By Dustyn Addington
Part I: of Implicit Bias in Health Care
The power is out, but you still flip the light switch.
If a friend were to ask you about it, you would say, “Of course, I know the power is out.”
“But you flipped the light switch,” your friend might say.
At a conscious level, you correctly believe the power is out. At the same time, there is something in us, in the hidden, underground parts of our minds that operate automatically. We hold an association between the light switch and producing light. When we say we know the power is out, we speak sincerely. However, we act differently, revealing the implicit association. The disconnect between our actions and our explicit beliefs is startling.
Similarly, many people can sincerely say, “I am not racist,” and still hold prejudiced associations. At a conscious level, they believe that people are fundamentally equal, with no caveat for race, sex, gender, or sexual orientation. They would stake their reputation on it. They will have contempt for racists and sexists. They would be correct—as far as they know.
Yet, if they are a professor, they are more likely to ignore emails from female Chinese names. If they have the power to hire, they are more likely to hire men. If they are on a jury, they are more likely to find a person of color’s behavior to be hostile.
They flip the switch, even though they sincerely, even vehemently, assert that the power is out.
The Kirwan Institute for the Study of Race and Ethnicity describes implicit bias as:
The attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or intentional control. Residing deep in the subconscious, these biases are different from known biases that individuals may choose to conceal for the purposes of social and/or political correctness. Rather, implicit biases are not accessible through introspection.
What makes implicit bias implicit is the level at which the association operates. To figure out many facts about ourselves, we merely look inward. What’s my favorite color? Blue. Do I like this chair? Not really. Am I a patient person? Sometimes, but not always. I turn my attention to the contents of my own mind and see what’s there. However, we are not able to see everything that’s that there.
This is a matter of access. We have access to a set of facts about ourselves, but the crucial finding from a host of recent research on cognitive and social psychology is that we do not have access to all the facts about ourselves.
If we don’t have access to all the facts about ourselves, then you can be wrong about yourself. This poses a difficulty for the concept of sincerity. For personal matters, sincerity and truth are closely associated. If a person sincerely states that they like you, you believe that it is true that they like you. The same goes for what they say about what foods they like, where they live, and when they were born.
Implicit bias wedges apart sincerity and accuracy about personal facts. You can sincerely say, “I am not racist,” and be incorrect. These are not beliefs that a person is aware of but decides not to share for fear of shame, backlash, or other repercussions. A person with implicit bias is not deciding to hide their bias. They are unaware of their bias. This feels weird because if I don’t know that I’m racist, who would be in a position to say that I am?
Implicit bias can be detected by several measures, but the most prominent measure is the Implicit Association Test (IAT), which measures the response time between distinct concepts. The measure firsts ask you to pick a statement that best describes you: whether you prefer a racial category over another or have no preference between them, for example. The IAT then measures your response time as you sort concepts into categories. The response time is a signal which tells researchers how closely related the concepts are to the person taking the test. If you closely associate “dog” and “friendly” you will be quick to categorize the word “dog” with the word “friendly,” and slow to categorize “dog” with “aggressive.” The test is not a perfect or complete window into the unconscious, but it provides some access to the associations we hold without our conscious awareness.
In this realm of the unconscious, actions speak louder than words. A disconnect between one’s explicit avowals and one’s implicit associations can show up in a variety of ways. For example, in the research that explores different responses to two sets of application materials, absolutely identical to one another except for one difference – the name:
Faculty participants rated the male applicant as significantly more competent and hireable than the (identical) female applicant. These participants also selected a higher starting salary and offered more career mentoring to the male applicant. The gender of the faculty participants did not affect responses, such that female and male faculty were equally likely to exhibit bias against the female student.
This is one result among many. It shows, however, the real impact of implicit bias on the everyday. It is not a psychological curiosity or an abstract threat. And healthcare is not immune to implicit bias. In fact, because human lives and well-being are at the center of health care, it is crucial that this issue is taken up and addressed. In Part II, we will dive into the specifics of how implicit bias produces structural injustice in health care systems.
Dustyn Addington is the Assistant Director of Learning and Strategy at the Foundation for Healthy Generations. He is also a graduate student in the Department of Philosophy at the University of Washington, researching bias, knowledge, and judgments.