Indian Journal of Medical EthicsEthical considerations in medical photography
Avinash Supe
Do camera footage and still photographs depicting death, disease and injury represent an invasion of privacy, or are they appropriate forms of publicity? Recently, photographs of patients suspected to be suffering from severe acute respiratory syndrome (SARS) were published in newspapers as well as shown on TV, causing inconvenience and social stigma to all patients. While there was a need to follow quarantine procedures, there was no necessity to widely publicise the pictures. That act has caused mental and social harm to these individuals.
A profession must observe ethical standards; otherwise it will lack respect, credibility and may also lay itself open to legal penalties. A medical photographer is part of a team working for the benefit of a patient and, thereby, the society. The end product of his activities is the photographic record. The photographer must ensure that the end product of his photography is treated with the same respect as is accorded to other records of the patient.
Permission of the patient
Informed written permission of the patient must be obtained before photography is undertaken. A simple explanation such as 'The doctor wants a picture as part of your confidential medical records to help him assess your treatment' is usually acceptable. If it is a part of a project, this must be mentioned in the consent form and approved by an ethics committee. In an educational institution, the photograph may be used for teaching or for reference in the treatment of similar cases. Care must be taken to respect the dignity and beliefs of the patient. Every patient has a right to refuse to be photographed or to withdraw consent. If a patient decides to withdraw consent, the records must not be used. Photographs of the unconscious patient may be taken, provided a written consent is obtained from the responsible person who has brought the patient and later, from the patient himself.For photography of internal organs at operation or in the post-mortem room as well as in endoscopic, pathological or microscopic documentation, permission of the patient is not necessary, as the identity is not revealed. To maintain the anonymity of these images, it may be wise not to record the patient's name with the stored image. Images are catalogued with an image number and date. The patient's name should not be shown in reproduction of X-rays, electrocardiogram (ECG) or encephalogram (EEG) tracings, temperature charts, etc. Negatives, master transparencies, original digital camera files and videotapes must be logged and stored appropriately.
Recording without consent may be prescribed in certain circumstances such as suspected non-accidental injury of a child where the recording of injuries is demonstrably to the benefit of the patient.
Relationship with patients
An individual has a fundamental right to privacy. Unauthorised publication may have social and legal repercussions for the patient concerned. For instance, disclosure of pregnancy, abortion, plastic surgery or the contraction of a sexually transmitted disease, if made known without express permission may cause embarrassment to the patient. It can result in legal proceedings against the hospital.
The medical photographer has a professional responsibility, both towards the patient and medical staff, to regard all the photographs taken as being confidential. He has no legal or moral right to display or publish photographs in a book or drug manual or film without the written permission of the patient and the doctor in charge of the treatment.
Digital photography of patients
The availability of digital cameras has now made recording and storing of images easy. However, there is tremendous scope for manipulation or tampering of digital images is tremendous. To maintain the integrity of the image, manipulation may only be carried out to the whole image, and must be limited to simple sharpening, adjustment of contrast and brightness, and correction of colour balance. Images of patients may be transferred to personal computers for use in connection with ethics committee-approved and data-registered research projects or for the preparation of teaching materials.
Relationship with the medical profession
The ethics of clinical practice are based on 'trust' in the doctor by the patient and other members of the healthcare team. If disagreement occurs between the medical photographer and members of the medical and nursing staff, the discord should never be referred to in front of the patient; difficulties should be quietly and reasonably resolved elsewhere. In teaching hospitals, the medical photographer also has a vital role to play in the production of teaching aids for the numerous professionals being trained within the hospital.
Hospital etiquette and negligence
The codes of practice in operating and post-mortem rooms must be learned before the medical photographer enters either of the areas and he must strictly observe them. Rules include requesting for permission to enter a ward, not disturbing a doctor while he is with a patient and not interrupting a nurse while she is dressing a patient's wound are based on the need for maximum care of the patient. It is advisable to have a female nurse present if a male photographer is photographing a female patient. The photographer has a moral responsibility to see that the records do not represent the patient in an undignified fashion.
There may be a possibility of causing harm to a patient if the photographer is not careful. This may occur if the lens hood falls into the operation field, or by causing burns to the mucous membranes due to photographic lamps. However, this is rare. Photographers should also be aware that a seizure might be precipitated by repeated electronic flash discharges. He must change into proper operation theatre attire to maintain asepsis. If necessary, cameras should be covered with disposable plastic. One of my teachers used to set up a sterile trolley, cover the camera with disposable sterile plastic and change his gloves to take photographs. Though this was time-consuming, it prevented harm to patients.
