendments (FWPGA) Q.7) provided EPA with explicit
pollution control objectives, means and enforcement responsibilities; they
also charged EPA with the responsibility for determining feasible control
measures for various sources and types of pollution. Further, these laws
also provided the criteria to be used in EPA decision-making on permLssable
discharge levels from different classes of sources and on ambient levels of
pollutants for air and water (18). The implications of these two pollution
control programs for the regulation of radiation from power plant sources,
and for the use of cost-benefit analysis and ALARA in decision-making, are
discussed in subsequent sections of this chapter.
EPA has not played an integral role in NRC's regulation of power plant
design and operation, despite the broad authority conferred by the Reorgan-
ization Plan on EPA for setting "generally applicable environmental standards
for the protection of the general environment from radioactive material" (15),
and despite the obvious connections between emissions at the source (controlled
by NRC) and the of fsite levels of radiation (EPA responsibility).
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Responsibility for this limitation of EPA's role stems to some extent
from the Office of Jfenagement and Budget (CMB) and the Executive. In a
memorandum from CMB to the EPA dated December 7, 1973, the following direc-
tive was contained and accepted by EPA.
.. .this memorandum is to advise you that the decision is that
AEG should proceed with its plans for issuing uranium fuel cycle
standards, taking into account the conments received from all
sources, including EPA: that EPA should discontinue its prepar-
ations for issuing, now or in the future, any standards for
types of facilities; and that EPA should continue, under its
current authority, to have responsibility for setting standards
for the total amount of radiation in the general environment
from all facilities combined in the uranium fuel cycle, i.e.,
an ambient standard which would have to reflect AEC's findings
as to the practicability of emission controls....
EPA was thereby directed to limit its activities to the setting of general
environmental standards, and further directed to set such standards in con-
formance with AEC determinations as to the economic and technical feasibility
of available source control measures. It should be noted that environmental
limitations on other toxic and hazardous pollutants, for example, those sub-
ject to regulation under the air and water pollution control laws, are
usually required to be established primarily on the basis of environmental
and health effects, rather than on the basis of economic and technical
feasibility (19).
Off site, or general environmental, radiation levels and exposures can
be controlled most effectively through restrictions on the siting, design,
and operation of new sources;and through backfitting and other design and
operational requirements on existing sources. (See Introduction and Figures
IV. 1 and IV.2.) Therefore, a coordinated effort at radiation control, in-
volving the EPA, NRC, and the States, would be necessary if either agency
wants to meet fully its responsibilities for environmental quality and human
health.
These responsibilities are manifest in judgments that should be made
for regulating radiation, such as:
a) Acceptable environmental levels and exposures (EPA, with local and
State health inputs);
b) Optimal locations or sites for emitting sources (EPA, NRC, and
primarily the states);
c) The "dose conmLtment" that should be allocated to existing and new
sources over the long term (20)(EPA, NRC, and federal and state
authorities responsible for energy growth and new facility approvals);
d) The technical and economic feasibility of the control measures and
design features of power facilities, necessary to meet off site
objectives (NRC, EPA); and
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e) The consistent reduction of emission levels and exposures called
for by the ALARA concept; through new "control technology--
forcing" standards and modifications of prevailing requirements,
as justified by the balancing of costs and benefits attributable
to the reductions being considered, and by the feasibility of the
technologies to be utilized (EPA, NRC) .
EPA's achievements to date in this area have been limited primarily to
articulation of the "dose commitment" concept (20) and the announcement in
1975 of proposed, generally applicable environmental standards for radiation
levels and exposures related to the uraniun fuel cycle (14). The standards
proposed by EPA are relatively high, and far greater than current radiation
levels associated with presently operating facilities; this leaves to the
NRC discretion in imposing conditions on new and existing facilities (21) —
provided that the levels arising from any source do not exceed the EPA upper
limits, an unlikely event. This issue and the various levels as quantified
are discussed further.
Neither the NRC nor EPA has chosen to use ALARA as a dynamic regulatory
principle which would constantly force on NRC licensees the requirement to
further limit emissions in the public interest, as such further limitations
are justified by off site radiation levels (which may accrue from sources
other than the particular facility in question); and as justified by improving
conditions of technological and economic feasibility for more stringent emission
controls. Nor has EPA played any role in the formulation of criteria and guid-
ances for optimal site selection as another means of implementing ALARA and
improving overall regulation of environmental radiation. EPA has therefore
complied fully with the OMB memorandum discussed above, and Congress has not
determined whether this executive branch determination accords with Congres-
sional enactments and legislative history, and with the public health and
welfare.
Discussion of these matters immediately raises the issue of EPA dis-
cretion. EPA inherits its basic authority from the FRC and the AEG through
the Reorganization Plan (7), and as a matter of course, the discretion and
duties that accompany that authority. The original authority provided the
FRC to "guide" the agencies (22) does not impose any duty on EPA to become
involved in the regulation of facility siting, design and operation, nor to
participate in the implementation of ALARA. However, the original grant of
authority to the AEG (23) established an AEC duty to set and implement stan-
dards as required by the public interest; thereby indicating that EPA, as
heir to this duty, should now be playing a key role in carrying out the
several regulatory tasks outlined above.
Although the Reorganization Plan discusses standards only in terms of
their general applicability, the EPA role, of necessity, must also involve
regulation of a facility-specific nature when extraordinary or exceptional
circunstances surrounding a site, a plant's operation, or actual off site
levels render the generic approach inadequate to provide for the public
interest. Certainly, this facility-specific regulatory role is not precluded
by the terms of the Reorganization Plan. Nevertheless, EPA has adopted
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standards approach of general applicability only, and has left facility-
specific regulation to the NRC (14).
By an independent route, EPA has been involved with the review of specific
facility proposals of NRC applicants. The National Environmental Policy Act
(NEPA) (24) and Guidelines of the U.S. Council on Environmental Quality (25)
provide that EPA and other agencies with jurisdiction or special expertise
review environmental impact statements (EIS) including those done by the NRC
at the construction and operating permit stages of power plant approval.
This EIS review role has been made mandatory for EPA by section 309 of the
Clean Air Act, which requires EPA to review the actions of other federal
agencies, as embodied in their EIS's, from "public health" and "environmental
quality" perspectives, and to report problems to the Council on Environmental
Quality (26).
This is adequate authority for EPA review of and public comment on spe-
cific facility proposals in virtually all pollution respects, including
radiation and the implementation of ALARA in the siting, design and future
operations of the facility. Nevertheless, EPA's position on the radiation
aspects of such review has been to rest content with its recently announced
proposed standards of general applicability. If EPA formally adopted ALARA,
its review of the EIS's done on nuclear power and fuel cycle matters could
be a means of implementation of this important concept on a facility-specific
basis.
The EPA also possesses authority under the Clean Air Act (27), the
Federal Water Pollution Control Act (PWPCA) (28) and the Safe Drinking Water
Act (SEftJA) (29) that could involve it further with radiation discharges aricT~
off-site levels. SDMA requires EPA to issue regulations for "contaminants"
which have been defined to include radiological materials (30) ; the Clean
Air Act requires EPA to regulate pollutants that are determined by the
Administrator to be hazardous to public health (31); and the EWCA requires
that EPA (1) regulate the discharge of water pollutants from point sources,
including this discharge of radioactive materials (32), (2) establish
effluent (discharge) standards for toxic pollutants (33), and (3) approve
appropriate water quality (ambient) standards to be established by the
states (34).
These statutes provide specific duties and less discretion to the EPA
than its inherited AEC authority, in that they require EPA to act, provide
explicit criteria for agency use in regulation, impose time limits, and pro-
vide for citizen suits and judicial review.
EPA has not implemented the Clean Air Act and the fWCA insofar as they
apply to releases of ionizing radiation from nuclear power plants, maintain-
ing that responsibility for regulating such releases into air and water rests
with the NRC. To maintain this position of deference to the NRC with regard
to releases into water, EPA appealed a decision of the U.S. Court of Appeals
for the 10th Circuit, Colorado PIRG v. Train (35), to the U.S. Supreme Court.
In the decision of the Court of Appeals, EPA was ordered to set effluent
standards for the discharges of radioactive waste water from nuclear power
plants, in accordance with the Court's interpretation of the regulatory
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responsibility imposed on EPA by the FWPCA-^which statute includes "radio-
active materials" in its definition of pollutants subject to EPA control by
means of effluent and ambient limitations. The Supreme Court, in reversing
tiie Court of Appeals (36), accepted EPA's argument that the regulation of
such effluents is a responsibility which rests with the NRC, under prior
Atomic Energy legislation (37), and that EPA's radiation discharge responsi-
bilities under IWCA relate only to the release of "other" radioactive
materials such as radiun and accelerator-produced isotopes (38).
The Supreme Court's decision thereby constitutes a limitation on EPA's
use of its statutory authority to control an important pollution problem at
the source, and has created an exception to the otherwise all-inclusive
scheme for water pollution control as designed by the Congress in the FWPCA--
a scheme which requires EPA to regulate (1) electric generating facilities
as "point sources" (39); (2) "radioactive" effluents (40); (3) other waste-
water discharges of a polluting nature (e.g., thermal, anti-corrosion chemicals,
etc.) from nuclear plants (41); and (4) toxic materials (42). Since EPA is
carrying out most of these other tasks and could develop interagency mechanisms
for drawing on NRC radiation expertise, there should not have been any adminis-
trative or technical difficulties in extending its program to radiation dis-
charge regulation. EPA, therefore, appears not to have undertaken any
regulatory functions of significance with regard to ionizing radiation.
3. The States
The states are involved with EPA, as noted above, in carrying out the
requirements of the Clean Air Act, FMPCA, and the Safe Drinking Water Act,
all of which require EPA approval of state implementation plans, review of
subsequent state performance, and EPA action upon state default (43) - How-
ever, in light of the Supreme Court's decision in Colorado PIBG (36), regu-
lation of waterborne discharges from nuclear power plants rests with the NRC,
and neither EPA nor the states through their PWPCA programs under EPA authority
have authority to regulate such wastewater discharges. Further, any independent
role for the states in controlling such wastewater discharges, has been excluded
as a result of the decision of the U.S. Supreme Court in Northern States Power
Co. v. Minnesota (44) . In this decision, the Supreme Court affirmed a circuit
court ruling that the regulation of such discharges from power plants is a
federal responsibility, as a result of federal preemption established by the
Atomic Energy Act of 1954 and the subsequent scheme of federal legislation
and regulation. Colorado PIRG and Northern States would also appear to pro-
vide a basis for excluding any EPA or state role in regulating airborne
discharges of ionizing radiations under the Clean Air Act or other authority,
on the basis of the Supreme Court's findings in these decisions as to
Congressional intent, although cases on the air discharge issue have not
materialized to date. Therefore, the states have no apparent opportunity to
directly control discharges of ionizing radiation from nuclear power plants
into the air and water.
However, the general authority of the states under the Constitution (45)
to protect public health, safety and welfare has provided a basis for state
authority in determining acceptable levels of radiation in the offsite
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environment. State and local authorities have established various, criteria
and standards relating to offsite exposure and ambient levels of radiation
(46). On this basis, and consistent with the ambient water quality pro-
visions of the FWPCA, several states have also developed radiation standards
and criteria for ambient water quality as part of their effort to achieve
water quality objectives (47). This activity has not been challenged in the
courts, and such regulation of offsite, ambient levels would seem to fall
outside the scope of federal preemption defined in Northern States, and out-
side the scope of NRC authority defined in Colorado PIRG, since both cases
dealt with the issue of a direct attempt to regulate waterbome discharges
by agencies other than the NRC (48). Therefore, if the states have any role
in regulating ionizing radiation, it is founded on their "police power and
consists of their ability to regulate the offsite environment for purposes of
protecting public health, safety, and welfare.
Finally, the states have their land use authority, under the regulatory
powers conferred by the Constitution, to further provide for public health,
safety and welfare at state and local levels. In addition to zoning and sub-
division control methods of regulating land use, many states now provide for
special board and procedures to govern the siting of major facilities, such
as power plants and transmission lines.
The NRC has no express authority to acquire power plant sites for
utilities, nor does it have authority to change or override state and local
laws governing land use, but is limited to considering the suitability of
those plant sites proposed by applicants for plant construction licenses.
Applicants must, therefore,-acquire title or lease to sites, and conform to
use restrictions, under prevailing state and local laws; in addition to
securing NRC approval and construction permit under NRC regulations and
guidelines which have been promulgated to insure public safety.
States have the opportunity to restrict or confine radiation hazards
at the pre-construction, site-review stage. The implications of this growing
state role, demonstrated by the creation of energy facility-siting boards and
their use of environmental and safety criteria (e.g., in Massachusetts, New
York, Maryland, etc.), are extremely significant for the regulation of ionizing
radiation, irrespective of implementation of ALARA by NRC and EPA (49) .
The potential for an enlarged state role in controlling ionizing radia-
tion may be limited by (1) a lack of state resources to carry out the technical
analyses necessary for safe siting (50); and (2) the traditional dependence of
the states on federal agencies, primarily the AEG and NRC, in establishing
regulations.
With regard to the issue of state resources, a World Health Organization
assessment noted:
While 47.. .states have adopted legislation.. .to control.. .ionizing
radiations, there are major divergences in the implementing regu-
lations .. .Only 50 percent have adopted most of the provisions of
the model regulations (suggested by the Council of State Govern-
ments, and drawn up with the collaboration of the AEC and the
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PHS.. .eleven states have no regulations for the control of radio-
active materials not subject to the Atomic Energy Act of 1954...
The following are reported to be major inadequacies...(1) lack of
regulations or failure to update regulations...(2) insufficient
funds and personnel... (4) lack of uniformity in the control of
health hazards from the use of radium and accelerator-produced
radionuclides including safety standards, inspection requirements,
regulations and enforcement (46) .
As for state dependence on the NRC, "Suggested State Regulations for
Control of Radiation" (SSRCR) have been promulgated and updated periodically
following an original initiative by the Council of State Governments, the
AEC, the U.S. Public Health Service and other federal agencies. The lead
role has been played by the AEC, insofar as the SSRCR deals with power plant
radiation, and the latest SSRCR, published in 1974 (50) also involved inputs
from the Food and Drug Administration and the Conference of Radiation Control
Program Directors representing state agencies. EPA was not involved in the
most recent SSRCR effort.
C. Decision-Making
1. Concepts
The position that there is no safe or threshold level for human expo-
sure to radiation has been adopted by the NRC and EPA (51) - Therefore,
regulation cannot be premised on achieving and maintaining a level of radia-
tion in the ambient environment, above natural background, that is safe for
human health.
In light of this position, regulation of ionizing radiation can be based
on either of two approaches:
(a) total prohibition of any releases to the offsite
environment from energy facilities (as well as
from mpfii'pal and industrial facilities) , the
zero-discharge approach; or
(b) allowance of releases to the offsite environment and
resulting exposures only as justified by a balancing
of interests, such as can be accomplished, in part,
through the use of cost-benefit analysis. This so-
called "rational approach" thereby provides controls
on radiation levels to the extent the associated costs
of control and the externalities such as damage to
human health are balanced or offset by the benefits
to be derived from the use of the radioactive materials;
i.e., the benefit-cost approach. The analytical and
ethical issues and limitations of this approach to the
regulation of radiation are addressed in other chapters
of this report.
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The zero-discharge approach (52), which would essentially halt the
construction and use of nuclear~~power facilities, has been rejected by
the NRC (53) and ignored by the Congress. Therefore, subsequent discussion
of regulation will focus on the benefit-cost approach now being employed (54) ,
There are three points implicit in the benefit-cost basis for regulating
radiation:
(1) Regulation should be responsive to changes in the economics
and technology of radiation control, and to new knowledge
of health effects and other consequences.
(2)j The balance point at the margin for costs and benefits
determines the radiation level to be prescribed.
(3) Since the costs include carcinogenesis and genetic muta-
genesis as health effects, the latter occurring over
several generations, whose significance cannot be quanti-
fied at values acceptable to all in society, the task is
not amenable to traditional or formal benefit-cost analysis.
Nevertheless, the benefit-cost structure or procedure should
be used to the extent possible to provide for as rational a
decision-process as possible. These ''unquantifiable*' vari-
ables, or rather, "arbitrarily-quantifiable" variables should
therefore be identified by the regulators and exposed to some
form of open, participatory process of quantification; since
quantification of all variables is ultimately necessary for
conducting the benefit-cost process.
These points are made in recognition of various factors which may be
included in the regulatory process to consciously distort the benefit-cost
analysis for purposes of enhancing public health and safety, such as:
(a) the use of safety or weighting factors in light of uncertainties about
information, or in light of significant public concerns and fears; and
(b) the payment of a premium above the nrjm'TniTn total cost to society for
purposes of providing additional protection to a particularly exposed group
such as those who live in the environs of a power plant. The use of such
factors should be articulated and subject to review outside the agency.
The benefit-cost approach has been adopted by the NRC for purposes of
setting radiation regulations, and reinforced by NRC adoption of the general
principle that radiation exposure to the public should be kept "as low as
is reasonably achievable (ALARA), or as MARA, has been formally defined:
as low as is reasonably achievable taking into account the
state of technology, and the economics of improvements in
relation to benefits to the public health and safety, and
other societal and socioeconomic considerations, and in
relation to the utilization of atomic energy in the public
interest (55).
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ALARA therefore represents at least an affirmation of the use of benefit-
cost analysis in regulation. The following discussion considers agency and
judicial experience with benefit-cost and ALARA to date.
2. Nuclear Regulatory Commission
a. Pre-1975
From the time of the first comnercial reactor to 1970, the AEG
licensing system suffered from lack of sufficient information on the long-
term health effects of ionizing radiation. Therefore, the AEC had no
"rational" (cost-benefit) basis for its numerical values on radiation
exposure limits, and proceeded on the basis of conservative assumptions.
Disputes between AEC staff and a utility over the degree of radiation con-
trol to be imposed could only be resolved by negotiation and ultimately by
AEC imposition of essentially arbitrary numerical values.
The environmental movement and public concerns over the quality of
AEC regulation increased in the late 1960's; and challenges to AEC standard-
setting and other aspects of AEC decision-making were brought to the courts
for judicial review (56) by the early 1970's. The AEC adopted the ALAP/AIARA
concept and began to incorporate it into its regulatory programs in 1970 (57),
as has been generally discussed thusfar.
During the long gestation period of ALARA quantification, the 1970-
1974 period during which Proposed Appendix I was employed to impose interim
conditions on licensees (58), the AEC's "Staff System" operated without
dollar values for health damage caused by radiation exposure, and therefore
lacked a key element for cost-benefit calculation (59). Without such dollar
values, the AEC nevertheless set limits for maximum individual exposures;
but had no rational basis for dealing with the exposure of large nunbers of
people at low levels of ionizing radiation that leads to statistically-
determined cases of cancer and birth defects under the linear damage hypothe-
sis.
Control measures that would make no difference for the case of the
most exposed individual, but which could be justified on the basis of cost-
benefit analysis for large population exposure, were therefore not imple-
mented. As a result, a utility could have conceivably been free to stop
with its control measures once the most exposed individual limit was reached,
instead of being forced to control at a level determined by a cost-benefit
balance point.
Another problem with the "Staff System" arose from the condition
that design calculation limits for radioactive iodine emission had reached
the limits of technology. The Staff, therefore, designed a method for use
on a case-by-case basis. If a proposed reactor would exceed the design
limits for radioiodine, it would nevertheless be deemed in compliance if a
list of specified control measures for iodine removal (Base-Line-In-Plant,
or BLIP) would be installed. Since the calculations were conservative, and
there was no dollar value for radiation exposure, the Staff could not
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deternrine by benefit-cost analysis if such exceptions were justified.
However, since old plants without such measures produce exposures much
less than the 15 iriR. limit for radioactive iodine, the method was based
on the assunption that the public would not be exposed to undue health
risk, but possibly would be exposed to excessive costs passed on through
the utilities' rate structure (60) .
b. 1975: New System
The NRC, in its recent ALARA opinion, (61) has irodified the "Staff
System" in order to correct such defects. It has assuned an interim dollar
value for the societal cost of a man-retn (62), imposed a requirement of
benefit-cost calculations using that figure (63), and dispensed with the
BLIP feature (64). The dollar values of $1000 per total-body man-rem and
$1000 per-man-thyroid-rem chosen are admittedly arbitrary and conservative,
and NRC proposes to hold rulemaking hearings to set a final figure (65) .
The NRC opinion retains limits on individual exposure, but adds a
requirement that further measures will be required if justified by cost-
benefit calculation based on the total dose to the population (66) . This
will eliminate the possibility that a utility would be permitted to maintain
control at a level no greater than that necessary for individual limits, and
presumably carries out the implication of ALARA for case-by-case pressure.
The new system, then, has an improved structure, with numbers to
refer to during the design process, limits for protection of the most-exposed
individuals, and clear directions for measures to reduce the population dose-
measures that depend on the cost-benefit balance that is required by ALARA.
However, several major regulatory issues remain, and are now discussed.
ALARA is one of the most important of numerous design factors built
into NRC regulations for licensing new facilities, and also has implications
for "backfitting" existing plants as well. "Backfitting" would involve the
addition of radiation controls to existing plants, as justified by cost-
benefit analysis, and is more expensive than installation of similar controls
at the time of facility construction. NRC has left the matter for future
consideration on a case-by-case basis, and has excluded any generic approach
(67).
"Backfitting" also becomes a possibility for the current generation
of reactors to be licensed under Appendix I, for example, where actual growth
of the receptor population is markedly different from the expected population
growth used in design calculations at the time of original licensing. Under
such conditions, NRC has the options of either "backfitting" the plant in
question or restricting its operation (68). Neither the NRC nor the states
have confronted this issue of receptor population growth and its implications
for plant operation, and' it is admittedly a politically difficult task
involving social planning and land use restrictions for the environs of plant
sites.
To ensure that ALARA and other conditions are met, licensees are
retjuired to monitor their operations and provide feedback to the NRC. Data
is collected on actual emissions, off site levels, and land-use patterns in
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the vicinity, and such feedback to NFC should also ensure that application
of AIARA-based regulations will be responsive to changes or unexpected con-
ditions (68).
Although data collection tasks are well-defined, the overall informa-
tion feedback loop from operational (actual) data to design calculation to
regulatory modifications regarding controls has not functioned well from a
benefit-cost perspective. NRC, H?A and the energy industry all agree that
present calculational models overestimate radiation exposure—by more than a
factor of ten in the case of iodine, for example (69). The ALARA concept,
which implies a balance between costs and health risks, will therefore not be
fully realized until NRC develops design calculations that incorporate oper-
ating experience.
NRC dealt with the problems posed by the calculational process at
some length in its Appendix I opinion, admitted that present calculations are
highly conservative, expressed support for realistic calculations, and pro-
vided several points for guidance "on how calculational procedures should be
used in determining design objectives" to implement Appendix I. (Realistic
models are preferred, an applicant may use approximations it his assumptions
were conservative, parameters used should be best estimates, etc.)
The implications of this condition are numerous: (1) a margin of
safety is presumably being provided the public because operating experience
indicates that, for example, only 1 mR. of exposure to radioiodine occurs,
despite NRC limitations of 15 mR.; (2) the utilities and ultimately the public
are paying for "unnecessary" levels of control—in the sense that such control
levels have been pushed beyond the balance point of ALARA analysis; (3) NRC
regulations based on ALARA have a continuing credibility problem from a cost-
benefit perspective; (4) NRC retains considerable discretion to allow facili-
ties to operate above the "norm" at which they are demons trably capable of
operating, up to the higher NRC limitations—on a case-by-case basis;
(5) NRC can authorize the cluster-siting of several reactors, with each neet-
ing its Appendix I limitations, without breach of the 15 mR. limit for iodine.
These unexpected benefits of lower exposure from actual operations are welcome,
and demonstrate technological capabilities. They should be evaluated against
the costs, and particularly against the condition that ALARA is not yet being
fully-implemented and that the resulting decision-processes in NRC regulation
remain considerably arbitrary. Since these unexpected benefits accrue at the
discretion of the NRC and reflect current technological capabilities which
are economically feasible for the utilities, it would appear that the responsi-
ble ALARA position for the NRC to adopt would be one of continuous self-
limitation of its own discretion, through the continuous promulgation of rules
reflecting these now achievable lower emission levels.
Appendix I, as the regulatory manifestation of ALARA, has additional
implications tor facility-siting and design standardization.
ALARA has not been invoked for purposes of siting new power facili-
ties. This is due in part to the limited role played by the NRC in siting:
a role basically of a "negative" review nature, prescribing geological,
population and other constraints for facility-siting (70). NRC considerate
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of siting has, since 1970, been extended to the review of alternative sites
available to a construction license applicant, under the requirements of
the National Environmental Policy Act (NEPA) (71) . This presumably ensures
that the site to be selected is the most acceptable of those reasonably
available, as determined by the traditional siting criteria employed by NRC.
It does not ensure that the site will be optimal, from an ALARA perspective
(72).
The primary siting role therefore has essentially fallen to the
utility and the cognizant state energy boards recently established (49) .
This allocation of siting roles basically accords with the Constitution,
which provides the states with land use authority under the general grant of
"police power" (45), as discussed earlier. However, ALARA considerations
could be translated into siting criteria by NRG and EPA, and offered to the
states and utilities as guidelines for use along with other criteria used by
the relevant state authorities. This task of working with the states to
implement ALARA is discussed in Section C.3.
Standardization of reactor design remains an NRC objective to re-
place the practice of custom-designed reactors, in order to achieve cost
reductions, quality control and enhanced safety (73). The standardization
review process would test possible reactor design in different hypothetical
sites—lake, river, offshore, etc.—with assumed population distributions.
For a specific facility, site review would ideally be_ reduced to whether the
actual site parameters are no worse than the hypothetical.
ALARA implementation can be in conflict with aspects of standardi-
zation, since the former calls for site-specific balancing of several factors
to determine design limitations, and the latter provides for a generic
approach to design limitations for plants which fall within certain site and
population parameters.
Appendix I appears to integrate appropriately AIARA with standardi-
zation. The individual dose limits are already standardized—being derived
from calculations involving hypothetical standard reactors and hypothetical
standard sites (51) . Case-by-case pressure on the population dose is pro-
vided by the requirement that all controls justified on a benefit-cost basis
be added: if an actual site is worse than the standard site in some respects,
radiation control measures will be added until the population dose is brought
down to the benefit-cost value. Since the NRC is not directly involved in
siting, there is still the possibility that an inferior site will be selected
because of local or state land use decisions and utility acquisitions. How-
ever, the population would still be protected by the benefit-cost provisions,
and the only undesirable effect would be an increase in electrical cost as
compared with some other site. The state level is probably a preferable
location for these tradeoffs to be made between dollars and land use objec-
tives .
The NRC has recently run into difficulty in trying to achieve
standardization without fully implementing the ALARA approach of Append:!--I I
In!York Committee for a Safe Environment v. Nuclear Regulatory Commission (74) ,
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the Federal Court of Appeals for the District of Columbia determined that
the NRC cannot consider the satisfaction of a single numerical guideline
(the radioiodine—thyroid dose limit of 15 mR. per year) the equivalent of
meeting its ALAP (now ALARA) regulations, since:
The Coranission definition... (of AIAP) .. .requires consideration
of health and safety effects, costs, the state of technology, and
utilization of atomic energy in the public interest. While the
last two factors may be constant for any reactor built or operating
during a particular time, period, the first two vail presumably
vary depending on the circumstances of each reactor. Since two of
the four factors which determine whether radioactive emissions are
1 as low as practicable' are not constants, the Commission is pre-
cluded from determining that any particular positive level of
emissions satisfies its requirement in all cases.
Since Appendix I, itself, specifies that in addition to satisfying the numeri-
cal guides,
the applicant shall include in the radwaste system all items of
reasonably demonstrated technology that when added to the system
sequentially and in order of diminishing cost-benefit ratio
effect reductions in dose to the population reasonably expected to
be within 50 miles of the reactor...
the court concluded that "...(the) 'as low as practicable' standard requires
individual consideration of the costs and benefits of reducing radioactive
emissions from any particular reactor below the numerical guidelines."
Therefore, the NRC is to be held accountable for the application of AIARA
and benefit-cost on an individualized licensee basis, irrespective of the
standarization measures it seeks to implement.
The implications of ALARA for NRC enforcement must also be addressed.
Appendix I deals both with the design criteria and also with enforcement of
operating conditions to meet these criteria, as noted earlier. The calcula-
tions involved can be broken down into two groups—those that deal with the
amount of radioactivity that will be released, and those that predict how a
given amount of radioactivity will spread through the environment, in particu-
lar into the food chain. For enforcement, actual emissions data are used in
the second stage of the calculations (75).
