Observation is Never Merely Looking: Photography, Medicine, and the Problem of Interpretation

Introduction

Throughout the development of the photographic medium, attempts to improve medical care and expedite scientific advancement have led to the successful integration of new (and old) photographic techniques. From the ‘simple’ clinical portraits of patients to the complex and groundbreaking emergence of X-Rays and MRI scans, the relationship between photography and science has evolved in tandem, each advancing in response to the needs and possibilities of the other. This essay, through exploring the science/photography relationship, will argue that photography has incorporated itself into - and can continue to develop alongside - medicine. Whilst aiming to analyse how the relationship changes the fundamental understanding of photography, this essay will first begin by exploring whether or not all photographs are, in and of themselves, ‘scientific images’. Looking at the voice of Frizot, who argues in favor of a scientific understanding of photography, this essay will analyse how such an argument contrasts with Gunthert’s beliefs in photographic interpretation. It looks at discussing big questions behind the sociological understandings and perceptions of photography, such as the fundamental question: What can be considered a photograph, and are these photographs inherently scientific?. The first section aims to document the pertinent voices of this discourse, and to analyse comparative arguments to draw conclusions as to the most logical way to perceive and categorise such photographic relationships. The second section of the essay, through looking at notorious clinical photographers such as Diamond and Duchenne, will also discuss the historical role of photography in science and medicine, outlining potential ethical concerns and power imbalances. It will dissect the unavoidable imbalances of power between the doctor/patient relationship, and contextualize historically, how such relationships have tipped the scales towards an abuse of power. Such discourse leads on to the third section of the essay, which will discuss how power imbalances, biases, and ethical considerations can impact the perceived and consequential veracity of photographic imagery, and what this therefore means for the photographic medium within a medical and scientific context. Whilst questioning the objectivity and veracity of imagery, this essay will argue that whilst photography can aid scientific and medical observation, it requires critical and intellectual interpretation. Throughout the three sections, this essay will overall explore the photography/science relationship, and how sociological perceptions, understandings, and historical usages of the medium, can impact veracity, and what this means for the future of the integration of photography into science, and its uses within a medical context. It aims to future-proof the photography/science relationship, through deconstructing sociological ideas, as well as historical criticisms, to integrate a better understanding of how photography can be utilised with a scientific and medical context. 

Section 1 - What is a scientific image, is all photography scientific images ?

The consideration of what defines a photograph as a scientific image has been held under pertinent discourse for several decades. There are, arguably, two key individuals at the deictic centre of this discourse. In his book ‘A New History of Photography’, Frizot (1998) described ‘photography’s artistic ambitions’ (pp. 273) as having often been regarded as ‘more important than its other uses’ (pp.273). Those other uses, he continues to describe, have been separated into a variety of categories, one of those categories being ‘“scientific photography”’ (pp. 273), which was designated its own category as a means to ‘make it easier to classify work along corporatist lines, in a developing context of craft-activity which permitted few deviations from the norm’ (pp. 273). Frizot’s argument therefore follows that what is commonly recognised as ‘photography’ tends to privilege its artistic or expressive functions, and photographic expressions that follow more corporate and regimed functions (such as medical photography) are frequently overlooked as legitimate photographic practices. These other such mediums are often considered ‘less noble’. Frizot, however, endeavours to adjust to a new pathway of thinking, instead positing that ‘all photographs can a priori be considered to be scientific images’ (pp. 273). His justification for such claims is that photographs are ‘measurements of luminous phenomena’ (pp. 273), created by instruments whose ‘parameters and mechanisms are controlled by the user’ (pp. 273). It is therefore clear that a photograph could justly be defined as a scientific image, by reason of its very nature of production. It is created, at its very basic understanding, to be a measurement of light, and therefore as they are able to be used as such, cameras and photographs are tools of science. 

