While performing my daily routine of checking articles related to tattoo complications on Pubmed, i read with interest on the 30th of May the recent case report by Hendren et al about an exceptional case of lethal infection by Vibrio vulnificus after tattooing in a 31 yo male
To summarize this case report, it is the exceptional and unfortunate conjonctions of several factors: i) an immunocompromised patient with liver cirrhosis 2) who took a bath in the Gulf of Mexico, 3) several days after getting a tattoo on the leg. The tattoo wound acted as a door for the aquatic bacteria to lead to sepsis shock, intensive care unit and death of the patient 2 months after admission.
The article includes several pictures of the patient, including the « culprit » tattoo. As it is customary in a rising number of medical journal, a consent was obtain from the patient for the use of the clinical information and picture for possible medical publication. The mention « patient consent: obtain » is stated at the end of the article.
In the field of medical publishing, it is well known that tattoos, as well as bracelets, rings, even manucure nails may allow patient ‘s recognition. It is customary to obtain the permissions to use the pictures of a patient for medical publications. More and more journals are now demanding a signed consent of the patients in case of recognizable picture during the submission process.
However, we are talking here about publishing in medical/scientific articles, for which the access is usually limited to health care professional with institutional access (or private subscription. Lay people may read it as well in exchange of an access fee. The clinical data and pictures remain restricted to a medical setting and not a mass media coverage.
I was rather surprised this morning to discover by a link sent by a friend of an article on cnn.com about that very case.
The case report has gone viral (as it is usually the case) over the internet
All the pictures of the BMJ Case report article are here reproduced. The journalist wrote « In a typical case study, patients are referred to by their initials. In this case, what happened was so rare, the authors declined to provide even that, to prevent anyone from figuring out his identity ». However, the (commemorative) tattoo displays some specificities such as a date and a text, so anonymity is not guaranteed
Of course, the BMJ case report website has a very comprehensive and detailed patient consent and confidentiality policy with a form to be signed (and smartly available in different language)
When a patient signs the BMJ consent, he agrees to 7 different points including the following;
2) » The Information will be published without my name attached and BMJ Group will make every attempt to ensure my anonymity. I understand, however, that complete anonymity cannot be guaranteed. It is possible that somebody somewhere – perhaps, for example, somebody who looked after me if I was in hospital or a relative – may identify me »
However, in the BMJ consent, the point 5) draws some attentions
5) « The Information may also be used in full or in part in other publications and products published by the BMJ Group or by other publishers to whom the BMJ Group licenses its content. This includes publication in English and in translation, in print, in electronic formats, and in any other formats that may be used by the BMJ Group or its licensees now and in the future. In particular the Information may appear in local editions of the journal or other journals and publications published overseas ».
To me, either from the point of view of a physician who writes medical articles or from those of a patient, the consent is not sufficiently clear. I would not think that by « other journals and publication published overseas », the BMJ actually mean the potential viral diffusion by internet through high-impact high-audience journal such as cnn.com, http://www.independent.co.uk etc…
As a reminder, last year, during summer 2016, Thorax, an other BMJ journal published an exceptional case report of lung inflammation in a bagpipe player, with media coverage that lead a few days later the patient’s family to learn the diagnosis, once the case was published.
In 2013, Hacard et al reported that 78% of the patients considered that the consent form should list all the possible uses of the images. Only 44,3% were favorable for the use in health magazines and 32% in websites.
Hacard F, Maruani A, Delaplace M, Caille A, Machet L, Lorette G, Samimi M.
Patients’ acceptance of medical photography in a French adult and paediatric
dermatology department: a questionnaire survey. Br J Dermatol. 2013
The possible use of patients’ picture for large audience journals should clearly be distinguished from other academic uses/publishing and explained to the patients.