The nuclear industry has made a case for the proposition that
temporary violations of the standards must be tolerated, because (a) complex
systems always vary in performance, (b) there is insufficient evidence that
public health has been endangered, and (c) because it is highly import-ant to
maintain a continuous supply of electricity (76). Some participants in the
Appendix I hearings argued that limitations established under Appendix I on
a plant-specif ic basis should be treated as absolutes (77), and this argument
appears to rest on distrust of administrative discretion in general, and of
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the NRC in particular. Certainly public confidence in the administrative
process is a factor that cannot be ignored.
The NRC has chosen enforcement flexibility, providing "if the
quantity of radioactive material actually released in effluents—during
any calendar quarter is such that the resulting radiation exposure, calcu-
lated on the same basis as the respective design objective exposure, would
exceed one-half the design objective annual exposure—the licensee shall:
(1) Make an investigation to identify the causes for such release rates;
(2) Define and initiate a program of corrective action; and (3) Report these
actions to the Commission within 30 days from the end of the quarter during
which the release occurred" (78).
Two features stand out, emphasizing the broad scope of NRC enforce-
ment discretion:
(1) By implication, the licensee will be allowed to exceed
the emission standards by a substantial amount indefi-
nitely, without even calling the NRC's attention to
the matter.
(2) If the licensee exceeds the exposure limit, and sets to
work on a program of corrective action, there is no indi-
cation of the time-scale on which the licensee will be
required to act.
Both these situations are governed at the discretion of the NRC.
The NRC may "require the licensee to take such action as the
Commission deems appropriate" (79) and it would surely move against a li-
censee who proposed to continue indefinitely at a rate 1.9 times the
Appendix I value; or who proposed to wait until his defective fuel rods
reached the end of their normal life before replacing them. Nevertheless,
a degree of trust in the NRC is called for, which may prove difficult to
satisfy (80) . Even though a complete specification of possible reactions
to such developments is impossible, NRC could provide further details on
enforcement, and specific criteria and time frames for corrective action (81).
Closely tied in with the enforcement issue is the previously-discussed
matter of producing practicable standards. The fact that design calculations
predict hypothetical exposures that are generally much higher than those ob-
served in practice has a great deal to do with the flexibility afforded the
NRC staff and with NRC tolerance of utility performace at variance with pre-
scribed conditions. This tolerance is not shared by those who prefer regula-
tion without discretion (without confidence in the NRC Staff), and who would
be likely to seek to close down a plant because of temporary violations of
limitations imposed on the basis of initial design calculations.
An NRC administrator is therefore in a dilemma—he. must balance the
known costs of reducing the operating level or of closing a power plant against
tihe risks caused by indeterminate exposure of the public to new levels of
radiation emission. Given that the initial design calculations are known to
b$ highly conservative, an NRC official may decide to permit the situation to
cdnrinue for some months; but, lacking data, is unable to present a rational
defense of his action (82).
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Finally, ALARA implies change with time. Thusfar, the NRC standards
have been consistently tightened; but in principle, they can be loosened as^
well. It would therefore appear necessary to prevent any convenient loosening
or maintenance of the status quo as a result of various pressures, particularly
under less favorable economic circumstances for the power industry, by setting
health boundary conditions as a necessary part of the ALARA quantification
processes (83), as discusled in later sections of this chapter.
3. EPA and the States
EPA and the states have played insignificant roles in the regulation of
radiation from nuclear power facilities; and there is no history of benefit-
cost, ALARA and similar analytical techniques worth reviewing. Therefore, this
section focuses largely on the implications of such analytical techniques for
EPA and state decision-making, to the extent they enjoy discretion sufficient
for implementation, as discussed above.
Although EPA has employed some form of balancing analysis in its regula-
tory efforts on radiation to date, the agency has not adopted the ALARA con-
cept, nor articulated cost-benefit as its analytical method. In the agency's
"Proposed Standards for Radiation Protection for Nuclear Power Operations"
recently announced, the following language has been used to describe the analyti-
cal method employed:
In developing the proposed standards, EPA has carefully con-
sidered, in addition to potential health effects, the available
information on the effectiveness and costs of various means of
reducing radioactive effluents, and therefore potential health
effects, from fuel cycle operations. This consideration has
included the findings of the AEC and the NRC with respect to
practicability of effluent controls, as well as EPA's own con-
tinuing cognizance of the development, operating experience, and
costs of control technology. Such an examination made it possible
to propose the standards at levels consistent with the capabili-
ties of control technology and at a cost judged by the Agency to
be acceptable to society, as well as reasonable for the risk
reduction achieved. Thus the standards generally represent the
lowest radiation levels at which the Agency has determined that
the costs of control are justified by the reduction in health
risk. The Agency has selected the cost-effectiveness approach
as that best designed to strike a balance between the need to
reduce health risks to the general population and the need for
nuclear power. Such a balance is necessary in part because
there is no sure way to guarantee absolute protection of public
health from the effects of a non-threshhold pollutant, such as
radiation, other than by prohibiting outright any emissions.
The Agency believes that such a course would not be in the best
interests of society (84).
This preamble to the subsequently-announced limits on individual doses
to members of the public and limits on quantities of certain long-lived
radioactive materials in the general environment reflects a number of
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assumptions and exercises of EPA discretion that are not in harmony with the
deployment of cost-benefit analysis and ALARA by NRC.
Sound regulation of radiation would require the EPA's exercise of its
generally-applicable, environmental standard-setting functions be synchronized
with the analytical processes of the NRC (benefit-cost, ALARA) and the other
agencies such as the Department of Transportation (DOT) and the Food and Drug
Administration (FDA), which EPA acknowledges as having ".. .the responsibility
for the implementation and enforcement of both this guidance and these stan-
dards.. .as a part of their normal regulatory functions" (85).
The interrelationship of the regulatory functions of the several agencies
is adequately demonstrated by the simple diagram presented as Figure 4.
Closely related to this issue is the need to adopt, at an interagency
level, the same values for health effects, control costs and other elements
of the coranon analytical processes to be used. EPA appears to be the most
appropriate agency to assume the lead role in this task, as it is the only
agency without obvious developmental interests in the construction and opera-
tion of the facilities emitting radiation.
The task of setting health parameters, or general societal levels of
radiation in full recognition of risks and the lack of detailed knowledge of
exposures and pathways, has been discussed in the prior section as a measure
necessary for enlightening the public and preventing abuses which can creep
into balancing analyses when they are used to achieve hidden objectives.
This task should be carried out by EPA in conjunction with the Public Health
Service (PHS) of the Department of Health, Education and Welfare (DHEW), as
PHS is assumed to have such generally-applicable health guidance functions
(86). To some extent, EPA undertakes this task in setting radiation standards
for drinking water, under the provisions of the Safe Drinking Water Act (87),
because such standards will have to be based on data and an overall record
which emphasizes health considerations if they are to be upheld under judicial
review since, in this case, health parameters for radiation exposures arising
from ingestion of public water supplies would appear to be a necessary part
of the record if the resulting standards are not to be considered "arbitrary
and capricious" (88).
The EPA "proposed standards for environmental radiation protection from
nuclear power operations" (89) contain a number of other issues which relate
to the use of benefit-cost and ALARA-based analyses. Chief among these issues
is EPA deferral of any controls on certain long-lived radioactive materials.
EPA has previously acknowledged that ".. .no methods are available to effectively
remove such materials from the environment once they have been released, and
such releases thus imply irreversible commitments for exposure of future gener-
ations , except for natural occlusion in environmental sinks... it (is) especially
important to consider tiie. consequences of irreversible commitment of these dis-
charges to the environment before they have occurred.. .Since control must be
instituted long before the impacts associated with these releases occur, pro-
jection of anticipated health effects which could result from a release of
these radionuclides constitutes a necessary basis for decisions concerning the
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NRC
Regulation of Design and
Performance of Power Plants,
etc.
FDA, HEW
Regulation of Performance
of Some Nuclear Medicine
Facilities
The Off-site Environment
Levels of Concentration and
Exposure to Individuals
DOT
Regulation of Transporting
and Packaging of Radioactive
Materials
FIGURE IV. 4; Regulatory Interrelationships
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need for institution of control over their release. Future decisions ought
to consider these dose ccranitments with respect to both the types of develop-
ment that should occur and the choice of controls that should be imposed...
krypton and tritiun are the radionuclides of major concern..." (90) .
Despite this, EPA has, in the proposed standards, deferred controls on
such releases. For example, controls on krypton-85 and iodine-129 have been
deferred to an effective date of January 1, 1983, when successful demonstra-
tion of control technology may be achieved; controls on environmental release
of tritiun and carbon-14 have been deferred to such time as the knowledge
base on control measures and their cost feasibility has been developed.
"Tritiun levels...are not expected to become significant until the late 1980fs,
and development programs are in existence for control... The Agency believes
that the development and installation of controls.. .are important objectives,
and will carefully follow the development of new knowledge concerning the
impact and controllability of these radionuclides" (90).
Thus, a wide range of discretion is currently enjoyed by EPA to allow
releases until feasible controls are available. Unless federal legislation
requiring EPA to carry out affirmative duties in setting such radiation
standards within the near future is enacted, EPA will not be accountable
for such deferrals.
Another deficiency in the regulation of radiation, which has been dis-
cussed earlier, is the failure of any federal or state agency to translate
radiation standards into enforceable siting regulations for nuclear power
facilities. EPA has eschewed a siting role. As explained in the proposed
standards: " it (EPA) has not attempted to specify constraints on the
selection of sites...even though the Agency recognizes that siting is an
important factor which affects the potential health impact of most planned
releases from operations in the fuel cycle. The (proposed environmental)
standards were developed, however, on the assunption that sound siting prac-
tices will continue to be prompted as in the past and that facility planners
will utilize remote sites with low population densities to the maximun extent
feasible."
This assunption is, therefore, grounded in past practice, which fails to
reveal a comprehensive siting approach on the part of the various siting
decision-makers: the state and local authorities, the utility, and the NRC.
Certainly, the states have only recently started to assume careful siting
responsibilities through the creation of energy facility siting or review
boards, thereby retrieving previously-delegated land use authority from
local levels of government (91). But primary siting responsibility still
resides with the local zoning and planning authorities in most states, and
with the utilities and their siting practices and mLnimization of exposures
and off-site levels have been apparently deficient in their decision-making
(92). The siting guidances provided by the NRC do translate dose limits into
site criteria, but have been inadequate to prevent siting in high population
deosity areas, a problem which has been magnified by the NEC's ignoring of
its own siting guidelines (93). At present, the public can only rely on liti-
gation and judicial review to assure that siting is appropriately conducted.
However, this path is costly and technically complex (94) .
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Further, a variety of procedural restrictions work against litigation
and judicial review of agency decisions, as the method to ensure that the
siting of specific facilities will be conducted in accordance with radiation
limitations. For example, the courts have held that those who refrain from
participation in rulemaking proceedings (e.g., the setting of ALARA limita-
tions) may not obtain direct judicial review of the regulations resulting
(95). This creates a situation which essentially precludes local or state
interests from achieving judicial review of a facility-specific decision,
when such review would call into question the appropriateness of generally-
applicable regulations for the specific facility site in question. This
serves to preclude most interest groups, since such groups generally develop
or mobilize after a particular site has been chosen and evaluated, and there-
fore cannot be expected to have participated in earlier rule-making proceedings.
EPA, through its new Land Use office, could provide the required siting
guidances based on those radiation levels and exposures which have been deter-
mined to be acceptable through the analytical procedures under discussion,
thereby filling a gap in the present regulatory system as well as developing
another facet of ALARA.
The limited authority of the states to regulate ionizing radiation and
possible future roles involving state and local regulation of ambient water
quality and land use, premised in part on reduction of radiation hazards,
have been discussed. Although ALARA has not been considered in current uses
of the police power, it could become a major feature of decision-making on siting
by state and local authorities. EPA could develop and provide the states with
tie necessary siting guidelines, and further could authorize state compliance
on ALARA siting through the state implementation plan requirements and other
state program features of the Clean Air Act and the FvJPCA (96). In this
regard, EPA also has authority to regulate underground and public water
supplies (84,87).
Federal preemption deserves careful analysis, despite the Northern States
and Colorado PTRG decision of the Supreme Court, for as discussed in Section
II, the doctrine is currently limited to authority for regulation of discharges;
but the states possess general health and other ambient or offsite authority as
a result of their police powers and the water quality provisions of FWPCA (but
not the Clean Air Act). The extent to which such offsite authority can be used
to force higher or more stringent discharge standards on a utility is still
unresolved. It would appear that states could choose to set such ambient re-
quirements , and thereby indicate a willingness to have their citizens bear
higher costs for radiation control through the rate-setting structure, or even
exclude nuclear power if necessary controls are not available, the national
interest in nuclear power would not necessarily be harmed (97) .
An assessment of the economic and operational implications for the
future of nuclear power under such possible conditions is required to reach
an appropriate decision on federal preemption vis-a-vis state authority over
offsite effects. The issue is too technical to be resolved through future
judicial decisions, but could be undertaken by a relatively disinterested
assessor, such as the Congressional Office of Technology Assessment (OTA),
which has necessary the institutional framework, methodologies and resources
(98).
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Consideration of enhancing the state role in this regard is justified
because the values and weights used in analyses for regulating nuclear
power are subjectively established. State and local values deserve con-
sideration because of this condition of subjectivity which is inherent in
decision-making on radiation, and because ultimately, the future of nuclear
power will hinge on state acceptance, local values and the availability of
facility sites—despite ALARA, benefit-cost, and federal preemption (99).
D. Basic Legal and Policy Considerations Attending Uses of Benefit-Cost
Analysis
Balancing costs and benefits for decision-making has long been a prac-
tice of each of the three major institutions of the legal system—the legis-
lature, courts and administrative agencies. The practice has been informal,
implicit, and unsystematic, with little recognition of its inherent subjectivity,
and with little concern for the limitations of the balancing techniques them-
selves .
However, several developments have now converged to make previous balancing
practices in the administrative agencies unacceptable: (1) the passage of the
National Environmental Policy Act and of other statutes for environmental pro-
tection whose provisions reflect Congressional understanding that agency regu-
lation is a multiple-objective task which calls for a complete balancing of
various interests (e.g.. economic, environmental) except in cases of overriding
threat to national security or public health; (2) the increasing sophistication
of analytical techniques; (3) the opening up of agency rule-making and adjudi-
catory procedures to public scrutiny, and the growing desire of various societal
sectors to use their increasing opportunities to influence the subjective
features of such agency decision-making; (4) the increasing rigor of judicial
review of agency decision-making, and the willingness of federal courts to
examine more fully the procedural and substantive aspects of agency determina-
tions.
In this section, an effort is made to identify some basic legal and policy
problems with the use of benefit-cost to manage and control technical develop-
ments, and to develop some general principles to guide future uses of benefit-
cost in government regulation. The judicial and administrative contexts in
which balancing occurs are briefly examined in light of the discussion of
preceding sections of this chapter, which focused on actual uses of benefit-
cost to regulate ionizing radiation.
1. Common Law
Within the conmon law, tort law, which includes the fields of negligence
and nuisance, has historically been of most significance for the securing of
relief from the adverse health effects of technological activities. The
essence of this field of law consists of judicial balancing. Green has
summarized this feature of tort law as follows:
The standard upon which the law of negligence is based is deter-
mined by weighing the magnitude of the risk of harm against the
\utility of the actor's conduct... the law of nuisance is based on
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the principle that conduct of the defendant is 'unreasonable in
the light of its utility and the harm or risk which results'.
As courts decide these cases, a body of laws comes into being
that reflects a judgment as to the benefit-risk applicable to
the activities in question. To the extent that decisions are
made that risks outweigh benefits the activities may be enjoined
by court action, or a rule of liability may be established that
has the effect of increasing the costs incident to the activity
and, in effect, deterring it (100).
Green has also described the limitations on the efficacy of the common law
and its judicial applications in making benefit-risk determinations in the
public interest:
1. ... the courts can act only on cases in which someone has been
injured or clearly threatened.. .Accordingly, the system is not of
much use in protecting society against very young...technologies.
2. Courts react only to information introduced in evidence in an
adversary context, and judges and juries may not correctly under-
stand technical issues. Cannon law principles, therefore, may
sometimes not accord with scientific fact.
3. There are frequently Immense difficulties, particularly where
the risk is of a slow, creeping cumulative nature.. .in showing
injury in a sufficiently legally adequate manner to warrant a
favorable decision for the plaintiff.
4. Conversely, there are frequently immense difficulties in show-
ing a causal relationship between an existing ill and the alleged
technological source of the injury.
5. The cannon law is extended to new problems by a trial and
error process in finding analogies to and distinctions from
earlier precedents. The formulation of new cannon law princi-
ples that adequately reflect the benefits and risks of new
technologies is, therefore, usually a long, slow and uncertain
process (100).
This describes why the cannon law is of limited utility in controlling the
adverse effects arising from activities using harmful substances such as
radioactive materials. Further cannon law limitations arise from the inade-
quacy of the remedies available to the courts—compensatory damages and
injunction. Damages are inadequate for the seriously-ill plaintiff, the
malformed fetus, and their families. Damages are also inadequate for deter-
ring or curbing the sources of the externality for broader societal protection
purposes, since they may be awarded only to the few plaintiffs who have per-
sisted in the courts for many years after the harmful activity was initiated.
Therefore, the law has no significant or timely function of deterrence, of
forcing more effective control measures when they are needed, on large scale
technological activities such as nuclear power. Injunctive relief is rarely
ordered by the courts against viable economic activities which are responsible
for the harms, since such activities concurrently provide employment and a
variety of other social and economic benefits which the courts are reluctant
to curb, on the basis of their rough attempts at balancing (101).
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For the case of nuclear power, with its releases of radioactivity and
creation of long-term risks and harms, two further conditions limit use of
the conmon law and its balancing processes for individual and societal
protection: the effects of the presence of a large but not necessarily
coherent government regulatory program on the common law, and the inability
of the common law to evolve and meet new problems.
The existence of regulatory agencies and their control programs "...
presents obstacles to the use of public nuisance actions where the existence '
of these agencies is used as a defense to injunction actions...even where
statutory language has expressly preserved unimpaired common law remedies..."
The obstacles include doctrines which enable the courts to defer consideration
of the issues sought to be raised by a plaintiff, such as the doctrines of
"primary jurisdiction" and "exhaustion of administrative remedies." The
defense "that compliance with administrative orders or permits.. .render a
nuisance action insupportable" presents another obstacle for the plaintiff
to overcome. Thusfar, these defenses have met with little favor in the
courts, but they indicate the possible synergistic relationship between
conmon law and regulation (102).
The common law, despite its "creative continuity," is usually unprepared
for some time to come to grips with new problems such as preconception injur-
ies—genetic injuries of the types that can be caused by ionizing radiation.
The reasons for this limitation range from the trivial to the substantial:
from antiquated statutes of limitations which preclude legal action beyond
relatively short time frames, to substantial difficulties of proving tiie causal
relationship between injury and alleged harmful action, to judicial reluctance
to recognize the very existence of a cause of action (103).
These, briefly described, are some of the major limitations on the common
law and its uses of balancing techniques to provide for timely and effective
social controls on a field such as nuclear power. Concurrently, and intimately
associated with these limitations, the 'market mechanisms" which have tradi-
tionally restrained new technologies until their externalities are reduced to
socially acceptable levels do not work adequately for a field such as nuclear
power which is marked by extensive government subsidization and protection (104) .
2. Legislation and Government Regulation
Congress has, in light of these failings of traditional social controls,
turned increasingly to the passage of legislation authorizing government
regulation in accordance with highly-specific objectives, program designs and
time frames. The burden borne by the regulatory agency becomes more socially
significant as the adequacy of the common law and market mechanisms has
diminished for particular fields of technology such as nuclear power.
Legislation and regulation applicable to nuclear power have been exten-
sively discussed in the preceding chapter, and a variety of issues attending
regulatory use of benefit-cost analysis—some structural, some substantive-
have been addressed in the specific context of nuclear power. Therefore, this
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discussion will be limited to some of the fundamental issues that seem to
attend use of benefit-cost analysis in government regulation, for the general
case.
(1) The National Environmental Policy Act
The National Environmental Policy Act (NEPA), became applicable to
federal agency decision-making in 1970 (105). NEPA contains the action-
forcing provision (Section 102 (2) (c)) which requires federal agencies to
assess the environmental implications of their intended "major actions."
These actions are those likely to have significant effects on environmental
quality—such as the issuance of construction and operating permits for nuclear
power plants (106), the promulgation of agency rules governing the performance
of facilities and activities using radioactive materials (107), and the develop-
ment of the breeder reactor program (108).
The structure of these assessments is specified in the Act, and the
resulting environnental impact statements (EIS) must therefore discuss the
range of anticipated environnental effects and alternatives to the proposed
action, among other considerations (109). The assessment task must involve
a "systematic, interdisciplinary approach" and must appropriately consider
"presently unquantifiable environmental amenities and values" along with
"economic and technical considerations" (110). Further, it is settled that
the assessment must be used in agency decisionHnoaking, and that NEPA therefore
requires "a rather finely turned 'and1 systematic balancing analysis in each
instance" (111).
Therefore, NEPA mandates the use of a balancing analysis in agency
decision-making on all matters of environmental significance. However, whether
the NEPA assessment process itself is to constitute the balancing analysis, or
whether the NEPA assessment provides information which is to be ultimately
balanced in some other agency's analysis along with other considerations, is
presently unclear. Similarly, whether a formal benefit-cost analysis involving
quantification of all factors, or an informal balancing on a best efforts basis
is required, is unclear. Federal courts facing these issues in litigation
challenging agency decision-making under NEPA have failed to resolve them con-
clusively and have occasionally stated that responsibility for evaluating uses
of benefit-cost and determination as to its adequacy is a matter for Congres-
sional review (112).
In light of these developments, agencies such as the NRC are now faced
with a sequence of several balancing tasks, imposed as a result of both NEPA
and the agency's own, self-imposed, requirements to use cost-benefit in its
decision-making. For example, the following balancing analyses are all now
potentially applicable to the NRC process of approving an application by a
utility for a license to operate a nuclear power facility:
(a) Use of benefit-cost by the NRC in promulgating agency
standards and other rules of general applicability to
power plant performance;
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(b) Use of benefit-cost by the NRC in promulgating limitations for
a specific power plant;
(c) Use of balancing analyses in determining whether or not the
separate construction and operating licenses should be issued
for a specific plant.
For the first two steps, use of benefit-cost is mandated by Appendix I
and other NRC regulations. Alternately, the use of a "balancing analysis"
is mandated by NEPA when such steps apply to major actions of environmental
significance.
F°r the dual licensing procedures of the third step, the NEPA mandate
for 'balancing analyses" is clear; and a federal court has recently cautioned
that the NEPA requirement applicable to the issuance of an operating license
may not be short-circuited—that a facility which meets NRC regulations does
not concurrently and automatically qualify for licensing without the required
weighing of risks and benefits under NEPA (113). Nevertheless, for the
specific case before it, the court concluded that:
Apart from the requirements of NEPA or similar ones already
implicit under AEA (Atomic Energy Act) , it would be pointless,
and a waste of agency resources, to require the AEG to reapply
efforts that have already gone into its basic health and safety
regulations, in individual licensing proceeding, in the absence
of some evidence that a particular facility presents risks out-
side the parameters of the original rule making. And in evalua-
ting the sufficiency of agency determinations in particular cases
it would be stultifying formalism to disregard the whole record
and test AEG compliance by only the evidence received at so-called
1 health and safety' hearings; or NEPA compliance only on the basis
of so-called 'environnental1 hearings.
This judicial decision promotes administrative efficiency by eschewing
duplication of balancing analyses, and seems to make good sense. But it is
clear that such efficiency is justified only when the risks and benefits
appropriate for the facility-licensing balancing task under NEPA have been
adequately considered in the prior balancing undertaken by the agency under
its own regulations (e.g.>Appendix I). Determination of these justifying
circumstances is a complex task which rests ultimately with the courts.
The extent to which the courts can handle this difficult task responsibly
will therefore depend on judicial willingness to examine the substantive
features of agency decision-processes, and the development of judicial exper-
tise on cost-benefit (114).
(2) Confusion on Benefit-Cost Analysis
There is continuing confusion in regulatory agencies over the techniques
of conventional benefit-cost and cost-effectiveness analyses, and this has
implications for the integrity of the regulatory process.
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Benefit-cost analysis measures a planned program's costs against
its expected benefits, using identical...units of measurement--
most often dollars—on both sides of the ledger. .. .Future
benefits and costs are usually discounted at some rate to reduce
them to present values (117).
The balance point at the margin between benefits and costs is the
point at which a program decision or a standard is "justified."
Cost-effectiveness analysis compares the cost of alternative
means for effectively achieving an agreed upon goal. The means
may be programs, technologies, devices or combinations of
approaches. The goals are often expressed in terms of public
policy as laws and standards (118).
The ALARA concept and NRC regulations discussed earlier are expressed
in terms of conventional benefit-cost, as a regulatory search for balance
points at which control levels can be prescribed. This implies that there
are no overall primary goals which have been agreed upon—no overall health
goals or health parameters, for example—and that regulation is a dynamic
and iterative process which evolves as inputs to the process change over
time. Thus, the benefit-cost approach essentially excludes the adoption of
fixed objectives for life and health, and its NRC application to radiation
regulation fully reflects this.
However, EPA expresses its approach to setting general environmental
standards for radiation exposure and levels as being a "cost-effectiveness"
approach (119). Presumably, therefore, objectives have been chosen or
adopted by EPA for which alternative control approaches have been compared.
Since EPA has not yet expressed any choice of health objectives or parameters
and since EPA consistently discusses its regulatory approach as being fully
compatible with feasible control measures as determined by NRC, it may be
that the EPA cost-effectiveness approach to setting radiation standards has
been conducted to achieve the technical-economic feasibility parameters
designated by NRC.
Of course, the foregoing analysis can be criticized on the basis that
the NRC has been conducting its benefit-cost analyses within the context of
assuned upper limits for hunan exposure and environmental levels of radiation,
upper limits (such as the 500 mR. standard) defined by various expert groups
such as ICRP and NCRP. These advisory organizations are basically self-
governing and unaccountable, and NRC may adopt their reconroendations only as
they can conveniently be implemented by the present state of the art of
control technology. Therefore, without the setting of health parameters and
upper environmental levels by an agency such as EPA in an open, accountable
process as discussed in preceding sections of this chapter, benefit-cost
and cost-effectiveness analyses used by NRC and EPA may lack credibility in
the societal context. •'.'.
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(3) Valuation in Cost-Benefit Analysis
Cost-benefit inevitably requires a series of analytical steps—
(a) identification of effects (costs, benefits)
(b) determination of their magnitude
(c) estimation of their probability of occurrence
(d) determination of the significance of each effect
(its value, in numbers)
(e) a sinming up and determination of the resulting
ratio.
Although one may quibble about an agency's conduct of the first three steps,
these are relatively open to professional critique and lay opinion, and
differences in judgement can be resolved. The fourth step—determination of
the significance of each effect—remains a troublesome issue. How to value
deaths and illnesses and dislocations of various types, for this generation
and for future generations?
The public at large must be invited into this quantification task. But
how? And how to guarantee an appropriate distribution of effects and the pro-
tection of minority rights (e.g., most exposed individuals off site) . And how
to guarantee the rights of unrepresented (future generation), particularly in
light of inadequate societal values placed on long-term, intangible effects?
No structure or concepts presently exist to resolve these valuation issues
attending the use of benefit-cost analysis (or for that matter, cost-effectiveness
analysis) , beyond the techniques for eliciting societal preferences which have
recently evolved in the applied social sciences.
Congressional rejection of benefit-cost for setting standards and for other
features of regulatory decision-making, in favor of the determination of health
parameters and other ambient effect-oriented approaches, is found both in legis-
lation relating to determination of highway and vehicle safety standards, and
in the legislative history and enactments on Clean Air and Water Pollution
Control (See Section C.3.) The federal courts, in reviewing regulatory agency
decisions on pollutants with considerable health implications, have also demanded
that health factors be given a high priority in the thinking and nature of such
decisions, implying that benefit-cost alone would be insufficient (115) .
(4) Technical and Economic Information in Beneift-Cost Analysis
In conducting benefit-cost analyses for developing standards, issuing
permits, prescribing design specifications and operating procedures, and other
aspects of regulation, information on the state of the art of various control
technologies and skills is critical. The information essentially relates to
the reliability of various control techniques, commercial availability, and
costs. Where the control techniques under consideration have already been
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practiced or used in other sectors of industry or other nations, or where
the control is available on a fixed-price basis or is otherwise a production-
line item, the information on reliability, availability and costs is fully
known to government regulators, and should be relatively accurate.
