To Tell the Truth
Ethical and Practical Issues in Disclosing Medical Mistakes to Patients
Albert W. Wu, MD, MPH, Thomas A. Cavanaugh, PhD, Stephen J. McPhee, MD,
Bernard Lo, MD, Guy P. Micco, MD
While moonlighting in an emergency room, a resident
physician evaluated a 35-year-old woman who was 6
months pregnant and complaining of a headache. The
physician diagnosed a “mixed tension
The patient returned to the ER 3 days later with an in-
tracerebral bleed, presumably related to eclampsia, and
made mistakes, but physicians often do not tell patients
or families about them.
Even when a definite mistake
results in a serious injury, the patient often is not told. In
one study, house officers reported telling their attending
physicians about serious medical mistakes only half the
time, and telling the patients or families in less than a
quarter of cases.
Highly publicized cases of fatal mis-
takes have heightened public and professional concerns
about how physicians and hospitals respond to serious
mistakes. When mistakes are not acknowledged in a
timely manner, there may be a perception of a cover-up,
and public confidence in physicians may be undermined.
The American Medical Association’s (AMA’s)
ples of Medical Ethics
(1957) states that a physician must
report an accident, injury, or bad result stemming from
his or her treatment.
However, many physicians inter-
pret these requirements to mean that they should report
to their superiors or to the hospital quality assurance or
rrare humanum est
practice, mistakes are common, expected, and under-
Virtually all practicing physicians have
: “to err is human.” In medical
risk management committee, rather than to the patient.
More recently, the
American College of Physicians Ethics
states, “physicians should disclose to patients in-
formation about procedural and judgment errors made in
the course of care, if such information significantly affects
the care of the patient.”
The AMA’s Council on Ethical
and Judicial Affairs states, “Situations occasionally occur
in which a patient suffers significant medical complica-
tions that may have resulted from the physician’s mistake
or judgment. In these situations, the physician is ethically
required to inform the patient of all facts necessary to en-
sure understanding of what has occurred.”
In this article, we analyze the various ethical argu-
ments for and against disclosing serious mistakes to pa-
tients. We also provide practical suggestions for how to
discuss the sensitive topic of mistakes with patients.
WHAT IS A MISTAKE?
We define a medical mistake as a commission or an
omission with potentially negative consequences for the
patient that would have been judged wrong by skilled and
knowledgeable peers at the time it occurred, independent
of whether there were any negative consequences. This
definition excludes the natural history of disease that
does not respond to treatment and the foreseeable com-
plications of a correctly performed procedure, as well as
cases in which there is reasonable disagreement over
whether a mistake occurred.
We categorize errors according to their genesis. Sys-
tem errors, also referred to as latent errors,
ily from flaws inherent in the system of medical practice.
In such errors, the system “sets up” individuals to make
mistakes, i.e., through the unavailability of medical records,
by confusing labeling of medications, and the like. When
a system error occurs, the physician shares responsibility
with other elements of the health care delivery system.
Conversely, individual errors are those deriving pri-
marily from deficiencies in the physician’s own knowledge,
skill, or attentiveness. For instance, a physician mistak-
enly prescribed a nonsteroidal anti-inflammatory agent to
a patient with renal insufficiency, resulting in perma-
nently worsened renal failure.
ual error, the physician has primary responsibility.
In such a case of individ-
Received from the Department of Health Policy and Manage-
ment School of Hygiene and Public Health, and the Division of
Internal Medicine, Department of Medicine, Johns Hopkins Uni-
versity, Baltimore, Md. (AWW); the Department of Philosophy,
University of San Francisco, Calif. (TAC); and the Division of
General Internal Medicine, Department of Medicine, University
of California, San Francisco (SJM, BL, GPM).
Presented in part at “Examining Errors in Health Care: De-
veloping a Prevention, Education and Research Agenda,” Octo-
ber 13–15, 1996, Rancho Mirage, Calif.
Address correspondence and reprint requests to Dr. Wu:
Health Services Research and Development Center, 624 North
Broadway, Baltimore, MD 21205.
