== Patient dignity ==

Many apsects of this topic are also covered in the section on privacy but it is more than that it is how patients' feel they are viewed and treated. It doesn't mean that patients should be completely covered up with only the part to be photographed showing. It is in our manner, how they are respected and even talked to we don't like being patronised nor do patients.

An example of this aspect happened in my first position as a fully qualfied medical photographer. One of the nurses insisted that another photographer only photograph the part that was needed with everything else covered up so the photographs that came back were with the part of the patient's clothes around their ankles and the rest rolled up in a bunch covering up their breasts. Everything was what might be termed using an old fashioned expression "seemly" but hardly dignified.

The image below published in 1912 from my collection on the [http://www.cladonia.co.uk/acromegaly/ History of Acromegaly and Gigantism] illustrates this point.

http://www.cladonia.co.uk/wiki/images/cushing-1912-06.jpg

The key references on this subject are:

To be added

== Body image ==

This is probably one of the most important considerations for photographers as we are recording the visual symptoms and these add to the patient’s distress as much as the actual disabilities reduce their quality of life.

Harris DL 1982 describes a set of symptoms attributable to patients who have been born with or developed abnormal appearance derived from their own personal history prior to corrective surgery. In the conditions concerned there was no bodily dysfunction, the symptoms were directly related to the distress and disability which reduced quality of life. The symptomatology was the same for the four groups assessed; congenital abnormalities; as a result of disease and injury; due to physiological processes such as reproduction; and the result of developmental disproportion.

The range of symptoms is shown in the table below.

  '''Symptomatology of abnormal appearance (Harris DL 1982)'''
  1. Induction and development of self-consciousness
     - Self-criticism
     - Criticism by others - Overt and covert
     - Mistaken identity
  2.Defence mechanisms
     - Camouflage techniques
     - Restricted lifestyle
     - Artificial behaviour
  3.Unavoidable distressing activities
     - Occupational, social, domestic
     - Recreational
  4. Downgrading of self-concept
     - Secrecy
  5.Difficulties in interpersonal relationships
     - With friends, strangers, opposite sex, spouse and doctors
  6.Rationalisation

Included in the discussion on defence mechanisms one of the activities which is avoided is being photographed. This self imposed restriction to lifestyle is one that should be carefully considered by medical illustrators.

Comments included the following:

''“Domestically one patient was so self-conscious of his facial scarring that he avoided answering the front door and spent much of his time in bed.” '' (Harris DL 1982)

It is important to have a professional attitude towards the client and their problems so that they are relaxed and reassured. Many subjects in Harris' study described how they had been unsuccessful in trying to rationalise their feelings. There is often an assumption, among healthcare workers and otehrs, that patients' will be able to rationalise their feelings.

''“That they should be able to do so seems to be a fairly common attitude amongst those who are not disfigured.”''

Care and support for patients should play an important part in how we broach the subject of clinical photography (Beloff H 1984, Sellins F 1991, Brennan J 1994) not only pre-operatively but also post-operatively in the early stages of healing when no one looks their best.

This is not only seen in patients who have disfigurements but in a wider number of people. Those undergoing cosmetic surgery will prefer not to be seen without their make-up on even to the extent of putting make-up back on having had a shower and to remove everything pre-operatively.


== Abuse of consent ==

'''Cleveland crisis 1987'''

The abuse of consent was one of the problems associated with the Cleveland Child Abuse cases (Butler-Sloss E 1988, Bryson D 1990). The table below gives an idea of the children’s reactions to photography:

  '''Comments on photography in children’s stories from interviews'''
  '''with official solicitor of those aged 8 and over.'''
  Photographs had been taken                                              12
  Woken up for photography (3 at night including examination)               4  (3)
  Did not like being photographed                                       2  (2)
  Proud of being part of medical record                                       1
  Number no idea why photographs were being taken (12 year old)               1  (1)
  Number of children who gave their stories                              32
  Number thought likely to be badly affected by further discussion;
  parents not wanting them to be troubled or proved to difficult to trace  19

This shows a considerable variation in understanding of the photographic procedure but there was no evidence given as to whether this was due to the understanding of the children or inadequacy of the consent procedure. The figures in brackets give a total of at least 6 children who were given insufficient information during the consent procedure.

'''Cases of malpractice in the literature'''

'''Case 1'''

'' “A photograph of a child with an endocrine disorder was taken for proper professional use in a hospital and subsequently sent to a medical publisher for inclusion in a textbook. A member of the publisher’s staff involved in the publication later resigned and joined a publicity department in the music recording industry. Faced with a design problem he recalled the picture in question and illegally obtained a copy from his previous employers. The picture subsequently appeared on a record sleeve produced by a group whose name, combined with the appearance of the child was in extreme bad taste.”''