However, where the control techniques under consideration are untested
or in a developmental or prototype or experimental stage, or where the tech-
nique will have to be "hand-tooled" or otherwise applied on an ad hoc basis
to specifications furnished by the potential purchaser, information on
reliability, availability and costs is normally not known to government
regulators except as submitted by the regulated industry. Securing accurate
information under these circumstances can be difficult, depending on the
industry in question and applicable legislation and regulations enabling
agency access to industrial information.
The quality of information from industry under these latter circumstances
has been openly criticized in Congress and the agencies for some time. Such
Congressional skepticism led to the passage of the Clean Air Act, with its
mandate for relative disregard of technical feasibility in establishing health-
related air quality regulations (116).
The nuclear power industry is the primary source of information on the
technical and cost features of proposed radiation control developments, and
such information following NRC evaluation, is used in NRC benefit-cost analyses
for setting regulations. Ongoing review of the quality of industrial informa-
tion, and of the quality of an agency's evaluations and uses of such information,
would seem necessary to ensure that benefit-cost will not be abused—in light
of regulatory experience with other industrial sectors.
(5) Forcing Advances in Control Techniques
Closely related to the foregoing issue of information quality control is
a larger question of critical importance to the regulation of health hazards
on a benefit-cost and iterative basis: is the regulatory program appropriately
forcing advances in control techniques and their timely use on the regulated?
This is a question that should be addressed at the time of design of legislation
at the Congressional level, and also continuously throughout the development of
regulations and their enforcement at the agency level.
This question can best be answered, for the nuclear power case, by an
extensive, independent assessment of NRC regulations and their effects in
forcing the development and use of new radiation control techniques by industry
and government itself.
However, some general impressions as to the implications of benefit-
cost regulation for technology-forcing can be offered.
First, because of the difficult information problem described earlier,
analyses may employ misleading information and therefore not force advances
in techniques which are otherwise imminent or reasonable to expect.
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Second, the benefit-cost task of balancing contains no inherent incen-
tive for the development of control techniques, since it uses information on
available and proven techniques and tends, in this regard, towards maintenance
of the status quo on technological matters.
Unless health objectives or parameters are agreed on and employed, the
health effects can be conveniently selected and valued at levels which, in
the analysis, will bring about a balance point always within the realm of
currently feasible techniques. In this sense, those health effects which, if
valued, would bring about a new technique-forcing result, which could have
significant economic impact on plants, can be excluded from the analysis on
various grounds. For example, the long-term global health effects of iodine,
krypton, and carbon-14 release (48) . if valued (and the valuation would certainly
and always be arbitrary) could have a significant impact on the economics of
nuclear power until new and economic techniques became available to lessen or
prohibit their discharge.
For this reason, benefit-cost as a basis for regulating pollutant dis-
charges can be regarded as a mandate for lessening discharges and ambient effects
only as new techniques become feasible. By not forcing and directing advances
in control techniques by means of the threat of shutdown if health parameters
are not achieved, benefit-cost can become a mechanism for "economically con-
venient" regulation.
(6) Some Troublesome Assumptions in Benefit-Cost Analysis
Underlying the application of benefit-cost analysis to ionizing radiation
two assumptions:
The first assumption can be described as confidence in management capa-
bility and technological advances to handle future problems which have been
predicted on the basis of current practices. Presently allowed levels for the
production of radioactive wastes and for the operational release of radioactive
iodine, krypton and tritium, for example, are justified on the assumption that
when these substances closely approach dangerous environmental levels, manage-
ment capabilities and new techniques will be available and feasible to prevent
the levels from actually being reached. In light of the irreversible and
dangerous nature of such levels for many generations, this assumption is a
critical one and must be well-founded. The basis for this assumption about
future capabilities to solve the radioactive waste material and carbon-14
problems now building up, should be examined in open forum for societal decision-
or policy-making beyond the NRC and EPA levels.
The second assumption relates to the presumed mutability of societal
values. Measuring benefits is based on a snapshot of current values and
consumption patterns, tends to assume their perpetuation, and uses these
values for determining the benefits in the analysis. This leads inevitably
to future projections based-on these present values, inadequate consideration
of alternatives such as "social engineering" or consumer education, and has
obvious consequences for the benefit-cost analyses in question.
are
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E. Conclusions
This review of benefit-cost has been limited to its use in regulatory
context—the context of administrative and judicial decision-making on the
control of the harmful externalities of various regulated activities such
as energy production.
The questions about uses of benefit-cost in the regulatory context which
have been raised in this chapter are significant in that they relate to
societal capacity to protect human health and welfare for this and the succeed-
ing generations which will bear the risks of contemporary decisions on radio-
activity and other harmful substances.
Serious consideration should be given to the adoption of alternatives to
traditional economic benefit-cost analysis for such regulatory decision-making,
in the light of the questions which have been raised. It is unlikely and
unacceptable that alternatives will be chosen which do not balance various
factors in some systematic and structured process. For example, one possible
alternative is an appropriately comprehensive cost-effectiveness analysis for
societal health objectives and risk parameters (e.g., carcinogenic risks)
established by Congressional or other institutional processes which are accept-
able as being socially representative. Cost-effectiveness analysis requires
the articulation of objectives, the weighing of the alternative means to achieve
these objectives, and the selection of the least costly approach.
The task of making such decisions by Congress or other acceptable insti-
tutions on health objectives would certainly be difficult, but once accomplished,
the results could serve to ensure that regulatory decision-making on energy and
other activities involving harmful externalities is accountable to articulated
societal objectives for environmental health. This process would additionally
force consideration of our role in providing stewardship for future generations.
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FOOTNOTES
1. See generally, statutes cited in "Radiation Initiatives," memorandum
of Office of Radiation Programs, U.S. Environmental Protection Agency
(June 1975). The most important statutes are discussed in this chapter
with specific citations.
2. 42 USC 2233. "Each license shall be in such form and contain such terms
and conditions as the Commission may, by rule or regulation prescribe to
effectuate the provisions of this chapter."
3. Executive Order 10831 (14 August 1959), Section 274h of the Atomic Energy
Act of 1954, as amended by Public Law 86-373 (23 September 1959) .
4. 42 USC 2233 (see footnote 1) . The statute makes no reference to external
advice.
5. 10 CFR 20 in general, and 10 CFR 20.105 for off site individual exposures.
"There may be included in any application for a license or for amendment
of a license proposed limits upon levels of radiation in unrestricted
areas—The Conmission will approve the proposed limits if the applicant
demonstrates that the proposed limits are not likely to cause any indi-
vidual to receive a dose to the whole body in any period of one calendar
year in excess of 0.5 rem." (Note: by implication, exposures in excess
of 0.5 rem may be approved.)
Although the regulations permit exposures of 500 mR. it has been found
that actual exposures have been less than 1 mR. for nearly all plants.
6. Energy Reorganization Act of 1974, Section 201(f), 88 Stat. 1243.
7. Reorganization Plan No. 3 (1970) Section 2(a) (5 USCA Appendix II) .
"There are hereby transferred to the Administrator (of the EPA): all
functions of the Federal Radiation Council (42 USC 2021(h)).
8. 10 CFR 20.1(c)
The NRC stated that no change in substance was intended, but the change
was intended to clarify the purpose of dose limitation. The change
brought the NRC into agreement with the International Comnission on
Radiological Protection, which had previously made the same change.
(Publication 22; Implications of (Commission Recomnendations that Doses
be Kept as Low as Readily Achievable), International Commission on
Radiation (1973).:
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9. Proposed Appendix I was published in the Federal Register June 9, 1971
(36 F.R. 11113) . Public hearings commenced January 20, 1972. The
Nuclear Regulatory Commission issued its opinion and final version on
April 30, 1975, announced in the Federal Register on May 5, 1975.
10. Nuclear Regulatory Commission: Rnl
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As no disjointed array of separate programs can, the EPA would be able--
in concert with the States—to set and enforce standards for air and
water quality and for individual pollutants. This consolidation of
pollution control authorities would help assure that we do not create
new environmental problems in the process of controlling existing ones.
Industries seeking to minimize the adverse impact of their activities
on the environment would be assured of consistent standards covering
the full range of waste disposal problems."
16. Clean Air Act, 42 USC Section 1857c et seq.
17. Federal Water Pollution Control Act Amendments of 1972, 33 USC Section
1251 et seq.
18. FWPCA, Title II, 33 USC Section 1251 et seq., CAA, 42 USC Section 1857c
et seq.
19. See 42 USC Section 1857c-7 and 33 USC Section 1317, sections from the
air and water pollution acts, respectively.
20. EPA has articulated an important concept for radiation regulation, the
"radiation dose commitment" concept, which "... simply defined, is the sum of
all doses to individuals over the entire time period the (radioactive)
material persists in the environment in a state available for inter-
action with humans...calculated for a specific release at a specific
time.. .obtained by summing the person-rems delivered in each of the years fol-
lowing release to the environment until the material has been reduced to in-
nocuous levels by either radioactive decay or removal from the bio-
sphere by other means." The concept is an important one, which has yet
to be accepted or even publicly acknowledged by source control authorities.
As EPA has noted: "Since control must be instituted long before the
impacts associated with these releases occur, projection of anticipated
potential health effects which could result from the release of these
radionucleides constitutes a necessary basis for decisions concerning
the need for institution of control over their release. Future decisions
ought to consider these dose commitments with respect to both the types
of development that should occur and the choice of controls that should
be imposed." (From Environmental Radiation Dose Ciommitment: An Appli-
cation to the Nuclear Power Industry, U.S. E.P.A. Office of- Radiation
Programs, EPA-520/4-73-002, Feb. 1974, pp. 3, 5.)
21. MEPorandum of Understanding Between EPA and AEG. 38 F.R. 24936 (Sept. 11,
1973) par. (1); and 38 F.R. 32965 (Nov. 29, 1973). See also Colorado
PIRG case, Note 47, infra.
22. Executive Order 10831 (14 August 1959); Section 274h of the Atomic
Energy Act of 1954, as amended by Public Law 86-373 (23 Sept. 1959).
Presently found at 42 U.S.C. 2021(h).
The Federal Radiation Council (FRC) was established by executive order
in 1959.
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In the accompanying press release from the White House it was noted
that:
"(d) The Department of Health, Education, and Welfare (will) continue
as the Federal focal point for guidance and assistance to the states
with respect to contamination by and biological effects from radiation
sources not now under control of the ConnrLssion (AEC)."
It is thus apparent that the FRC was created to advise regulatory
agencies, but that no standard setting authority was given or intended.
23. 42 USC 2012(e).
24. National Environmental Policy Act of 1969, 42 USC Section 4321 et seq (1970):
Section 102 (2) (C) requires that the agency preparing an Environmental
Impact Statement (EIS) "shall consult with and obtain the comments of
any Federal Agency which has jurisdiction by law or special expertise
with respect to any environmental impact involved."
25. "Guidelines: Preparation of Environmental Impact Statements", U.S.
Council on Environmental Quality, 38 F.R. 20550 (August 1, 1973).
26. The Clean Air Act, 42 USC 1857h-7 (1970), Section 309.
27. Clean Air Act, 42 USC 1857c-7 (1970).
28. FWPCA, 33 USC Section 1362 (1972).
29. SDWA, 42 USC Section 300f(6)(1974).
30. SDWA, 42 USC Section 300f-j (1974).
31. Clean Air Act, 42 USC Section 1857c-7 (1970).
32. FWPCA, 33 USC Section 1362 (1972).
33. FWPCA. 33 USC Section 1317 (1972).
34. FWPCA, 33 USC Section 1342(b) (1972).
35. Colorado PIRG v. Train, FSupp 991 (1974); 507 F.2d 743.
36. Train v. Colorado PIRG. U.S. , 8 ERG 2057 (June 1, 1976).
37. 42 USC Sections 2131-2140; 10 CFR 20.
38. 40 CFR Section 125. l(x) (1973); CCM1ENT.
39. FWPCA, 33 USC Section 1316 (1972).
40. FWPCA, 33 USC Section 1362 (1972).
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41. FWPCA, 33 USC Section 1362 (6) (1972).
42. FWPCA, 33 USC Section 1317 (1972).
43. Clean Air Act, 42 USC Section 1857c-5. The states were to adopt plans
to enforce the EPA's national primary and secondary air standards;
subject to the Administrator's approval. The EPA has had to take over
enforcement of several state plans.
FWPCA, 42 USC Section 1311-1345. The states are to set set water quality
standards and to implement them, subject to EPA approval. State-EPA
interaction is complex. The states may set stringent standards and
thereby impose more stringent conditions upon individual polluters than
the EPA national effluent limitations require.
SEWA, 42 USC Section 300g-2, provides that the states are to have pri-
mary enforcement responsibility under the Act. The state must adopt
regulations at least as stringent as the EPA's national primary and
secondary water quality standards, and must also provide for enforce-
ment procedures that meet with the Administrator's approval. See
"Interim Primary Drinking Water Regulations: Notice of Proposed
Maximum Contaminant Levels for Radioactivity", 40 F.R. 34324 (Aug. 14,
1975), 40 CFR Section 141.
44. 447 F 2d 1143 (1971); aff'd. 405 U.S. 1035 (1972).
45. U.S. Const. Amend. 10. "Public safety, public health, morality, peace
and quiet and law and order do not constitute the entire scope of the
police power." Berman v. Parker, App. D.C. 1954, 75 S.Ct. 98, 348
U.S. 26.
46. See Protection Against Ionizing Radiations; A Survey of Current World
Legislation. World Health Organization. Geneva (1972); in particular.
the section on "State Legislation" in the United States, pp. 277-283.
47. See Water Quality Standards Criteria Digest; A Compilation of Federal/
State Criteria on Radiation, U.S. Environmental Protection Agency (August
1972).
48. In Northern States, the State of Minnesota attempted to regulate the dis-
charge of radioactive effluents from a power plant, using standards that
were considerably more stringent than those of the AEG. The Circuit
Court held that preemption of such regulation was implicit in the Atomic
Energy Act of 1954; and the Supreme Court approved without comment.
49. M. Baram, "State Energy Legislation and the Siting of Facilities" in The
Northeastern States Confront the Energy Crises. Conference Proceedings,
N.Y. State Senate (1975), NSF-RA-G-75-050.
50. "Health Education and Welfare: Suggested State Regulations for Control
of Radiation", 40 F.R. 29749 (15 July 1975).
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51. See Policy Statement: Relationship Between Radiation Dose and Effect,
EPA (3 March 1975) for EPA adoption. For background on AEC and FRC
positions, see Concluding Statement of Position of Regulatory Staff:
Public Rulemaking Hearing on Numerical Guidelines for Design'Objectives
ana1 Limiting Conditions for Operation to Meet the Criterion "As"Low As
Practicable' for Radioactive Material in Light-Water-Cooled Nuclear
Power Reactors; Docket No. RM-50-2, U.S. Atomic Energy Commission
(February 20, 1974), pp. 36 and 37.
52. Note 10, See pp. 66, etc. "Consolidated National Intervenors argued
that no radioactive discharges should be permitted." (p. 66)
53. Note 10, See p. 106: "In our judgment the guidelines we have adopted
are necessary and reasonable", (re NRC final decision on employment
of Appendix I, in reference to opposing views).
54. Note 10, See various NRC statements, expressing adoption of the cost-
benefit approach—e.g., p. 11, 12, etc.
55. 40 F.R. 33029. See Note 15, supra.
56. See for example: Crowther v. Seaborg, 312 F.Supp. 1205 (D. Colo. 1970),
(challenging 10 CFR 20, in part); Calvert Cliffs Coordinating Committee
v. AEC, 441 F.2d 1109 (D.C. Cir. 1971), (challenging AEC re non-compliance
57. 35 F.R. 18385 et seq. (December 3, 1970).
58. Note 10, See pages 2-4.
59. Note 51, supra. See Concluding Statement..., pages 41-43.
60. Note 51, supra. See Concluding Statpment..., pages 14-15.
61. Note 10, See pages 12-16.
62. Note 10, See p. 11.
63. Note 10, See pages 91-95.
64. Note 10, Page 90.
65. Note 10, Page 11.
66. Note 10, Pages 113-119.
67. Note 10, Page 35.
68. Note 10, Pages 31, 34-35, etc. Also see General Design Criterion 64,
"Monitoring Radioactivity Releases" of Appendix A to 10 u?k i?art 50;
and Regulatory Guide 4.1 etc. of the ABC.
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69. Note 10, Pages 126-130. See also page 33. The critical iodine-milk
path can be tested. See AEG Regulatory Guide 4.3.
70. 10 CFR Section 100.
71. NEPA, 42 USC Section 4321 et seq. (1970).
72. The Calvert Cliffs decision (Note 70, supra) calls for AEC use of the
full envirormentaT impact statement in facility decision-making, and
for such decision-making to be founded on a "finely-tuned, balanced
analysis." This clearly does not require selection of the optimal site
on the basis of ALARA criteria and conditions.
73. See Sections 29 and 182b of 42 USC 2039, 2232b, the Atomic Energy Act;
and proceedings of the ACRS Subcommittee on Standardized Nuclear Unit
Power System (SNUPPS). Also see Policy Statement on Standardization of
Nuclear Power Plants. AEC (April 28. 1972); State on Methods for Achieving
Standardization of Nuclear Power Plants, AEC (March 5, 1973).
74. 6 ELR 20107 (D.C. Cir. Dec. 9, 1975).
75. Note 10, Pages 33, 34, etc.
76. Note 10, Pages 17-19, etc.
77. Note 10, Page 105.
78. Note 10, Page 105.
79. 10 CFR 50.36(a)(2).
80. Difficulties in the operation of Vermont Yankee and other facilities,
resulting in releases above prescribed levels, have aroused public
interest groups and local and state health authorities, particularly
in light of the failure of the AEC to respond with timely enforcement.
81. See "Criteria for Determining Enforcement Action and Categories of Non-
Compliance", and other elements of 10 CFR Part 2, for specifications on
enforcement to date. Also see Report to the Congress on Abnormal
Occurrences; Jan.-June 1975, U.S. NRC, P.B. 245-404 (Oct. 1975) which
provides interim criteria for abnormal occurrence determination. Of
particular interest is that off site receptor exposure does not qualify
as an abnormal event unless it is in excess of 500 mR., far in excess
of limitations now imposed under ALAP, and indicative once again that
despite technological advances over a decade, 500 mR. remains as the
only enforcable limitation of the NRC.
82. The courts have been sympathetic to delay, when "further study" by the
NRC is undertaken. See Nader v. NRC, 5 ELR 20342 (D.C. Cir. May 30,
1975) for judicial tolerance of NRC delay in the matter of emergency
core cooling systems.
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83. Note 14, supra. The EPA's proposed environmental standards for the
uranium fuel cycle (annual dose equivalents to the whole body, thyroid,
etc.) were developed on the basis of considering health effects and the
costs of available control measures. The proposed standards reflect a
balancing, and do not constitute the health boundary conditions discussed.
84. Proposed Standards: Radiation Protection for Nuclear Power Operations,
EPA, 40 F.R. 23420 (May 29, 1975).
85. Id. Page 2340.
86. Public Health Service Act, 42 USC 241 and 243.
87. 42 USC Section 300f-j. See EPA "Interim Primary Drinking Water Regu-
lations: Proposed Maximum Contaminant Levels for Radioactivity," 40
F.R. 34324 (Aug. 14, 1975).
88. Administrative Procedure Act, Section 10(e)(B)(l), 5 USC Section 706
(2) (A) (1970).
89. Environmental Radiation Dose Commitment; An Application To The Nuclear
Power Industry, EPA (February 1974).
90. Note 84, Pages 23422-23423.
91. See state enabling acts for New York, Maine, Massachusetts, cited in
Baram, note 61, supra; and implementing regulations.
92. 10 CFR Section 100.
93. Porter County Chapter of the Izaak Walton League of America v. AEC, 5
ELR 20274 (7th Cir. April 1, 1975); reversed U.S.S. Ct., 6 FUR 20040
(Nov. 11, 1975). However, NRC siting criteria have forced several pro-
posed sites to be abandoned.
94. Alyeska Pipeline Service Co. v. Wilderness Society, 5 ELR 20286 (U.S.
May 12, 1975).
95. Gage v. AEC. 156 U.S. App. D.C. 231, 479 F.2d 1214 (1973).
96. CAA, 42 USC Section 1857c-5; FWPCA, 33 USC Section 1313.
97. See H.R. 441, a bill introduced in the 1st session of the 94th Congress
by Congressman Fish (January 14, 1975), which would allow the states to
regulate the emission of radioactive effluents concurrently with the NRC.
"(3) it is the intent of this Act to establish the concurrent authority
of the several States to regulate such radioactive emissions, including
the authority to enforce standards for such radioactive emissions, which
permit lesser quantities of such emissions from such facilities than do
the standards established by the Commission."
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98. 2 USC Section 475.
99. For judicial recognition of the role that local values and laws should
play in federal agency decision-making (in the NEPA context), see
Maryland Planning Service v. U.S. Postal Services. 5 ERG 1725 (1973).
100. H. Green, "Comments on Legal Mechanisms", in Perspective on Benefit-
Risk Decision-Making. National Academy of Engineering (1972).
101. See M. Katz, "The Function of Tort Liability in Technology Assessment",
38 Univ. Cincinnati L. Rev. 587 (1969) and cases cited therein.
102. Quotes from 60 ALR 3d 665.
103. See C. Moore, "Radiation and Preconception Injuries: Some Interesting
Problems in Tort Law", 28 S.W.L.J. 414 (1974).
104. See discussion of the Price-Anderson Act, 42 U.S.C. Section 2210 et.
seq. in "Atomic Power and Indemnification of Accident Victims," p. 17-
35, in A. Reitze, Environmental Planning; Law of Land and Resources,
N. American Int'l Publ. (1974).
105. 42 USCA 4321 et seq. (1970).
106. 10 CFR Part 51, for NEC's "Licensing and Regulatory Policy and Pro-
cedures for Environmental Protection."
107. See, for example, 39 FR 5356 (Feb. 12, 1974) for NRG notice of prepar-
ation of environmental impact statement on the "WLde-Scale Use of
Mixed Oxide Fuel" (Plutonium Fuel Cycle).
108. Scientist's Institute for Public Information v. AEG, 5 ERG 1418 (D.C.
Cir. 1973).
109. 42 USCA 4332(2)(C).
110. 42 USCA 4332(2) (A) and (B).
111. Calvert Cliffs Coordinating Committee v. AEG, 2 ERG 1779 (B.C. Cir.
1971).
112. M. Triantafillou, "Cost-Benefit Analysis in the Context of NEPA,"
unpublished paper (Dec. 1975), Harvard School of Design.
113. Citizens for Safe Power v. Nuclear Regulatory Commission. 6 ELR 20095
(D.C. Cir. Dec. 22, l$7b).
114. See H. Leventhal, "Environmental Decision-Making and the Role of the
Courts," 122 U. Pa. L. Rev. 509 (January 1975) for an extremely useful
analysis of judicial review and its limitations.
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115. See EOF v. Ruckleshaus, 439 F. 2d 584 (D.C. Cir. 1971); EDF v. EPA,
465 F. 2d 528 (D.C. Cir. 1972).
116. J. Bonine, "The Evolution of Technology—Forcing in the Clean Air Act,"
Monograph 21, Environment Reporter, Bureau of National Affairs, v. 6,
n. 13 (July 25, 1975).
117. FWPCA, 33 USC Section 1314(b) (1) (B).
118. FWPCA, 33 USC Section 1314(b)(2)(B).
119. FWPCA, 33 USC Section 1316(a); 10 CFR 40.
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GHAPTER V
BENEFIT-POST ANALYSIS FOR ENERGY PRODUCTION
A. Introduction 125
B. Concepts and Philosophy 126
C. Methodology 127
D. The Consideration of Benefit-Cost Analysis in Comparison of .... 130
Nuclear Power with Fossil-Fueled Power
E. The Feasibility of Benefit-Cost Analysis as a Means of 138
Comparing Nuclear vs. Fossil Fuel Power Cycles
F. Conclusions 139
References
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Chapter V was prepared for this report by a subcomnittee consisting of the
following:
Bruce C. Netschert - Chairman
National Economic Research Associates, Inc.
Washington, B.C.
Seymour Abrahamson
university of Wisconsin
Madison, Wisconsin
Edward L. Alpen
University of California
Berkeley, California
Michael S. Baram
Massachusetts Institute of Technology
Cambridge, Massachusetts
Cyril L. Comar
Electric Power Research Institute
Palo Alto, California
Hans L. Falk
National Institute of Environmental Health Sciences Center
Research Triangle Park, North Carolina
John V. Krutilla
Resources for the Future, Inc.
Washington, B.C.
Oliver Smithies
university of Wisconsin
Madison, Wisconsin
Arnold Zellner
University of Chicago
Chicago, Illinois
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CHAPTER V
BENEFIT-COST ANALYSIS FOR ENERGY PRODUCTION
A. Introduction
Chapter III sets forth the concepts involved in benefit-cost analysis
in the abstract and defines the terms employed, again in the abstract. This
chapter examines its application to the use of nuclear energy in the gener-
ation of electric power. The question to be addressed is whether benefit-
cost analysis can be used in the development of a national strategy for
energy production.!/
It may be argued that, in addition to the choice between nuclear and
conventional technology, there is also another choice—that of supplying the
power or not supplying it. Although the provision of new generating capacity
to some extent involves the replacement of obsolescent capacity, the bulk of
the requirements for new capacity are to satisfy expected growth in electricity
consumption. If that growth were to be reduced or eliminated, the need for
new capacity would be correspondingly reduced.
Conservation^-'can take place in response to three different motivations.
The first is the economic motivation, or response to price. As previously
noted, when external environmental costs become internalized—that is, as
costs which were not previously components of price become components through
the installation of cooling towers, the use of low-sulfur fuels, the treat-
ment of stack gases, etc.—the price of electricity may be expected to rise.
Consumers, both individual and business, can then be expected to use less
electricity.
Conservation also occurs as a result of what may be termed individual
ethical motivation. For some it is both a moral obligation and a source of
personal satisfaction to reduce their electricity consumption, even if this
entails some loss of material well-being (e.g., doing without air conditioning
and tolerating lower indoor temperatures in winter). Or, as was true during
the oil embargo of 1974, individuals and businesses may practice conservation
— There are, of course, other energy sources and technologies that could be
considered and encouraged as alternatives. At this point, however, these
sources, such as solar, geothermal, wind, tidal, etc., are potential as
contributors to the national energy picture. For the purposes of this
report, it is preferable to investigate the application of benefit-cost
analysis to existing technologies.
—''unless otherwise noted, the word conservation is used to mean conservation
of electricity.
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as a matter of patriotism, to do their part during a period of national
emergency.
Thirdly, conservation may occur as a result of legislation or regulation
which decrees that less be used.
Conservation under the first two motivations can be said to dispose of
the issue. To the extent consumers respond to higher prices by using less
electricity and to the extent they conserve for personal ethical reasons,
conservation is "automatic." It does not depend on a decision reached
through the kind of formal benefit-cost analysis being applied here. With
respect to conservation through governmental action, the cost-benefit com-
parison that is relevant is a matching of the costs and benefits of having^the
additional power against the costs and benefits of doing without it, including the
costs of governmental action referred to above. We will here consider only the
choice between the use of nuclear versus fossil fuel technology.
B. Concepts and Philosophy
The problem of determining the most beneficial means of providing
adequate future electricity supply is complicated by the large number of
alternatives. The judgment we have made that the proper comparison is
between nuclear and fossil fuel technology does riot mean that we have,
therefore, two neat packages, labeled "nuclear" and "fossil fuel." Within
the former there are the choices among light-water reactors, high temperature
gas reactors, liquid metal fast breader reactors, and so forth. Within the
latter there are the choices among coal, oil and gas as the fuel and the
technologies for the use of each.
In view of the large number of alternatives possible, a strategy of
benefit-cost analysis is required which will permit the breakdown of costs
into manageable portions. The costs must be integrated over time, since
some are of long duration, many times greater than a single lifetime (e.g.,
the disposal of long-lived nuclides, the somatic and genetic effects to
present and future generations from exposure of individuals to mutagenic
and carcinogenic substances from burnt fuel or to radiation, the exhaustion
of a given resource, etc.), or are likely to occur only rarely (e.g., cata-
strophic failure, sabotage).
To be of maximum usefulness in decision-making, the benefit-cost analysis
should be part of any over-all analytical sequence something like the following:
1. Identify as many as possible of the costs and risks of each energy
source, integrated over time and as a function of the total energy
produced from that source.