Volume 12, December 1997
The considerations in the disclosure of latent errors
differ from those in the disclosure of individual errors. For
example, in a latent error, the physician is often one link
in a chain of causes generating the error. Accordingly, the
disclosure of such an error may not be the sole responsi-
bility of the physician. In what follows, we consider only
the arguments for a physician to disclose his or her indi-
vidual error to a patient. We also restrict ourselves to mis-
takes that cause significant harm, without regard to their
Errors causing harm can be subdivided into cases
that are not medically remediable and those that are med-
ically remediable. We argue that the physician has an ob-
ligation to disclose mistakes that cause significant harm,
which in the judgment of a risk manager or malpractice
insurer is likely to be remediable, mitigable, or compen-
sable. Only in rare cases would a physician be permitted
not to disclose a mistake causing harm to the patient.
Specifically, physicians might be permitted not to tell if
they have good reason to believe that disclosure would
undermine the patient’s autonomy in some way (e.g., in-
capacitate the already severely depressed patient). Or the
patient might have told the doctor explicitly, “Doctor, if
anything goes wrong, I don’t want to know about it.”
Two ethical theories assist in thinking about the dis-
closing of a mistake: consequentialism and deontology. A
consequentialist ethical theory holds that one ought to do
that act which will realize the best overall consequences.
A deontological theory maintains that one ought to do
that act by which one fulfills one’s duties or obligations.
Both consequentialist and deontological theories ground
arguments for disclosure. In what follows, we first con-
sider arguments based on consequences; then, we attend
to arguments based on a physician’s duties.
POTENTIAL BENEFITS AND HARMS
Potential Benefits of Disclosure to the Patient
The patient could benefit in many ways from knowing
that a mistake had occurred. Such knowledge would al-
low the patient to obtain timely and appropriate treat-
ment to correct problems resulting from the mistake. Dis-
closure therefore can prevent further harm to the patient.
In some situations, close monitoring or a medical proce-
dure may be necessary to mitigate the consequences of a
mistake. Patients may be unwilling to permit or cooperate
with necessary measures if they are unaware of the rea-
son for doing so.
When further treatment is indicated,
disclosure is essential for informed consent. Otherwise,
the uninformed patient is placed at risk of subsequent
misdiagnosis and improper or inadequate treatment.
Disclosure of a mistake may also prevent the patient
from worrying needlessly about the etiology of a medical
problem. For example, a patient who was prescribed too
much warfarin resulting in excessive anticoagulation suf-
fered a gastrointestinal bleed. Telling patients about such
mistakes may resolve their uncertainty about the cause of
their condition, possibly allowing them to feel better by
explaining that recurrence would be unlikely.
Disclosure of a mistake also provides patients with
information needed to make informed decisions. Patients
may develop more realistic expectations about their doc-
Acknowledgment of fallibility brings
uncertainties into the open, reduces the possibility of
misunderstandings, and encourages the patient to take
greater responsibility for his or her own care.
In the case of an injury, knowing about a mistake
may allow the patient to obtain compensation for lost
earnings or to pay for care necessitated by the injury,
to at least get a bill written off. Such compensation might
be obtained through settlement rather than lawsuit; un-
der the current system, obtaining such compensation
would be difficult or impossible without disclosure of the
Finally, disclosure of a mistake can promote trust in
physicians. Patients have a presumption of truth-telling.
Thus, a patient who is not informed of a mistake may feel
angry and betrayed
; the patient may think that a privi-
leged relationship has been violated.
Potential Harms of Disclosure to the Patient
Patients may be harmed by learning that a mistake
was made in their care. The knowledge may cause alarm,
anxiety, and discouragement. It may destroy patients’
faith and confidence in the physician’s ability to help
them. Patients may become disillusioned with the medical
profession in general. This may cause them to decline
beneficial treatments, or decrease their adherence to ben-
eficial treatment regimens or habits.
Not all patients want to know everything about their
medical care. Some would rather not be burdened with
the complexities of their illness. The well-meaning disclo-
sure of potentially serious, but inconsequential mistakes
may cause unwelcome confusion. In such cases, patients
may feel they would be better off not knowing that a mis-
take had been made in their care. As the
of Physicians Ethics Manual
states, “society recognizes the
‘therapeutic privilege,’ which is an exemption from de-
tailed disclosure when such disclosure has a high likeli-
hood of causing serious and irreversible harm to the pa-
tient.” However, the American College of Physicians offers
the following caution: “On balance, this privilege should
be interpreted narrowly; invoking it too broadly can un-
dermine the entire concept of informed consent.”
