Personal views: Most patients don’t read the BMJ
Authors: James J Rankine
Journal: BMJ (1998)

Colleagues stopped me in the corridor to discuss it. Others wrote of their own similar experiences on Christmas cards that year. The reason for this sudden rush of attention? I had written a personal view in the BMJ (17 December 1994, p 1666). No research paper I have written has provoked such a response. It led me to believe that most doctors read the personal view section. But since 1994 there have been changes at the BMJ, and if the article had been submitted today it would not have been accepted. The issue is one of patient consent. 

The personal view contained details of a father’s response to being confronted with the diagnosis of Down’s syndrome in his newborn son. I was aware that he might recognise himself from the details but was confident that others would not identify him. So far, no litigation having resulted, it seems I am in the clear, although having drawn attention to it again might prove to have been a risky move. I would not have sought the patient’s consent as this would have merely brought the article to the patient’s attention and caused an embarrassing situation. 

The BMJ and other journals have moved from the traditional means of protecting patient confidentiality by anonymity to one of obtaining patient’s consent. The problem was highlighted when a patient made a complaint to the General Medical Council after two psychiatrists reported details of her case in a psychiatric journal. A local newspaper reported the case and a friend of the patient recognised her from personal details that included the patient’s occupation. The psychiatrists were found not guilty of serious professional misconduct, but future cases may be viewed differently when the GMC adopts new guidelines shortly. The draft reads: “You must obtain consent from patients before publishing personal information about them as individuals in journals, textbooks, or other media in the public domain, whether or not you believe the patient can be identified. Consent must therefore be sought to the publication of, for example, case histories about, or photographs of, patients.” 

Psychiatric case reports may contain personal details relevant to the patient’s personality and deal with diagnoses for which there remains considerable social stigma. No one would argue that patient consent should not be obtained in these instances; the question is where you should draw the line. 


There has been recent debate in the controversies section of the journal of the American Medical Association (JAMA) about whether or not the rules on gaining consent for publication should be absolute (27 August 1997, pp 624-6,628-9,682-3). The first article by D E Snider describes a manuscript which failed to be published because of the lack of a patient’s consent. It concerned an outbreak of drug resistant tuberculosis which had attracted considerable media attention, partly the result of legal action brought by one family who claimed that the outbreak was mishandled by the health department. Despite the fact that the patient’s details were in the public domain, because the patient had been interviewed by a major newspaper, informed consent for publication was required. Because of the impending legal action the authors were prevented from obtaining this consent as legal counsel advised them and other health department staff not to speak with the patient. 


“I wouldn’t even recognise my lungs in a centrefold spread in the BMJ”



I too have fallen foul of the new ruling. While not on a par with a full research paper, titled “An inappropriate present for a doctor,” it was accepted for publication in the “memorable patient” section of the BMJ and considered to be an “excellent and thought provoking story” by the editorial team. It has not appeared in print because of the absence of patient consent which the editorial staff acknowledged would be embarrassing to obtain. Moreover it would have required considerable detective skills on my part to track down a lady who was already very elderly 10 years ago and living hundreds of miles from where I now live. The issue was not that others would recognise her but that she might recognise herself. 

There are many situations in which it would be inappropriate to ask a patient for consent. Implied criticism of a patient’s behaviour or a doctor’s management and light hearted humorous articles are examples where patient consent might be difficult to obtain without damaging the doctor and patient relationship. Are articles like this to be written only about patients long dead and gone? 

The strict application of the ruling inevitably leads to farcical situations. As a radiologist I have several films that might interest the Minerva column in the BMJ. One is the computerised tomogram of a patient with a lung tumour that cuts through the aetiological agent giving a perfect cross section of a packet of cigarettes in the patient’s pocket. I can describe this film to you but to reproduce the image would require the patient’s consent. The underlying assumption is that patients might possibly recognise themselves from a particular section. This is absurd. I wouldn’t even recognise my lungs in a centrefold spread in the BMJ. 

The purpose of this article is not for an aggrieved author to vent spleen on the editorial staff of the BMJ. They are doing a difficult job in difficult times, and the fact that you are reading this shows that they are not afraid of a bit of criticism. 

For those of you who are wondering what the “inappropriate present for a doctor” was, I will leave you with this cryptic clue: most doctors don’t do it.