2. Seek alternative strategies within each category of energy supply
to reduce the significant costs.
3. Sum the minimized costs within each category.
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4. Determine, if possible, the costs of controlling the rate of
increase in electricity assumption.
5. Estimate the costs of developing new sources of energy (solar,
fusion, etc.) and extrapolate, if possible, the merits of the
new sources relative to existing sources.
6. Determine an overall strategy that minimizes the time-integrated
costs relative to the benefits.
It is important that one of the products of the analysis be a listing
of the true costs of the elements in all the fuel cycles which are commonly
considered by the public to be particularly dangerous or the costs of which
have not received adequate attention. This should help the public to assess
the validity of the decisions in relation to their fears and to base their
own decisions on rational choices.
Thus, benefit-cost analysis of various kinds of power production may
well include not only the costs and benefits of providing electrical energy
from competing sources, but also the costs and benefits to society of using
more or less energy, i.e., of having all of the energy it demands as compared
with having an energy shortage. Consequences of energy surplus or shortage
which require value judgments are outside the scope of benefit-cost analysis
as considered here.
C. Methodology
In considering the appropriate methodology for application to the
benefit-cost comparison of nuclear versus fossil-fueled power, it is useful
to begin with the concept of "lowest practicable level" (see p. 18, Ref. 2)
of radiation for regulation or control guidelines.
Regarding the point sources, the criteria used in conventional benefit-
cost analysis, stated in inverted order in ICRP #22 (1), are that the total
benefit associated with an irradiating activity must be greater than its total
cost and that radiation reduction through control practices must be pressed
to the point at which the benefits from further radiation reduction (residual
damage reduction) no longer exceed the cost of achieving the reduced radiation.
In the case of radiation and radiation control benefits and costs asso-
ciated with nuclear power, radiation exposure of a population is a cost and
the control of this radiation is a benefit. The excess radiation with which
we are concerned as a cost is that released outside the reactor and from which
there are no benefits.
As noted earlier (p. 74), if the market-determined costs of factor ser-
vices and product prices represent their total social costs and benefits, there
is no need for complicated additional benefit-cost analysis. When there are
incidental costs incurred or benefits received by parties not involved in the
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market transactions, we have "extrannarket" costs and benefits, or
"externalities," that must be evaluated to determine whether the activities
in question are worth undertaking (i.e., total social benefits exceed total
social costs).
In the nuclear power cycle, ionizing radiations occur as an unwanted by-
product of the generation of electric power. Some individuals will risk being
irradiated or will staffer the consequences of radiation who were not parties
to any of the market transactions involving purchase of factor services. Thus,
there is need to evaluate the additional costs and benefits (if any) from the
production of electricity by means of nuclear reaction.
If all of the externalities associated with nuclear power were confined
to the operations of the nuclear reactor proper, it would be necessary to
estimate only the extra-market costs at the reactor site. However, since
there are somewhat similar side-effects associated with activities at various
stages in the fuel cycle, e.g., mining, and reprocessing of spent fuel, where
such extra-market phenomena are significant, a comparable benefit-cost anal-
ysis needs to be undertaken to correct the market indicated costs of such
activities at the relevant stages in the fuel cycle.
For purposes of clarification regarding market-compensated contrasted
with extra-market costs, we can refer to the case of coal mining. Given
widespread current knowledge of the occupational hazards, the risk-mitigating
practices instituted (such as better ventilation), and the residual risks, it
is reasonable to assume that the increased probability of adverse health ef-
fects in coal mining are now, or will eventually be, incorporated in a dif-
ferential scale of pay as compared with occupations having a lower probability
of adverse health effects. Accordingly, if this side-effect of mining were
fully market compensated, the total social cost of the intermediate product
would be reflected in its market valuation. There would be no need to carry
out complicated estimates of health-related costs unless third parties were
affected as a result of the resource extraction activity.
To summarize, the benefit-cost analysis associated with nuclear power
production needs to include not only the operations of the reactor proper but
also the activities at various stages in the fuel cycle at which nonmarket-
compensated costs, i.e., authentic externalities, arise. For instance, the
analysis would include the health costs of persons affected by environmental
contamination but not of those nuclear plant employees who had voluntarily
assumed a given health risk in exchange for higher pay.
Another feature of the benefit-cost analysis of nuclear power requires
attention, since there is, at the present time, an adequate technical sub-
stitute for nuclear reaction in electric power production (fossil fuel com-
bustion). The end product, i.e., electricity, is the same for both. Typically,
when alternative technologies exist that produce indistinguishable final con-
sumption services, we regard the benefits as identical. With benefits iden-
tical, the only area for evaluation is the relative costs of the two (or more)
technologies; and the advantage or benefit (if any) of one can be no greater
than the savings in costs (if any) over the most economical alternative.
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Accordingly, to determine Aether the total benefit from a nuclear power
plant exceeds its total cost, it is essential to compare its total cost with
the corresponding cost of the most economical alternative technology. This,
in effect, may represent the necessary evaluation to achieve the "lowest
practicable level" when we consider the problem in the context of the ambient
environment rather than radioactive releases at a point source.
When it becomes necessary to consider two or more fuel cycles in de-
fining the lowest practicable level, we have also to determine their optimal
mix. Typically, this has been done by projecting "requirements" at historic
growth rates and simulating the growth of the power system using several ex-
pansion strategies. However, different considerations will arise in the future
if the assimilative capacity of the environment is overtaxed. At this point,
conservation strategies, as well as non-conservation (production) technologies,
must be considered among the alternatives. It is likely that over some energy
growth ranges conservation actions can be taken to make additions to the power
system unnecessary and at lower social cost than the cost of expanding the
power system. This would be of relevance to defining "lowest practicable
level" for ambient conditions (2).
As noted earlier, it is outside the scope of this report to specify in
detail the methodology that would permit continuous optimization over time
allowing for conservation as well as expansion technologies in optimal mixes.
However, useful elements of the total problem can be factored out for attention.
One feature of the problem generally not encountered, or treated, in conventional
benefit-cost analysis involves the continuing impact of accumulating long-lived
radioactive effluents on large populations. Also not treated are the potentially
different implications for mutagenesis and carcinogenesis of the effluents from
alternative fuel cycles. Typically, the social cost of the continuing environ-
mental burden has not previously been taken into account. (For a related prob-
lem in which this has been taken into account see references 3, 4, and 5.)
All of these are irreversibilities. Accordingly, the evaluation of. the cost
of an irreversible decision, and the cost of bearinq the risk associated with
such'when taken in the face of uncertain future conditions (6), is an area
of peculiar relevance to the evaluation of nuclear power and the objective of
reducing radiation to the lowest practicable level both at source points and
in the ambient enviroranent.
The mathematical treatment of problems associated with distribution and
uncertainty is given in Chapter III. From it, we draw two conclusions:
(1) Even if we can legitimately accept (or ignore) the distributional effects
of a program involving radiation exposure, including the intergenerational
effects, measurement of the expected value of the costs of the exposure will
probably not capture the full value of the costs, due to the risk aversion of
the affected individuals; and, (2) the unusual time distribution of the costs
and their potential magnitude raise serious questions about the appropriateness
of following standard practice discounting all benefits and costs and looking
only at their present value.
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D. The Consideration of Benefit-Cost Analysis in a Qanparison of Nuclear
Power with Fossil-Fueled Power
We have seen from the foregoing that there are difficult and unresolved
theoretical issues in the application of benefit-cost analysis to power gen-
eration. Since the benefit-cost estimates involve extra-market health and
non-health environmental costs as well as market determined costs and prices,
how feasible does such a benefit-cost analysis appear? With consideration
of the benefits of power deferred for the moment, our interest centers on the
feasibility of an undertaking to measure the total social cost—including
human health and non-health environmental costs—whether arising from radi-
ation, other kinds of pollutants having health implications, or other forms
of environmental degradation that may not be related to adverse health
effects.
The undertaking of such a measurement is a large effort. At least two
such efforts have been commissioned to evaluate the social costs of the fuel
cycle technologies underlying the generation of electric power. One by a
group at the Argonne National Laboratory (ANL) is a completed study the re-
sults of which were published in 1973 (8); the other, by a group at the
Brookhaven National Laboratory (BNL), is still in progress, with only a pre-
liminary report (in the nature of an interim progress report) available for
review (9). The ANL study, entitled Social Costs for Alternative Means of
Electric Power Generation for 1980 and 1990, provides a basis tor assessing
the feasibility question we have raised.
The ANL study attempts estimates of the relevant costs for each of the
fossil fuel cycles—coal, oil, and gas—for two light water nuclear reactors,
and for the high-temperature gas-cooled slow, and the liquid-metal-cooled
fast, breeder reactors. Two sets of data are presented for each fuel cycle,
i.e., health and accident effects, and non-health environmental effects for
each of the several fuel cycles basically in biomedical and/or physical terms;
...id, ult mately, an attempted transformation to the extent possible, of all
human and natural resource impacts, whether market incurred or extra-njarket,
into moi._;tary units to represent social costs.
Since it is likely that there are extra-market environmental effects
associated with each stage of each of the several fuel cycles, estimates are
provided for the mining, refining (where applicable), transportation and
energy conversion stages, for the fossil fuel cycles; and for mining, milling
and fuel fabrication, the reactor proper, and the reprocessing stage including
the transportation of spent fuel to the reprocessing plant and the return ship-
me of materials from it to the power plant, for the nuclear fuel cycles.
An example illustrating activities, environmental agents or factors, and their
effects where it is possible to do so for a coal-fired power plant (1980), is
shown in Table V.I, reproduced from the ANL study.
At the top are shown the conventional market costs such as for capital
services, fuel, and standard operating and maintenance costs. These include
all of the internal costs of the power plant operation, and include in part
some of the social costs of occupational hazards to the extent these are
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TABLE V.I
(From Reference 8)
Annual Effect of 1000 MWe Coal-Fired Power Plant Operation in 1980
Mining Transportation Power Plant Total
Conventional costs (10^ $) "
Fuel 21 8 29
Capital 55 55
0 & M 77
Occupational accidents
Deaths 0.98a 0.055 0.03 1.1
Non-fatal injuries 40.5a 5.1 1.5 47.1
Mandays lost 8330s 570 350 9250
Mining3
Land disturbance by stripping (acres) 300
Land subsidence, underground mining (acres) 200
Mine drainage, tons 10,000
Sulfuric acid in drainage, tons 80
Dissolved iron in drainage, tons 20
Rail Transportation
Public death 0.55
Injury 1.17
Days lost 3,500
Transportation and Handling loss, tons 10,000
Ash collected, tons 250,000
Sulfur retained, tons 46,000
Waste storage area, (acres) 5
Thermal Discharge, 1010 kWh(t) 0.69
Stack Discharge, lO^O kWh(t) 0.16
Air Emissions, tons:
Flyash 2,000
Sulfur dioxide 24,000
Carbon dioxide 6,000,000
Carbon monoxide 700
Nitrogen oxides (as N0Ł) 20,000
Mercury 5
Beryllium 0.4
Arsenic 5
Cadmium 0.001
Lead 0.2
Nickel 0.5
Radium 226, Ci 0.02
Radium 228, Ci 0.006
Facilities land use, acres** 150
a - 50% of production from strip mining and 50% from underground mining.
b - facilities are for two generating units at a site and include fuel preparation but exclude transportation
area.
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reflected in differential pay scales and incorporated into the price of the
coal delivered to the power plant.
Subsequent row entries include occupational hazards converted into annual
estimates of workdays lost and other aspects of environmental deterioration
due to the activities at each of the stages of the fuel cycle associated with
a 1000 MWe power plant. Stack emissions from burning a 1980 "representative"
coal mix are given, but no effort is made to estimate the fraction of the
population affected based on the distribution of such emissions, nor is any
attempt made to estimate mortality or morbidity resulting from the health
effects of the combustion products of coal emitted from the stacks. It should
be noted that environmental effects are given in terms of final impacts in
some cases (even ultimately transformed into monetary units in the case of
conventional costs) and in other cases simply as agents that have unspecified
effect on the environment such as arsenic, mercury and sulfur dioxide measured
in tons, or landscape degradation in terms of acres of land disturbed. In
short, effects are measured in several dimensions; dollars, workdays, tons,
acres and even curies. The conversion of these into a common unit of measure
will be discussed below, after examination of the corresponding Table V.2 for
a pressurized light water reactor (PWR), rlso taken from the ANL study (8).
Again, we have the conventional costs, some part of which may represent
internalized costs of some of the occupational hazards shown in subsequent
row enteries. These occupational hazards, and non-health or accident related
environmental effects, again, are presented in a variety of units of measure
seemingly appropriate for description of physical or biomedical effects asso-
ciated with the various activities at the several stages in the PWR fuel cycle.
In Table V.3 following, we reproduce the data in which attempts were made
to monetize the physical and/or biological effects to the extent possible,
allocated between external and internal costs for the coal fuel cycle. It
should be noted that a half of all occupational hazard losses are attributable
to "conventional" or market costs—the other half to external costs that are
included in total social costs. The division between internal and external
costs was said to be arbitrary by the authors of the ANL study. Accidental
deaths were taken, as suggested by Bureau of Labor Statistics sources, to
average 6,000 lost working days per case, and an arbitrary $50 per day was
taken as the monetary value of the loss. An argument was advanced for dis-
counting the stream of losses experienced over time, but this was not done—
and, as discussed above, it is not altogether clear why there should be a
discounting of lives, and if not, why their value should be monetized. In
any event, sensitivity analysis conducted with values set both at one-half
and double the monetized value are purported to affect the outcome of the
study negligibly.
For landscape degradation associated with coal mining, it was assumed,
in the ANL study, that ten percent of the coal production would come from
contour mining, 40 percent from area strip mining, and 50 percent from under-
ground mines. Costs of restoration were treated as if they had been incurred
by the mine operators and reflected as internal costs in the price of coal.
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TABLE V.2
(From Reference 8)
Annual Effect of 1000 MWe PUR Operation In 1980
Mining
Conventional Cost (106 $) 1.9
Occupational Accidents
deaths 0.09
nonfatal injuries 3.6
mandaye lost 762
Public Casualties From Transportation
deaths
nonfatal injuries
mandays lost
Miners radiation exposure (WLM) 110
Other occupational exposure (man-rad) -
Tailings produced at mill (103 MT)
Solid radioactive waste disposal (102 ft3)
Cost of transportation accidents (103 $)
Cost of fab. & repro. accidents (103 $)
Facilities land use (acres)0
Strip mining of uranium and mill tailings (acres) 5.5
Burial of solid radioactive wastes (acres)
Net destruction of uranium (MT)
Thermal discharge (1010 kWh(t) )
(103 MB(t) )
Population exposure from reactor
accidents other than Class 9 (man-rem)
Radioactive releases to atmosphere (Cl)
H-3
Kr-85
1-129
1-131
Xe-131m
Xe-133
Cs-134
Rn-222
U-234
U-238
Total U
Pu-241
Total Pu
Others
Radioactive releases to waterways (Ci)
H-3
1-129
1-131
Cs-134
U-234
U-238
Total U
Others
Milling -
Fabrication3
7.9
.005
1.5
88
-
-
-
-
15
79
77
-
.03
-
2.2
.15
-
-
-
-
-
-
-
_
_
-
-
44
.006
.002
.009
_
-
-
-
-
-
-
.1
.04
.2
.0008
Reprocessing &
Reactor Transportation0 Total
68.8
.01
1.3
110
-
-
-
-
300
-
22
-
_
-
.04
1.1
1.4
2.1
2
-
5500
-
_
180
580
-
-
_
-
_
_
_
_
580
-
.03
.01
-
-
-
.1
1.4
.002
.12
15
.009
.08
60
-
30
-
13
1.6
.03
-
-
.31
-
-
-
-
16000
28000
.0003
.004
50
-
.007
-
V)
M)
M)
.003
.003
.2
350
.0002
.00002
.01
.002
.0007
.003
3.
80.0
0.1
6.5
975
.009
.08
60
110
345
79
110
1.6
.06
300
7.7
0.5
1.1
1.4
2.1
2
16000
29000
.0003
.004
230
580
.007
44
.006
.002
.009
.003
.003
.2
930
.0002
.03
.02
.1
.04
.2
3.
a Milling, Conversion, Enrichment, and Preparation and Frabrication
Reprocessing and all Transportation steps.
c Facilities are for two generating units at a site and include fuel preparation and recovery but exclude
transportation area.
-------
TABLE V.3
(From Reference 8)
Evaluated Effects of 1000 MWe Coal-Fired Power Plant Operation in 1980
Category
Conventional Cost
Capital
0 & M
Fuel
Mining & Transportation
Contour Strip
Area Strip
Underground
Mine Drainage
Comment
Internal
10% of production for 1000 MWe plant
The external cost associated with uprooting
families and reclamation has been estimated.
40% of production. Roughly 250 acres--
external cost taken to be $500/acre.
1/2 of production. Roughly 200 acres—mine
deep enough that subsidence does not effect
property.
From the report, Acid Mine Drainage in Appa-
lachia, $3.5 million for 500 billion gallons
of drainage. For 2.4 million gallons the
cost is $20.
Internal Effects
1Q6 $ MDL
55
7
29
External Effects
106 $ MDL*
0.1
0.1
to
Transportation
Loss of coal
Non-employee
accidents
Power Plant
Thermal Discharge
Pollution Damage
Other Pollutants
All Occupational Accidents
Strip Mining
Underground Mining
Transportation
Power Plant -
10,000 tons at $9/ton. C
50% external assumed. C
1.3 million kWt.
S02 and particulates.
External not evaluated. -
50% external assumed.
Total Occupational Accidents C
-
1750
-
-
-
650
3500
300
170
4620
-
0.09 1750
0.4
0.8 U
U U
650
3500
300
180
0.23 4630
*MDL — man-days lost.
U
unevaluated
C — included in conventional cost
-------
-135-
Attention was given to displacement of individuals as a result of strip
mining deposits underlying their lands, and this charged to social costs
appearing as an externality.
One serious deficiency in the attempt to provide comprehensive coverage
in monetized values of extra market impacts, was the inability of the authors
to find a basis for a quantitative estimate of adverse health effects from
stack emissions of sulfur dioxide, nitrogen oxide, and other products of fos-
sil fuel combustion. To this extent the estimated social cost of the fossil
fuel cycle is incomplete—a deficiency in addition to the possibly inadequate
estimates of some categories of evaluated social costs.
An example of the attempt to monetize the physical and biological effect
of the nuclear fuel cycle (PWR) is shown in Table V.4. The occupational
accidents and disabilities are allocated, as in the fossil fuel cycle, half
to internal (conventional) and half to extra-market components of social costs.
All of the potential adverse effects from radiation throughout all stages are
evaluated, except for the class 9 accident—which at the time of the ANL re-
port preparation was under study by the Rasmussen group, and with publication
of the Rasmussen Report (10) could now be included.
Considerable disagreement is already apparent in the estimation of the
risk of major catastrophies in commercial nuclear power plants. Where such
disagreement is important, preventative steps will need to be taken to nullify
the effects of any incorrect estimate of the risk. The costs of these pre-
ventative steps will appear as "costs" of the unquantifiable risk. For ex-
ample, the effects of a catastrophic release of radioactive materials which
could occur on a loss of collant accident in a light water reactor might be
considerably reduced by placing reactors in regions of low population density.
Much of the cost of this major risk of uncertain magnitude would then be ap-
parent as a finite increase in cost of power transmission needed to reduce
the upper estimate of the risk to an acceptable level.
While the environmental dose commitment of radionuclides is illustrated
for tritium, and krypton, the total global dose commitment for all radio-
nuclides was not undertaken. An EPA study (1974) (11) includes materials
that could lead one to believe the effects of the excluded radionuclides, the
actinides in particular, could be of greater long run consequence than the
included tritium and krypton. A recent study by Cohen (12) takes a position
contrary to the EPA Study (1974).
Accidental loss of life and premature deaths associated with the PWR
cycle were treated similarly with the coal cycle. That is, a death was assumed
to result in an average 6000 mandays lost and a manday was valued at $50.
There are serious problems with efforts to place a value on a life as we know.
Ideally, it would be preferable to have an expression from each individual
as to how much he would need to 'be compensated to have some low probability
of premature death or some specified adverse health effect increased by some
appropriately small amount. In this way, it would be possible to avoid having
an individual place a value on a life other than his own, and in this case the
expression would be in terms of increasing by a specified amount a low probability
-------
TABLE V.4
(From Reference 8)
Evaluated Effects of 1000 MWe Operation In 1980
Item
Conventional Cost
Capital
0 & M
Fuel
Occupational accidents
Non-employee accidents during
transportation
Miners radiation exposure
Other occupational exposure
Population exposure from reactor
accidents other than Class 9
Population exposure from Class 9
reactor accidents
Population exposure from the
evaluated normal releases
Cost of transportation accidents
Cost of fabrication accidents
Cost of reprocessing accidents
Thermal discharge at reactor
Genetic effects from radiation
exposure
Comment
internal
50% external assumed
50% external assumed
future deaths—50% ext.
future deaths—50% ext.
future death—all ext.
future deaths—all ext.
almost completely int.
almost completely int.
almost completely int.
external
external
Public
Occupational
Internal Effects External Effects
millions mandays millions mandaye
$ lost $ lost
60
6
14
C
C
C
C
U
C
C
488
30
33
207
U
.024
.0001
.0095
0.6
0.014
0.48
488
.0015
.002
.01
38
33
207
M
UJ
T
190*
290
920
C-covered in the conventional cost, for example, by insurance payments.
U-unevaluated
-------
-137-
of premature death or disability. This, of course, appears not to be
practicable, less so for the general population that might be exposed to
low levels of ionizing radiations even than for the exposed occupational
groups, and absolutely impossible for those who are the yet unborn victims
of genetic effects induced by radiation releases to the environment.
Accordingly, while it is desirable to avoid having to depend on a procedure
something like that employed in the ANL report, if some common unit of mea-
sure is ultimately required, it may not be possible to avoid it as a pragmatic
matter, although the specific value and its rationalization need not be
accepted.
The use of the 6000 workdays at $50 a day, if accepted, still does not
eliminate problems in connection with its application. We must remember that
the monetized value is only a surrogate for the loss of life for the great
bulk of the mandays lost. If we regard life as of value in a sense different
from the embodiment of factor services, or labor, we should then question the
appropriateness of discounting the value associated with life because of the
time of its demise. Accordingly, the differential value employed for somatic
and genetic effects ($300,000 v. $100,000) in the ANL study also might be
questioned quite apart from the essentially arbitrary basis for the calculation
of the surrogate monetized amount.
There is also the question of the appropriate range of estimates of the
local and global doses of radiation when the entire family of long-lived radio-
nuclides released into the environment is considered. These may increase
greatly the adverse health effects from radiation but whether or not they
will do so is subject to considerable uncertainty. Accordingly, the uncer-
tainty surrounding the effects of the environmental dose commitment of the
long-lived radionuclides was not treated by the ANL report in its assessment
of the cost of nuclear power production.
As noted above, an uncertainty in estimating certain risks does not
necessarily prevent one from making an estimate of the costs of reducing the
risk. For example, the dangers to the public of the inadvertent release of
radioactive contaminants and the exposure of some members of the nuclear
labor force to large amounts of radiation are likely to be reduced if repro-
cessing of spent fuel is not attempted at this time. Selection of this method
of reducing these risks would appear as costs in various ways, such as an in-
crease in the price of uranium when easily recoverable supplies are exhausted
and the cost of stock-piling spent fuel. The time-integrated national cost
might, however, be reduced since better technologies for reprocessing are
likely to be developed, or the need to reprocess will disappear as new sources
of energy become available.
There are several subjects that are not treated in the ANL report. Two
of them are the storage of longrlived radioactive wastes and the security of
all radioactive material in transit as well as in storage. In view of the
intense controversy these subjects have generated, some explicit attention to
the risk^ and costs they involve is in order. A third untreated subject is
the preptoduction costs in the nuclear cycle; that is, the very large investment
-------
-138-
in R&D that lies behind the construction and operation of nuclear plants.
A fourth is the cost of regulation, on both the nuclear and fossil fuel
scores. If the analysis is to be truly complete, all of these items should
be included.
E. The Feasibility of Benefit-Cost Analysis as a Means of Comparing Nuclear
vs. Fossil Fuel Power Cycles
As stated in the preceding section, the ANL study provides a basis for
assessing the applicability of benefit-cost analysis to the problem at hand.
It constitutes an exhaustive and meticulous attempt to make such an application.
Yet it is clear that at this stage the reckoning of the social costs in the
analysis is seriously incomplete. Presumably, using the ANL study as a point
of departure, the missing elements of the analysis might be capable of devel-
opment with further effort, and other elements that may be deficient in treat-
ment at this time might be more adequately addressed following constructive
criticism and research, or a consensus on the conventions which need to be
adopted.
Yet even if all these matters were to be successfully resolved it would
not necessarily refine the analysis sufficiently to have identified the optimal
point between radiation control practice and radiation damage reduction, or the
costs involved. That is, what we have in the ANL study is only one point on
each of the cost curves relating social cost to output (electricity from a
1000 MWe power plant operating at an assumed 75 percent plant factor), without
explicit consideration of the relation between radiation control and radiation
damage reduction. The issue of accuracy aside, Tables V.3 and V.4 in the pre-
ceding section suggest that the social cost of the evaluated cost elements of
nuclear are less than the social costs of the evaluated elements of the coal
fuel cycle, given the mix of coal and nuclear assumed for the ANL study. But
in neither case have the control costs of pollutants been adjusted at the
margins nor the pollution damage been assessed. One reason is that we have
no convincing measures of the costs and benefits of reducing the emissions of
toxic substances associated with energy production.
There appear to be several possible approaches. One is to attempt first
to develop adequate dose response relationships for non-radiation pollutants
(products of fossil fuel combustion) to a level comparable with the dose re-
sponse relationships available in connection with radiation. Then the analysis
could be refined to include comparison of incremental control costs with damage
reduction for all types of pollutants, including radiation, for both fossil
and nuclear systems.
Even this would relate to only the point source, "local optimum" aspect
of the problem. If the radiation at that point will still contain releases
into the environment of long-lived radionuclides that do not have permanent
natural sinks from which they will not be resuspended to become health risks
again, it is likely that the relation of social costs among the various fuel
cycles will be subject to change over time. To provide at any time the optimal
mix among fuel cycles represents an incredibly complex dynamic optimization
-------
-139-
problem, which suggests that benefit-cost analysis may not be equal to the
problem. Indeed, given the degree of uncertainty inherent in the problem it
may never be possible to answer some of the relevant questions completely.
For example, the estimates of social costs of the fuel cycles were predicated
on the assumption of properly functioning plant and equipment. Built-in back-
stop safety features to abort adverse effects of malfunctions were included.
However, to further allay concerns about serious accidents occurring at the
reactor proper, redundant emergency safety systems may be required extensively
as backstop fail-safe measures. It is this apparent need for redundancy in
backstop emergency systems, to reduce even more a low probability of a cata-
strophic accident, that is at least partly responsible for the mounting costs
of nuclear reactors in recent years. For this and other reasons, it would
appear that our estimates of costs are not particularly firm, even aside from
the dynamic optimization problem.
But quite apart from the increasing costs of providing fail-safe techno-
logical systems, there are problems associated with the possibility of "mal-
functioning personnel" at critical stages of the nuclear fuel cycle —and perhaps
equally serious '*malfunctioning members of society" bent on achieving objectives
through violent means. In the study by Willrich and Taylor (1974) (13) the
problem of deliberate sabotage and theft is analyzed and the suggestion emerges
that a disciplined terrorist organization, for example, could misappropriate
enough fissionable material and comnand the technical capability to fashion a
crude nuclear explosive. As the scale and extent of the nuclear power industry
increase, other things remaining equal, opportunities for diversion of poten-
tially (socially) hazardous radioactive materials will increase. This is par-
ticularly true as fission technology expands outside of control of the U.S.
Government, in part, it is likely, to areas of political instability. Less
progress has been made in the design and stability of fail-safe social sys-
tems and universally accepted social contracts than in the design of techno-
logical systems.
When the scope of social costs is extended to include differential suscep-
tibility to sabotage between different energy conversion technologies, some
would hold that the approach that focuses narrowly on the conventional elements
of benefit-cost analysis is inappropriate to the problem (14). We believe,
however, that the issue is not a technical one in which conventional comparison
of resource costs among alternatives alone is at issue, but that in addition to
this economic analysis, there is need for a process of choice that will con-
sider ethical and political as well as economic issues, in which the larger
concerned public is intimately involved.
