Clinical images are integral to medical education, research, and clinical communication. In digital environments, however, their circulation may extend far beyond the original context of care or publication. Once incorporated into textbooks, conference materials, online repositories, educational platforms, and digital archives, clinical images may persist for decades and move across jurisdictions, institutions, and technological systems [1-6]. Digital health governance frameworks increasingly address the ethical management of health data, secondary data use, and artificial intelligence (AI) applications in medicine [7-11]. These frameworks primarily emphasize prospective safeguards, including informed consent, lawful processing, data security, and accountability [12-18]. By contrast, comparatively less attention has been devoted to the long-term persistence and downstream reuse of legacy educational materials after their initial publication. This governance gap is particularly significant for clinical images because identifiability may persist even after partial anonymization. Existing publication guidance emphasizes that masking the eye region alone may not adequately protect anonymity and that consent should be obtained whenever identifiability cannot reasonably be excluded [1-6]. Recent studies similarly report uncertainty among clinicians, publishers, and editors regarding acceptable standards for publication and reuse of patient photographs in digital environments [3,4]. Within educational ecosystems, responsibility for consent verification is frequently fragmented. Authors, publishers, universities, libraries, repositories, and digital platforms operate within partially overlapping but insufficiently coordinated mandates. Publishers may rely primarily on author declarations without independent validation, while educational institutions may not systematically evaluate whether consent remains valid across subsequent editions, formats, or digital dissemination channels [1,2,4]. Pediatric clinical images require particular ethical attention because they originate in contexts characterized by vulnerability, dependency, and limited autonomy [19-22]. Individuals depicted in such materials may later encounter their own images in educational or online settings decades after image creation. These situations raise questions regarding privacy, dignity, autonomy, and long-term control over personal data. This viewpoint uses a longitudinal case involving pediatric clinical images disseminated without identifiable consent records as an analytical reference point for examining governance limitations related to persistence, reuse, accountability, provenance, and withdrawal of legacy clinical materials within contemporary digital health ecosystems. Rather than aiming to establish prevalence, the article uses this illustrative case to explore broader governance challenges associated with the long-term circulation of sensitive clinical materials across educational and digital infrastructures.

The governance concerns discussed in this article are illustrated through a longitudinal case spanning more than 3 decades (1991-2026). The discussion draws on educational materials, institutional correspondence, publisher communications, and regulatory findings related to the dissemination of pediatric clinical images across educational and digital infrastructures. The case came to attention in 2023 when an adult medical professional recognized his own pediatric clinical images in publicly accessible educational materials. The images originated from hospital-based clinical care during childhood and adolescence in Poland and had subsequently circulated through academic textbooks, conference presentations, lecture materials, e-books, digital repositories, and online educational platforms. The identified materials included more than 40 editions and reprints of academic medical textbooks in addition to conference resources, downloadable slide collections, and publicly accessible online teaching materials. Dissemination occurred across both print and digital environments, including institutional libraries, educational syllabi, online repositories, and multimedia-sharing platforms. The images included full-body representations of children approximately 3 to 17 years of age. In several instances, full facial features and intimate anatomical regions remained visible. Some materials contained no anonymization, while others used partial masking techniques such as covering the eye region. However, these measures did not reliably prevent recognition where additional facial, bodily, or contextual characteristics remained visible [1,3,5,6]. No identifiable evidence of informed consent for publication or long-term educational reuse could be located across the analyzed materials. The affected individual reported no prior awareness of the existence or dissemination of these materials before 2023. The case is informed by archival materials, institutional correspondence, and regulatory findings, including a decision issued by the Polish Patient Rights Ombudsman on August 27, 2025, concerning continued dissemination of intimate pediatric clinical images without verifiable consent. Identifying institutional and personal details remain intentionally limited because of ongoing legal and privacy considerations. Despite regulatory intervention, the materials remained accessible in 2026 across university libraries, academic reading lists, digital repositories, and previously distributed print editions. Institutional responses were fragmented and inconsistent, and no coordinated mechanism existed to support comprehensive provenance tracking, retrospective consent verification, or coordinated withdrawal across platforms and institutions.

This viewpoint illustrates how pediatric clinical images may persist across educational and digital infrastructures for decades without identifiable consent records, even after formal regulatory intervention. The documented case highlights governance limitations emerging not only at the point of initial publication, but also through the long-term absence of mechanisms capable of supporting consent traceability, provenance verification, coordinated withdrawal, and accountability across distributed systems. Current digital health governance frameworks remain primarily oriented toward prospective data collection and processing. However, the continued circulation of legacy clinical materials suggests the need for lifecycle-based governance approaches capable of addressing persistence, reuse, reidentification risk, and downstream dissemination within evolving educational and AI-enabled ecosystems [13,16-18,23-25]. This viewpoint proposes a lifecycle governance perspective for the long-term management of sensitive clinical materials, emphasizing retrospective consent verification, provenance-aware dissemination, reuse validation, and coordinated remediation mechanisms spanning health care institutions, publishers, educational systems, repositories, and digital platforms.