Potential Benefits of Disclosure to the Physician
The physician might also benefit from disclosing a
mistake to the patient or family. The knowledge of making
a mistake that harmed a patient can cause the physician
to experience great emotional distress.
Wu et al., Disclosing Medical Mistakes
cian may be relieved to admit the mistake. In the case of a
serious mistake, the patient or family member may be the
only person able to forgive the physician for making the
mistake. This may be the only way for the physician to
gain absolution for the mistake.
ate the physician’s honesty, and disclosure of a mistake
actually may strengthen the doctor-patient relationship.
For example, when one of the authors failed to obtain a
serum ferritin test during the evaluation of a patient re-
ferred for an enlarged liver, the diagnosis of hemochroma-
tosis was delayed significantly. When the patient was told
about the omission, he responded, “That’s O.K. After all,
doctor, you can’t think of everything.”
Candid disclosure of a mistake may decrease the like-
lihood of legal liability.
Some have suggested that a
strong doctor-patient relationship makes patients less
likely to bring suit.
Furthermore, if the patient learns
about a mistake and brings a lawsuit, failure to disclose
may place the physician in greater jeopardy.
Disclosing mistakes may help physicians to learn and
improve their practice.
In a survey by Quill and William-
son, responding physicians reported that sharing errors
with colleagues, students, friends, and sometimes pa-
tients prevented isolation, and marked the beginning of
grieving about and learning from the mistake.
a mistake may also help the physician accept responsibil-
ity for it, and may help the physician make constructive
changes in practice.
Physicians may also learn vicari-
ously from mistakes made by others, and be able to avoid
making similar mistakes themselves.
Many patients appreci-
Potential Harms of Disclosure to the Physician
Revealing a medical mistake to a patient is often diffi-
cult and painful for the physician. The patient may be-
come angry and upset, and such reactions can be highly
stressful to doctors.
Many physicians fear that disclosing a serious medi-
cal mistake will expose them to the risk of a malpractice
suit. If a lawsuit ensues, the physician may be subjected
to increased malpractice premiums as well as psychologi-
Disclosure of a mistake may harm the physician
through loss of referrals, hospital admitting privileges,
preferred provider status, credentials, and even licensure.
Selective contracting and physician profiling by managed
care organizations create more tangible threats to the
physician’s livelihood. The development of the National
Practitioner Data Bank
adds the possibility that an inci-
dent will leave a permanent mark on the physician’s
record. Disclosure of mistakes may also damage the phy-
sician’s reputation through the loss of respect or status
among colleagues. In small communities, the physician’s
public reputation may also suffer.
Following disclosure of a serious error, the career of a
physician-in-training may be harmed by poor evaluations
or letters of recommendation, or even dismissal. Even
without the expectation of overt punishment, it is difficult
to admit wrongdoing.
A consequentialist argument for the disclosure of
mistakes to patients would be framed in terms of the
above-noted benefits and harms to individual patients
and physicians. In the doctor-patient relationship, a phy-
sician is to act for the sake of the patient; therefore, in
weighing the benefits and harms of disclosure, the bene-
fits and harms to the patient should have greater weight
than those to the physician. There are also duty-based
grounds for holding that, in certain cases, a physician
should disclose medical error to a patient. We now turn to
THE PHYSICIAN’S DUTIES
In what follows, we argue that a physician’s responsi-
bility to disclose a mistake to a patient can be derived
from the fiduciary character of the doctor-patient rela-
tionship (that is, the fact that this relationship is based
The fiduciary character of this relationship
can be further articulated in accordance with the princi-
ples of nonmaleficence, beneficence, respect for patient
autonomy, and justice.
Primum non nocere
, “first, do no harm,” states the
principle of nonmaleficence: a caregiver has a grave re-
sponsibility to avoid harming the patient.
ple of beneficence enjoins physicians to act for the best
interests of their patients’ health even if the physician’s
own financial or professional well-being is not benefited
by so acting.