F. Conclusions
We have seen that the application of formal benefit-cost analysis to the
trade-off between nuclear and fossil fueled power suffers from severe limita-
tions, some of which are due to data imperfections, others to the nature of
the method. Does this mean that it is of little or no use in decision-making
and policy formulation? In giving the answer to this question, it is helpful
to review the major shortcomings of benefit/cost analysis and the results of
its application.
-------
-140-
It was noted at the beginning of this chapter that the analysis would
not include the treatment of conservation through government policy (as dis-
tinguished from individually motivated conservation). The reasons for this
exclusion should now be apparent: the difficulties are too great. If the
policy being considered as an element in the benefit-cost analysis is the
deferral of present consumption of energy resources in favor of the benefits
that will accrue to society in the future, those beneifts, as we have seen,
cannot be treated in present value terms. But what weight should then be
given to them? We do not know how to reach an objective answer to this
question.
The preceding discussion also emphasizes the difficulty or impossibility
of attempting to reduce many disparate elements to the cannon denominator of
the dollar value. Equally troublesome (and in the end probably a more im-
mediately serious shortcoming) is the inability to deal with unknowns and
uncertainties in assessing the effects of the different fuel cycles, both
fossil and nuclear. How does one treat the carbon dioxide effect, for ex-
ample? Does the continued and increasing use of fossil fuels threaten to
reduce average world temperatures? Although there are opinions on both
sides, no one knows. Does the continued expansion of power generation
threaten to alter the earth's heat balance? Again, no one knows. What is
the long-term effect of submicron ash particles from coal combustion? Are
there synergistic effects? What are the somatic effects on future generations
of exposure of the present generation to radioactivity (whether from nuclear
or fossil-fueled generation)? Can nuclear waste products be adequately
sequestered until they are no longer hazardous?
With time, the number and degree of such uncertainties should diminish.
Thus, the fact that the analysis must remain "unfinished11 given the present
state of knowledge does not mean that it cannot be done better in the future.
It is, therefore, important to identify the uncertainties as far as possible,
so that unknowns do not remain unknown unknowns.
Where does this leave benefit-cost analysis? At the lower levels of
decision-making, where the decisions are largely technical, it is indis-
pensable. As one proceeds up the successive levels of decision-making,
policy decisions must inevitably include more value judgments, and at these
levels the usefulness of traditional benefit-cost analysis tends to recede
from that of providing criteria of choice to that of providing ancillary
information. Benefit-cost analysis is economic analysis, and where the sci-
ence of economics is inapplicable, so, too, is the benefit-cost comparison in
the formal sense.
We conclude, nevertheless, that, in light of the charge to which we have
addressed ourselves, benefit-cost analysis applied to the choice between
nuclear and fossil-fueled power may have some value. Although formal benefit-
cost analysis cannot yield results which, in effect, make possible objective
decisions at higher policy levels the exercise is nonetheless useful in for-
malizing the comparison to the extent possible and in identifying and making
explicit the value judgments implied in a decision, thus enlarging the basis
of knowledge to which, in the end, ethical judgments must be applied.
-------
-141-
CHAPTER V
1. International Conmission on Radiological Protection. Report #22.
Implication of Conmission Recommendation that Doses be Kept as Low
as Readily Achievable. Pergamon Press Ltd. 1973.
2. Krutilla, J. V. and Page, R. T. Towards a responsible energy policy.
Policy Analysis, January 1975.
3. Krutilla, J. V. and Cicchetti, C. J. Testimony before the federal
power ccranission in the matter of: Pacific Northwest Power Com-
pany and Washington Public Power Supply System. Hearings, Washington,
B.C., 1970.
4. Fisher, A. C., Krutilla, J. V., and Cicchetti, C. J. The economics of
environmental preservation: a theoretical and empirical analysis.
American Economic Review, September 1972.
5. Fisher, A. C. and Krutilla, J. V. Valuing long run ecological conse-
quences and irreversihilities. Journal of Envirormental Economics
and Management, September 1974.
6. Cicchetti, C. J. and Freeman, A. M. Option demand and consumer surplus.
Quarterly Journal of Economics, August 1971.
7. Arrow, K. J. and Fisher, A. C. Environmental preservation, uncertainty
and irreversibility. Quarterly Journal of Economics, May 1974.
8. Hub, K. A., Asbury, J. G., Buehring, W. A., Cast, P. F., Schienker, R. A.,
and Weills, J. T. Social Costs for Alternate Means of Electrical
Power Generation for 1980 and 109TT Argonne National Laboratory,
Argonne, Illinois. 1973.
9. Brookhaven National Laboratory, The Biomedical Assessment Group, L. D.
Hamilton (ed.). The Health and Environmental Effects of Electricity
Generation—A Preliminary Report. Upton, New York, Brookhaven
National Laboratory, 1974.
10. ("Rasmussen Report"). U.S. Nuclear Regulatory Cormri.ssion. Reactor
Safety Study: An Assessment of Accident Risks in U.S. Coranercial
Nuclear Power Plants,- Report WASH-1400, NRC, Washington, D.C.
October 1975.
11. U.S. Environmental Protection Agency. Environmental Radiation Dose
Commitment: An Application to the Nuclear Power Industry (1974).
-------
-142-
12. Cohen, Bernard L. The Hazards in Plutonium Dispersal. Inst. for
Energy Analysis, Oak Ridge Associated Universities, March 1975.
In press.
13. Willrich, M. and Taylor, T. B. Nuclear Theft: Risks and Safeguards.
Cambridge: Ballenger Publishing Co., 1974.
14. Kneese, A. V. The Faustian Bargain. Resources, Number 44, Washington,
D.C.: Resources for the Future, September 1973.
15. Friedman, M. and Savage, L. J. "The Utility Analysis of Choice In-
volving Risk," Journal of Political Economy, Vol. LVI, No. 4,
August 1948.
16. Mishan, E. J. Cost-Benefit Analysis. New York: Praeger, 1971.
17. Fromn, G. Civil Aviation Expenditures, in R. Dorfman, ed., Measuring
Benefits from Government Investment, Washington: Brookings
Institution, 1965.
-------
-143-
CHAPTER VI
BENEFIT-COST ANALYSIS FOR MEDICAL RADIATION
A. Sunmary and Reconraendations 146
B. Introduction « 147
C. Risks from Medical Radiation 149
D. Ethical Considerations in Medical Radiation 149
E. General Concepts and Models of Benefit-Cost Analysis 151
for Medical Radiation \
1. Introduction 151
2. Averted Costs 152
3. Economic Resources: Benefit-Cost Models 153
a. Resource-Use Model 153
b. Resource-Loss Model 156
4. Reduction of Risk Model 157
F. Application of Resource-Loss Benefits Model to Diagnostic 158
Radiology
1. Concepts and Parameters 158
2. Valuation of Benefits from Diagnostic Radiology 162
G. Application of Resource-Loss Costs Model to Potential 163
Radiation-Induced Somatic Disease from Diagnostic
Radiology
1. Conceptual Problems 163
2. Valuation of Costs from Diagnostic Radiology 165
H. Application of Resource-Loss Costs Model to Potential 167
Radiation-Induced Genetic Disease and Hereditary
Effects
-------
-144-
Contents - continued
I. Sumnary of Economic Benefit-Cost Analysis of Diagnostic 169
Radiology
J. Application of Reduction of Risk Model 170
1. Mass X-ray Screening in Diagnostic Radiology 170
a. Mass X-ray Screening of the Breast (Mammography) 170
b. Mass X-ray Screening of the Chest 173
2. Chest Radiography 173
3. Special High-Dose Diagnostic Procedures 174
a. Cardiovascular Disease 175
b. Cerebrovascular and Neurological Disease 176
K. X-ray Examination of Pregnant Women 176
L. Application of Reduction of Risk Model in Radiotherapy 177
1. Malignant Disease 177
2. Non-Neoplastic Disease 178
M. Reduction of Dose in Medical Radiation Usage 179
1. Radiological Equipment and Installations 179
2. Radiological Techniques 179
3. Clinical and Other Professional Judgment 179
4. Radiation Protection 180
-------
-145-
Chapter VI was prepared for this report by a subcommittee consisting of the
following:
Jacob I. Fabrikant - Chairman
McGill University Faculty of Medicine
Montreal, Canada
Seymour Abrahamson
University of Wisconsin
Madison, Wisconsin
Murray Eden
Massachusetts Institute of Technology
Cambridge, Massachusetts
Earle C. Gregg
university Hospitals
Cleveland, Ohio
George B. Hutchison
Harvard School of Public Health
Boston, Massachusetts
Albert W. Hilberg
Division of Medical Sciences - Assembly of Life Sciences
National Research Council - National Academy of Sciences
Washington, B.C.
-------
-146-
CHAPTER VI
BENEFIT-COST ANALYSIS FOR MEDICAL RADIATION
A. Summary and Recommendations
1. Sutrroary
The chapter reviews briefly the risks and economic costs of medical
radiation—diagnostic radiology as well as nuclear medicine and radiation
therapy—in terms of somatic and inheritable disease and direct and indirect
dollar costs of radiological health care services. The ethical considerations
relating to radiation protection are placed in perspective as regards expo-
sures to patients in the present day patterns of the practice of medicine in
the United States. Certain general concepts are introduced which aid in the
development of benefit-cost models and which apply solely to the use of ionizing
radiations in diagnosis and therapy in our health services systems. These in-
clude the impact of societal decision-making relative to the health and well-
being of the individual in society and society as a whole and, thus, the
perception of risk and disease as it affects society and its efforts to improve
the quality of life. The models developed are based primarily on the economic
cost of illness and are designed to achieve a benefit-cost relationship. To
quantify this relationship, insofar as possible, dollar valuation has been
used. This method represents only one form of calculating a relative value.
The values cited are illustrative of the analytical process only and are not
to be taken as actual measures.
The models developed are imprecise and general. The unifying simplicity
achieved by application to a single common unit, the dollar, relates costs
(resources used by society to achieve its aims, viz., radiological health care
delivery) to benefits to be derived (improved quality of life, involvement in
societal productivity, etc.) by the individual and by society. The preven-
tion of disease and the failure to cure existing ill-health is considered
in terms of the loss of human resources, e.g., present and future lives saved,
human productivity, etc. In this model, the reduction of radiation risk is
considered as a means to achieve improvement in the benefit-cost ratio.
Specific examples are used in the application of these models: (1) in
diagnostic radiology, mass screening surveys (e.g., mammography) and certain
high dose procedures; (2) in radiation therapy, the treatment of cancer. In
these models, valuation is inescapable, but economic terms are used only to
achieve an arithmetic method readily understood by society.
The reduction of risk model is developed using a reduction of dose
method; models are described to achieve this without reduction of potential
benefits of medical radiation to the individual and to society. An approach
to the development of alternative technologies and methodologies in the
-------
-147-
radiation sciences is considered briefly. Appendices are included to assess
the value of the genetically significant dose and the status of federal and
state regulations.
2. Recomnendations
a. Benefit-cost analysis should be used in decision-making
relative to medical radiation and health care delivery to
large populations in society. Dollar valuation, which
should be used only as a relative value, provides a method
to relate all direct and indirect costs to the benefits
accrued. Methods for benefit-cost analysis for medical
radiation based solely on the economic costs of illness
and evaluation of human life are limited and may apply to
society as a whole for decision-making in the allocation
of limited resources available; these methods do not neces-
sarily apply in specific circumstances of health and illness
to single individuals.
b. Efforts should be directed to improving the benefit-cost
ratio, without limiting the benefits derived from modern
radiological services to society. The benefit-cost ratios
for medical radiation may be improved without loss of benefit
by decreasing the potential health risks through dose reduc-
tion methods, e.g., shielding of radiosensitive tissues,
improving imaging systems and elimination of unnecessary
exposures to large populations.
c. The role of diagnostic x-ray examinations in medicine and
dentistry, particularly in children must receive careful
study before a full understanding of the benefits and the
costs to the individual and to society can be determined.
d. Careful benefit-cost analysis should be done prior to carrying
out mass x-ray screening programs of large populations.
B. Introduction
Medical radiation represents the largest source of man-made radiation
exposure to the general population at the present time (1,2). This exposure
is almost exclusively to low LET radiations from the diagnostic use of x-rays
and radioisotopes and the therapeutic use of x-rays and radioactive source
materials, such as cdbalt-60 or radium. In the 1960's, the average yearly
radiation dose to the U.S. population from medical exposure was in the range
of 60-100 mrem per person compared with approximately 100-125 mrem from
natural background (1,3). Large numbers of persons receive diagnostic radio-
logical x-ray examinations, and these x-ray exposures represent the main source
of radiation dose to the population from medical radiation (see Table VI. 1)
(1,3). Therapeutic radiation for neoplastic and non-neoplastic diseases
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TABLE VI.1
USPHS X-Ray Exposure Study - 1970 (3)
(million)
Population of United States 200
Number of x-ray visits 179
Number of persons receiving one or more ' 130
x-ray procedures
Number of x-ray examinations performed 212
Number of medical x-ray visits 112
Number of medical x-ray examinations 140
Number of dental x-ray visits 68
Number of dental x-ray examinations 70
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contrihutes only a small proportion of the average yearly radiation dose,
whereas exposure from radioactive isotopes in nuclear medicine provides only
a fraction of this value (3).
Total health care spending in the United States in 1974 amounted to $104
billion, an increase from $83 billion estimated for 1972 and $94 billion in
1973 (4,5). Medical care spending claims more than 7.5 percent of the Gross
National Product, which in 1974 exceeded $1.35 trillion. The average health
expenditure per person in 1974 was $485, almost two-thirds of which was for
hospital care and physician's services. Radiological health care delivery
for diagnosis and treatment claims approximately 7 percent of the total annual
health care spending, about $7 billion.
In 1974, approximately 140,000 medical x-ray machines and 143,000 dental
x-ray machines were in use in the United States (6). In addition, some 7,500
non-medical x-ray, fluroscopic and analytical x-ray devices were being used
in industry, research, and education. Currently, some two-thirds of the popu-
lation of the united States receives a medical radiological procedure each
year (3).
Since 1962, the number of hospitals in the United States with clinical
radioisotope facilities has more than doubled, from 1,500 to well over 3,000.
In this decade, the growth rate has been linear, increasing by 50 percent
during the first five years. During the 1973-1975 interval, it was estimated
that the sale of medical radiopharmaceuticals and nuclear medical instruments
rose from $110 million to $200 million. From 1971 through 1974, the estimated
number of organ scanning and function procedures rose from 4 million to 9
million.
C. Risks from Medical Radiation
Estimates of the somatic and genetic risks from radiation have been pro-
vided by the NAS-BEIR Comnittee (1), ICRP (7), and the UNSCEAR (2). In view
of gaps in our knowledge of the dose-effect relationship in the human situation,
the linear non-threshold hypothesis has been used in assessing somatic and
genetic risks in regard to human radiation protection (1).
D. Ethical Considerations in Medical Radiation
The uses of radiation in medicine may be categorized as diagnostic and
therapeutic, and investigational. The goal of these medical uses of radiation
is to achieve maximum health benefits, and this goal must be weighed in the
context of a broader mission of seeking mrximm well-being of society. In
this broader frame, health benefits must be weighed against costs. The costs
themselves include both health' hazards and economic costs, services and re-
sources. In addition to information on the costs and benefits, a benefit-cost
evaluation requires a relative value system, a method for trade-offs. Its
impleme&tation requires an informed society capable of understanding the
values.
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For medical radiation, as well as for certain uses of radiation in
energy production, the problem of balancing benefits and costs is complicated
by issues of ethics and discrimination. As an example, increased years of
life expectation or increased economic productivity can be a useful measure
of health benefit in some contexts. If, however, these parameters are used
to balance the benefit-cost equation against the elderly with limited life
expectancy or those with limited productivity, important values of society
will have been overlooked.
The problem of evaluating medical uses of radiation is further com-
plicated by historical considerations. The introduction of radiological
techniques in medicine has led to a dependency on its application in both
diagnosis and therapy, particularly in cancer therapy. Throughout most of
the decades since its introduction, the measure of the health hazard from
radiation has been only poorly known and even now many issues remain unclear,
particularly with relation to the hazard of exposure at low doses. Further-
more, for many of the uses of these radiations, health benefits have been
dramatic, particularly when used in diagnosis of suspected medical conditions
of major morbidity and in treatment of cancer. For these uses, it has been
assumed, probably correctly, that no formal evaluation was necessary to
determine the direction of the benefit-cost balance. For certain other uses,
for example, in diagnostic x-ray screening of persons in whom there is no
suspicion of disease or in therapy of many non-neoplastic conditions, the
balance of values is less clear. However, here, too, decisions have commonly
been made on the basis of informal evaluation.
Costs to be balanced against benefits include health hazards, costs of
services, and costs of resources. Principal decisions may require choices
among these complex costs. As an example, the costly technology of radiation
protection requires a determination of the minimal total cost, the sum of the
health hazard cost and the radiation protection cost, and all related to a
fixed benefit from the medical radiation use. As a further example of the
complexity of the cost side of the equation, the health hazard includes both
the somatic and the genetic hazard.
A special consideration in the use of medical radiation is the individ-
ualized nature of the decisions that must be made. If a decision is made to
carry out a diagnostic radiological procedure or to undertake a course of
radiotherapy for a given patient, the principal benefit will accrue to this
individual. There are general benefits to society from an individual's
health, and there are hazards to future generations, but these are usually
secondary issues. While the individual must be informed and included in the
decision-making, he will in most instances not have sufficient understanding
of the issues to contribute meaningfully, and the physician must accept the
main burden of making decisions that often vitally affect the individual.
This circumstance is contrasted with the decisions to be made relative to
uses of radiation in energy production where large populations are involved.
The present basis for radiation protection of the health of the public
is essentially the establishment of upper acceptable limits fi^r individual
and population exposure and of dose-limiting recomnendations and guidance for
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special cases. These recommendations imply: (1) any biological hazards,
both to the individual and to the population, are offset by commensurate
benefits; (2) the risks are acceptable both to the individual and to society—
this acceptability may best be judged by comparison with other risks encoun-
tered in life, though the basis for such comparison is complex; (3) the
beneift-cost balance should be made as favorable as possible; and (4) under
the assumption of a nonthreshold dose-effect relationship, a health hazard
component of the cost must be considered to exist for every radiation use.
Diagnostic and therapeutic radiation are expensive. Costly equipment
and hospital facilities, highly trained professional and supporting personnel,
and expensive direct and indirect costs, are required to make radiology safe
and reliable. Aside from the reduction of risk and any radiation hazards to
individuals and the general population, effort should be constantly directed
to placing economic considerations into proper perspective. Wasted radiation
in medicine is costly to the consumer, and provides no benefit to the individ-
ual and future generations. Thus, any deliberate exposure to medical radia-
tion should also be concerned with the balance between benefit and cost, and
may be justified by the benefits that are expected to result. Large costs
may be reduced, for example by simplifying examinations performed for the
immediate medical and dental needs of the patient, by centralizing sophis-
ticated and costly equipment, personnel, facilities, and services for
regionalization and delivery of health services to larger populations; by
careful benefit-cost analysis of mass x-ray screening surveys for the early
detection of specific curable disease, and particularly the early diagnosis
of cancer; by the determination of degree of benefit to be derived by the
patient examined for occupational, insurance, and medical-legal purposes;
and by the assessment of the efficacy of the treatment of non-neoplastic
diseases with ionizing radiations.
E. General Concepts and Models of Benefit-Cost Analysis for Medical Radiation
1. Introduction
Health services programs are designed not solely to prevent disease and
to improve health, but equally to decrease costs resulting from illness and
disease. For example, the benefits of controlling disease may be simply
assessed as the current costs of the disease which are thereby averted by the
program (8-11), and such benefits, or averted costs, can be listed into three
broad categories (12): (1) resource-use, i.e., the actual expenditures on
medical care; (2) resource-loss, i.e., the estimated losses of current pro-
duction or, preferably, human productivity; and (3) resources-transfer, i.e.,
payments for certain hidden costs transferred from the well to the sick. The
pain and discomfort accompanying and following any disease may be included in
both resource-use and resource-loss categories.
Quantifying such costs and the symmetrical averted costs then may be
achieved roughly by summation of identifiable activities. For example:
(1) The direct costs or expenditures on medical care and health services
include all costs of the services of physicians, paramedical personnel,
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drugs, hospital facilities, equipment, etc.; these are both capital and
recurring costs and are quantifiable as resource-use. (2) The losses of
current production of individuals who are ill, but who otherwise would be
well and productive may be determined as resource-losses: (a) the loss of
gross earnings resulting from a loss of working hours in order to have diag-
nosis, treatment, and to be rehabilitated to productive activity, and (b) a
reduction in gross earnings as a consequence of the social, psychological,
or physical constraints which render a person less productive (or less employ-
able) . Here, pain and discomfort associated with disease are not easily
quantifiable; the procedure of evaluation of such intangibles is usually
arbitrary. (3) Transfers of resources may be determined as costs to the
givers and benefits to the receivers; disease takes resources, in the form
of cash payments or hidden subsidies, away from those who are well and have
paid costs of the program, to those who are ill.
Because of limited economic resources available to society, it is be-
coming increasingly important to make proper allowances for losses, or gains,
arising from changes in the incidence of disablement, disease, or death, and
, the costs of health services necessary to avert the losses and to improve the
gains or benefits. The analysis of saving life may be considered symnetrical
with that of losing it. One conrnon analysis of the loss of life, in spite of
many dissatisfactions with the method, is the net output method of calculating
the economic worth of a person's life and, therefore, the loss to the economy
of society consequent upon his illness or death. The analysis may provide a
conservative estimate based on an arbitrary value of human life expressed in
terms of lifetime earnings, and based on past and present earnings, consump-
tion, and discounting to the present the person's expected future earnings.
The loss to the economy takes into account the expected gross earnings, the
duration of life expectancy, and the social rate of discount. (An appropriate
figure for the value of human life is not easily determined; one figure may
be approximately $300,000.00 based on data of the American National Standards
Institute (18, i.e., an assumed productive value of $50.00 per day, or a loss
of 6,000 working days as a result of accidental death.) Furthermore, the
economic value of the non-employed but "productive" housewife may be deter-
mined on the same basis of costs for skilled or professional services performed
and prorated as household jobs, rather than simply as a domestic helper in the
home.
2. Averted Costs
The special problems of quantifying the effects of health services pro-
grams is a matter for physicians and health engineers. The health economist
is concerned with the problem of valuing the benefits per life saved or illness
avoided. In this regard, a death avoided means that a loss of a productive
life may be avoided. In other words, the present value of this activity is
an economic benefit, and that benefit is credited to the activity for saving
life.
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An initial step to estimate the value of the measure for saving life
or reducing illness, thereby improving health, is to determine what the
average individual whose health is improved or life is saved would earn
(or produce) over the rest of his life. The following discussion will use
principles (9,10,13,14) in which a useful distinction is made between the
effects of disability (or loss of working time away from work) and debility
(or loss of capacity while at work). However, in each category, the multi-
plicity of variables, such as life-expectancy and human productivity, pre-
clude calculation of the precise influence of a particular health services
program on a subpopulation.
Another approach to benefit-cost analysis infrequently used is to esta-
blish that various kinds of risk to health exist, and then decide how much
to spend in reducing these various risks. This implies that the individual
and society can evaluate diminution in risk. However, the primary purpose
of this approach in established health services programs in which risks exist
is nevertheless exactly the same as that of the averted cost .approach, namely
to save lives and reduce illness. This will be discussed later in greater
detail.
3. Economic Resources; Benefit-Cost Models
There is a need for clarifying cost concepts in current use to classify
and estimate costs of health services^ Economic costs, in a limited sense,
arise out of the impact of disease and injury upon the use, distribution, and
availability of economic resources. One method (11,13) is based on the effects
of such health services on the use, distribution, and quantity of available
economic resources for health care delivery.
a. Resource-Use Model
The direct costs of health programs involve manpower and material re-
sources required for prevention, diagnosis, treatment, and rehabilitation of
each of the major diseases and disabilities. Available estimates indicate
that the part of the nation's manpower and of goods and services produced
(both public and private expenditures) that is devoted to health care has
continued to increase substantially during the past 50 years (4). For ex-
ample, in 1929, it was estimated that health and medical expenditure was
approximately $4 billion, or about 4 percent of the Gross National Product.
Since 1965, total national health spending has risen from $39 billion to
$56 billion in 1969, to $104 billion in 1974, approaching 8 percent of the
Gross National Product (4,5). During the period from 1950, per capita ex-
penditure for health rose from $78 to $485. During the 1960's, there was a
steady expansion of federal and state authority in the field of health care.
In the 1970's, a primary political objective appears to be attempts to de-
velop a rational system for regulation and control of health services that
ultimately will moderate cost increases and make medical costs more predict-
able to the government, the private sector, and the consumer (5). For
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example, during the 1950-1974 period, spending by federal, state, and local
governments increased from $3 billion to $41 billion or from 26 percent to
over 40 percent of total health expenditures, primarily due to the introduc-
tion of Medicare and Medicaid programs in the 1960's.
Only rough determinations can be made of the actual resource-use costs
of radiological health services. The resources directly devoted to the pre-
vention, diagnosis, treatment, rehabilitation, and research in specific health
programs are represented by the financial outlays of public and private health
insurance and other agencies, employers, and individuals and their families.
For radiological health care delivery systems, these are sizeable costs and
include both fixed and recurring expenditures for: (a) health services pro-
vided by radiologists and other physicians, hospitals, dentists, technologists,
nurses, and other health personnel; (b) complementary corrmodities, such as
x-ray film, radiopharmaceuticals, chemicals, and other medical supplies;
(c) public and private health agency programs, mass x-ray screening and
surveys (e.g., breast, for early diagnosis of cancer) for some disease pro-
grams or socio-economic groups; (d) a part of capital expenditures for con-
struction of radiological equipment, and expensive recurrent maintenance,
used in the provision of radiology health services and the production of
complementary radiological health goods; (e) a part of costs of training
radiological health services personnel; and (f) radiological research.
While seme progress has been made in the development of cost estimates
for the radiological health care expenditures which encompass most of these
categories of outlays, estimates in current use fall far short of even a
complete account of both public and private expenditures for hospital and
radiological services. However, sane economic information is available.
During 1970, approximately 210 million medical and dental x-ray and radio-
isotope examinations were performed in the United States. If it is assumed
that the average cost per examination to the medical consumer was $22, as
for a chest x-ray examination, then the direct recurring expenditures for
all chest x-ray examinations to the population would be in excess of $1.4
billion; and for all diagnostic radiological health services and supplies
in that year the cost would be approximately $4.6 billion (Table VI. 2).
If, conservatively, it is further assumed that this represents two-thirds
of the costs of all resource-use for radiological services, the remainder in-
cluding the capital expenditures for construction, purchase, and maintenance
of health plant and x-ray facilities used in the provision of radiological
health services, and in the production of complementary health goods, then a
conservative estimate of all direct costs or resource-use directly devoted to
all radiological health care services and supplies approaches $7 billion.
This represents a radiological health expenditure per person of approximately
$35 or 7 percent of the per capita expenditure for all health services.
A brief tabulation of the distribution of diagnostic x-ray examinations
only obtained from the USPHS 1970 X-Ray Exposure (XES) Study (3) and based
on the average 1975 medical professional services fee schedule (Connecticut
Medical Services (15) can provide a simplified accounting of the cost of the
medical consumer. Based on some 140 million medical and 68 million dental
x-ray examinations in the United States in 1970, the costs to the medical and
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TABLE VI.2
Resource-Use Costs Model
Distribution and Dollar Costs of Medical
and Dental X-Ray Examinations in the Year 1970
1 o
Body Area Number Cost ($) per
Type of Examination (million) Exanri nation
Chest (thorax) 65 22
Upper abdomen 15 22
Lower abdomen 17 39
Upper extremities 10 17
Lower extremities 12 22
Head, neck, and other 10 22
Gastrointestinal series 6.6 50
Barium enema 3.5 50
All other fluoroscopic examinations 2.5 40
Dental radiography 68 12
(Prom XES, 1970 Survey) (3)
- (From CMS, 1975) (15)
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dental consumer can be shown to approximate $4.5 billion (Table VI.2). Thus,
the estimated resource-use costs to the health services consumer, assuming
that the medical and dental x-ray costs determined represent approximately
two-thirds of all direct resource-use costs for all radiological health ser-
vices, would be therefore estimated to approximate $7 billion.
b. Resource-Loss Model
The loss of resources arising from sickness and injury may be considered
in terms of human resources lost or impaired as a result of the deleterious
effect on society's productivity caused by sickness (12,13). This may be
justified in the sense that only limited resources are available and that
without sickness and injury, health services would be unnecessary so that
the available resources would be free for other productive uses in society.
Part of the total economic cost of illness is the actual loss of economic
(human) resources, notably human labor, available to a productive society.
