Patient Consent for Publication: Case Reports and Images

A signed treatment consent and a black bar over the eyes will not get a case report past a medical journal. Publication needs its own consent.

Guide · 11 min read · Directive Publications Editorial Team

Consent for publication is a separate consent

A patient who agreed to surgery, to a biopsy, or to join your study has not agreed to appear in a journal. Editors will ask for a second, separate signature, and they will hold the submission until they have it.

The baseline many medical journals follow is the ICMJE guidance on protecting research participants. It says identifying information, including names, initials and hospital numbers, should not be published in descriptions, photographs or pedigrees unless it is essential for scientific purposes and the patient, or a parent or guardian, gives written informed consent for publication. It also says:

• an identifiable patient must be shown the manuscript to be published
• patients should be told whether identifiable material may be available on the internet as well as in print
• nonessential identifying details should be omitted
• the published article should say that consent was obtained

The first point is the one a treatment form can never satisfy, whatever its wording:

When anonymisation is not enough

Removing the name rarely makes a single patient anonymous. ICMJE says consent should be obtained if there is any doubt that anonymity can be maintained, and the features that make a case worth reporting, such as a rare condition or an unusual complication, are the ones that let a relative, a clinician who treated the patient, or the patient recognise it.

BMJ's patient consent policy puts it plainly: true anonymisation is difficult to achieve, because journal articles stay available for a long time and technology keeps making identification easier. Its de-identification aid adds that BMJ will ask for consent for case reports even when they are very well de-identified.

Journals draw the line in different places:

• BMJ Case Reports requires a signed consent form for every case report about a living person, without exception.
• The BMC editorial policies require written consent for any manuscript that includes details, images or videos relating to an individual, but say consent for images may not be required where they are entirely unidentifiable and no personal details are reported, with the editor deciding.

Decision rule: if your paper describes one patient or a handful, plan to get consent from the start, and de-identify as well, not instead.

What counts as identifiable patient information

Direct identifiers are obvious; indirect ones look harmless alone. This table follows ICMJE and BMJ's de-identification aid:

Two points are easy to miss. Your own affiliation can locate the patient, because a rare condition at a named regional hospital may point to one person. And small numbers stay identifiable: BMJ's guidance for authors treats groups of fewer than five as identifiable, which matters for small case series.

A worked example of trimming text:

Keep a detail only if the clinical point depends on it. Delete rather than alter: if you change details to de-identify a patient, ICMJE expects you to give assurance that the changes do not distort the scientific meaning.

Clinical images need their own check

Eye bars and blurring do not work. ICMJE states that masking the eye region in photographs is inadequate protection of anonymity. BMJ does not accept photographs where facial features are blurred or covered by black bars, and it requires consent for facial images.

Crop, do not disguise. Show only what the clinical point needs. BMJ accepts cropping to preserve dignity and privacy, but not cropping used to avoid the need for consent in a case report.

Check what is inside the image. Radiographs, ultrasound stills and scanned slides can carry the patient's name, date of birth, record number, scan date or site, printed on the image or stored in the file. Remove both.

Lock your edits. Where you have cropped or removed parts of a photograph, BMJ asks for a flattened file such as TIFF or JPEG so the removed parts cannot be restored.

BMJ's policy allows images such as X-rays, ultrasound images, pathology slides or undistinctive parts of the body to be used without consent so long as they are anonymised. Read that exception narrowly: BMJ itself says it does not apply to BMJ Case Reports, which requires a signed form for every case report about a living individual without exception. An anonymised radiograph inside a case report still sits in an article that needs consent.

1. Image cropped to the finding
2. No names, numbers, dates or site labels on the image or in its file
3. No face, tattoo or birthmark visible without consent
4. Edited files flattened
5. Legend does not add identifying detail

A seven-step consent process

Start as soon as you decide to write the case up.