Frizot further justifies this claim of science by elaborating on his understanding of a photograph's use of light, reiterating his belief that cameras are instruments which record and measure. He poses how photographs from the beginning ‘challenged the limits of our visual perception’ (pp. 273), inarguably referencing the many scientific advancements and discoveries we have been able to attribute to how photography allows us further visual analysis, such as X-Rays, MRI and CT scans. He critiques this modern development of photography, in which aesthetics have taken rise and we’ve forgotten the scientific roots of the photographic medium, discussing that prior to this development 

‘it mattered little whether the images produced were “beautiful” - it was enough to know that they added in some way to our vision of the world providing information that was accessible to everyone, everyone, that is, who knew how to interpret it’ (Frizot, 1998, pp.273).

It is clear that to Frizot, it is important to consider the roots of photographic development, and appreciate how photography has not always been a tool of artistic creation, limited by rules and bound by interpretations, but rather a tool of scientific development. It flourished, juxtaposed, under the strict, corporatist and clinical world of science. The photographic medium paved the way for new discoveries, and it was not a tool which had to produce something of ‘value’, as its productions were inherently valuable in the nature of themselves. 

One could consider, however, the proposition that we should instead shift the focus of the analysis of the photography/science relationship towards how the images are received, instead of how they are produced (Gunthert, 2000, My translation). 

‘The determination of photography as a tool of vision is fundamentally based on a change in the perception of the images produced, a change which depended less on their actual results than on their interpretation, within the framework of a voluntary strategy of bringing together photography and science’ (Gunthert, 2000, pp.29-30, My translation).

Gunthert therefore disagrees with Frizot, arguing that photographs are not inherently scientific as the dissection of the photography/science relationship falls not upon the creation of an image, but rather on the interpretation of it. Gunthert alludes to the notion that, rather critically, the landscape of photography is changing, and the veracity of imagery is under more critical analysis than ever. Whilst he was writing this from the photographic perspective of 2000, it remains, in the contemporary understanding of photographic discourse, more true than ever. The ‘bringing together’ (Gunthert, 2000, pp.30, My translation) of photography and science has been a voluntary strategy, not a natural one. Photographs are not inherently scientific by nature, rather we have intentionally sought to use photographs as a scientific tool. Gunthert (2000, My translation) describes Frizots diagnosis as a misunderstanding, arguing that it is a ‘theoretical and tactical elaboration’ (pp.29) of Jules Janssen’s famous formula, ‘photography is the retina of the scientist’ (pp.29). It is by this argument that it is clear that Gunthert disposes of Frizot’s position entirely. Whilst Frizot critiqued this over-interpretive culture that’s begun to develop with the photographic medium, Gunthert welcomes it. He stands on the irrelevance of the creationary period of an image, asserting its importance only once it has been created. 

The ‘heuristic function’ (Gunthert, 2000, My translation) of photography is an idea brought up by Gunthert, in his aims to characterise the medium as one which can help discover. It is this ‘heuristic function’ which allows emphasis to be placed on the interpretation of images, not the creation of them. This is not an unsimilar parallel to that drawn by Frizot, as aforementioned in this essay, his argument from the start, was that photography provided ‘information that was accessible to everyone, everyone, that is, who knew how to interpret it’ (Frizot, 1998, pp.273). It is therefore to be acknowledged that both Gunthert and Frizot believed in the use of photography as a tool of science, however the differences lie in the application of meaning within the medium. Frizot’s understanding of all images being scientific, allows for a better understanding of the origins of photography, and perhaps a more insightful approach to the use of it within science. Gunthert’s reasoning that a photograph can only be understood as a tool of science insofar as its interpretation, allows for more movement amongst creative approaches to the medium; its acceptance as a heuristic tool dictates that its use within science is not limited. 

The discourse of photography as a tool of science is important, in order to understand how the medium sits within a medical context. There are many social understandings of photography, largely within a creative context, however the field of photography can also be understood along more corporatist lines. 

Section 2 - The history of photography within science

Soon after its creation, photography was very quickly understood as a useful tool within science. In the 1840s, French physician Alfred Donné and his assistant Léon Foucalt presented their microphotographic representations of various bodily secretions to the French Academy of Sciences. In 1895, Wilhelm Roentgen discovered X-Rays, in which immediate attempts were made as to the applications of this within a medical context (Curtis, 2012). Some of the most notable examples of the early use of photography in medicine are clinical portraits. A prominent example of this being Hugh W. Diamond’s clinical portraits demonstrating the ‘Physiognomy of insanity’ (Royal College of Physicians, 2023). 