In cases in which harm resulting from a
mistake can be reversed or ameliorated, the physician is
obligated to do so. For example, if a sponge has been left
in a patient after surgery, the sponge can be removed and
infection can be prevented. In such cases, remedying or
mitigating the harms caused by a mistake often requires
the physician to disclose the mistake to the patient.
Respect for patient autonomy enjoins physicians to
disclose a mistake that seriously harmed a patient.
is the case when full disclosure frees patients of mistaken
beliefs concerning their past, present, or future medical
conditions, thus enabling them to make informed deci-
sions about future medical care.
even if the patient does not need to know of the error in
order to make future decisions about medical care. This is
because patients have a claim to know their own history
and to be free of mistaken beliefs concerning their past,
present, or future medical condition.
cian’s obligation to respect patient autonomy indicates
that a doctor has an ethical obligation to disclose mis-
takes to patients.
When a nonremediable mistake has been made, the
doctor may have an ethical duty to disclose it to the pa-
tient so that the patient can be compensated. Justice re-
quires that people be given what is due to them. It would
be unfair not to compensate a patient who was seriously
harmed by mistake, e.g., for further medical care necessi-
It may also be the case
In short, a physi-
Volume 12, December 1997
tated by the mistake, for income lost due to the mistake,
for pain and suffering, or for loss of function. The more
serious the harm and the greater the need of the patient
for compensation, the greater the physician’s responsibil-
ity to make amends.
Physicians may be less obligated or not obligated at
all to disclose a mistake that had little marginal impact,
such as a serious medication error involving a moribund
patient or the failure to recognize a pneumothorax caused
during a failed attempt at cardiopulmonary resuscitation.
Although it can be argued that disclosure is discretionary
in these cases, the counter-argument can be advanced
that even these mistakes should generally be disclosed.
The physician has little to lose by so doing. These cases
may provide a good opportunity for open and honest dis-
cussion and may strengthen the relationship with the pa-
tient or family.
In summary, the fiduciary character of the doctor-
patient relationship indicates that a physician has the
ethical duty to disclose error to a patient when disclosure
furthers the patient’s health, respects the patient’s auton-
omy, or enables the patient to be compensated for serious,
Practical Issues in Disclosure of Mistakes
Accepting the physician’s obligation to disclose mis-
takes, there are practical issues concerning whether,
when, who, and how to tell about the mistake. For uncer-
tain cases, who should decide whether or not to tell? Is
there an ideal time to tell the patient? What should be
done in the case of the incompetent patient? When more
than one physician was involved, who should tell the pa-
tient? What should be the role of hospital quality assur-
ance and risk management personnel?
Deciding Whether to Disclose a Mistake.
disclosing a mistake seems controversial, who should de-
cide whether or not to tell? The individual physician is bi-
ased against disclosure, and can easily rationalize the de-
cision not to tell. The burden of proof should be on the
physician to justify not disclosing a mistake. However, the
decision should not be left to the individual physician’s
judgment. It would be important to obtain a second opin-
ion to represent what a reasonable physician would do
and be willing to defend in public. This second opinion
would be particularly important in cases in which there
was an adverse outcome, and the physician is inclined
to tell. A formal body such as an institution’s ethics com-
mittee or quality review board seems preferable to informal
consultation with peers, who might be similarly reticent.
In cases in which
Timing of Disclosure.
considered. Although the patient might benefit from
learning about a mistake as soon as possible after it oc-
curred, disclosure should be made at a time when the pa-
tient is physically and emotionally stable. For example,
The timing of disclosure should be
disclosure of a surgical error should be delayed, if possi-
ble, until the patient has recovered sufficiently to be able
to understand and deal with the information.
Who Should Disclose the Mistake?
by a physician in training, responsibility is shared with
the attending physician of record. It may be most appro-
priate for the attending physician and house officer to dis-
close the mistake to the patient together.
may be appropriate to involve an institutional representa-
tive, such as a hospital administrator, risk manager, or
quality assurance representative, in the disclosure.
When a mistake is made
The Incompetent Patient.
decision-making capacity can still appreciate an apology.
However, some patients lack the mental capacity to un-
derstand and appreciate what the physician tells them
about medical errors, even if the discussion is simplified.
