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Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population
  1. Arjun S Byju1,
  2. Kajsa Mayo2
  1. 1 Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
  2. 2 University of Rochester Medical Center, Rochester, New York, USA
  1. Correspondence to Mr Arjun S Byju, Yeshiva University Albert Einstein College of Medicine, Bronx, New York 10461-1900, USA; arjun.byju{at}


Defined as patients who ‘lack decision-making capacity and a surrogate decision-maker’, the unrepresented (sometimes referred to as the ‘unbefriended’, ‘isolated patients’ and/or ‘patients without surrogates’) present a major quandary to clinicians and ethicists, especially in handling errors made in their care. A novel concern presented in the care of the unrepresented is how to address an error when there is seemingly no one to whom it can be disclosed. Given that the number of unrepresented Americans is expected to rise in the coming decades, and some fraction of them will experience a medical error, creating protocols that answer this troubling question is of the utmost importance. This paper attempts to begin that conversation, first arguing that the precarious position of unrepresented patients, particularly in regards to errors made in their care, demands their recognition as a vulnerable patient population. Next, it asserts that the ethical obligation to disclose error still exists for the unrepresented because the moral status of error does not change with the presence or absence of surrogate decision-makers. Finally, this paper concludes that in outwardly acknowledging wrongdoing, a clinician or team leader can alleviate significant moral distress, satisfy the standards of a genuine apology, and validate the inherent and equivalent moral worth of the unrepresented patient.

  • decision-making
  • capacity
  • medical error
  • truth disclosure

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  • Contributors ASB: conceived of the original topic and thesis, conducted literature review and wrote the manuscript. KM: performed edits, contributed to discussion of ethics and apology and gave input on feedback on manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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