Image usage

You must seek the patient’s written consent to publication in The BMJ if there is any chance that he or she may be identified from a picture, from its legend or other accompanying text. Patients are almost always willing to give such consent. We no longer publish pictures with black bands across the eyes because bands fail to mask someone’s identity effectively.

We will need the patient to sign our consent form, which requires the patient to have read the article. Please print out the form, fill in the details about the article, ask the patient or next of kin to sign the form, and then send or fax it to us or scan it and upload it to our online editorial office as a supplemental file to your article.

Our policy on obtaining consent for publication of pictures of patients is a subset of our general policy on any confidential material that arises from the doctor-patient relationship. This policy also reflects the UK General Medical Council’s rules on publishing confidential clinical material. However, the GMC does not insist on separate permission to publish what the GMC calls the “recordings” listed below, provided that, before use, the recordings are effectively anonymised by the removal of any identifying marks. Please remove details such as patients' names and dates of birth from images before sending them to us. The GMC's list includes:

• Images taken from pathology slides;
• X rays;
• Laparoscopic images;
• Images of internal organs; and
• Ultrasound images

When such an image is accompanied by text that could reveal the patient’s identity through clinical or personal detail, however, The BMJ does need the patient’s signed consent to publication. Please use our consent form for any image that does need consent to publication or, indeed, for the text of any article that might lead to identification such as a case report, paper, personal view, filler, or letter. Please print out the form, add the paper’s title and reference number, ask the patient or next of kin to sign the form and then scan it and upload it to our online editorial office as a supplemental file to your article.

We can use an image that has been published before only if it has no copyright or if the copyright holder has given us permission for its use on thebmj.com, in the print issue of The BMJ and in associated publications such as local editions of The BMJ. If you would like to use in an article in The BMJ an illustration that has already been published elsewhere in a journal or book please ask the publishers to give permission. Most will agree, as long as The BMJ credits the original publisher, although some will charge you a reproduction fee.

If an image has no copyright, please tell us the precise details of where you obtained it and who gave you permission to use it in The BMJ. Please note that many medical illustration departments expect to be acknowledged. If images come from your colleagues you will need to seek their written permission and check whether the photographs have been published previously in other books and journals.

If you are using line drawings or tables that have been taken from or adapted from published papers, then you are responsible for getting the publisher's permission to republish or adapt them. We would then publish such an image with a legend saying something like "Adapted with permission from...[ref]" or "Reproduced with permission of the American Academy of Sciences from xxx et al[ref]".

We’re happy to use works of art when appropriate but it can be difficult and expensive for us to publish: copyright clearance is often particularly slow, use may be restricted by limited licences, and some artists will not permit their work to appear on websites. In the UK, copyright in a literary, dramatic, musical, or artistic work (including a photograph) lasts nuntil 70 years after the death of the author. Given the complexities of copyright clearance for such artwork, please let us do it and give us plenty of warning if you would like to include such images in your article.

If you find the ideal picture on a website we will still have to clear copyright. And, although the image may look right on your computer screen, it may not be good enough to print. Pixel strengths for screen use (72 dots per inch) and those required for good quality printing (300 dots per inch) are worlds apart. This means that we will have to find and request a high resolution version.

If you have found or produced pictures or other figures to illustrate your article please submit them to our online office along with your manuscript.

Image strengths should, ideally, be at least 300 dots per inch; those below 200 dots per inch may produce fuzzy images in print. Please supply image files at at least 100% of the intended printed size. We are unable to enlarge images by more than 5% from the original size supplied without a corresponding loss of quality. Please provide for each image a few words of text to explain its content (the legend) and say where it came from (the credit).

When submitting figures such as graphs, scattergrams, and histograms, please provide the numerical data on which they are based. We may decide that data presented in a histogram would be clearer and more useful in a table. The BMJ redraws some technical figures and line drawings, so please supply these in a clear enough format for our artist to follow.

We will not change any feature, person, or situation in an image with the intent to deceive by altering appearance or activity. Nor will we enhance or alter a clinical picture except to remove extraneous and distracting parts of the image. Journals have been cropping images in this way for decades, since long before the advent of digital photography. We do not enhance radiographs because they are not enhanced in real clinical practice. This means, however, that we will often have to decline to publish radiographs. They do not tend to reproduce well in print unless they are of very high resolution and quality.

We do sometimes alter non-clinical images, and our guidelines on this are listed below. And, very occasionally, we alter clinical images that we are using primarily as art rather than information, for example on The BMJ’s cover. When we have altered an image in any of these ways, we state this in the legend or cover note. If the colours in an electron micrograph, scintillogram, thermal image, or other clinical image has been enhanced or changed, please explain this in the legend.

Why we sometimes alter images in The BMJ:

• To enhance colour, sharpness, and texture without altering the intention or meaning of the image;
• To enhance text within the image to make it readable;
• To remove irrelevant text from an image that confuses the view or meaning of the image;
• To remove irrelevant features that detract from the image such as an arm appearing at the side of the photo or a lamp post apparently coming out of someone’s head;
• To delete one or more people from the background if their presence is irrelevant;
• To superimpose a person or other image on a different background to make a collage, not to deceive;
• To alter the image of a person in such a way that the alteration is obvious, is not offensive, and has a clear purpose (such as putting a modern character in historical costume); or
• To construct any collage from images that we have permission to use in that way,

These guidelines relate mainly to pictures used in the non-clinical sections of The BMJ, such as the news or reviews sections.