There is no need to inform an incompetent patient. How-
ever, if there is a family member or other effective decision
maker, this surrogate should be informed. The physician
who will be taking care of the patient in the ambulatory
setting should also be informed.
Many patients with impaired
What to Say?
sons. The facts of the case may be too complicated to be
explained easily, and may not be known precisely. The
physician may be tempted to frame the disclosure in a
way that obscures that a mistake was made.
Disclosure of a mistake is an instance of “breaking
bad news” to patients.
There is need for medical edu-
cation about conducting these discussions. The upsetting
news that a mistake has occurred and information re-
garding the consequences should be presented to the pa-
tient in a way that minimizes distress. The
lege of Physicians
guidance, which could be applied to the disclosure of a
mistake: “Information should be given in terms the pa-
tient can understand. The physician should be sensitive
to the patient’s responses in setting the pace of disclo-
sure. . . Disclosure should never be a mechanical or per-
The physician should recognize that
patients or families may become upset or angry, and ac-
cept this as a natural response, taking care not to react
In telling the patient about an error, the physician
should begin by stating simply that he or she has made a
mistake. It may be helpful to describe the decisions that
were made, including those in which the patient partici-
pated. The course of events should then be described in
detail, using nontechnical language. The nature of the
mistake, consequences, and corrective action taken or to
be undertaken should be stated. The physician should
then express personal regret and apologize for the mis-
take. Finally, the physician should elicit questions or con-
cerns from the patient and address them.
The harm of disclosing a mistake may be minimized if
disclosure is made promptly and openly, if apologies are
Disclosure is often difficult, for several rea-
offers the following
Wu et al., Disclosing Medical Mistakes
offered, and if charges for associated care are forgone.
When the mistake had a major adverse impact on the pa-
tient, an offer should be made to cancel charges for sub-
sequent care needed to remedy the mistake and to pro-
vide the necessary supportive services.
Financial amends should include all extra expenses
incurred, such as physician services, error-generated lab-
oratory fees, hospital expenses, and drug costs. Hospital
risk management teams sometimes adopt and malprac-
tice insurers sometimes encourage such an approach,
which may reduce the number and size of malpractice
suits. The physician rarely if ever pays for any of these
services out of pocket. Under capitated payment, the hos-
pital or group absorbs the costs (if individual physicians
are capitated for pharmacy services they may also share
the costs). If health insurance is available to pay for med-
ical care, a decision should be made whether or not to bill
the insurer for the services. It can be argued that the in-
surance company bears some co-equal responsibility be-
cause it insures the patient for all outcomes. However,
companies may want recourse to reclaim some of the
money. In all cases, it is important that hospital adminis-
tration and risk management be involved in decisions and
negotiations about billing.
A physician who had prescribed a sulfonamide to a
patient known to be allergic to sulfa, causing an anaphy-
lactoid reaction, might say, “Mrs. Smith, I have discovered
what has caused you to become so ill. I regret to say that I
made a mistake. Before prescribing the medication for
your infection, I failed to check whether you were allergic
to it. You are. The itchy rash, joint pains, and fever you
now have are due to the allergy. I am giving you ibuprofen
and diphenhydramine to help you feel better, and I expect
you will gradually improve over the next several days. I
feel very badly that my not checking has caused you to
have this reaction. I am sorry. Of course, there will be no
charges for the antibiotic or the medications I am now
prescribing to remedy my mistake. Do you have any ques-
tions for me?”
Overcoming Barriers to Disclosure
From a pragmatic point of view, physicians are often
most concerned about the potentially harmful personal
consequences of disclosing a mistake. In blunt terms,
physicians may question whether any possible benefits to
the patient are worth the possible risks of a lawsuit to
their career or livelihood. This clash between ethical ide-
als and pragmatic reality is a difficult one. It may sound
unconvincing to exhort physicians to do what is best for
the patient. However, the AMA’s Council on Ethical and
Judicial Affairs states, “Concern regarding legal liability
which might result following truthful disclosure should
not affect the physician’s honesty with a patient.”