In order to quantitate the loss, one method would be to value the loss in
dollars. For such valuation, it is necessary to estimate the productive out-
put "foregone." In other words, if sickness and injury could be prevented,
eliminated, or limited in time, it would be important to determine how much
productive gain (benefits to society) those persons who are presently ill
would have contributed to societal resources.
In general, the effects of sickness and injury on the amount of human
labor available for productive purposes may be considered under three main
categories (9,10,13): (1) debility, or the loss of productive capacity of
individuals while at work; (2) disability, or the loss of working or other-
wise productive time; and (3) death, or the actual loss of workers. Based
on this definition, various stages in achieving a calculation of the estimated
previous output lost may be considered. However, these stages assume that for
any estimate of work-loss due to a disease or injury, if it were not for the
disease, those sick persons in the productive age groups stricken by the disease
would have otherwise been well and therefore employed and productive. Clearly,
certain conceptual problems arise which make precise estimates of resource-
loss difficult to compute. For example, the assumption that the resource-loss
as a result of illness is productive human labor must make some provision for
costs of certain societal activities which are necessary concomitants, such
as unemployment and the impact or direct effect of unemployment on the inci-
dence of disease and injury. Some provision must account for persons who
are disabled or die prematurely who would otherwise be in good health.
Further assumptions must also be made for the time scale (the loss in a
given time period), the loss of working time of the individual in relation
to the work-force participation (for any single period estimate, the resource-
loss of the young who have not as yet entered into the productive work-force,
and of the retired-aged, would be zero or possibly a negative value), loss of
output due to debility, and so on.
For the purposes of the resource-loss model which follows, a one-year
estimate may be chosen. It is conceptually a much simpler time scale, and
it involves fewer assumptions. Within the framework of the model, certain
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provisions can be made for the loss of a productive work-life (i.e., total
disability or death). However, no attempt is made for allowances which in-
clude future discounting, productivity increases, and consxmption. In the
model calculation of resource-loss estimates for chest x-ray examinations in
diagnostic radiology, therefore, the loss in production may be viewed as a
loss within a given time period; the one-year estimate for 1970 (for
which the most recent data are available) is chosen. Provision for loss
over a productive life of children who have not yet entered the work force
is made, and it is assumed that all individuals who have entered the work-
force have remained.
Certain costs and benefits in health are intangible circumstances which
can be readily identified, but not easily quantified, e.g., the production or
relief of pain, the development of anxiety or its amelioration, or the extent
of physical or psychological discomfort. Such circumstances have a direct
impact on the health and well-being of individuals, affecting debility or
disability, and indirectly the capacity for a productive life. Other cir-
cumstances, such as the prevention of death or reduction in lives lost, can
be readily quantified in an arithmetic sense, but cannot be valued with pre-
cision in a market sense. These intangible costs and benefits are, neverthe-
less, extremely important, and must be taken into account in any benefit-cost
analysis model, since they are essential for decision-making processes in
health care services systems. It is difficult to gain some idea of the
importance of such intangibles, and in practice, attempts at assessment of
their relative importance, however imprecise, are frequently made by per-
ception techniques on grading questionnaires.
4. Reduction of Risk Model
A major criticism of the resource-loss benefit-cost model is that it
implies that a person's health and, therefore, life can be valued by the pro-
ductive capacity of the individual. The simplest application of the model is
that of an increase in the risk of death. Similar application can be made in
relation to increase in risk of injury as well as death. Thus, there are two
basic objections to the resource-loss model: (1) it fails to take into ac-
count different levels of valuation of more productive members of society,
and (2) it assumes that society values an individual only in terms of his
economic contribution. The model does not take into account such intangible
circumstances as pain, discomfort, anxiety, bereavement, and attempts to
deter death.
Furthermore, society recognizes and invests heavily in the non-productive
members of society, e.g., health and education for children, and health and
well-being of elderly, retired persons. Thus, the non-productive persons in
society could represent a substantial cost (or benefit) value to society to
be added to the lost productivity factors, affecting the net contribution to
society. The values determined by the resource-loss model should be modified
to assess the net contribution to society, and such values must therefore be
considered as the 'lower level that society would be prepared to place on an
individual's life.
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An approach to an assessment of how society might value non-economic
losses (or gains) may be considered in terms of the risk, and its avoidance.
In other words, an extension of the resource-loss model can be applied to
reduced risk of death, and to reduced risk of injury and disease. The model
is symnetrical; for example, an increase in number of diseases and deaths is
a recognized by-product of growth of economic activity resulting from the in-
creased use of ionizing radiations in medical practice. A reduction in the
number of diseases and deaths can be a by-product of some growth of an economic
activity such as in preventive medicine.
In benefit-cost analyses of health programs, the traditional approach
has been that: (1) the major purpose of the program is to save lives and
reduce illness; (2) death or illness avoided means that a loss of human pro-
duction may be avoided; (3) the problems center on valuing the benefits per
life saved or per illness avoided; (4) the economic value of a human life
saved varies according to a variety of factors, including age, and can be
determined with some precision; and (5) the non-economic value of a human
life can be ascertained based on the costs society will spend to save a life.
None of these factors, except possibly the last, takes into account the multi-
plicity of variables entering into the effects of disability, debility, and
death, among the most important of which are the risks leading to illness and
death. Rationality in decision-making assumes that it is possible to decide
how much to spend to reduce various kinds of risk. Furthermore, since
societies, both in their public and private capacity, do incur measureable
costs to reduce recognizable risks, it has been demonstrated amply that their
valuation of diminution in risk can be determined, and even quantitated from
their behavior (16).
F. Application of Resource-Loss Benefits Made! to Diagnostic Radiology
1. Concepts and Parameters
In terms of benefit and costs, three categories of x-ray examinations
and radioisotope scanning procedures can be classified (17). In each of
these, it is possible to identify particular benefits to be balanced against
a cost or detriment, either economic or to health, or both.
The first category comprises the vast majority of x-ray and radioisotope
examinations which are performed for the immediate medical needs of the pa-
tient who is ill. The traditional policy of American medicine is that of
attempting to restrict this category of examinations to those which would
control and confirm clinical diagnoses tentatively established by physical
and other methods of clinical diagnosis, and would affect subsequent manage-
ment of the patient. A benefit-cost analysis by the physician at the time
is invariably impractical and would be unlikely to affect the decision to
perform the necessary radiological examinations. Nevertheless, the extent,
frequency, and degree of completeness of these examinations are' subject to
wide variation in different hospitals, health agencies, or private offices.
It would appear that many of these procedures could possibly be ;carried out
with much lower doses of radiation to the patient with little decrease in
benefit.
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The second category is the mass-screening or case-finding diagnostic
x-ray examinations which expose large health populations. These x-ray surveys
are designed as part of disease-control programs, e.g., mammography for breast
cancer, to improve the health and well-being of the individual and of the com-
munity. Until recently, little effort was placed on assessment of cost-
effectiveness and benefits to be derived, but authorities responsible for
planning and measuring health resources are now beginning to submit such
mass-screening programs to careful benefit-cost analysis. The benefits are
those current costs of the disease which are averted by the program and such
benefits are compared with the resource-costs of the program. A small group
of screening x-ray examinations include those tests directed at "exclusion"
of diagnoses rather than confirmation, usually on a selected basis in the
course of management of symptom-free patients. In all, a relatively small
proportion of all x-ray examination procedures may fall into the screening-
survey category.
The third category includes a large group of specific x-ray examinations
carried out for preventive medical and dental needs of persons who are other-
wise in good health and for occupational, insurance, medical-legal, and
psychological purposes. These should be evaluated to assess the particular
benefits to be derived by the person actually exposed.
Table VT.l lists some important statistics from the 1970 United States
Public Health Service X-Ray Exposure Study (3) on which the following resource-
loss benefits model estimates are based.
Diagnostic (investigative radiological health care services may be looked
upon as part of the resource-use of health resources directly devoted to the
prevention, diagnosis, treatment, and rehabilitation of diseased or injured
persons who are temporarily or permanently lost from the total human labor
force during that year. One component of the resource-use costs is the cost
of off-setting disease and impairment which cause a loss of human labor and,
therefore, of economic resources. Hence, these are resource-use costs to
offset resource-losses, but on the assumption that an estimate of work-loss
(which may be valued in dollars by health economists) as a measure of produc-
tivity loss due to illness may be determined by the productivity of the persons
affected by the disease who would have otherwise been employed. The inves-
tigative x-ray or radioisotope examination may be considered an essential part
of the health services system necessary to return these persons who are ill
to full productivity in society. As such, the x-ray examination may be
evaluated by its beneficial effect on the overall resource-loss costs, that
is, the prevention of debility, disability or death, thereby being of benefit
to the patient vfao is ill.
In this model, assumptions must be made on the value or benefit of a
particular x-ray or radioisotope examination in each case, the efficiency of
the procedure, the, precision 6t the x-ray diagnosis, and its influence on the
effectiveness of management of the patient affecting prognosis of that indi-
vidual.Furthermore, it must be assumed that all these activities, however
subjective and qualitative, can be quantified and that each is maximal in order
to provide a rougbli estimate of benefit (i.e., resource-use costs less prevented
resource-loss costs) ^Aiich can be computed.
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It mast be recognized that these are assumptions derived at the present
time solely from impressions of clinical radiological practice in medical
care services in the United States. Such assumptions are subjective and
speculative, since no quantitative data are available on which to base more
firm figures. The following assumptions are made for purposes of the model
only:
(a) It has been arbitrarily assumed that of all medical x-ray examinations
performed in the year 1970, perhaps 85% did not help to prevent any
resource-loss directly benefiting the patient exposed; that is, the
x-ray examination, however essential and beneficial to the patient,
prevented no debility or disability in the year of exposure, 1970.
Included here would be the majority of examinations in the second
and third categories outlined above.
(b) It has been arbitrarily assumed that approximately 8% of all medical
x-ray examinations in 1970 prevented minimal debility or disability
in the patient exposed in the year 1970"!TTris would include pri-
marily confirmatory diagnostic x-ray and radioisotope examinations
for already clinically diagnosed disease established in first
category or examinations (e.g., most chest x-rays, bone and joint
x-ray examinations, sinus x-rays, etc., that is, those x-ray examin-
ations already established in the diagnosis and management of chronic
diseases such as chronic lung disease, arthritis, headaches,and
sinusitis, etc.).
(c) It has been arbitrarily assumed that perhaps some 4% of all medical
x-ray examinations prevented moderate debility and disability in the
patient exposed in the year 1970.Tnese examinations would include
more specialized examinations usually performed in hospitals, e.g.,
gastrointestinal series for peptic ulcer, cholecystograms for gall-
bladder disease, excretory urograms for hypertension or renal
disease, etc.
(d) It has been arbitrarily assumed that approximately 27o of all medical
x-ray examinations prevented Egjor debility or disability in the
patient exposed in the year 1970. Such examinations would include
the diagnosis and management of serious fractures of the skull,
spine or hip, gastrointestinal studies for surgical emergencies,
specialized vascular x-rays for peripheral vascular disease, etc.
(e) It has been arbitrarily assumed that approximately 1% of x-ray
examinations prevented complete disability in the patient exposed
in the year 1970. Here, such specialized x-ray examinations as
cerebral angiography, coronary angiography, and other specialized
neurovascular and cardiovascular x-ray procedures would be included.
The x-ray examinations usually comprise a sequence of investigative
procedures, frequently involved in the diagnosis and management of
patients with diseases which represent the leading causes of death—
diseases of the heart and blood vessels, cancer, cerebrovascular
disease, and accidents. A special category in this group would be
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those x-ray examinations which resulted in the prevention of death
in the year 1970, that is, prevention of the resource-loss over a
productive work-life of the individual stricken by the disease.
A cost estimate of the value of each x-ray procedure may be considered
in relation to the resource-loss as a result of sickness, that is, loss of
human labor. Simplifying the valuation, there are basically two stages in
calculating the estimated productive output foregone: 1) estimating the
loss in productive work time, and 2) assigning a money value to the output
that his lost work time represents (12). This is done to obtain an index
which takes into account all aspects of disability prevention and includes
lives saved (or deaths prevented). This index is a relative value; it may
then be converted to a dollar value which represents the composite value of
the loss of productive output attributable to debility, disability, or death.
However, dollar valuation represents only one form of calculating a relative
value; the values cited in the models are illustrative of the analytical process
only and should not be taken as actual measures. The economic value may be
used to represent a very rough estimate of the expected increase in productive
output that would occur if the loss of resources due to sickness were dimi-
nished or ultimately eliminated.
In the simplified model, such conceptual problems as the impact of
unemployment and full employment, multiple diseases in the same individual,
time scales, loss of working time, work-force participation of the young
and retired-aged, and loss of output due to debility, disability and death,
present formidable problems beyond the scope of the present approach. How-
ever, the net output method of calculating the economic worth of a person's
life, is one quantitative concept which may be used and which, inpart, takes
many of the complex variables into account.
To derive the benefit of a particular class of x-ray examinations, the
resource-use cost may be used to offset the resource-lost cost by assigning
a relative value to the disability-prevention of the individual. A number of
assumptions must be made! It has been arbitrarily assumed; 1) that the
average per capita income of the working individual at the present time may
be determined; e.g., it may be $50 per day for 200 working-days per year;
2) that a minimum disability represents a 10% loss of working-days per year;
i.e., from 1 to 20 days, a mean of 10 days in this model, the productivity
loss would average approximately $500 in one year; 3) that a moderate dis-
ability represents the loss from 10% to 20% of the working-days per year or
from 21 to 40 work-days; in this model the productivity loss would average
approximately $1,500 in one year; 4) that a major disability represents the
loss from 20% to 40% of the working-days per year, or from 41 to 80 work-days,
a mean of 60 work-days; in this model the productivity loss would average
approximately $3,000 in one year; 5) that total disability represents the
complete loss of all working days in one year; this may occur due to injury
or sickness at any time during the year. This would be the loss from 40% to
100% or from 81 to 200 work-days; a mean of 140 days; in this model the pro-
ductivity loss would average approximately $7,000 in one year; 6) that in
this special situation of death of a productive individual, the entire future
lifetime earnings,of the individual, is lost in that year; that is, a loss of
\
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approxamately $300,000 in that year. However, since the loss can occur at
any time during the productive life-span, then one-half, or approximately
$150,000 of the life-time earnings may be considered as a resource-loss in
that year. In this case, the prevented-loss of the entire future expected
life-time earnings of the individual would result. It has been assumed that
only a very small percentage of the total disability category comprises this
special situation.
2. Valuation of Benefits from Diagnostic Radiology
Table VI.3 illustrates the application of the model to determine an
estimated valuation of the resource-loss prevented (extent of disability
days prevented) by diagnostic chest x-ray examinations in the year 1970
based on the "resource-loss benefits model." The stream of medical benefits
in the determination of a benefit-cost ratio, fitted to the present trends
and not discounted for the future, can be estimated. Conversion to dollar
value results in total benefits of $14.6 billion. The dollar cost (from
Table VI. 2) of the chest x-rays are estimated at $1.43 billion. It is note-
worthy that in 1971 approximately 5.1 disability work-days were lost per
employed person per year (77.4 million persons employed) (20).
A complete summary of the total dollar value benefits from diagnostic
radiology derived in 1970 in the united States by the entire population based
on a "resource-loss benefits model" would require a much more complete knowl-
edge of the patterns of medical x-ray examinations than is available at the
present time. Very rough assumptions can be made on the percentage distri-
bution of the disability-prevention values for the various categories of
medical x-rays, and these concepts may not apply at all in estimating benefits
from dental x-ray examinations or diagnostic nuclear medicine procedures.
Furthermore, dollar valuation represents only one form of calculating a
relative value; the values cited here are illustrative of the analytical
process only and should not be taken as actual measures. The dollar value
of $14. Ł billion for benefits derived from chest x-ray examinations may be
considered as a conservative estimate, since the model is based primarily
on only one premise, vis., the improvement of health through prevention of
disease and effective diagnosis and treatment of illness contributes to the
efficiency of the population's productive capabilities. The model takes
into account the effect of the resource-losses of those persons who have
not as yet entered the work force (e.g., children under age 18), non-employed,
but productive persons in society (e.g., housewives), and those who have left
the productive population (e.g., the elderly-retired), through the mechanism
of resource-transfer benefits. The model does not take into account costs
which would otherwise have been transferred from the well to the sick. The
model also attempts to quantify effects of debility and disability due to
illness on productivity of the individual.
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TABLE VI.3
RESOURCE-LOSS BENEFITS MODEL
Estimated Work-Loss Prevented (Dollar Value-Benefits) from Diagnostic Chest X-Ray Examinations
(*)
Extent of Disability
Prevention
(Work-days-Saved)
Definition"
Number of
Distribution^ Examinations
(Millions)3
Dollar Benefit
Factor/Exam 4
100%
65.0
Benefit5
(109 dollars)
'(None
Minimal
Moderate
Major
Total
Days
(1-20)
(21-40)
(41-80)
(81-200)
Mean
0
10
30
60
140
0
10
20
40
100
85
8
4
2
1
55.3
5.2
2.6
1.3
.6
0
500
1,500
3,000
7,000
0
2.6
3.9
3.9
4.2
$14.6 billion
to
1. Percentage disability-prevention
2. Percentage-distribution of diagnostic chest x-ray examinations
3. Frequency of x-ray examination in millions (3)
4. Benefit factor per x-ray examination in dollars (work-value-day ($50)x mean number of days)
5. Work-loss prevented resulting in productive work-days in dollar value (frequency x benefit factor)
(*) Dollar valuation represents only one form of calculating a relative value, the values cited
here are illustrative of the analytical process only and should not be taken as actual measures.
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G. Application of Resource-Loss Costs ^fodel to Potential Radiation Induced
Somatic Disease from Diagnostic Radiology
1. Conceptual Problems
Conceptual problems arise in the development of a "resource-loss costs
model" since in its simplest form it represents and assumes that the primary
effect of sickness and death is on human labor available for productive
purposes (12). The model assumes that persons who die from or are disabled
by the disease would otherwise be in good health, that indirect costs of the
disease cannot be readily summated, and that a time scale can be applied over
a productive work life. Nevertheless, the concepts of loss of working time
and indirect economic costs caused by disease and illness in populations
have been examined (11) and are accepted in welfare economics. Certain objec-
tions arise on ethical grounds, understandably, such as the conversion of
human lives to money terms, the difficulties in assessing human suffering,
and the tendency to regard the savings of children's lives and those of other
non-productive members of society as costs rather than gains. However, the
economic costs of a disease or a death represents only one model for the
evaluation of a health program and its efficacy; other models are equally
valid for development of cost estimates of disease and death.
A "resource-loss costs model" for diagnostic radiological exposure
could be developed in terms of estimates of somatic risks and potential
genetic risks (1). Knowledge of the distribution of diagnostic x-ray and
radioisotope examinations, the size of the populations examined, and the
dose to the individual and to the population exposed is necessary (3).
The somatic risks of special concern are cancer-induction, the increased
radiosensitivity of the embryo and fetus (effects of antenatal radiography),
and the consequences of possible mutation-induction in germinal cells re-
sulting in genetic handicaps among the descendants of irradiated populations.
Based on the premise that the resource lost as a result of radiation-induced
illness and death is human labor, the model would assess the value of the
loss by estimating the "output foregone" resulting from death, disability,
or debility. The value of the productivity loss may then be estimated by
1) determining the loss of productive work-time, and 2) assigning a money
value to the productive output that this lost work-time represents (12ji!
Table VI.4 contains estimates of the distribution of the numbers of
diagnostic x-ray examinations of various body regions, numbers of persons,
and radiation doses that are required for application in the model for
estimation of risks and, therefore, costs. The estimate of dollar value
costs for the potential deleterious effects (radiation cancer) of diagnostic
chest x-ray examinations is based on the data in Table VI.4; dollar valuation
represents only one form of calculating a relative value; the values cited
here are illustrative of the analytical process only and should not be taken
as actual measures.
The data in Table VI. 4 may be used to estimate the total dollar value
costs expected to result from radiation-induced cancers in .adults derived in
1970 in the united States by exposure of the population in Łhat year to
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TABLE VI.4
Estimated Distribution of Diagnostic X-ray Examinations, Persons and Radiation
Doses, United States, 1970 (A,D)
Body Area
Thorax
Chest, R
E
Chest, PFG
Thorax
Abdomen
Extremities
Head, Neck, Other
TOTAL Medical
TOTAL Dental
Number X-ray
Examinations
(Millions)
65
49
10
6
32
22
10
129
68
Percentage „
Distribution
51
25
17
100
100
38
8
5
Estimated.,
Persons
(Millions)
39
29
6
4
19
13
5
77
59
Dose/Exam Tissues at
(mrads) Greatest
Risk
40
100
thyroid, bronchus
and lung
bone marrow,
breast, bone
40
100
5
stomach & colon,
bone marrow, bone,
uterus and ovary
bone marrow, bone
50
thyroid, bone
marrow, bone
50 I thyroid, bone marr
A. USPHS,XES Survey, 1970 (3)
B. Estimated from (3)
C. Estimate based only on examination distribution and rate
D. ICRP No. 16, 1970 (21)
E. R, Radiographic; PFG, Photofluorographic
bone
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diagnostic x-rays. The economic costs are based on the "resource-loss model"
by converting the loss of life due to radiation neoplasia into loss of pro-
ductive capacities of the affected population. The total economic value
represents an estimate which does not include morbidity from causes other
than radiation-induced cancer, or the costs of diagnosis and treatment of
these individuals as patients. These latter costs \arould necessarily be
included in the resource-use costs.
The somatic effects to be considered in the application of a resource-
loss costs model include neoplasia in adults, effects on growth and develop-
ment (developmental abnormalities and spontaneous abortions) and childhood
neoplasia (1).
The large number and the diversity of body tissues exposed to x-rays
during the various diagnostic examinations and wide variations in doses
administered and in tissue sensitivity, preclude any precise assessment of
the incidence of induction of neoplasia by radiation (2,21). However, from
the evidence available, it appears that the low level radiation doses from
medical and dental x-ray exposure during diagnostic procedures could be
important in regard to cancer induction (1). It would appear that among the
most important of these is the somatic dose to the bone marrow, the thyroid,
the bronchus and lung, the stomach, the osseous tissues, and the breast
(Table VI.4). The chest (thorax) x-ray examination encompasses all of these
tissues, and this may be used in an illustrative example of the application
of the resource-costs loss model; the following example demonstrates the
method for calculation of estimates of dollar value-costs for potential
somatic effects (radiation-induced neoplasia) of diagnostic chest x-ray
examinations.
2. Valuation of Costs from Diagnostic Radiology
In 1970, the USPHS XES Survey (3), 65 million chest (thorax) x-ray examin-
ations were carried out (Table VI.4). Of these, 49 million were radiographic
examinations, 10 million were photofluorographic (PFG) and 6 million were
other studies of the chest and thorax. The chest x-ray examination rate for
children was less than for adults; 10 percent of the chest x-rays (or approx-
imately 5 million examinations) were children under age 15, and the examin-
ation rate was 10 per 100 children. The estimated mean exposure per film for
radiographic chest examinations was 27 mR (3). Assuming 2 film exposures per
examination in half of these patients, and one film in the remaining inves-
tigative x-ray studies, then the average radiation dose to the tissues of the
chest, including the thyroid, the bronchus and lung, the active bone marrow,
the breast, and bone from adult radiographic examinations was about 40 mrads
per examination (21), and thus, an additional 1 million person-rads to the
exposed population. The total somatic tissue radiation dose to the exposed
adult population due to the chest x-rays in 1970 therefore, would be approxi-
mately 3.2 million person-rads. This does not take into account the in-
creased dose from photofluorographic examinations of the chestj; however, the
use of PFG chest examinations has been discontinued by the United States Public
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Health Service and other health agencies through action by the Food and Drug
Administration under authority of the Radiation Control for Health and Safety
Act OP.L. 90-602) (22,23).
On the assumption of linearity of the dose-effect relationship (1,26),
a conservative estimate of the excess cancer risk due to radiation exposure
of these tissues would be one excess cancer case arising in 1 million exposed
persons per year per rad. The radiation cancer risk due to chest radiological
examinations in adults would be 3.2 excess cancers of the bone marrow, thyroid,
bronchus and lungs, breast and osseous tissues of adults. If it is assumed
that all children's chest x-rays delivered only half the dose, but that this
is offset by the increased radiosensitivity of juvenile tissues, then an addi-
tional 0.2 million person-rads could result in 0.2 excess cancers in each of
these tissues. The breast may be some 3 times more radiosensitive to cancer
induction than the other tissues (1,2); the excess breast cancers expected,
therefore, would be 4.8 excess cases. The thyroid in children may be about
3 times more radiosensitive than the adult thyroid tissue for radiation cancer
induction (1); for thyroid cancers, therefore, approximately 3.9 excess cancers
would be expected to occur in the entire population exposed to chest x-ray
examinations. If it is further assumed that all radiation-induced cancers,
including thyroid cancers, lead to death, then there would be, in each year
following exposure, approximately 3.2 excess deaths due to leukemia induced
in the bone marrow, 3.2 excess deaths from cancer of the bronchus and lung,
3.2 excess deaths from bone cancer, 4.8 excess deaths from breast cancer,
and 4.1 excess deaths from thyroid cancer. The total would be 18.5 excess
cancer deaths in the population exposed in the year 1970. Over a 10-year
period, there would be 32 leukemia deaths; over a 25-year period there would
be an additional 383 deaths, or a total of 408 cancer deaths. In the year
1970, this could therefore represent the loss of the life-time productive
earnings of the adult individuals and children who do not enter the work-force,
and thus potential economic productivity loss (work-loss) equal to (32 x
$150,000) + (365 x $150,000) + (18 x $300,000) = approximately $64 million.
Valuation of costs of potential somatic effects of antenatal radiology
can be used to estimate the dollar value costs derived in the united States
in 1970 resulting from such x-ray exposure. Information is required on
obstetrical and pelvimetric x-ray examinations, their distribution, the fetal
doses, and the birth rate. The fetal and neonatal developmental abnormalities
and loss (spontaneous abortions), and childhood neoplasia, are special categories
arising from the radiosensitivity of the embryo and fetus exposed in utero.
The dollar value-costs of the work-loss estimated by the "resource-loss costs
model" must take account of the fact that the fetuses or children who die or
are seriously disabled never enter the work-force, and the potential entire
lifetime earnings of each of these individuals is lost.
The total dollar value-costs to society resulting from potential radiation-
induced somatic disease arising from diagnostic medical radiation exposure to
the united States population in the year 1970 can be estimated by means of the
"resource-loss costs model." In the model illustrated, no attempt has been
made to determine the extent of unspecified somatic disease and ill-health as
a result of impaired physical and mental well-being. This might be mainfested
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in a decrease in the individual's work productivity, or possibly an increase
in disability days, but such changes are too complex to be assessed in this
model with any precision. For this reason, the total costs may be considered
as a conservative estimate. The degree of improved well-being and health
(which can decrease the extent of disability and increase the individual's
work productivity) arising from the benefits of diagnostic radiological pro-
cedures may be considered as symmetrical with the losses (i.e., ill-health);
the present model precludes determination of precise figures. The total
economic value estimated in the application of the model largely represents
the productive work-loss from the human labor force which can contribute to
the gross productivity of society. The medical care costs must be discounted
in the future, but would appear in the resource-use costs model estimates at
a future date.
H. Application of Resource-Loss Costs Model to Potential Radiation-Induced
Genetic Disease
The application of the resource-loss costs model to potential radiation-
induced genetic disease and hereditary effects requires a great deal more
information on the genetic risks from radiation that is presently available.
The NAS-BETR Report (1) presented a rough benefit-cost analysis of radiation
exposure by measuring the future economic costs of potential genetic casualties.
The approach used concepts of the resource-loss costs model to determine the
genetic damage to be expected after one generation from one man-rem, and then
equated this value to dollar costs of United States health services in 1970.
This monetary value ranged from $12 to $120 per man-rem. A number of assump-
tions were implied and no attempt was made to analyze the numerous and com-
plex variables involved in any comprehensive resource-loss costs model.
Based on the NAS-BETR, Report (1), the main classes of genetic disease
and hereditary effects to be expected from radiation exposure include auto-
somal dominant traits, chromosomal and X-linked recessive diseases, congenital
anomalies, recognized abortions, and a large, non-specific category of un-
specified genetic illness. The autosomal dominant traits represent a broad
spectrum of diseases in the fetus, neonatal infant, and growing adult. The
model would require precise information on the expression of these diseases
in the population, their incidences of morbidity and mortality, and age
distribution; the birth and fertility rates of the exposed population; a
knowledge of the doubling dose (or similar parameter) of radiation for
mutational effects in man; a frequency distribution of diagnostic x-ray
examinations affecting the gonadal dose, and hence the genetically signifi-
cant dose, in both women and men; and an estimate of the loss to potential
economic productivity (and direct costs of ill-health) in society of the
individuals in future generations affected by the genetic disease, with
appropriate future discounting.