‘As an early photography enthusiast, and also the superintendent of an asylum in Surrey, Dr. Hugh Welch Diamond was the first practitioner to use photography in a way that he believed enhanced the effectiveness of his diagnosis therapeutic treatments. To him, photographs preserved a faithful and accurate medical record’ (Royal College of Physicians, 2023). 

Diamond believed that physiognomy (the inaccurate belief that different features of, in this case, mental illness are expressed in the outer appearance, facial expressions, body gestures, hairstyles and even the outfits of patients) could be used to diagnose mental health issues, and took photographs in an attempt to cure these individuals by shocking them into a sane state of mind. The people he photographed were all women, and aside from the notable male/female power imbalance that reverberated through society at that time, there remained still a palpable power imbalance between the photographer and the individual having their photo taken. Not only was Diamond likely to be the only one in the pair able to function and understand a camera, he also held a hierarchical position above the women both in career and in that these were lower-class, vulnerable women who were not considered to be of sane mind. Whilst these photos were intended to be clinical portraits that ‘presented a faithful and accurate medical record’ (Royal College of Physicians, 2023), Diamond would dress and pose the women as he wanted. This representation of mental health through clinical portraiture was one of power and control, and a reflection of the white and wealthy. When considering how photography has been used in the aforementioned manner, it leaves many questions as to how the use of photography within medicine should be regulated. Physiognomy has since been debunked countless times, and does not hold much weight in contemporary medical practices, however this highlights the unstable veracity of imagery and interpretation, especially when we are bound by faulty observation. 

Similarly, French neurologist Guillame Benjamin Amand Duchenne believed that photography could be used to capture emotions and was a reliable form of documentation, saying himself that ‘Only photography, as truthful as a mirror, could attain such desirable perfection’. This wavers, however, in our understanding of the counterfeit clinical portraits of Diamond. Whilst both examples remain significantly outdated, the modern approach to clinical photography has been described, as recently as 2002, as an entirely ‘one-way process’, in that ‘The clinicians reap any benefits and little attention is paid to the person within the photograph’ (Creighton, Alderson, Brown and Minto, pp.67, 2002). It is rather easy, in clinical photography, to see the patient as an unusual case or one of particular interest, rather than an actual living and feeling human being. 

In a blog post from 2012 (author unknown), Henry Sigerist is referenced. Sigerist, writing from a medical perspective on the doctor-patient power imbalance in 1932, wrote that 

‘“The physician’s profession gives him power. The physician knows poisons. More than that: chemical, physical and biological forces of high potency are placed freely in his hands. The physician enters all homes on the strength of his profession. Secrets are divulged to him which the patient would hesitate to tell to his closest relations and they give the physician power over the patient”’ (NO NAME, 2012).

The author of the blog muses in response to Sigerist’s words that this power imbalance has only grown in the modern world. They speak from their own personal experience, as a worker in the medical industry, of the weight they know their words carry. It weighs heavier on the scales of power, however, when photography is introduced to the mix. Clinical photographs are just the tip of the iceberg; when MRIs, CT scans and X-rays are a useful tool and one which is often incredibly anxiety inducing for the patient, the medical professional behind the imagery holds a great amount of power in their hand. When working with someone who may very well be making a life or death decision, especially one they are so fearful of, but must take with so few options, it is integral that great care is taken. Can informed consent of these photos truly be given, however, when the power balance scales are so heavily tipped one way? This question leads us to a much larger point. We may be hyperconscious of the power imbalance and subsequent ethical considerations, but what does this mean for the veracity of imagery when used for medical observation? If patients can be so easily persuaded, and so easily guided by doctors, there can be no true and confident assertion as to the veracity of a medical photograph. The veracity of photography therefore leaves much to be desired, and even further begs the question, is it reliable in practice as a visual of observation?

