Filming of Patients in Academic Emergency Departments The following report is the result of the first SAEM Ethics Consultation request. Due to the general interest of the topic, and with the permission of the individual who requested the consult, the consultation report is published below for the benefit of the membership. Please contact SAEM with any consultation requests. Catherine A. Marco, MD and Gregory L. Larkin, MD, MSPH, for the SAEM Ethics Committee Consultation from the SAEM Ethics Committee Questions: 1. When is filming of ED patients in academic emergency departments appropriate? 2. What conditions should be met to enable commercial ventures involving the filming of ED patients? Use of Recorded Images for Medical Records A longstanding tradition exists of producing and maintaining medical records and documentation of medical care delivered to patients, in all medical settings, including the emergency department. In recent years, the paper documentation of medical records has expanded to, in some settings, include photographs and videos. There is little debate that these venues are appropriate when used for documentation in the confidential medical record, as these services are clearly provided for the best interest of the patient. Recorded Images for Educational Purposes Debate arises when other uses are proposed for various additional uses of the medical record (including photographs and video). Use of patient photographs and video for educational purposes is rapidly expanding.1,2,3 Although consent is not always obtained prior to taking the photos, standard practice is to obtain consent from the patient, or surrogate, prior to the dissemination of these modalities. There are several logical justifications for the use of filming of patient encounters for educational purposes: 1. There is a benefit to the medical community, and to society, by improving the quality of care. There is a clear educational benefit of multimedia educational presentations4-8 and of retrospective video quality analysis.2,3 2. The proposed audience includes health care professionals, who routinely encounter such settings. 3. Film records are not publicly available. Recorded Images for Commercial Purposes Filming of patients for commercial purposes (such as television programs or movies) clearly presents unique moral questions. Although some argue
that there is educational value to society,9 the primary motivations for such filming are public education, entertainment, and financial benefit to proprietors. The clear alternative to filming of patients is the simulation of events, which can be based on true incidents. Numerous ethical arguments against the use of recorded images of ED patients for commercial purposes exist, including: 1. Many patients are unable to consent prior to recording, due to medical condition. 2. Patients who are technically able to consent may feel coercion whether overt or camouflaged, in part due to the inherent vulnerability of their position as a patient. 10 Rawlsian conceptions of justice mandate that the most vulnerable should accure benefits first when societal burdens and benefits are apportioned.11 3. Confidentiality and privacy of patients and health care providers are severely invaded. 4. Film crews may interfere with patient care, both physically and subliminally. The presence of commercial, nonmedical staff in the ED may pose a significant distraction, and conflict of interest for already overburdened and stressed health care providers. 5. Both the Code of Conduct for SAEM12 and the Code of Ethics for ACEP13 put the interests of patients above all else. Filming patients without any tangible patient-centered benefit clearly violates both the letter and the spirit of these Codes. There may conceivably, be some circumstance in which the the commercial use of recorded images of ED patients could be justified in limited circumstances. To be justifiable, these circumstances arise rarely, but could occur when benefit to patients is clearly demonstrated. Review by a multidisciplinary ethics committee or an institutional review board may be of value to ascertain that such conditions of patient-centered benefit are in force. When the appropriate use of images are deemed to be helpful, significant community and patient advocate representation should be invoked prior to project initiation. Although not directly applicable to this question, the FDA Waiver of Consent guidelines for emergency research14 may provide a useful model. Although these guidelines were specifically designed to facilitate the conducting of emergency research in situations where obtaining traditional 12
written informed consent is not feasible, they provide a model for obtaining proactive input from the institution and community prior to initiation of a project in which informed consent is not feasible. The feasibility of obtaining agreement from an overwhelming majority depends in large measure on the wording of the question. (For example, “You wouldn’t mind if we took a few pictures, would you?” versus “Would it be okay with you if the television crew were to videotape you after a car accident, as you lie unconscious, naked, and bloody, on a stretcher, surrounded by strangers in the ER?”). Summary 1. Filming of ED patients for medical records is acceptable, provided routine confidentiality of records is maintained. 2. Filming of ED patients for peer review and professional educational purposes is acceptable, provided informed consent is obtained when possible, and patient confidentiality is maintained. 3. The SAEM Ethics Committee discourages the commercial use of images of ED patients in academic emergency departments. 4. Commercial filming should only be considered in rare cases, where benefit to patients and society can be clearly demonstrated, and where overwhelming support of the Emergency Department staff, the institution and the community is demonstrated. 5. If permitted, fastidious attention should be paid to patient confidentiality and voluntary informed consent, and strict limitations should be enforced to prevent adverse effects on patient care. References 1. Brooks AJ, Phipson M, Potgieter A et al: Education of the trauma team: video evaluation of compliance with universal barrier precautions in resuscitation. Eur J Surg 1999; 165:1125-8. 2. Ellis DG, Lerner EB, Jehle DV et al: A multi-state survey of videotaping practices for major trauma resuscitations. J Emerg Med 1999; 17:597-604. 3. Olsen JC, Gurr DE and Hughes M: Video analysis of emergency medicine residents performing rapid-sequence intubations. J Emerg Med 2000; 18:469-72. 4. Herxhaumer A, McPherson A, Miller R et al: Database of patients’ experiences (DIPEx): a multimedia approach to sharing experiences and information. Lancet 2000; 355:1540-3.
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