patient should have ownership of the photographs and
control their distribution.
So, how should clinical images be shared with a
larger audience, if at all? Clinical photographs have
become a widely used educational tool and routinely
appear in presentations as well as in hard copy and
electronic publications. However, when clinical photographs are intended solely for educational purposes,
they no longer provide a direct benefit to the patient.
The benefit has now shifted to a societal impact; that
is, to educate others in the hope of providing improved
patient care in the future. 3 But once the benefit shifts
away from the patient, that individual is left with a
risk to confidentiality. The consent issue is no longer
simply whether a clinical photograph may be created
but now includes permission to use the photograph. 5
Sharing digital images with a large audience
reduces that ability to control the distribution of sensitive photos. Web-based presentations and the wide
availability of electronic publications makes controlling access to patient photographs a challenge. With
this concern in mind, even though a physician may be
passionate about education, his or her duty to uphold
the patient’s right to privacy and confidentiality is still
of the utmost importance; therefore, the physician
must exercise great care when using sensitive photos
for nonpatient care-related activities.
Option 2: The resident obtains informed consent
from the patient and continues to carry out the
steps outlined in Option 1.
The actions associated with Option 1 remain relevant to
this option. However, two important concepts require
more careful attention. In health care, informed consent is integral to shared decision making and is based
on respect for patient autonomy. 6 Informed consent
provides patients with an opportunity to participate
in their own medical care and aims to avoid deceit
and coercion. 7, 8 When obtaining informed consent,
a physician typically details the risks, benefits, and
limitations of all available options.
Based on this understanding of informed consent,
would obtaining anything less than informed consent
for clinical photography infringe upon a patient’s right
to autonomy? If the physician sees a significant risk
of breaching patient confidentiality and believes, for
example, that all patient photographs should be considered personal health information, then obtaining
informed consent would be the safest action, from an
ethical perspective, on the consent spectrum. If the
physician concludes informed consent is necessary,
then a decision between verbal versus written consent
must be made. In the case presented, verbal consent
would certainly be quicker, easier, and less obtrusive.
This approach also upholds the ethical principle of non-maleficence by aiming to minimize patient suffering.
However, from a legal standpoint, written consent may
be the recommended option to protect the physician
and hospital from future liability. 9
To help guide residents and other physicians
through the process of making an ethically complex decision, as in the case presented in this article,
it is recommended that health care institutions have
standards and policies in place that cover this issue.
Unfortunately, even when these policies exist, they
rarely address the specific issue of clinical photography. Institutions need to facilitate this process by
making policies available and compatible with current technology.
Option 3: The resident obtains informed consent,
takes several photos with his personal mobile
device, and e-mails the photos to the PRS using a
secure hospital e-mail address.
The resident’s decision in Option 3 highlights an
understanding of mobile device security issues and
the increasing need to develop secure modes of transmitting and sharing clinical photographs.
Text messaging through a mobile device should
always be viewed as a vulnerable mode of transmitting sensitive data. When a text message is sent, the
text is stored on a central server that is not compliant
Physicians must use these devices
prudently and remain informed of
the technological shortcomings.