Conscious and Unconscious Biases in Health Care

The Neuroscience

Learn more from Kimberly Papillon, Esq. about our reactions to the “other.”

Click here to read an invited essay by Kimberly Papillon, Esq., on the neurological contributions to judging those who are similar and dissimilar (PDF).*

Automatic Negative Associations: The “Other”

The neuroscience literature tells us that the brain has a unique ability to differentiate between those who are “like-us” or “in-group” from those who are “not like us” or “out-group.” If the encoded message is members of this group are not like us, the ventromedial prefrontal cortex is activated. According to Mitchell et al (2006), when the message is like-us, the dorsomedial prefrontal cortex is activated.14 The mere fact that the person is coded as not like us or implicit stereotyping results in differential treatment, with those like-us being treated better.15 In addition, the mirror neurons (those neurons that enable us to have experiential insight into others or have empathy) are not activated the greater the bias is.4 Implicit bias then can be a function of our brains automatically assigning a person to a group whom we have coded as “other.” Therefore, we have less interest and empathy for that person.

Emotional Reaction to Perceived Threat: The “Other Who Is Dangerous”

The brain not only codes the “other” as a matter of survival, it also interprets the situation as threatening or non-threatening.16 The literature suggests that there are overlapping neural systems that link fear with certain groups who are also coded as “other.”17 This type of implicit bias is called “affective bias”15 At the neural level, the magnitude of implicit preferences for in-group and against out-group correlates with the activation of the amygdala. The amygdala is a subcortical structure of the brain, part of the limbic system or the emotional brain, that has a major role in the “fight-flight response,” and it becomes activated within milliseconds.15,18 The speed of this deeply embedded automatic response creates a response well before thoughts and actions based on the more reasoned part of the well-meaning person’s brain. Because this type of implicit bias is linked to the part of the brain that is related to safety, it is more difficult to address.

Kimberly Papillon, Esq. explains more about emotional reaction to perceived threat.

Click here to read an invited essay by Kimberly Papillon, Esq., on amygdala activation and race. (PDF)*

The Role of Stress

The interactions health care practitioners and other health professionals have with patients and their family members do not occur in a vacuum. Health care professionals are operating under the influence of sociocultural factors in their personal life, professional life, organizational or practice milieu, and community contexts. Another dynamic in how can well-meaning people have bias comes from our understanding of the role of stress, cognitive load in particular, and the activation of stereotypes. This is particularly important to health care practitioners and other health professionals because they often work in stressful conditions and situations.

Under Pressure, Stereotyping is Easier

Cognitive load is defined as the mental activity imposed on working memory, which comes from competing mental tasks, environmental factors, and our own psychological state (e.g., fatigue) as well as from the demands inherent in the task at hand.9

It takes time and energy to pay attention to and process information that is unique to each individual patient. When health care practitioners are operating under a significant amount of cognitive load, there is limited energy available to attend to the uniqueness of any given patient. In the spirit of efficiency, well-meaning people may find that it is just easier to stick to the stereotype than take the mental effort to separate the person from the stereotype, and then make the mental corrections for the stereotype that was activated.9


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