Copyright and reproduction rights
Advertisements in medical journals and the lay press regarding pharmaceutical products occasionally project patients' images. A medical photographer owns the rights to any medical photograph and can sell or give away the reproduction rights to a photograph. He may agree to allow reproduction of a photograph, for a specified purpose, without giving up the copyright. This action does not prevent the copyright owner from similarly granting reproduction rights of the same picture to other sources, unless the original recipient of reproduction rights has been given sole reproduction rights. Though the laws may be varied, their purpose is to see that 'fair play' is adhered to in relation to the end product of a photographer's skill and industry. However, in such situations, reasonable medical or monetary benefit must reach the patients.Disposal of any unwanted photographs is another aspect of confidentiality. Any well-run department of medical illustrations has strict rules concerning this and will deploy a shredding machine for the disposal of unwanted films and prints. With the increased use of digital formats, there is a need for good net security in hospitals so that these pictures are not easily accessed if there is no permission for display from the patient and doctor concerned.Thus, the words 'primum non nocere' (first of all, do no harm) apply even in medical photography.
Further reading1. Sharpe D. I wish I had a camera: legal and ethical implications of EMS photography. J Emerg Med Serv 2002; 27:76-82.2. Creighton S, Alderson J, Brown S, Minto CL. Medical photography: ethics, consent and the intersex patient. BJU Int 2002;89:67-71; discussion 71-72.3. Gilson CC. Ethical and legal aspects of illustrative clinical recording. Br J Hosp Med 1994;7-20;52:225-9.4. Hood CA, Hope T, Dove P. Videos, photographs, and patient consent. BMJ. 1998;316:1009-1011.5. Jones B. Ethics, morals and patient photography. J Audiov Media Med 1994;17:71-76.6. Anderson C. Easy-to-alter digital images raise fears of tampering. Science 1994; 21:263:317-18.7. Hayden JE. Digital manipulation in scientific images: some ethical considerations. J Biocommun 2000;27:11-19.8. Richardson ML, Frank MS, Stern EJ. Digital image manipulation: what constitutes acceptable alteration of a radiologic image? Am J Roentgenol 1995;164:228-229.
Avinash Supe,Seth GS Medical College and KEM Hospital, Mumbai, 400012, India. e-mail:avisupe@vsnl.com
Avinash Supe
Do camera footage and still photographs depicting death, disease and injury represent an invasion of privacy, or are they appropriate forms of publicity? Recently, photographs of patients suspected to be suffering from severe acute respiratory syndrome (SARS) were published in newspapers as well as shown on TV, causing inconvenience and social stigma to all patients. While there was a need to follow quarantine procedures, there was no necessity to widely publicise the pictures. That act has caused mental and social harm to these individuals.
A profession must observe ethical standards; otherwise it will lack respect, credibility and may also lay itself open to legal penalties. A medical photographer is part of a team working for the benefit of a patient and, thereby, the society. The end product of his activities is the photographic record. The photographer must ensure that the end product of his photography is treated with the same respect as is accorded to other records of the patient.
Permission of the patient
Informed written permission of the patient must be obtained before photography is undertaken. A simple explanation such as 'The doctor wants a picture as part of your confidential medical records to help him assess your treatment' is usually acceptable. If it is a part of a project, this must be mentioned in the consent form and approved by an ethics committee. In an educational institution, the photograph may be used for teaching or for reference in the treatment of similar cases. Care must be taken to respect the dignity and beliefs of the patient. Every patient has a right to refuse to be photographed or to withdraw consent. If a patient decides to withdraw consent, the records must not be used. Photographs of the unconscious patient may be taken, provided a written consent is obtained from the responsible person who has brought the patient and later, from the patient himself.For photography of internal organs at operation or in the post-mortem room as well as in endoscopic, pathological or microscopic documentation, permission of the patient is not necessary, as the identity is not revealed. To maintain the anonymity of these images, it may be wise not to record the patient's name with the stored image. Images are catalogued with an image number and date. The patient's name should not be shown in reproduction of X-rays, electrocardiogram (ECG) or encephalogram (EEG) tracings, temperature charts, etc. Negatives, master transparencies, original digital camera files and videotapes must be logged and stored appropriately.
Recording without consent may be prescribed in certain circumstances such as suspected non-accidental injury of a child where the recording of injuries is demonstrably to the benefit of the patient.
Relationship with patients
An individual has a fundamental right to privacy. Unauthorised publication may have social and legal repercussions for the patient concerned. For instance, disclosure of pregnancy, abortion, plastic surgery or the contraction of a sexually transmitted disease, if made known without express permission may cause embarrassment to the patient. It can result in legal proceedings against the hospital.