We would make several responses to physicians who
hesitate to disclose mistakes that cause significant harm
to patients because of fears of litigation. First, disclosing
mistakes may reduce the risk of litigation, if patients ap-
preciate physicians’ honesty and fallibility.
ous mistakes may come to light, even if physicians do not
disclose them. Patients may wonder about the cause of
their changed condition, ask other caregivers, or even ask
their physicians directly. Any perception that the physi-
cian tried to cover up a mistake might make a patient
more angry and more litigious.
takes physicians can take steps to mitigate any harms
that may occur to them. Physicians can learn how to dis-
close mistakes in a manner that diffuses patient anger.
Furthermore, when mistakes have caused serious harm
to patients, physicians can take the initiative in recom-
mending to institutional risk management personnel or
malpractice insurers that a prompt and fair settlement is
made out of court.
For an injured patient to obtain compensation through
the tort system requires proof of negligence, defined as vi-
olation of professional standards. This creates an untena-
ble conflict for physicians, for whom compensation to the
patient demands the demonstration of malpractice. Acts
of negligence constituted only a small proportion of the
errors in the Harvard Medical Practice Study,
small proportion of injuries resulted in compensation for
the patient. Thus, the current system obstructs detection
and just compensation for errors and inhibits disclosure.
The need to report and reduce errors constitutes a major
ethical impetus for reform to a system of no-fault, nonad-
versarial patient compensation. Such a system would fa-
cilitate a move to a systems approach incorporating hu-
man factors research to reduce errors.
The fear of damage to reputation and loss of respect
from peers may also inhibit physicians from disclosing
mistakes. To overcome this barrier will require increased
recognition and acceptance of mistakes as part of clinical
practice. Guidelines should be created to describe what
physicians should do when they make a mistake. Such
guidelines should also describe what to do when a col-
league tells you about a mistake you have made or a mis-
take he or she has made. The importance of providing
emotional support needs to be emphasized. It is particu-
larly important to help physicians-in-training cope with
their mistakes in such a way as to help them maintain
their confidence and develop professionally.
Third, in disclosing mis-
and only a
Disclosure of Mistakes Made by Other Physicians
A physician who, in the care of one of his or her own
patients, learns of or witnesses a major error (e.g., a sur-
gical mishap) made by another physician, has several op-
tions. These include waiting for the other physician to dis-
close the mistake, advising the other physician to disclose
the mistake, arranging a joint meeting to discuss the mis-
take, or telling the patient directly.
patient relationship obtains in such a case, physicians
have an obligation to facilitate disclosure. However, they
may be reluctant to say anything because of lack of defin-
Insofar as the doctor-
JGIM Download full-text
Volume 12, December 1997
itive information, because of the thought that “there but
for the grace of God go I,” or because of fear of hurting the
feelings of colleagues, or of straining professional relation-
ships. Social norms militate against disclosing when a
colleague makes a mistake. From an early age, we are so-
cialized against “tattling” on our peers. In addition, physi-
cians may fear that disclosure would lead to libel suits.
Unfortunately, there are no guidelines describing the obli-
gations of a physician who learns of a mistake made by
another physician on his or her own patient.
The simplest solution is to leave the discussion up to
the physician who made the mistake. However, there is
no assurance that the patient actually will be informed.
By advising the physician who erred to tell the patient,
the observing physician may fulfill his or her responsibil-
ity for disclosure, but the patient also may not be in-
formed. Simultaneously advising quality assurance or
risk management personnel would increase the likelihood
that the patient would be told. Arranging a joint confer-
ence with the patient and original physician would assure
the observing physician that appropriate disclosure was
made, while preserving the primacy of the relationship be-
tween the other physician and patient. These other op-
tions failing, one might tell the patient directly of the er-
Although this conversation may be awkward and
may interfere with the other physician’s relationship with
the patient, it does guarantee disclosure. Policy state-
ments from medical staff offices and medical societies, as
well as potential involvement by these bodies, are needed
to guide and facilitate these difficult interactions.
Consideration of the doctor-patient relationship indi-
cates that a physician has ethical obligations to disclose
significant errors when disclosure benefits the health of
the patient, respects the patient’s autonomy, or is called
for by justice. This is so even if such disclosure does not
benefit the physician. Only in rare cases, when disclosure
would threaten to undermine the patient’s autonomy, or
when the patient explicitly states a preference not to be
told about such untoward events, should the physician
not disclose the mistake. These same considerations sug-
gest that a physician also has a considerable duty to en-
sure that disclosure occurs when, in the care of his or her
own patient, another physician makes a serious mistake.
