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Unrepresented patients are those who have no surrogate or advance directive to guide medical decision making for them when they become incapacitated. While there is no perfect solution to the problem of making medical decisions for such vulnerable patients, 3 different approaches are noted in the literature: a physician approach, an ethics committee approach, and a guardianship approach. Recent policies and laws have required an approach that is "tiered" with respect to both who is involved and the gravity of the medical treatment questions at issue. In a general sense, some variant of a tiered approach is likely the best possible solution for jurisdictions and health institutions-both those already with and those without a tiered approach-to the challenging puzzle of treating unrepresented patients. Single Greatest Category of Problems Unrepresented patients are incapacitated individuals whom Pope describes as having "no available friends or family to make medical decisions as 'default' surrogates." 1 These patients typically fall into 3 groups: those who are homeless or mentally ill, those who by "choice or life history" do not have family or friends who could act as a surrogate, and those elderly patients who have outlived their family and friends. 2 Indeed, the problem of addressing the "care of decisionally incapable patients" who have no surrogate to engage in the decision-making process is a bioethical puzzle and has been deemed by Karp and Wood to be "the single greatest category of problems" encountered by hospitals and clinicians. 3

Because human errors should be regarded as expected events, health care organizations should routinize processes aimed at human error prevention, limit negative consequences when human errors do occur, and support and educate those who have erred. A just culture perspective suggests that responding punitively to those who err should be reserved for those who have willfully and irremediably caused harm, because punishment creates blame-based workplace cultures that deter error reporting, which makes patients less safe.

CRISPR technology has made questions about how best to regulate human genome editing immediately relevant. A sound and ethical governance structure for human genome editing is necessary, as the consequences of this new technology are far-reaching and profound. Because there are currently many risks associated with genome editing technology, the extent of which are unknown, regulatory prudence is ideal. When considering how best to create a prudent governance scheme, we can look to 2 guiding examples: the Asilomar conference of 1975 and the German Ethics Council guidelines for human germline intervention. Both models offer a path towards prudent regulation in the face of unknown and significant risks.

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