1. Read the target journal's consent policy. Download its form if it has one; BMJ, for example, says alternative forms rarely meet its legal requirements. Note who signs, how the form is submitted and where the original is kept.
2. Remove nonessential identifiers. Trim the text, legends and images first, so the patient consents to the version you will submit.
3. Show the patient the material. Give them the manuscript, every image and every legend, in a language they understand. At BMJ, if the patient has not seen the final version, the form must be amended to say what they did see.
4. Explain what publication means. The article may be read worldwide, reused and shared online, and anonymity cannot be guaranteed. If you are their treating clinician, say clearly that declining will not affect their care; BMJ's guidance notes patients may otherwise feel it could.
5. Get written consent from the right person. Where someone other than the patient signs, record their relationship and the reason.
6. Store the form as required. Keep the signed original as your institution and journal require, and upload it only as the journal specifies; BMJ asks for it as a file for editors only.
7. Declare consent in the manuscript. Use the journal's wording and section (see below).

If revision adds an image or new personal detail, the consent you hold does not cover it, so go back to the patient before resubmitting. If you supervise trainees writing case reports, checking this step is part of the research integrity responsibilities of a lab lead.

What a consent form for a case report must cover

Use the journal's form when it has one. If you are using an institutional or generic form, check it covers these points, drawn from ICMJE, BMC and the BMJ form:

1. A description of the material, with a copy attached
2. Confirmation the patient has seen the material and the article, or a record of exactly what they saw
3. That the patient's name will not appear, but complete anonymity cannot be guaranteed
4. That the article may be available worldwide online, and under an open licence where the journal uses one
5. That the material may be reused in other formats, translations or promotional material, where the journal does this
6. That consent can be withdrawn before publication but not after the article has gone to press
7. The signer's name, relationship to the patient if not the patient, and the reason for signing on their behalf
8. The name and position of the person who explained the form

BMC requires consent to publication under the relevant Creative Commons licence, so a form that says only "for publication in a medical journal" may not be enough there.

Proxies, deceased patients and patients you cannot reach

Journal policies and local laws differ most here, so treat this table as a map of the questions, not the answers.

The "who may consent" column is the part that travels worst. Who counts as a legally authorised representative, whether a relative qualifies at all, and what happens after death are set by the law where the patient was treated, not by the journal, and the answer can differ between two countries whose journals use identical forms. So do not read the England and Wales position above as a default: if you work elsewhere, ask your ethics committee or legal office who may sign in your jurisdiction, get that answer before you approach anyone, and tell the editor which law you relied on.

When the usual route is closed, record each attempt to reach the patient or family and explain the situation to the editor at submission.

What to declare, and where the form goes

ICMJE recommends that the published article say consent was obtained, and BMC requires a statement to that effect in the manuscript. A version to adapt:

Put it where the journal asks, often a declarations or ethics section, in its wording if it gives one. Our manuscript submission checklist covers the other declarations that sit alongside it.

Where the signed form lives also varies. ICMJE says consent should be archived with the journal, the authors or both, as local law dictates, and notes that some journals have authors keep the form and send a written attestation instead. BMJ asks that the original be held by the treating institution. Either way, keep it retrievable long after publication.

If consent turns out to be missing after publication, act quickly. Springer Nature's editorial policy says that where personal data is published without consent, editors will retract the article or obscure the identifiable data. Our guide on when and how to correct the published record explains how to approach the journal.

Talk to the patient first, write second

The hardest consent problems start when the report is written and the images chosen before anyone asks the patient, who may by then be hard to reach or unwilling. Reverse the order: choose the journal, read its policy, raise the idea with the patient early, then write knowing exactly what you may show. The signature comes later, once they have read the version you intend to submit, because ICMJE requires that an identifiable patient be shown the manuscript to be published and the BMJ form requires the patient to have read the article. A form signed before the manuscript exists is the same failure as a treatment consent.

Directive Publications brings its author guidance, ethics statements and research integrity policies together on its For Authors page, so you can check what is expected before you approach the patient.