The medical photographer has a professional responsibility, both towards the patient and medical staff, to regard all the photographs taken as being confidential. He has no legal or moral right to display or publish photographs in a book or drug manual or film without the written permission of the patient and the doctor in charge of the treatment.
Digital photography of patients
The availability of digital cameras has now made recording and storing of images easy. However, there is tremendous scope for manipulation or tampering of digital images is tremendous. To maintain the integrity of the image, manipulation may only be carried out to the whole image, and must be limited to simple sharpening, adjustment of contrast and brightness, and correction of colour balance. Images of patients may be transferred to personal computers for use in connection with ethics committee-approved and data-registered research projects or for the preparation of teaching materials.
Relationship with the medical profession
The ethics of clinical practice are based on 'trust' in the doctor by the patient and other members of the healthcare team. If disagreement occurs between the medical photographer and members of the medical and nursing staff, the discord should never be referred to in front of the patient; difficulties should be quietly and reasonably resolved elsewhere. In teaching hospitals, the medical photographer also has a vital role to play in the production of teaching aids for the numerous professionals being trained within the hospital.
Hospital etiquette and negligence
The codes of practice in operating and post-mortem rooms must be learned before the medical photographer enters either of the areas and he must strictly observe them. Rules include requesting for permission to enter a ward, not disturbing a doctor while he is with a patient and not interrupting a nurse while she is dressing a patient's wound are based on the need for maximum care of the patient. It is advisable to have a female nurse present if a male photographer is photographing a female patient. The photographer has a moral responsibility to see that the records do not represent the patient in an undignified fashion.
There may be a possibility of causing harm to a patient if the photographer is not careful. This may occur if the lens hood falls into the operation field, or by causing burns to the mucous membranes due to photographic lamps. However, this is rare. Photographers should also be aware that a seizure might be precipitated by repeated electronic flash discharges. He must change into proper operation theatre attire to maintain asepsis. If necessary, cameras should be covered with disposable plastic. One of my teachers used to set up a sterile trolley, cover the camera with disposable sterile plastic and change his gloves to take photographs. Though this was time-consuming, it prevented harm to patients.
Copyright and reproduction rights
Advertisements in medical journals and the lay press regarding pharmaceutical products occasionally project patients' images. A medical photographer owns the rights to any medical photograph and can sell or give away the reproduction rights to a photograph. He may agree to allow reproduction of a photograph, for a specified purpose, without giving up the copyright. This action does not prevent the copyright owner from similarly granting reproduction rights of the same picture to other sources, unless the original recipient of reproduction rights has been given sole reproduction rights. Though the laws may be varied, their purpose is to see that 'fair play' is adhered to in relation to the end product of a photographer's skill and industry. However, in such situations, reasonable medical or monetary benefit must reach the patients.Disposal of any unwanted photographs is another aspect of confidentiality. Any well-run department of medical illustrations has strict rules concerning this and will deploy a shredding machine for the disposal of unwanted films and prints. With the increased use of digital formats, there is a need for good net security in hospitals so that these pictures are not easily accessed if there is no permission for display from the patient and doctor concerned.Thus, the words 'primum non nocere' (first of all, do no harm) apply even in medical photography.
Further reading1. Sharpe D. I wish I had a camera: legal and ethical implications of EMS photography. J Emerg Med Serv 2002; 27:76-82.2. Creighton S, Alderson J, Brown S, Minto CL. Medical photography: ethics, consent and the intersex patient. BJU Int 2002;89:67-71; discussion 71-72.3. Gilson CC. Ethical and legal aspects of illustrative clinical recording. Br J Hosp Med 1994;7-20;52:225-9.4. Hood CA, Hope T, Dove P. Videos, photographs, and patient consent. BMJ. 1998;316:1009-1011.5. Jones B. Ethics, morals and patient photography. J Audiov Media Med 1994;17:71-76.6. Anderson C. Easy-to-alter digital images raise fears of tampering. Science 1994; 21:263:317-18.7. Hayden JE. Digital manipulation in scientific images: some ethical considerations. J Biocommun 2000;27:11-19.8. Richardson ML, Frank MS, Stern EJ. Digital image manipulation: what constitutes acceptable alteration of a radiologic image? Am J Roentgenol 1995;164:228-229.
Avinash Supe,Seth GS Medical College and KEM Hospital, Mumbai, 400012, India. e-mail:avisupe@vsnl.com
