Zach Patterson, Zack Marshall, and a grade 8 class in Calgary replicate a study showing the availability of patient photographs from medical case studies on the open internet.

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We are a Grade 8 elective class of 13 students at the Simon Fraser School in Calgary, Alberta. We have been learning from professors and industry experts to gain understanding about scientific processes outside of what we learn in our core science class. We recently worked with Dr. Zack Marshall at the University of Calgary, who helped us become curious about online privacy. We discovered that our medical privacy isn’t as safe as thought. Our project was based on previous research conducted by Dr. Marshall and his team in the Journal of Medical Internet Research. A follow-up study was published in 2024, which was the basis for a recent Impact Ethics commentary.

Sometimes doctors and surgeons ask patients for permission to take medical photographs of injuries or particular health conditions. In specific situations, a doctor might also ask their patient for consent to publish the photograph in a medical journal, alongside a description of the treatment, and patient outcome. When a patient gives consent to have their images published in a medical journal, they might assume that these photographs are going to remain only in that medical journal for professionals to examine and learn from. However, in the age of the internet, there are all sorts of potential ways that these images can be distributed and found in other, more public places, causing potential breaches of privacy and consent. As a Grade 8 class, we wanted to examine this issue, and want to make suggestions for how to proceed based on our findings.

Photo Credit: Quinn Dombrowski/flickr. Image Description: A video camera directed at a hospital bed.

Our overall goal for the project was to examine photographs of patients in case reports published in medical journals to see if these private images are showing up on Google Images. Our method consisted of three different groups responsible for 1) searching (typing the title of the article in quotations into Google Images and saving the search results), for 2) comparing search results to the original case reports, and for 3) tracking our findings about whether the images were found online or not, in a spreadsheet.

After 113 case report searches on Google Images we found:

• 71 had photos on Google Images that were identical to the case reports.
• 42 of the case reports had no photos on Google
• With 71 case reports the positivity rate was about 63%, over half.

The issue as we see it is: did these patients give consent for their pictures to be on Google Images? Or just in the case reports? Dr. Marshall’s original study of a similar nature, found a 76% match rate, 13% more than us. Patients’ body parts and other identifying aspects have been leaked beyond the journal where they were originally published. While doctors typically seek consent from patients to publish medical photographs, sometimes the doctors are unaware of the risk of patient photographs appearing online. We are not sure whether patients were told that their photographs could appear on sites like Google Images as part of the consent process – this means that their consent may not be truly informed.

The problem is that case reports are being shared on the internet for everyone to see. When the case report is published online, patient photographs also become available. As young students, we wouldn’t feel comfortable with medical concerns or images of our bodies being publicly available on the internet, and it is likely that there would be very few who would be ok with this. Patient privacy is key.

This is a consent issue. At this time, Dr. Marshall and colleagues have been interviewing various stakeholders who are involved in case report publication, including journal editors, publishers, and individual doctors. It seems from the early results that many are not aware, and are as shocked as we are about the prevalence of this issue.

We feel that to protect patient privacy, there are a few things that could be done:

1. There needs to be an open and honest discussion about what patient consent means in the age of the internet. How does our perception of these issues need to change knowing that images can be farmed directly from publishers’ websites, despite many of them needing payment to access?
2. Privacy within these images can be increased. In many of our studies we would be looking at a medical issue affecting the face (such as ears, nose, facial skin). A small black bar would be placed over the patient’s eyes, as an attempt to make them anonymous, leaving much of the face exposed. Knowing this image has a high percent chance of making it on the internet, is there a better way to anonymize these individuals?
3. Communicate these findings to patients and others. Members of the public need to understand that despite our best efforts, their images could end up on the internet for public viewing. As the medical community engages in these meaningful and ethical discussions, it becomes easier to put pressure on companies like Google who are finding and hosting these private images as part of their search algorithms.

We have a great deal of respect for the medical profession and the important work of research. We hope that our experience can be a learning opportunity for all.

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Zach Patterson is an EdD Candidate in the Werklund School of Education, University of Calgary and Assistant Principal in the Calgary Board of Education

Zack Marshall is an Associate Professor in the Department of Community Health Sciences, University of Calgary