Section 3 - Photography as a visual for observation

When considering photography as a visual for observation, Curtis (2012), looked towards Bernard’s understanding, within his book ‘An Introduction to the Study of Experimental Medicine’. Curtis stated that ‘Observation should not intervene, like experiment, instead, it should merely record, describe, even transcribe “nature’s dictation”’ (Curtis, 2012, pp.68). At first, this is a reasonable conclusion to draw. When approaching photography as a tool of visual observation, especially in a medical context, it is important to remain aware of your observations, and not allow for them to be impacted by any pre existing connotations. It is, however, imperative to understand that not only is the veracity of photography much brought into question, but it is almost impossible to achieve the complete objectivity of an observer. 

Burdened by pre-existing beliefs, as aforementioned, Hugh W. Diamond had intentionally altered the perception of the images taken in order to further his agenda. Whilst this does represent a rather extreme case within history, it points out an unavoidable truth about human objectivity. We cannot, in any case, be trusted to unbiasedly ‘transcribe “nature’s dictation”’. At best, one can describe what is seen, but interpreting the data as is needed in such a field as medicine, a certain level of trained skill is required. 

Observing medical imagery is not a neutral act, and medical professionals are taught what to look for through pattern recognition, hypothesis formation and comparison - which again leads to the reiteration of Curtis’ point that ‘Observation is never merely looking, it is an intellectual process of comparison’ (Curtis, 2012). As explained in the paper Learning to look: developing clinical observational skills at an art museum, the skills underlying these actions are, however, ‘rarely taught in medical school’ (Bardes, Gillers and Herman, 2001);

‘In clinical diagnosis, the physician observes, describes, and interprets visual information. However, the skills underlying these actions are rarely taught explicitly in medical school. Courses in physical diagnosis teach the students to recognize normal and abnormal findings, especially the cardinal signs and symptoms of disease, but do not emphasize the actual skill of careful looking in itself. Looking is often assumed.’ (Bardes, Gillers and Herman, 2001). 

The paper's introduction then goes on to elaborate that contrary to this, in visual arts ‘the act of looking carefully is made explicit’ (Bardes, Gillers and Herman, 2001). It was therefore hypothesised that by looking at paintings, medical students would be able to improve their visual literacy and observational skills, and that these skills would then be able to be translated towards the observation of patients. Such hypotheses were later proven to be correct, with results showing that

‘Improvement in skills were documented by comparing comments from the pre-test and post-test. In the pre-test, describing a photograph of a middle-aged woman, students focused on her grooming, make-up, and jewellery, as well as describing her features objectively. In the post-test, describing the same photograph, students were more precise in their descriptions. They also inferred more from their observations, remarking that the subject appeared sad, anxious, worried, and perhaps ill as well.’ (Bardes, Gillers and Herman, 2001).

Other medical training institutions, such as Yale or Harvard, have often included art analysis training into their courses in order to improve diagnostic evaluation and visual literacy (Naghshineh et al., 2008). Another study from 2008, aimed to ‘improve students’ visual acumen through structured observation of artworks, understanding of fine arts concepts and applying these skills to patient care’ (Naghshineh et al., 2008); the study results ultimately found that students who had participated - in comparison to their classmates who did not - ‘had increased sophistication in their descriptions of artistic and clinical imagery’ (Naghshineh et al., 2008). 

The findings of both of these studies suggests that art can and does play a huge role within science and medicine. Not only within its more practical aspects, i.e, the integration of photographic medical imaging, but also in regards to theoretical and training aspects of the medium. It also refines further the notion that observation is an intentional skill, and requires specific training - and perhaps assistance to execute more accurately; this can be understood as to where the integration of photography plays a role.

When considering only clinical portraits and medical images of things which can be seen with the naked eye (therefore excluding medical practices such as X-Rays, CT scans, etc.), we can of course understand that photographs may not reveal what they purport to. When taken with the aim of simply documenting ‘Nature's dictation’ however, with as little interference as possible, then any observational mistakes lie largely on the observer, and thus could be made regardless of whether the observations are made through looking at a photograph, or the patient themselves. This poses a new lease for clinical imaging, and a new found sense of trust as the burden of impartiality has been lifted from the shoulders of the photographic medium. Impartial observation relies on the observer, but a photograph can be used to aid such observations. Such uses of photography clinically also allow for documentation of changing conditions. Take, for example, a patient with a rash. Should the rash be changing and developing in significance quickly, photographic documentation of the ailment would allow for observation of changes. 

