Conscious and Unconscious Biases in Health Care

It’s How We are Wired

Diverse PeopleThe fields of cognitive and social psychology, anthropology, and the evolving body of research in neuroscience help explain these normal processes that generate implicit or unconscious bias.

Cognitive psychology provides solid insight into this seeming paradox. When humans are faced with understanding, processing, and acting on complex information, cognitive systems work to simplify the effort. These systems use categories and stereotypes rather than the individual details of the situation in an effort to reduce the cognitive load.7 The tendency to move into stereotypes is intensified when the situation in which a person is working to process the information is stressful.8-10 These stereotypes are not in a person’s awareness and may run counter to his or her conscious beliefs.11 This conscious or explicit bias is the result of early learning and constant exposure to negative societal portrayals of specific groups.12 In addition, there is a tendency to revert to group stereotypes in interactions with someone, if a person views that someone as a member of a group “other” than his or her own. This “otherness” may be race, ethnicity, education level, or even age.12

The self-protective function of the reflexive system requires that it operate quickly. As such, it uses small bits of information on which to act. These bits of information are codified into social categories. Embedded memory that comes from early socialization, life experiences, and social context populates the interpretation of the categories into stereotypes. Feelings about the group become activated. Feelings, beliefs, and attitudes about the group are then imposed on a person. If the group is categorized as an “out-group,” the normal processes of a stress response become activated.2,4,13 Bias may then be expressed in affect, body language, and differential treatment. Similarly, when a person is stressed, the reflexive system overrides more deliberate reflective processes and allows a person to make decisions based on the stereotypes.2 In this case, attitudes, behavior, and decisions are made without full information about an individual, but rather on the basis of the embedded memory encapsulated within the stereotype.

Let’s now examine more carefully the processes involved in the creation of stereotypes and the role of stress as factors that underpin unconscious bias.