Similar parameters would be required for recessive genetic traits, for
congenital anomalies (e.g., those due to unbalanced chromosomal rearrangements
and aneuploidy, and due to X-cbrooosome-linked recessive traits), for all other
recognized abortions, and for a large and poorly understood class of
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genetic damage of unrecognized abortions that results in failure of the egg
to implant or results in post-implantation death. This latter group of
spontaneous abortions is too early to be detected, and occurs unrecognized
within the first month of pregnancy. The contribution of radiation dose
from diagnostic x-ray exposure to an increased incidence in this group
cannot be ascertained. In such an analysis, this loss may possibly be con-
sidered as a future resource-loss and since the numbers of individuals af-
fected may be extremely large, but the circumstances are natural consequences
occurring in reproductive biology, this situation has not been considered to
have an appreciable effect on human well-being.
Non-specific ill-health due to unspecified genetically determined
disease, possibly resulting in diminished or poor physical and mental health
is extremely difficult to assess (1). The 1972 NAS-BEIR Report (1) included
an attempt to measure the economic cost of radiation resulting in unspecified
genetic illness, and estimated a dollar cost of 1 rad. The contribution of
the the total cost of all unspecified genetic illness could then be estimated
from this figure, and the dollar cost would be distributed over many gener-
ations into the future (1), taking into account discounting into the future.
I. Summary of Economic Benefit-Cost Analysis of Diagnostic Radiology
Any examination of benefit-cost analysis of medical radiation would
require a thorough understanding of all the categories of benefits and costs
necessary to achieve a calculation to measure the effectiveness of diagnostic
radiological investigative and therapeutic procedures in modern health care
services in the United States. One very rough approach taken in the present
analysis has been to develop medels based on resource-use costs, resource-
loss costs, and resource-loss benefits. In the illustrative examples, the
years 1970 and 1974 were chosen, since the data are available to permit a
rough assessment of resource-use and resource-loss factors. However, certain
of the calculations necessary must extend Into the future and, therefore,
must consider the effect of future discounting. The approach assumes that
society invests in man, that there is an economic value of human life relative
to the attainment of a state of optimal health, that economic costs of disease,
injury, and death are measurable, and that the indirect basic economic costs
of depressed health may be equated, in large part, to time lost from the full
desired capacity or quality of life. The development of benefit-cost analysis
of the economic impact of illness and death, and their prevention, are based
on the assumption that each person has an economic value to society, and that
if the individual becomes ill or dies before fulfilling his life expectancy
there is a measurable economic loss generated because of the obviation of
potential nroductivity.
Multiple models can be used to arrive at crude dollar-value costs and
value-benefits, and these take into account either direct costs of services
or indirect costs affecting health. From calculations of time lost from
work force participation, estimates of the dollar value of lost economic
productivity can be developed. Nevertheless, it is recognized that while
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dollar valuation may appear inescapable, economic terms remain marketplace
terms. Therefore, they are inadequate to describe the true worth of a human
life or the social value of the individual person. However, they do provide
avenues to quantitate, in part, the socioeconcmic impact of ill-health and
death due to disease and injury. For decision-makers who are responsible
for planning health activities, economic valuation, however crude, may assist
in: 1) defining the important problems, 2) determining their magnitude,
3) describing tangible benefits and costs of problem solution, 4) deter-
mining program priorities, and 5) selecting program alternatives.
J. Application of Reduction of Risk Model
1. Mass X-ray Screening in Diagnostic Radiology
This model assumes that the reduction of the incidence of disease, suf-
fering, and death is an activity to be regarded as a collective societal
good. As an example, a societal or government scheme of early diagnosis of
debilitating or morbid disease affecting a large population can be considered
to save a certain number of lives annually. An advantage of the "reduction
of risk" model is that it gives decision-makers the opportunity to assess
the economic and social costs of a health service in terms of alternatives.
The use of mass screening programs in diagnostic radiology lends itself
to this model. Two important illustrations may be considered from the second
category group of diagnostic x-ray examination, vis., mass x-ray screening
of the breast (mamnography) for breast cancer, and mass x-ray screening of
the chest for pulmonary tuberculosis and cancer of the lung.
For mass x-ray screening programs to be valuable and feasible, they
should meet most of the following criteria: they should be safe, relatively
inexpensive, simple to carry out, convenient for both the screened popula-
tion and the personnel, reliable and sensitive, specific for the disease,
and provide a good yield of curable cases. For pulmonary tuberculosis, mass
chest x-ray screening fit many of these criteria when the yield of positive
cases was high, and especially when effective chemotherapy was introduced
and provided a method for treating the diseases successfully. Recent studies
have demonstrated that current x-ray screening for lung cancer in older
persons could possibly fulfill a number of these criteria, except that the
yield of curable cases is extremely low (28). On the other hand, restricting
x-ray screening to certain high-risk groups may not necessarily improve the
yield of curable cases of neoplasia in some populations (e.g., lung cancer
in heavy cigarette smokers, especially those with a chronic cough (29)), but
may be of value in certain high-risk populations (e.g., the high incidence
of breast cancer in American women (30)).
a. Mass X-Ray Screening of the Breast (Mamrography)
Breast cancer is the leading cause of death from neoplastic disease
among women in the united States; it occurs in some 6 percent of all women
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during their lifetime. Approximately half of these women die within
15-20 years after the initial diagnosis, a third of the deaths in
that population result from breast cancer. Furthermore, during the period
1935-1963, the age adjusted mortality for American women over 25 years of
age fell from 15.2 deaths per 1,000 population to 9.3 per 1,000, a decrease
of almost 40 percent, whereas deaths from breast cancer in the same age
group remained much the same at 40 cancer deaths per 100,000 population (30).
Cancer detection programs have emphasized the importance of early
diagnosis in breast cancer. The introduction of mammography for early
diagnosis of the disease provides certain benefits, but whether mass x-ray
screening surveys for breast cancer in women are worthwhile depends in large
measure on the prevention or delay of deaths and on its acceptability and
cost to the general population. The Health Insurance Plan of New York
(H.I.P.) Study of Shapiro and his colleagues (30) suggests that mamnographic
screening (combined with clinical palpation) in a carefully controlled popu-
lation of women 40 to 65 years of age detects cancer at an earlier stage,
and that earlier diagnosis and treatment results in improved survival, at
least in the short term of the first 6 years thus far studied. However,
since in this study breast cancer was detected on average only 20 months
earlier, frequent re-examination would be essential, and even with annual
x-ray re-examination, almost a third as many breast cancers were detected
solely by the women themselves.
Irwig (31) has suggested that the detection of breast cancer by com-
bined palpation and manmography is costly, both economically as well as to
the general well-being of the patient. At present-day resource-use direct
costs, a mammogram (unilateral or bilateral) costs approximately $33 (15).
Assuming decreased direct costs on the basis of mass screening, and adding
costs of combined clinical palpation and mammography, an estimate of a
minimum of $30 per examination would be conservative. At the expected
cancer detection rate of 1-2 cases per 1,000 women examined, the cost may
be estimated to be about $20,000 per breast cancer detected. If the H.I.P.
Study (30) result of an approximately 44 percent decrease in deaths at 6
years is assumed, the cost of each additional case surviving up to 6 years
would be $45,000. Thus, in the 31,000 women aged 40-65 years examined,
improved survival over the 6-year period thus far studied occurred in 36
cases, at a cost of $1.6 million. It follows that, if the mass mamnographic
screening program were extended to include most women in the United States
aged 40-65 years, perhaps 31 million women, then the cost of all cases
surviving up to 6 years would be approximately 1,000 times, or $1.6 billion.
The productivity resource-loss prevented as a result of the cancer deaths
prevented on the other hand would be approximately ($50 x 200 work-days x 6) =
$60,000 per life saved, or (36 x 103 x $60,000) = approximately $2.2 billion.
From the dollar valuation point of view, the benefit-cost ratio would only
be about 1.4 after 6 years. The data demonstrate a differential in deaths
between study and control groups and it appears that more than 36,000 deaths
may ultimately be avoided.
Ttie problem is compounded by the fact that the breast is a relatively
radiosensitive tissue to the induction of cancer, and that mammography is a
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relatively high-dose x-ray examination. The radiologic techniques for
manmography vary; average radiation doses in controlled programs range from
1-5 rads for the skin and under lying tissues of the breast. The risks of
induced neoplasms as a result of irradiation of the bone marrow and the body
as a whole are acceptably small.
A rough estimate of the radiation hazards from all malignancies asso-
ciated with the mammographic examinations in the Health Insurance Plan Study
(30) has been determined based on the following assumptions: 1) 20,000
women examined with an average of 3.2 x-ray studies per woman; 2) the breast
tissue dose was 2 rads, the lung dose 0.2 rads, the bone marrow dose 0.04
rads, and other tissue dose 0.02 rads; 3) the carcinogenic risk is linear,
the women were exposed at exact age 55, the mid-point of the plateau period
was 14.5 years with respect to leukemia, and 30 years with respect to all
other organs, and years of life expectancy are not taken into account. The
number of expected deaths from cancer, therefore, was breast, 3.5; lung, 0.2;
leukemia, 0.05; and other, 0.01; the total is approximately 4 cancer deaths
at all sites due to radiation exposure. The data suggest that the cancer
deaths appear to be equivalent to approximately one-tenth of the breast
cancer deaths avoided in the first 6 years, suggesting benefit/cost ratio
of a factor of 10. However, mammographic procedures may employ radiation
doses much greater than in the controlled Hospital Insurance Plan Study, and
the benefit would be correspondingly reduced. Furthermore, manmography studies
indicate that the procedure for women under age 50 does not result in a de-
crease in breast cancer deaths and the risk of radiation-induced cancer is
greater, so that mass mammographic x-ray screening of younger age-group
women would appear to involve a net hazard.
If the assumptions based upon the H.I.P. Study were to be extended to
the entire population at risk, then it would be estimated that a minimum of
6,000 radiation-induced cancer deaths over a lifetime would result in the
female population in the United States. This would occur since all women
would be x-rayed annually until death, increasing the radiation dose, and
hence the radiation cancer risk in women who would not have developed the
disease spontaneously. However, something less than 10 times that nuriber
of breast cancer deaths would be avoided. While this appears to be an
acceptable benefit-cost ratio, there are effective ways of improving the
safety margin, mainly by decreasing the radiation dose to as low as practicable
and by selecting for examination the female population which would appear to
greatest risk of breast cancer. The use of clinical palpation alone would
have some reduction in death rate. Furthermore, the H.I.P. Study indicated
that a biopsy procedure was required in some 5-10 cases per 1,000 women
screened on manmography. Some 80 percent of the women biopsied were found
to have benign disease of the breast. This is costly, not only from the
point of view of a surgical procedure, but probably to a much greater degree
in terms of personal and family anxiety and well-being.
When all factors are considered, the present x-ray screening methods
for breast cancer are time-consuming and costly; to be effective, they re-
quire frequent x-ray re-examination and the false-positive rate is high.
The low incidence and detection rate of breast cancer in women imder age
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40 does not justify mass x-ray screening in this population. Economically,
the net benefit-cost ratio is less than 1.0, and thus better and cheaper
screening methods are required. At the present time, it would appear that
selected mammography should be restricted only to "high-risk" groups in
early detection screening programs (e.g., women with strong family predis-
position to breast cancer, patients with clinical signs and symptoms, patients
with previous breast cancer).
b. Mass X-Ray Screening of the Chest
The experience in the United States has demonstrated that the case-
finding capability of mass screening photofluorographic (PPG) chest x-ray
examinations for pulmonary tuberculosis control and early detection of
cancer of the lung no longer is of value. The costs and risks are too
high for the benefits derived, the incidence of pulmonary tuberculosis has
decreased and case-finding techniques using inmBiological tests are cheaper
and more readily available, and "early" diagnosis of cancer of the bronchus
by PFG x-ray screening techniques have not influenced the survival or
quality of life of those patients treated for the neoplastic disease.
In the instance of mass x-ray screening of the chest for lung cancer,
dollar resources of the conmunity could hardly be sufficient to afford the
expense incurred in the small yield of cured cases of lung cancer based on
the premise of early detection through semiannual PFG chest screening.
Furthermore, the biological nature of the disease, in respect to detection
and diagnosis, precludes the effective use of PFG screening for lung cancer;
economic resources might be better spent on prevention and on examining the
relationship of the human behavior of smoking to chronic lung disease (29).
2. Chest Radiography
X-ray examinations of the chest comprise 40% to 50% of the diagnostic
radiological studies performed in the united States; in 1970, over 65 million
chest x-rays were carried out on 129 million persons (3). In large part, the
chest x-ray examination is now considered as an extension of the clinical
history and physical examination in medical practice, and no longer a spe-
cialized investigatory examination. As a result, the radiation dose to the
population is high; more than 50% of the population bone marrow dose is due
to chest x-rays (32,33). If it is assumed that the average cost to the
medical consumer is over $20 per examination, then almost $1.5 billion is
spent annually in the united States for this examination alone.
Sagel et al. (34) analyzed 10,000 chest examinations in a large univer-
sity hospitaT and, based on the incidence of positive findings and the low
yield of positive results, demonstrated that: 1) routine screening chest
radiographs, obtained because of hospital admission or elective surgery, are
not warranted in patients under 20 years of age; 2) the lateral x-ray pro-
jection; should be eliminated from routine screening chest examinations in
patients 20-39 years of age; 3) the lateral x-ray projection should be part
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of the examination whenever chest disease is suspected. Thus, while
occasionally a treatable condition may be discovered on routine (but
clinically unnecessary) chest radiography in an otherwise healthy child
or young adult to the age of 20 years, it would appear prudent to eliminate
routine chest radiography as a standing medical order in this age group.
Approximately one-third or 21 million of the chest x-ray examinations
of the population are of persons under age 29. In 1970, 47 percent of the
thoracic examinations were performed with 2 or more x-ray films compared with
31 percent in 1964; the increase was largely due to the use of lateral views
for routine chest examinations (3). Thus, if it is assuned that two-thirds
of the examinations in the under-29 year group were in the "routine" category,
then 14 million examinations did not require lateral x-ray projections at
all. If, by eliminating lateral projections, the cost of these examinations
were decreased to half, then approximately $11 x 14 million or $150 million
would be saved annually, or about 10 percent of the total dollar cost. A
commensurate decrease in bone marrow dose would be expected, as well, par-
ticularly in patients under age of 20 years. In these circumstances, where
screening for tuberculosis is the major concern, routine tuberculin skin
testing is a much more practical method, as well as being medically, bio-
logically, and economically sound, particularly in comparison with chest
radiography.
It would appear, therefore, that the value of the "routine" chest x-ray
examination in patients without specific clinical indications should be
examined carefully, particularly in regard to diagnostic yield, likelihood
of diagnostic accuracy, and cost-effectiveness as regards increased time,
costs and exposure. A logical extension of this would be the use of the
chest x-ray examination of the child and young adult, and the use of screen-
ing programs, as alternative techniques, such as tuberculin skin testing,
which would appear more effective in large populations without evidence of
clinical chest disease.
3. Special High-Dose Diagnostic Procedures
The five leading causes of death in 1974 in the United States account
for over 75 percent of the total numb"er of deaths (35). The death rate for
diseases of the heart, the leading cause of death, was 353.1 per'100,000
population. The estimated death rate for malignant neoplasms, including
neoplasms of lymphatic or hematopoietic tissues, was 169.5 per 100,000 popu-
lation; for cerebrovascular disease, 97.2 per 100,000 population; for ac-
cidents, 48.9 per 100,000 population; and for influenza and pneumonia, 25.7
per 100,000. Except for malignant neoplasms, in which the death rate in-
creased by 1 percent from 1973, all other rates of the leading causes of
death were reduced from the previous year.
In the diagnosis and management of these diseases, medical radiation
plays a substantial role. The decrease in mortality rates is in part due to
increased efficiency in the use of medical diagnostic x-rays and radioisotopes,
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and in the curative (and palliative) treatment of neoplastic diseases with
therapeutic radiation. Whereas heart and circulatory diseases, cexebro-
vascular diseases, and neoplastic diseases result in substantial costs to
society in terms of disability and productivity loss, the investigatory
procedures in medical practice to diagnose, assess, and manage these diseases
also represents a high cost both in risk and economic costs (36).
It would be worthwhile, therefore, to apply the reduction of risk and
costs models to high-use examinations in x-ray services for high-morbidity
(and thus, high disability) and high-mortality diseases and high-dose situ-
ations. Three areas about which useful information is available are:
1) cardiovascular disease, and particularly ischemic heart disease,
2) cerebrovascular and neurological disease, and 3) x-ray examinations
in pregnancy.
a. Cardiovascular Disease
The influence of advances in diagnostic radiology on the medical prac-
tice of cardiology and the management of cardiac disease is well documented
(37). In the management of patients with ischemic heart disease, i.e.,
coronary artery disease, the leading cause of coronary thrombosis, radio-
logical techniques have now become routine methods of investigation.
It is estimated that more than 100,000 coronary angiographic x-ray
examinations are currently carried out each year in the United States.
Assuming a dose of 20 rads per examination, approximately 2 million person-
rads result, with perhaps an expected 2 excess cancers of the bronchus and
2 excess cancers of the mediastinal tissues (e.g., lymphoma) occurring
after 15-25 years. However, such excess cancer cases will only arise in
patients who survive ischemic heart disease in their advanced year. This
excess is placed in perspective when it is recognized that the death rate
of diseases of the heart in 1970 was 3,620 per million population and in
1974 it fell to 3,530 per million population. Thus, the excess risk of
dying from heart disease would still remain approximately 1,000 times greater
than from radiation cancer. Furthermore, even if these advanced radiological
techniques are effective in reducing mortality by only 1 percent, and per-
haps as much as 3 percent, then the relative benefits derived from lives
saved would be 10-30 times the costs possibly resulting from radiation injury.
However, the economic costs of cardiac catheterization and angiocardio-
graphy are not small. An analysis for the costs of cardiac catheterization
procedure for 1973 carried out in a large university hospital (38) indicated
that approximately 720 cardiac catheterization procedures were performed at
a total cost of nearly $300,000. The cost for actual utilization, therefore,
was approximately $482 per procedure. These costs are primarily fixed, that
is, resource-use costs (e.g., equipment, space, personnel). If each pro-
cedure required 4 days of hospitalization for admission, investigatory
testing and evaluation, then an additional $600 must be added for hospital
fee costs, and perhaps $100 for tests. Loss of productive work time, may be
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estimated at $200. The total economic costs, therefore, would be approximately
$1,400 per patient, or $1.4 billion each year.
b. Cerebrovascular and Neurological Disease
Cerebrovascular and neurological diseases represent the third highest
cause of mortality in the United States; in 1974, the estimated death rate
for Cerebrovascular disease was 97.2 per 100,000 population, a decrease of
5 percent from the rate of 102.1 for 1973, and the lowest level since be-
fore 1969 (35). In large measure, the development of new techniques in
neuroradiology have made possible the early diagnosis of curable disease;
however, in the proliferation of complex invasive techniques, the costs of
radiological health care in neurology have escalated.
In the United States in 1970, there were 4.2 million skull x-ray exami-
nations (3); 17 million x-ray films were exposed at an average dose of 330
mrads per film (3,21). The total somatic dose to the active bone marrow and
the eye would be (4.2 x 10& x 4.1 x 330 x 10~3 rads) = approximately 5.7
million person-rads, and the excess neoplastic diseases to be expected would
be approximately 6 leukemias and 6 bone cancers. The productivity loss from
12 cancer deaths would be $1.8 million. It would be substantially less if
perhaps half the number of x-ray films were used per patient examination
for a normal skull x-ray.
A recent cost-effectiveness study on cranial computerized axial tomo-
graphy (39) demonstrated a potential savings of $2.2 million per diagnostic
facility based on 2,500 examinations per year, savings of inpatient and out-
patient health services, and the decrease in the number of invasive neuro-
radiological investigatory studies performed and the number of beds occupied
(number of admissions and duration of hospital stay) by neurological patients.
Whereas it is too early to attempt to evaluate the diagnostic and therapeutic
benefit and the elimination of hazard for patients in economic terms, never-
theless, the immediate benefits of this new non-invasive technique for
studying the brain appear impressive.
K. X-Ray Examination of Pregnant Women
ICRP No. 9 (40) included a recommendation that, when medically appro-
priate, x-ray examinations of the female abdomen and pelvis should be limited
when pregnancy is probable and to delay these examinations to a time when an
embryo or fetus cannot be exposed to radiation. The most conmon radiographic
procedures resulting in significant exposure of the fetus in utero are x-ray
pelvimetry and the obstetrical abdomen. However, the efficacyJ,pf these
examinations on improvement of delivery and decrease in fetal mortality and
morbidity has not been established.. The need for screening pregnant patients
for cephalopelvic disproportion or fetal postmaturity can be carried out
with diagnostic ultrasound, which thus far appears relativelyharmless. In
the future, x-ray pelvimetry and the obstetrical abdomen may become unnecessary,
and possibly abandoned to be replaced entirely by safe and reliable techniques
of antenatal ultrasonography.
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L. Consideration of Reduction of Risk in Radiotherapy
1. Malignant Disease
Radiation therapy is being used more frequently, alone and in conjunc-
tion with surgery or chemotherapy, for the cure or palliation of malignant
disease in the individual. The radiation doses are high, are confined, and
are tissue-limiting, and the cancer age group is relatively advanced. Thus,
the radiation exposure contributes little to the genetic dose affecting
future populations. Furthermore, whereas there may be a savings of large
numbers of individual lives, or prolongation of individual lives in comfort
and dignity, the net effect is at most a marginal impact on total life
expectancy in the society.
In 1974, in the United States the estimated death rate due to malignant
neoplasms, including lymphatic and hematopoietic tissues, was 169.5 per
100,000 population, an increase of less than 1 percent from the rate of
167.3 for 1973. This represents 18.5 percent of the total deaths in that
year, and was the second leading cause of death in the United States. The
yearly incidence of malignant disease is about 3,000 new cases per million
population, or some 600,000 new cases occur annually. Most patients are
treated with surgery and radiotherapy; about half of all cancer patients
receive radiotherapy in the course of their disease. Cancers of the lung,
colon-rectum, breast, uterus, prostate, and kidney-bladder, which represent
about half of all cancers, are the major causes of death due to neoplasia.
If the survival rate is approximately 130 cases per 100,000 population,
then the deaths avoided each year due to all treatment is approximately
260,000 in the entire population. The death rate rises substantially over
the age of 55 years. If it is assumed further that the survival after 5
years following treatment is below 50% for major cancers, and that 50% of
all cancer patients receive radiotherapy, then some estimate of productivity
loss can be determined. Assuming a mean age of 55 years at the time of
treatment and 600,000 new cancer patients each year, then 300,000 cancer
patients are treated with radiation, half for cure and half for palliation
of their disease. Only half (or 150,000) of these patients survive to the
age of 60 years, many of whom may be considered cured of their disease,
when life expectancy rates at age 60 years are taken into account. Thus,
if it is assumed that without radiation treatment the treated patients would
have died within 5 years, then radiotherapy given in the year 1974 saved the
lives of (300,000) - (169.5/105 x 2xlo8/2) = approximately 130,000 patients
in that year, but only about 65,000 will survive after 5 years. If the
average remaining lifetime of the cured patients at age 55 can be determined,
then the maximum survival resulting from radiation therapy could be estimated.
The resource-use cost model may be used in the evaluation of delivery
of radiation therapy services. Bloom et al. (41) studied 16 hospitals in
New England and determined the cost of~facTLities, equipment and personnel,
and demonstrated that the cost of providing radiation therapy for cancer
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invariably exceeded the income derived, and many of the direct costs per
treated patient ranged from about $150-$600, and this cost was greatest in
the high patient-load teaching hospitals and cancer centers due to the
larger and more costly equipment and personnel. However, if 300,000 pa-
tients per year receive radiation therapy for malignant disease, and if it
is assumed that half of these patients are treated for palliation (lower
cost) and the remaining patients receive a curative regime (higher cost),
then the average costs to the consuner may be very roughly estimated at
(150,000 x $150) + (150,000 x $600) = approximately $112.5 million. If a
most conservative estimate is used, since the direct (and indirect costs)
of providing radiation therapy services invariably far exceeds the income
derived, and the total of all radiation costs per treated patient was at
the maximum value ($600), and there are comparable amounts for all other
hospital services and for hospitalization, then the average cost per pa-
tient would be $1,800, and the total cost of all health services for pro-
viding radiation therapy would be (300,000 x $1,800) or approximately $540
million. The benefit-cost ratio based on economic terms could then be
determined. This model does not include intangible factors such as com-
fort, relief of pain, and other non-quantifiable circumstances surrounding
the treatment of cancer patients.
In this context, however, it must be emphasized that such an analysis
should be considered in terms of the total oncological services to society;
it should have little relevance to the individual patient under treatment
for neoplastic disease. For many reasons, and especially for ethical and
moral reasons, society has chosen to spend heavily out of the limited re-
sources available for health care of the individual. This invariably pre-
cludes the need for impractical economic benefit-cost analysis of direct
diagnostic or therapeutic radiological health care in the individualized
situation for a given patient (see page 177).
2. Non-neoplastic Disease
At the present time, no precise estimate of the number of patients
treated with radiation for non-neoplastic diseases is available in the
United States. The practice of radiation treatment for diseases other
than cancer has diminished in recent years, particularly as alternative
methods of treatment in clinical pharmacology have become available and
equally effective. Included here, for example, are treatment for bursitis,
tinea infections, certain viral warts, peptic ulcer, and arthritis. In the
treatment of non-neoplastic disease, the radiation doses are less than in
the treatment of cancer. It would appear prudent to reduce or eliminate
this practice wherever possible, and to employ alternative methods of treat-
ment, thereby avoiding unnecessary radiation exposure, and lessening any
possible contribution to the gonadal and somatic doses, and consequent
effects. The problem is being studied by the National Academy of Sciences.
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M. Reduction of Dose from Medical Radiation Usage
Steps necessary to decrease population exposure from medical radiation,
particularly the avoidance of unproductive radiation exposure, may be con-
sidered in three main areas: 1) radiological equipment and installations;
2) radiological techniques; and 3) clinical and other professional judg-
ment. Recent progress in these areas includes the following:
1. Radiological Equipment and Installations
Improved standards of diagnostic x-ray equipment efficiency and x-ray
beam collimation and alignment have resulted in significant reduction of
the dose to the patient from scattered radiation, or from the direct beam,
and in the improvement in the quality of the x-ray image. Appropriate fil-
tration of the x-ray beam has helped in obtaining maximum information from
many types of radiological examinations.
In diagnostic nuclear medicine, reductions in dose have been achieved
by imaging devices and cameras, the use of short-lived isotopes, and by the
application of computer technology.
In therapeutic radiology reductions of dose to nontarget tissues have
been achieved by the introduction of linear accelerators, precision of dosim-
etry obtained with the application of computer techniques, and the use of new
interstitial sources.
2. Radiological Techniques
Appropriate positioning devices for patients and improved techniques
for the visualization of internal organs (e.g., contrast media, tomography,
computerized axial tomography) have helped reduce the number of unnecessary
repeat diagnostic x-ray examinations resulting primarily from unsatisfactory
radiographic technique or inaccurate clinical interpretation. Shielding
devices (such as gonadal shields now readily available) and beam collimation
have been developed which eliminate a large fraction of unnecessary x-ray
exposure of radiosensitive organs, such as the testis, ovary, bone marrow,
and thyroid. Improved diagnostic x-ray receptors (screens and films) asso-
ciated with correct radiation exposure, grids, film processing, and film
viewing have been developed^ - The restriction of the use of photofluorography
(mass radiography), has led to the elimination of unnecessary exposured at
relatively high levels of dose to large populations.
3. Clinical and Other. Professional Judgrent
Assessment of the clinical value of certain high-dose procedures of
fluoroscopy (e.g., pediatric chest fluoroscopes for cardiac disease) and
cinefluorography (e.g., avoiding cystourethrography in children) has resulted
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in a decrease and possible elimination of many examinations. The training
of radiological personnel for improved knowledge, skill and operations to
meet the continuously increasing demand for clinical radiological services
has led to the development of uniformly high standards and quality of health
care.