At large, this essay has discussed clinical imagery and the veracity of such endeavours. In contemporary medical practices however, photography is largely used for observation of features not available to the naked eye. 

Photography is often used within medicine as a basis for empirical observation of phenomena which is hidden to the naked eye, however, such observations may become significantly less substantial when the veracity of truth claims is unconscionable. Whilst photography is integrated into medicine to ‘insure this state of pure receptivity’ (Curtis, 2012, pp.68), it is critical to acknowledge that our understanding of a camera's objectivity relies solely on the camera’s ‘perceived ability to document phenomena “objectively”’ (Curtis, 2012, pp.69). When considering the place of photograph within a medical context, an intellectual and active approach to understanding must therefore be undertaken. One cannot idly sit back and merely observe photographic imagery, for photographs cannot be taken ‘objectively’. 

‘These authors therefore recognised, as did Bernard, that observation is never merely looking - it is also an intellectual process of comparison’ (Curtis, 2012, pp.78). 

With this reasoning, it remains consistent with the truth that photography may somewhat accurately be considered a dependable tool for medical observation. A scientist can rely on a photograph to provide, in a few circumstances, a methodology of archival observation. Whilst it remains consistent that the veracity of imaging is not unwavering, and the discourse is well academised, the postulation that the skill of observation relies tactically on an intentional and intellectual process confirms the factuality that a photograph may be relied upon for scientific observation, if done so with care and intent. If we take, for example, the ampleness of X-Rays within a minor injuries unit, we can ascertain that the medical industry is already aligned with such ideas, and photography has successfully incorporated its condition as a document into various areas of the scientific registry. 

Whilst observational skills and visual literacy can be improved through the use of advanced photographic imaging, and through the incorporation of visual arts training into medical students’ curriculum, the presence of human bias remains. It is important that these biases remain acknowledged, as even with training, doctors can misinterpret images due to unconscious bias, or lack of diversity in training materials. There is a lot of literature available which documents racial inequities in health care delivery, and some research suggests that these inequities are embedded in the curricular edification of physicians and patients (Louie and Wilkes, 2018). A paper entitled Representations of race and skin tone in medical textbook imagery investigated this hypothesis by ‘considering whether the race and skin tone depicted in images in textbooks assigned at top medical schools reflects the diversity of the U.S. population’ (Louie and Wilkes, 2018). Through conducting this research, the paper found that although racial diversity amongst textbooks seemed to accurately represent racial diversity within the US, the came could not be said for skin tones;

‘While the textbooks approximate the racial distribution of the U.S. population - 62.5% White, 20.4% Black, and 17.0% Person of Color - the skin tones represented - 74.5% light, 21% medium, and 4.5% dark - overrepresent light skin tone and under represent dark skin tone’ (Louie and Wilkes, 2018). 

These findings suggest that medical students are being trained and educated through textbooks which do not accurately represent populations. The underrepresentation of darker skin tones ultimately leads to poorer ability to observe, recognise and diagnose in patients with darker skin tones. Accordingly, it becomes necessary to recognise that an over-reliance on visual ‘evidence’ can reinforce systemic disparities if not critically examined. In medicine, photographs are often treated as neutral or objective, however images do not interpret themselves. If the medical professionals who are interpreting them are operating with unconscious biases, then the decisions made from those images - such as diagnostic or treatment pathways - can reflect and amplify existing inequalities and inequities. 

As discussed, observation and photography can often go hand in hand; visual arts training can improve visual literacy in medical students, and more advanced photographic medical imaging allows for the visual observation of phenomena hidden to the naked eye (X-Rays, CT Scans, MRI Imaging, etc.). It is, however, important to recognise a key and burgeoning component of the photographic medium and medical field: the introduction of artificial intelligence (AI). 

