Chris Kaposy and Zack Marshall reveal that patient photographs in medical case reports are often picked up by Google Images, which makes these sensitive images widely available. __________________________________________

Case reports published in academic medical journals often include photographs of patients. For instance, these publications might describe lesions that resulted from an infection, the outcomes of surgery, or bone fractures, illustrated with pictures of a patient’s body. Such reports typically are posted on the journal’s website, along with the accompanying photographs. What is not often understood is that such photographs can be picked up by Google Images, which can make them available to the public beyond those who read the journals publishing the case reports.

We are members of a research group that documented the availability of often sensitive and private medical photographs via Google Images. To study this issue, we compiled a random sample of 585 recently-published case reports. Of these reports, 186 had patient photographs. In total, 142 out of the 186 had at least one photograph that could be found in Google Image search results, 76.3% of all case reports that had photographs in our sample.

Photo Credit: Jozi Duarte/flickr. Image Description: A picture of a camera and a stethoscope together.

Based on this finding, we argue that if a medical case report contains photographs and is published online, more often than not one of these photos will be available to the general public through Google Images. Among the photos that were available in this way, 18.3% were images of eyes, faces, or of the full body of the patient. We judged that almost 11% were images that could potentially lead to the identification of the patient. Another striking finding was that it is not only photographs in open access journals that get aggregated into Google Images search results. Many of these photographs, 65% in total, were originally published in closed access journals.

One of the ethical problems with this technological turn of events is that when patients consent to have their photographs taken for publication in a case report, they might not be consenting to the wide availability of these images. Patients might not be aware, and they might not be made aware, of this possibility through the informed consent process. Indeed, clinicians themselves who are authoring these case reports might not be aware of this unintended result either. After all, the purpose of writing a case report is to have it published in an academic journal in order to contribute to medical knowledge. What happens after publication is typically out of an author’s hands. 

In a related research project, members of our team studied a sample of consent forms on journal websites used for the publication of patient images in medical journals. The sample came from journals and publishers that had published case reports studied in our larger project. The researchers identified 18 consent forms that are used for 132 different medical journals (publishers often use the same consent form for this purpose for multiple journals). Just over half of these consent forms (10 out of 18) mention the possibility of photographs being available to an audience outside of the journal website. Few (only 3) revealed the possibility that one’s medical photographs could be linked to the social media platforms of a journal or a publisher.

Clearly, the consent processes associated with the publication of patient photographs need to be improved. Journals and publishers should adopt standardized guidelines on both the consent process for including patient photographs in case reports, as well as on how these photographs are made available to search results through websites like Google Images. Furthermore, it is important to seek input from industry partners like Google to determine the underlying causes of this issue, which threatens patient privacy and confidentiality, as well as to identify potential solutions.  

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Chris Kaposy is a Professor at the Memorial University Centre for Bioethics, and an editor of the Impact Ethics blog. On Mastodon @ChrisKaposy@mindly.social

Zack Marshall is an Associate Professor in the Cumming School of Medicine, Department of Community Health Sciences at the University of Calgary.