Videos, photographs, and patient consentBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7136.1009 (Published 28 March 1998) Cite this as: BMJ 1998;316:1009
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Hope, Hood and Dove (1) rightly stress that "the internet and electronic
publishing are powerful tools for the dissemination of medical information
and have created a demand for medical images" and emphasise that patient
images should, in most circumstances, not be used without consent. However,
in the age of the Internet, the links between images, patients and medical
students and staff are complex and non-intuitive, so that the enormous
potential of the Internet and World Wide Web in medical education need
not be neglected because of ethical issues. Beginning with the issue of
security, Hope, Hood and Dove (1) state that "with current levels of security
on the internet, there is little to ensure that such images are not widely
seen, distributed, or misused." On the contrary, it is not difficult to
limit who can see what images over the web, either by limiting web-access
to a given image or page to certain IP addresses, subnets, or domains,
by using password protection or for very sensitive material, by using encryption
through public key cryptography (see The World Wide Web Security FAQ: http://www.w3.org/Security/Faq/wwwsf3.html#Q17).
Of course, once medical students have downloaded digital images they could
pass them on to those outside the medical profession, however, to do so
would be to flout local and professional ethics in the same way as showing
confidential photographic images to their non-medical associates. With
the easy availability of image manipulation software, it is relatively
easy to create images that do not reflect a true likeness of any real individual.
For example, cover-girl images are commonly touched up to remove blemishes
or make the whites of their eyes whiter; the magazine Wired has featured
a cover image of O. J. Simpson as a near-Scandanavian caucasian (http://www.wired.com/wired/3.09/images/oj.lrg.jpg);
the Benetton magazine "Colors" once commissioned a picture of Ronald Reagan
suffering from AIDS, complete with multiple Kaposi's lesions (http://www.wired.com/wired/2.09/departments/elec.word.html)
and the Face Factory software allows one to assembly line drawings of faces
from parts of other people's faces (http://nr-atp.cit.cornell.edu/~jtp5/).
We wished to see whether we could, in a single afternoon, create fictional
images of photographic quality illustrating medical conditions. We began
by attempting to create a malar butterfly rash such as one might see in
systemic lupus erythematosis on a face that does not exist in the real
world. To create the face, we used the morphing program MorphMan 95 on
a PC to combine the faces of the two authors. Next we used Photoshop 3.0
on a Macintosh to create the rash (Figure 1), repeatedly employing the
magic wand tool and adjusting the hue of selected areas.
When we showed this image to a medical colleague asking for the diagnosis,
he neither suspected that the rash was fake, nor did he recognise us in
the image. Next we attempted to create a fictional image of a melanoma.
We morphed together two melanoma images that we obtained from the Internet,
then placed the composite image onto an image of the arm of one of the
authors (MJP). We then used Photoshop's clone tool to alter the shape and
textural surface of the lesion (Figure 2).
In doing this, one could argue that we have used images without consent;
however as with combining research data, in combining images in this way,
the final image is probably so far removed from any one patient as to obviate
the need for consent. Had time permitted, we could have combined dozens
rather than just three images. In such cases how much of an image would
warrant consent--following a reductio ad absurdam, would use of a single
pixel require informed consent? We conclude that in the age of Lara Croft
and Kyoko Date (http://www.etud.insa-tlse.fr/~mdumas/kyoko.html),
it is time for medical illustrators and educationalists to free themselves
from the constraints of real world images--the future is virtual!
Competing interests: No competing interests