Amongst the developing AI boom of the 21st century, AI has become increasingly integrated into medical diagnostics. A paper from 2017 outlined how an artificial intelligence algorithm had been developed that could ‘detect pneumonia from chest X-rays at a level exceeding practicing radiologists’ (Rajpurkar et al., 2017). This shows huge potential in the developing world of medical diagnostics, however it could raise concerns about photography shifting away from human interpretation. One major concern lies in AI’s supposed ‘objectivity’. As a visual for observation, as aforementioned, it could be argued that a photograph only has meaning insofar as one interprets it. When considering this philosophy and its applications amongst medical photography, it reveals the need for trained eyes to interpret medical imaging for diagnostic purposes. The introduction of AI into this role may purport to provide a seamless and more advanced interpretation and diagnostic recognition, however the hamartia of an AI hero lies amongst its creationary faults; AI is only as accurate as it is trained to be. The biases held by medical professionals, as aforementioned, can seep into diagnosis and medical interpretations. This calls into question if AI is really a superior diagnostic tool, or is it itself burdened by the preexisting beliefs already held by society?

A paper entitled ‘Dissecting racial bias in an algorithm used to manage the health of populations’ (Obermeyer et al., 2019) investigated a widely used commercial algorithm used by health systems in order to ‘identify and help patients with complex health needs’ (Obermeyer et al., 2019). These health systems use metrics such as health care cost predictions rather than illness, however unequal access to care means that less money is spent caring for black patients than it is for white patients (Obermeyer et al., 2019). This paper therefore found that, given this disparity, ‘despite health care cost appearing to be an effective proxy for health by some measures of predictive accuracy, large racial biases arise’ (Obermeyer et al., 2019);

‘Remedying this disparity would increase the percentage of Black patients receiving additional help from 17.7 to 46.5%... We suggest that the choice of convenient, seemingly effective proxies for ground truth can be an important source of algorithmic bias in many contexts’ (Obermeyer et al., 2019).

This demonstrates that whilst AI can in theory reduce bias, it often simply reproduces biases found in the data it is trained on, fundamentally changing nothing, and reinforcing said biases. AI may be able to visually identify more in a photograph than humans (such as subtle pixel variations, or faster processing in regards to pattern recognition), however it cannot ethically interpret the data or its conclusions. Such points bring the discourse back to Curtis’ (2012) aforementioned contention that ‘Observation is never merely looking, it is an intellectual process of comparison’.

Conclusion

This essay aimed to disseminate pertinent arguments within the discourse of the photography/science relationship and reevaluate photography’s place within medicine. It aimed to adequately identify cause for concern within the photographic medium, and how this should be approached when incorporating photography into medicine. Section one discussed key sociological discourse surrounding the perception, and understanding, of what photography is. It broke down arguments from two prominent figures within the topic, each perpetuating their own view of the medium, one which either ties or somewhat separates itself from the realm of science. Section two went on to look at historical imbalances of power regarding the introduction of photography into medicine. It discussed how such imbalances occurred, looking at notable figures such as Hugh W. Diamond, and his treatment of female patients. This section also looks at, more broadly, how such imbalances can occur today. Irrespective of the current societal dismissal of such blatant misogyny and purposeful fraudulent clinical outputs, it looks towards how photographic doctor/patient power imbalances can a occur in a contemporary medical field. The third section of this essay draws on understandings from the first two sections, looking towards what this means for the veracity of photography, and therefore how that impacts its applications within a medical context - a context which often requires specific care and a level of confident certainty. This essay concludes that despite historical grievances and less than desirable applications and merges of the mediums, photography can continue to remain a useful and adaptive part of the scientific and medical registry. Despite its wavering veracity and the imperfect observational ability of the human observer, photography remains to be a reliable and particularly useful tool within science and medicine, so long as such observations and conclusions drawn from its usages are made purposefully and with intention. It is important for observers to be aware of biases, faults, and misconceptions of photographic outputs, therefore such discussions of discourse that have been held and acknowledged throughout this essay, are important to maintaining a trustworthy, reliable, and constantly advancing scientific tool. Photography remains not only a tool for creative expression and artistic outputs, but it moulds well with the corporate and clinical medium of science and medicine, perpetuating a more detailed and functional future in the way of scientific observation. 

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