4. Radiation Protection
A principal objective of radiation protection in medicine is to use the
radiological procedure most likely to produce the desired result with a dose
as low as practicable and acceptable to the patient and to the staff. This
implies that some radiation risk always exists, and if this is the case some
benefit-cost balance must be attempted. The patient himself benefits directly
from the examination performed as part of his treatment. Such considerations
are more difficult for other medical sources of population exposure, where
the individual irradiated may be asymptomatic and therefore not a patient and
therefore may not necessarily be one of those for whom benefit is claimed.
From the point of view of radiation protection, therefore, the problems in-
volve the balance between the value of dollar expenditure necessary to reduce
the already small exposure risks, and of similar financial expenditure on
other societal problems. Based on scientific evidence, a continued effort
must be pursued to maintain radiation exposure in medicine to the minimum
possible.
The greatest benefit to the patient and to the population with the least
possible radiation exposure involves a continued examination of the radio-
logical health care delivery system, and includes a decision-making process
for the selection of patients to be examined, the training and education of
personnel and the methodology of carrying out the radiation procedures, the
evaluation of the total radiological facilities provided, the efficiency of
diagnostic accuracy affecting treatment, and the cost-effectiveness of the
system.
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APFENDIX TO CHAPTER VI
AND STATE REGULATIONS
1. The Radiation Control for Health and Safety Act
The Radiation Control for Health and Safety Act of 1958. Public Law
90-602, 42 U.S.C. 263b et seq. (22) is a government regulation enacted by
Congress to provide for the protection of the public from unnecessary radi-
ation from electronic products. The Act recognized that because dangers may
exist from ionizing and non-ionizing radiation, there is a need to establish
control programs. These include the development and administration of per-
formance standards for control of radiation from electronic products and
research into the effects and control of radiation. Radiation covered in
the Act includes any ionizing electromagnetic or particulate radiation emitted
from an electronic product as the result of the operation of an electronic
circuit, and thus includes all medical and dental x-ray machines in diagnostic
radiology, and high energy x-ray machines used in radiation therapy.
The Act assigns to the Bureau of Radiological Health of the Department
of Health, Education, and Welfare (Food and Drug Administration, united States
Public Health Service) the responsibility to define, set, interpret, carry out
and enforce the standards and regulations for an electronic products radiation
control program. The regulations for the administration and enforcement of
the Act of 1968 (48) are compiled and revised periodically, and publication of
all regulations as amendments or deletions to the Act are issuances of the
Federal Register and the Code of Federal Regulations, Title 21 (21 CFR Sub-
chapter J). The two important sections of the Act include: 1) the radiation
safety performance standard for diagnostic x-ray systems and their major com-
ponents (43); and 2) regulations imposing necessary responsibilities on
manufacturers, assemblers, distributors, and dealers of such equipment (44).
a. The Diagnostic X-Ray Equipment Standard
The Federal Performance Standard for diagnostic x-ray systems 1) deter-
mines performance standards for components of diagnostic x-ray systems, and
2) requires that they be certified by the manufacturer as being in compliance
with the standard (43). The final standard for diagnostic x-ray systems Code
of Federal Regulations, Title 21, Sections 1020.30 - 1020.32, was issued in
the Federal Register on August 15, 1972, and applies to specified components
manufactured after August 1,'1974, including x-ray tube housing assemblies,
x-ray controls, x-ray high-voltage generators, fluoroscopic image assemblies,
x-ray tables and cradles, x-ray film changers and cassette holders, and beam-
limiting devices. The standard is an equipment performance standard and does
not specify equipment design features, thereby permitting manufacturers to
determine how to achieve levels of equipment performance in compliance with
\
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the standard. Furthermore, the standard does not regulate diagnostic x-ray
equipment users, i.e., it does not regulate the practice of medical or dental
radiological health nor does it control the use of x-ray equipment for a
specific purpose.
Whereas the important provisions of the standard are aimed at equipment
component design and hence performance, provision is tng^e for x-ray exposure
and beam quality, and for fluoroscopic exposure limits. The standard requires
that x-ray systems provide improved exposure reproducibility and linearity of
the x-ray output, and prescribes certain acceptable levels of x-ray beam quality
which may be achieved through appropriate filtration. Further, the standard
establishes maximum exposure rates for fluoroscopic equipment; patient-
entrance exposure is limited to 10 R per minute for fluoroscopic equipment
with automatic exposure or brightness control, and an exposure limit of 5 R
per minute for equipment with high-level control operated in normal position
and unlimited in the high-level position.
b. Regulations for Assembly and Reassembly of Diagnostic X-Ray Systems
Section 21 CFR 1000.16 provides for control and improvement of assembly
and reassembly of the components of diagnostic x-ray systems (44), and at
present, extends into the period after August 1, 1979. In this regard, the
standard designates the role and responsibilities of the x-ray equipment
manufacturer and assembler, including installation requirements and appro-
priate record keeping.
2. State Radiation Regulatory Control
The Radiation Operations Staff of the Food and Drug Administration's
Executive Director of Regional Operations assists and advises the Bureau of
Radiological Health on regional and state radiological health activities in
regard to the reduction of unnecessary human exposure to man-made radiation.
The Radiation Operations Staff also coordinates all radiological health ac-
tivities at the Federal-State level. In the past 25 years, 47 states and
Puerto Rico have enacted specific laws for the regulation of ionizing radi-
ations, whereas the remaining 3 states and the District of Columbia assume
radiation protection standards under general public health laws. In 1974,
state and local agencies spent more than $10 million for radiation control
activities. Only a small part of these funds and the manpower are directed
toward compliance programs of medical x-ray activities in each State. Most
frequently, statutes designate the State health department as the agency
responsible for radiation protection with the authority to adopt regulations
(45).
In 1974, there were 138,491 medical x-ray machines reported in the united
States; 86% were registered, and of these 79% had been inspected at least once
in the past. Of the 27,000 machines inspected in 1974, more than 27 percent
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were found to be in noncompliance to State regulations or recommendations
(6). There were 142,875 dental x-ray machines reported in the United States;
85.5 percent of these have been registered. Some 75 percent of all machines
have been inspected at least once (25,000 in 1974), and some 80 percent of
those inspected were in compliance with State regulations or recommendations
(6).
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CHAFIER VI
1. NAS-BEIR 1972. The Effects on Populations of Exposures to Low Levels
of Ionizing Radiation. Report of the Advisory Committee on the
Biological Effects of Ionizing Radiations, National Academy of
Sciences-National Research Council, Washington, D.C., 1972.
2. UNSCEAR. United Nations Scientific Comnittee on the Effects of Atomic
Radiation. Ionizing Radiation: Levels and Effects. United
Nations, New York, 1972.
3. USPHS. Population Exposure to X-Rays. U.S. 1970. Food and Drug
Administration, DHEW Publication (FDA) 73-8047, DHEW, Washington,
D.C., 1973.
4. The Budget for Fiscal Year 1976, Special Analysis K, Federal Health
Programs, Federal Budget Message of the President, pp. 169-196,
U.S. Government Printing Office, Washington, D.C., 1975.
5. Spivak, J. Conference Comnentary. (In) Controls on Health Care.
Papers of the Conference on Regulation in the Health Industry,
pp. 175-180. Institute of Medicine, National Academy of Sci-
ences, Washington, D.C., 1975.
6. USPHS. Report of State and Local Radiological Health Programs. Fiscal
Year 1974, July 1975. DHEW Publication (FDA) 76-8017 USDHEW, PHS,
FDA, BRH, Rockville, Maryland, 1975.
7. ICRP Publication 8. International Commission on Radiological Protection.
The Evaluation of Risks from Radiation. A Report Prepared for Com-
mittee I of the International Comnission on Radiological Protection.
Pergamon Press, London, 1968.
8. KLarman, H. E. Syphilis Control Programs. (In) Measuring Benefits of
Government Investments, Ed., R. Dorfman, pp. 367-410, The Brookings
Institution, Washington, D.C., 1965.
9. Rice, D. P. Estimating the Cost of Illness. Health Economic Series
No. 6. United States Department of Health, Education, and Welfare,
PHS Publication No. 947-6, Washington, D.C., 1966. :
10. Rice, D. P. and Cooper, B. S. The Economic Value of Human Life.
American Journal of Public Health 57: 1954-1966, 1967. *.
r r
11. Mishan, E. J. Cost-Benefit Analysis. Allen and Unwin. London, 1971.
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12. Mushkin, S. J. and Collings, F. d'A. Economic Costs of Disease and
Injury. Public Health Reports 74: 795-809, 1959.
13. Mushkin, S. J. Health as an Investment. Journal of Political Economy,
Supplement, Vol. 70, No. 5, Part 2, pp. 129-157, October 1962.
14. Cooper, B. S. and Rice, D. P. The Economic Cost of Illness Revisited.
Social Security Bulletin, pp. 21-36, February 1976.
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16. Starr, C. Benefit-Cost Studies in Sociotechnical Systems. (In) Per-
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18. Sagan, L. A. Health Costs Associated with the Mining, Transport, and
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25. Brown, M. L. and Nelson, A. B. Medical X-Ray Visits and Examinations
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27. I.C.R.P., 1958. Reooranendations of the International Commission on
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28. Brett, G. Z. Earlier Diagnosis and Survival in Lung Cancer. British
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29. Bourcot, K. R. and Weiss, W. Is Curable Lung Cancer Detected by Semi-
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34. Sagel, S. S., Evens, R. G., Forrest, J. V., and Bramson, R. T. Efficacy
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35. USPHS. Monthly Vital Statistics Report. Provisional Statistics Annual
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38. Evens, R. G. Cost Accounting in Radiology and Nuclear Medicine. CRC
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1975.
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GLOSSARY
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GLOSSARY
ABCC: Atomic Bomb Casualty Commission
Absolute Risk: Product of assumed relative risk times the total population
at risk. The number of cases that will result from exposure of a given
population.
Absorption Coefficient: Fractional decrease in the intensity of a beam of
X or gamma radiation per unit thickness (linear absorption coefficient)
per unit mass (mass absorption coefficient), or per atom (atomic ab-
sorption coefficient) of absorber, due to deposition of energy in the
absorber. The total absorption coefficient is the sum of individual
energy absorption processes (Compton effect, photoelectric effect, and
pair production).
Accelerator (Particle): A device for imparting large kinetic energy to
electrically charged particles such as electrons, protons, deuterons and
helium ions. Common types of particle accelerators are direct voltage
accelerators, cyclotrons, betatrons, and linear accelerators.
Alpha Particle: A charged particle emitted from the nucleus of an atom
having a mass and charge equal in magnitude to a helium nucleus: i.e.,
two protons and two neutrons.
ALAP: As Low as Practicable
ALARA: As Low as Reasonably Achievable
ANL; Argonne National Laboratory
Atomic Mass: The mass of a neutral atom of a nuclide, usually expressed
in terms of "atomic mass units." The "atomic mass unit" is one-twelfth
the mass of one neutral atom of carbon-12; equivalent to 1.6604 x 10-24 gm.
(Symbol: u).
Attenuation: The process by which a beam of radiation is reduced in intensity
when passing through some material. It is the combination of absorption
and scattering processes and leads to a decrease in flux density of the
beam when projected through matter.
Average Life (Mean Life): The average of the individual lives of all the
atoms of a particular radioactive substance. It is 1.443 times the radio-
active half-life.
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BEAR Committee: Advisory Committee on the Biological Effects of Atomic
Radiation (Precursor of the BEIR Committee).
BEIR Committee: Advisory Committee on the Biological Effects of Ionizing
Radiations.
Benefit-Cost: A systematic process of comparative evaluation of all sig-
nificant benefits and costs of an activity and alternative courses,
including as major components the benefits, risks and costs related to
health, life span and quality of life.
Benefit-Cost (applied to Medical Radiation): A quantitative evaluation of
the health risks and economic costs to society resulting from medical
radiation exposure in relation to the benefits to the health and well-
being of society and its members derived from the application of ionizing
radiations in medicine.
Beta Particle: Charged particle emitted from the nucleus of an atom, with
a mass and charge equal in magnitude to that of the electron.
BLIP: Base-Line-In-Plant
Bone Seeker: Any compound or ion which migrates in the body preferentially
into bone.
CAA: Clean Air Act
Carrier: A quantity of non-radioactive or non-labeled material of the same
chemical composition as its corresponding radioactive or labeled counter-
part. When mixed with the corresponding radioactive labeled material, so
as to form a chemically inseparable mixture, the carrier permits chemical
(and some physical) manipulation of the mixture with less label or radio-
activity loss than would be true for the undiluted label or radioactivity.
Cation: Positively charged ion
CEQ: Council for Environmental Quality
Chamber, lonization: An instrument designed to measure a quantity of ionizing
radiation in terms of the charge of electricity associated with ions pro-
duced within a defined volume.
COPEP: Committee on Public Engineering Policy
Cost-effectiveness: The economy with which a given task, program or policy is
carried out. ^ ,
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Curie: The special unit of activity. One curie equals 3.700 x 1010
nuclear transformations per second. (Abbr. Ci.) Common fractions are:
Megocurie: One million curies (Abbr. MCi)
Microcurie: One millionth of a curie (3.7 x 104
disintegrations per second. Abbr. yCi.)
Mi Hi curie: One-thousandth of a curie (3.7 x 10'
disintegrations per second. Abbr. mCi.)
Nanocurie: One-billionth of a curie (Abbr. nCi)
Picocurie: One-millionth of a microcurie (3.7 x 10
disintegrations per second. Abbr. pCi)
Daughter: Synonym for decay product.
Decay Product: A nuclide resulting from the radioactive disintegration of
a radionuclide, formed either directly or as the result of successive
transformations in a radioactive series. A decay product may be either
radioactive or stable.
Decay, radioactive: Disintegration of the nucleus of an unstable nuclide
by spontaneous emission of charged particles and/or photons.
PHEW: Department of Health, Education and Welfare
Discounting Procedures: The method of calculating the present value of a
future sum to be symmetrical with the compound rate of increase,
Dominence: A case where as between two alternatives one produced both a
greater quantity of the desired result and at less cost than the other
with which it is compared.
Dose: A general form -denoting the quantity of radiation or energy absorbed.
For special purposes it must be appropriately qualified. If unqualified,
it refers to absorbed dose.
Absorbed Dose: The energy imparted to matter by ionizing radiation per
unit mass of irradiated material at the place of interest. The unit
of absorbed dose is the rad. One rad = 100 ergs per gram.
Cumulative Dose: Total dose resulting from repeated exposure to radiation.
Dose Equivalent (DE): Quantity that expresses all radiations on a common
scale for calculating the effective absorbed dose. It is defined as
the product of the absorbed dose in rads and certain modifying factors.
The unit of DE is the rem.
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Genetically significant dose (GSD): The gonad dose from medical exposure which,
if received by every member of the population, would be expected to
produce the same total genetic effect on the population as the sum of
the individual doses actually received. The GSD can be expressed
algebraically as:
GSD = E DNP
D-J = Average gonad dose to persons age i who receive x-ray examinations
N-J = Number of persons in population of age i who receive x-ray examinations
Pi = Expected future number of children for person of age i
Ni = Number of persons in population of age i.
Maximum Permissible Dose Equivalent (MPD): The greatest dose equivalent
that a person or specified part thereof shall be allowed to receive
in a given period of time.
Median Lethal Dose (MLD): Dose of radiation required to kill, within a
specified period, 50% of the individuals in a large group of animals
or organisms. Also called 1050-
Permissible Dose: The dose of radiation which may be received by an
individual within a specified period with expectation of no signif-
icantly harmful result.
Threshold Dose: The minimum absorbed dose that will produce a de-
tectable degree of any given effect.
Doubling Dose: The amount of radiation needed to double the natural
incidence of a genetic or somatic anomoly.
Dose, Fractionation; A method of administering radiation, in which
relatively small doses are given daily or at longer intervals.
Dose, Protraction: A method of administering radiation by delivering
it continuously over a relatively long period at a low dose rate.
Dose rate: Absorbed dose delivered per unit time.
Electron Volt: A unit of energy equivalent to the energy gained by an electron
in passing through a potential difference of one volt. Larger multiple units
of the electron volt are frequently used: KeV for thousand cor kilo electron
volts; MeV for million or mega electron volts. (Abbr. eV, 1 eV = 1.6 x 10'12 erg.)
EPA: Environmental Protection Agency ;
ERDA: Energy Research and Development Administration
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Exposure: A measure of the ionization produced in air by X or gamma radiation.
It is the sum of the electrical charges on all ions of one sign produced in
air when all electrons liberated by photons in a volume element of air are
completely stopped in air, divided by the mass of the air in the volume
element. The special unit of exposure is the roentgen.
Acute exposure: Radiation exposure of short duration
Chronic exposure: Radiation exposure of long duration by fractionation
or protraction.
External Costs: Costs falling on third parties not party to a market trans-
action, thus representing social costs not registered in market price or
costs.
Fission, Nuclear: A nuclear transformation characterized by the splitting
of a nucleus into at least two other nuclei and the release of a relatively
large amount of energy.
Fission Products: Elements or compounds resulting from fission.
Fission Yield: The percentage of fissions leading to a particular nuclide.
FDA: Food and Drug Administration
FRC: Federal Radiation Council
Fuel Cycle: The sequence of steps, such as utilization, reprocessing, and
refabrication, through which nuclear fuel passes.
Fusion, Nuclear: Act of coalescing two or more atomic nuclei
FWPCA: Federal Water Pollution Control Act
Gamma Ray: Short wavelength electromagnetic radiation of nuclear origin
(range of energy from lOKeV to 9MeV) emitted from the nucleus.
Gram Atomic Weight: A mass in grams numerically equal to the atomic weight
of an element.
Gram Molecular Weight (Gram-Mole): Mass in grams numerically equal to the
molecular weight of a substance.
Gram-Rad: Unit of integral dose equal to 100 ergs.
Half-Life, Biological: The time required for the body to eliminate one-half
of an administered dosage of any substance by regular processes of elimination.
Approximately the same for both stable and radioactive isotopes of a particular
element.
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Half-Life, Effective: Time required for a radioactive element in an
animal body to be diminished 50% as a result of the combined action
of radioactive decay and biological elimination.
Effective half-life = Biological half-life X radioactive
1/2-1ife
Biological half-life + Radioactive 1/2-life
Half-Life, Radioactive: Time required for a radioactive substance to lose
50% of its activity by decay. Each radionuclide has a unique half-life.
ICRP: International Commission on Radiological Protection
ICRU: International Commission on Radiation Units and Measurements.
Incidence: The rate of occurrence of a disease within a specified period
of time; usually expressed in number of cases per million (10°) per year.
Ion: Atomic particle, atom, or chemical radical bearing an electrical charge,
either negative or positive.
Ion exchange: A chemical process involving reversible interchange
of ions between a solution and a particular solid material such
as an ion exchange resin consisting of a matrix of insoluble
material interspersed with fixed ions of opposite charge.
lonization: The process by which a neutral atom or molecule ac-
quires a positive or negative charge.
Primary ionization: In collision theory; the ionization produced
by the primary particles as contrasted to the "total ionization"
which includes the "secondary ionization" produced by delta rays.
Secondary ionization: lonization produced by delta rays.
lonization density: Number of ion pairs per unit volume.
lonization path (track): The trail of ion pairs produced by an
ionizing radiation in its passage through matter.
Isotopes: Nuclides having the same number of protons in their nuclei,
and hence the same atomic number, but differing in the number of neutrons,
and therefore in the mass number. Almost identical chemical properties
exist between isotopes of a particular element. The term should not be
used as a synonym for nuclide.
Labeled Compound: A compound consisting, in part, of labeled molecules.
By observations of radioactivity or isotopic composition, this compound
or its fragments may be followed through physical, chemical, or biological
processes.
Latent Period: The period or state of seeming inactivity between the time
of exposure of tissue to an injurious agent and response.
LD50 (Radiation Dose) See: Dose, Median Lethal.
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Linear Energy Transfer (LET): The average amount of energy lost per unit
of particle spur-track length.
Low-LET: Radiation characteristic of Electrons, x-rays, and Gamma Rays.
High-LET: Radiation characteristic of protons or fast neutrons
Average LET is specified to even out the effect of a particle that is
slowing down near the end of its path and to allow for the fact that
secondary particles from photon or fast-neutron beams are not all of
the same energy.
Linear Hypothesis: The assumption that a dose-effect curve derived from
data in the high dose and high dose-rate ranges may be extrapolated
through the low dose and low dose range in zero, implying that,
theoretically, any amount of radiation will cause some damage.
LWR: Light Water Reactor
Man-Rems: See Person-Rems
Marginal (incremental) benefits or costs: The amount by which total costs
(benefits) are increased due to a change of one unit on the output of
the process in question. Mathematically, it represents the first de-
rivative of the total cost (benefit) function.
Market-incured Costs: Costs arising out of the need to pay factor services
(final consumption services) their market rates of hire (price).
Maximum Credible Accident: The worst accident in a reactor or nuclear energy
installation that, by agreement, need be taken into account in deriving
protective measures.
Medical Exposure: Exposure to ionizing radiation in the course of diagnostic
or therapeutic procedures. As used in this report, the term includes:
1. Diagnostic radiology (e.g., x-rays)
2. Exposure to radioisotopes in nuclear medicine (e.g., Iodine-131
in thyroid treatment)
3. Therapeutic radiation (e.g., cobalt treatment for cancer)
4. Dental exposure
Micron: Unit of length equal to 10~6 meters, (symbol p)
Morbidity: 1. The condition of being diseased.
2. The ratio of sick to all persons in a community
NAS-NRC: The National Academy of Sciences - National Research Council
NHTSA: National Highway Traffic Safety Administration
NCRP: National Council on Radiation Protection and Measurements
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Neoplasm: Any new and abnormal growth, such as a tumor. The term
"neoplastic disease" refers to any disease which forms tumors,
malignant or benign.
NRC: Nuclear Regulatory Commission
Nuclide: A species of atom characterized by the constitution of its
nucleus. The nuclear constitution is specified by the number of
protons (Z), number of neutrons (N), and energy content; or, al-
ternatively, by the atomic number (Z), mass number A=(N+Z), and
atomic mass. To be regarded as a distinct nuclide, the atom must
be capable of existing for a measurable time. Thus, nuclear isomers
are separate nuclides, whereas promptly decaying excited nuclear
states and unstable intermediates in nuclear reactions are not so
considered.
Person-Rems: The product of the average individual dose in a population
times the number of individuals in the population. Syn: man-rems.
Plateau: A period of above-normal, relatively uniform, incidence of
morbidity or mortality in response to a given biological insult.
PWR: Pressurized Light Water Reactor
Prevalence: The number of cases of disease in existence at a certain
time in a designated area.
Quality Factor (QF): The linear-energy-transfer-dependent factor by
which absorbed doses are multiplied to obtain (for radiation pro-
tection purposes) a quantity that expresses -- on a common scale for
all ionizing radiations -- the effectiveness of the absorbed dose.
Rajd.: The unit of absorbed dose equal to 0.01 j'/kg in any medium.
Radiation: 1. The emission and propagation of energy through space
or through a material medium in the form of waves;
e.g., the emission and propagation of electromagnetic
waves, or of sound and elastic waves.
2. The energy propagated through space or through a
material medium as waves. The term radiation or ra-
diant energy, when unqualified, usually refers to
electromagnetic radiation. Such radiation is commonly
classified by frequency: Hertzian, infrared, visible,
ultra-violet, x-ray, and gamma ray.
3. Corpuscular emissions, such as alpha and beta i%dia~
tion, or rays or mixed or unknown type, as cosmic
radiation.
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Background radiation: Radiation arising from radioactive material
other than the one directly under consideration. Background
radiation due to cosmic rays and natural radioactivity is always
present. There may also be background radiation due to the
presence of radioactive substances in other parts of the building,
in the building material itself, etc.
External radiation: Radiation from a source outside the body.
Internal radiation: Radiation from a source within the body (as
a result of deposition of radionuclides in body tissue).
Ionizing radiation: Any electromagnetic or particulate radiation
capable of producing ions, directly or indirectly, in its pas-
sage through matter.
Secondary radiation: Radiation resulting from absorption or other
radiation in matter. It may be either electromagnetic or particulate.
Radioactivity: The property of certain nuclides of spontaneously emitting
particles or gamma radiation or of emitting particles or gamma radiation
or of emitting x-radiation following orbital electron capture or of
undergoing spontaneous fission.
Artificial radioactivity: Manmade radioactivity produced by particle
bombardment or electromagnetic irradiation.
Natural radioactivity: The property of radioactivity exhibited by more
than fifty naturally occurring radionuclides.
Radioisotope: A radioactive atomic species of an element with which it shares
almost identical chemical properties.
Radionuclide: A radioactive species of an atom characterized by the con-
stitution of its nucleus. In nuclear medicine, an atomic species emitting
ionizing radiations and capable of existing for a measurable time so that
it may be used to image organs and tissues of the body.
Radiosensitivity: Relative susceptibility of cells, tissues, organs, organisms,
of any living substance to the injurious action of radiation. Radiosensitivity
and its antonym radioresistance, are currently used in a comparative sense,
rather than in an absolute one.
Rate, Recovery: The rate at which recovery takes place after radiation injury.
It may proceed at different rates for different tissues. "Differential
recovery rate": Among tissues recovering at different rates, those having
slower rates will ultimately suffer greater damage from a series of successive
irradiations. This differential effect is considered in fractionated radia-
tion therapy if the neoplastic tissues have a slower recovery rate than
surrounding normal structures.
Rays: Alpha: Beams of helium nuclei (2 protons and 2 neutrons)
Beta: Beams of electrons or positrons
Gamma: Beams of high-energy photons from radioactively decaying elements
_X: Beams of mixed lower energy photons
Neutron: Beams of neutrons
Proton: Beams of protons
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Reactor Breeder: A reactor which produces more fissle material than it
consumes; i.e., has a conversion ratio greater than unity.
Reactor Converter: A reactor which produces fissile atoms from fertile
atoms, but has a conversion ratio less than one.
Reactor, Nuclear; An apparatus in which nuclear fission may be sustained
in a self-supporting chain reaction.
Relative Biological Effectiveness (RBE): The RBE is a factor used to com-
pare the biological effectiveness of absorbed radiation doses (i.e., rads)
due to different types of ionizing radiation; more specifically, it is the
experimentally determined ratio of an absorbed dose of a radiation in
question to the absorbed dose of a reference radiation required to pro-
duce an identical biological effect in a particular experimental organism
or tissues. The RBE is the ratio of rem to rad. (If 1 rad of fast
neutrons equalled in lethality 3.2 rads of KVP x-rays, the RBE of the
fast neutrons would be 3.2).
Relative Risk: The ratio of the risk in those exposed to the risk to those
not exposed (incidence in exposed population to incidence in control
population).
Rem: A special unit of dose equivalent. The dose equivalent in rems is
numerically equal to the absorbed dose in rads multiplied by the quality
factor, the distribution factor, and any other necessary modifying factors.
The rem represents that quantity of radiation that is equivalent — in
biological damage of a specified sort — to 1 rad of 250 KVP x-rays.
Roentgen (R): The special unit of exposure. One roentgen equals 2.58 x 10"
coulomb per kilogram of air.
SDWA: Safe Drinking Water Act
Sigmoid Curve; S-shaped curve, often characteristic of a dose-effect curve
in radiobiological studies.
Softness: A relative specification of the quality or penetrating power of '
x-rays. In general, the longer the wave length the softer the radiation.
Specific Activity: Total activity of a given nuclide per gram of a compound,
element, or radioactive nuclide.
SSRCR: Suggested State Regulation for Control of Radiation
Thermography: A non-invasive diagnostic radiological imaging technique
which uses infra-red radiation to display the temperature distribution
emitted by the surface which characterizes the temperature distribution
of the various underlying organs and tissues of the body.
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Threshold Hypotheses: The assumption that no radiation injury occurs below
a specified dose level.
Ultrasonography: A non-invasive diagnostic radiological imaging technique
which uses acoustic radiation and the acoustic properties of biological
structure to display the structure and function of various organs and
tissues of the body.
UNSCEAR: United Nations Scientific Committee on the Effects of Atomic
Radiation.
Weighting Factor: The fractional weight by which a future sum is multiplied
to obtain any intermediate year's time equivalent value, in turn derived
from the compound interest formula.
X-rays: Penetrating electromagnetic radiations whose wave lengths are shorter
than those of visible light. They are usually produced by bombarding a
metallic target with fast electrons in a high vacuum. In nuclear reactions,
it is customary to refer to photons originating in the nucleus as gamma rays,
and those originating in the extranuclear part of the atom as x-rays. These
rays are sometimes called roentgen rays, after their discoverer, W.C. Roentgen,
<*J.S. GOVERNMENT PRINTING OFFICEU977 720-117/2025 1-3
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