1. Brennan TA, Leape LL, Laird N, et al. Incidence of adverse events
and negligence in hospitalized patients: results of the Harvard
Medical Practice Study II. N Engl J Med. 1991;324:370–6.
2. Leape LL. Error in medicine. JAMA. 1994;272:1851–7.
3. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn
from their mistakes? JAMA. 1991;265:2089–94.
4. Christensen JF, Levinson W, Dunn PM. The heart of darkness: the
impact of perceived mistakes on physicians. J Gen Intern Med.
5. American Medical Association. Principles of Medical Ethics; 1957:
6. American College of Physicians. American College of Physicians
Ethics Manual. 3rd ed. Ann Intern Med. 1992;117:947–60.
7. AMA Council on Ethical and Judicial Affairs and Southern Illinois
University School of Law. Code of Medical Ethics, Annotated Cur-
rent Opinions. Chicago, Ill: American Medical Association; 1994.
8. Lo B. Disclosing mistakes. In: Problems in Ethics. Baltimore, Md:
Williams & Wilkins; 1994:307–13.
9. Katz J. Why doctors don’t disclose uncertainty. Hastings Center
10. Veatch RM. The principle of honesty. In: A Theory of Medical Eth-
ics. New York, NY: Basic Books; 1981:214.
11. Vogel J, Delgado R. To tell the truth: physicians’ duty to disclose
medical mistakes. UCLA Law Rev. 1980;28:52–94.
12. Bok S. Lies to the sick and dying. In: Lying: Moral Choice in Public
and Private Life. New York, NY: Vintage Books; 1979:232–55.
13. Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310:118–22.
14. Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope
with their mistakes: doing better but feeling worse? West J Med.
15. Gutheil TG, Bursztajn H, Brodsky A. Malpractice prevention
through the sharing of uncertainty. Informed consent and the
therapeutic alliance. N Engl J Med. 1984;311:49–51.
16. Levinson W. Patient-physician communication. A key to malprac-
tice prevention. JAMA. 1994;272:1619–20. Editorial.
17. Robertson G. Fraudulent concealment and the duty to disclose
medical mistakes. Alberta Law Rev. 1986;25:215–23.
18. Bosk CL. Forgive and Remember: Managing Medical Failure. Chi-
cago, Ill: The University of Chicago Press; 1979.
19. Quill THE, Williamson PR. Health approaches to physician stress.
Arch Intern Med. 1990;150:1857–61.
20. Martin CA, Wilson JF, Fiebelman ND 3d, Gurley DN, Miller TW.
Physicians’ psychologic reactions to malpractice litigation. South
Med J. 1991;84(11):1300–4.
21. Oshel RE, Croft T, Rodak J Jr. The National Practitioner Data
Bank: the first 4 years [see comments]. Public Health Rep. 1995;
22. Pellegrino ED, Thomasma DC. For the Patient’s Good: The Resto-
ration of Beneficence in Health Care. New York, NY: Oxford Uni-
versity Press; 1988.
23. Beauchamp TL, Childress JF. Principles of Biomedical Ethics.
New York, NY: Oxford University Press; 1994.
24. Hippocrates. Epidemics, vol. I, x, (translated by WHS Jones).
Cambridge, Mass: Harvard University Press; 1939:165.
25. Nightingale F. Preface. In: Notes on Hospitals, 3rd ed. London, UK:
Longman, Green, Longman, Roberts, & Green; 1863:Iii.
26. Campbell ML. Breaking bad news to patients. JAMA. 1994;271:1052.
27. Davis H. Breaking bad news. Practitioner. 1991;235:522–6.
28. Girgis A, Sanson-Fisher RW. Breaking bad news: consensus guide-
lines for medical practitioners. J Clin Oncol. 1995;13(9):2449–56.
29. Relman AS. Telling patients ‘the truth.’ Physician’s Management.
30. Reason JT. Human Error. New York, NY: Cambridge University
31. Paget MA. Your son is cured now; you may take him home. Cult
Med Psychiatry. 1982:6:237–59.