''“The parents of the child began litigation against the hospital and demanded proof of authority for taking the photograph and for its subsequent publication. The case was aggravated by the fact that the registrar who requested the pictures had by that time moved to another authority.”''  (Gilson CC et al 1984)

'''Case 2'''

''“. . a female patient gave verbal consent to being photographed having an intrauterine device inserted. The clinician concerned employed a non-health service photographer although a professional medical photographic service was on hand.Much later, the patient was photographed under similar circumstances and in such a way that her face was shown. After this she realised that the two sets of pictures might be used together and she had personal reasons why she would not wish to be identified with the IUD technique. She was unable to contact the clinician concerned and turned to the photographic department who, understandably, could offer neither information nor any assurances about the uses of the photographs.”''  (Gilson CC et al 1984)

'''Case 3'''

The Health Service Commissioner, Sir Gerald Clothier, is to investigate the complaint of a patient that a full frontal nude photograph of him was published in a medical textbook with details of his case without permission (Cull P 1988, Anon 1984).

''“The picture had been published without his knowledge or consent and without the knowledge and consent of the owners of the picture, the Health Authority concerned who were also the author’s employers.”'' (Anon 1984)


We can all probably think of other cases of abuse of consent that have occurred at our own hospitals, at other medical illustration departments or even to us personally. Please feel free to add this kind of information in an as anonymous form as possible via a link of into the community portal or my Talk sections or via link in the main text.

  '''Important points'''
  - Ignorance of need for consent is not a defence
  - Undue stress to patients or patients relatives caused
    by non-adherence to proper procedure should be avoided, (Gilson CC 1984).
  - Avoid any use of photographs beyond the consent given by the patient
  - If you realise something is going wrong at any stage.
    - Try stop it continuing any further if possible
    - Inform management and the patient’s consultant
  - Avoid open ended photography ‘just a few more’
  - A patient can retract their consent to photography or use of the photographs at any time.

== Coping with a patient who has experienced abuse of consent ==

'''Mishandled photography'''

Mishandling of photography can cause considerable psychological distress over a period of many years often more so than a medical examination (Money J et al 1987). Victims of assault and injuries, especially sexual, are particularly vulnerable to distress from photography (Beloff H 1984). Photography itself constitutes a separate examination so it should preferably be undertaken at the same time as the initial examination (Butler-Sloss E 1988, Independent Second Opinion Panel 1988) in cases of sexual abuse.

It may be that you will have to photograph a patient who has suffered at the hands of another photographer whether it is a consultant with a camera, an amateur, or another medical illustrator. It will then be necessary to take longer to alleviate their fears and worries about the photographic process. Taking that little bit of extra time at the beginning can save considerable time in the actual process of clinical photography.

== Resources ==

'''Weblinks'''

'''References'''

Anon. (1984) Patient’s nude photograph published in textbook. Reprinted from “The Times” 11th July 1984. IMBI News; Aug: 2.

Beloff H. (1984) Social interactions in photographing -even in medical illustration . . . J Audiovis Media Med; 7: 44-7.

Brennan J. (1994) A vital component of care: the nurse’s role in recognizing altered body image. Prof Nurse; 9(5): 298-303.

Bryson D. (1990) Medical illustration and the report of the inquiry into child abuse in Cleveland, 1987: a commentary. Droitwich: Cladonia Resources. [http://www.cladonia.co.uk/papers/clevrep.pdf Paper pdf 28Kb]

Butler-Sloss E. (1988) Report of the inquiry into child abuse in Cleveland 1987. Cm 412. London: HMSO.

Cull P. (1988) Aspects of confidentiality, copyright, and accreditation. J Audiovis Media Med 1988; 11: 8-10.

Gilson CC Green P Cull PG. (1984) Confidentiality of illustrative clinical records. J Audiovis Media Med; 7: 4-9.

Harris DL. (1982) The symptomatology of abnormal appearance: an anecdotal survey. Br J Plast Surg; 35: 312-23.

Jones B. (1996) 'Drop 'em Blossom' - Clinical photography and patient dignity. J Audiovis Media Med; 19(2): 85-6.

Money J Lamacz M. (1987) Genital examination and exposure experienced as nosocomial sexual abuse in childhood. J Ment Nerv Dis; 175(12): 713-21.

Sellins F. (1991) The management of AIDS patients in the photographic studio. J Biol Photogr; 59(2): 57-60.