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Excerpted from: Dayna Bowen Matthew, Toward a Structural Theory of Implicit Racial and Ethnic Bias in Health Care, 25 Health Matrix: Journal of Law-Medicine 61 (2015) (105 Footnotes) (Full Document)


Dayna Bowen MatthewRecently, a group of researchers reported that physician implicit race and ethnicity biases do not affect their hypertension treatment for minority patients nor do such biases impact health outcomes for these patients. These findings are counterintuitive. Moreover, they are contrary to the weight of the emerging empirical record that has suggested that physician implicit bias is inversely related to the quality of doctors' treatment decisions, communication with, and perceptions of their minority patients. Examples include findings that implicit bias affects treatment decisions for heart disease, pediatric urinary tract infections, and diseases stereotypically associated with minority patient groups. The profound concern that this recent study raises has less to do with the danger that some may erroneously and prematurely celebrate the fact that physician bias is unrelated to the estimated 83,000 deaths of minority patients annually due to discriminatory health care. Rather, the real concern is that this study will join the copious body of social science literature on implicit bias in health care, which completely overlooks the fundamental structural nature of unconscious racism and its contribution to racial and ethnic inequality in the U.S. health care system. In other words, finding that a group of physicians' implicit biases are or are not associated with inferior treatment decisions for individual patients with a single disease is not the point if eliminating racial and ethnic health inequality is the goal. The persistent health disparities phenomenon is a structural problem, and therefore implicit biases that contribute to disparities must be structurally dismantled. Moreover, the racial discrimination that causes disparities is so fundamentally associated with poor health outcomes that finding an attenuated association between bias and hypertension treatment does not alter the structurally causal relationship between bias and health disparities overall.

In this article, I sketch out the broad contours of a new theoretical approach to the problem of health disparities. I assert that unconscious racism in medicine is an avoidable and reparable injustice that requires incentive and norm-changing solutions in order to radically disrupt the context in which medicine is currently practiced and under which minority patients currently suffer. Reforming the anti-discrimination legal regime is the solution explored here, but there are other structural solutions to consider that are also important to achieving health equality. For example, fixing systemic educational inequality, housing segregation, and the lack of universal health care coverage would go much farther toward equalizing health outcomes than changing discrimination laws. However, I believe that legal reform is also essential to bringing about health equality. Law has the effect of expressing and influencing shifts in social norms, which can permeate systems to affect structural change. Therefore, this discussion centers on reversing the trend toward acceptance of implicit bias as an inevitable, harmless fact of life. Put bluntly, I assert that unconscious racism produces invidious discrimination and an odious inequality that should be prohibited and punished by law. However, as long as the discussion of unconscious bias in health care continues to be framed in terms that examine only individual, cognitive contributions to the problem, the systemic solutions to the health disparities will fail to emerge. Researchers will continue to chase increasingly narrow observations about the hidden attitudes that pass stealthily between and among individual actors in the health care system, instead of pursuing the systemic resolutions for the fact that racial and ethnic discrimination at every level of health care delivery, financing, and organization, is a fundamental cause of poor health outcomes.

I submit that as a fundamental and theoretical matter, the question of whether physician bias is related to medical decision-making for individual diseases is far too small an inquiry. The implicit bias work by social psychologists to date has been defined and limited by a symbolic interactionism framework. This framework has permitted only de-contextualized, ahistorical, and individualized consideration of the broadly systemic and institutional problems that produce health care disparities and health inequality. In place of the individualized inquiries that have dominated the implicit bias discourse, I bring a critical theory perspective to bear on the problem of health disparities in general, and more specifically, on the question of whether individual and institutional providers' implicit biases contribute to these disparities. From this perspective, I analyze the political economy in which health care disparities occur. I apply constructs from structural violence theory to better understand the context in which physician bias operates, the structural inequality and racism that has produced this bias, and the inadequacy of cognitive and behavioral solutions alone to address it. I conclude by proposing a new theoretical construct that I call “structurally derived discrimination.” I offer this construct to add a broader theoretical perspective to the implicit bias discourse. I contend that without this perspective, the U.S. health care system will never eradicate, or even meaningfully reduce, health disparities caused by unconscious racism.

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Critical analysis of the social science literature that addresses physician implicit bias suggests that cognitive theories may have thus far overlooked the fact that social injustice, perpetuated by the state and all the institutions it touches, leads directly to the health and health care inequities that minority patients suffer. Indeed, state-perpetuated social injustice may lead to many related inequities as well, such as unequal housing, inferior education, and lack of safe environments, healthy food, and fair employment. All of these inequalities are structural, not individual, and fixing them will likely require structural changes to the larger context in which health care delivery occurs. Moreover, these inequalities are replicated in the provider, insurance, and educational institutions that surround health care delivery in this country. Cognitive theory solutions to the problem of implicit bias on an individual level cannot accomplish the reformative task alone. Proposed solutions that focus on educating providers or altering cognitive processes must occur within a framework that recognizes a need for accompanying external changes that reinforce socially acceptable and morally desirable behaviors.

The physician decision maker is currently constrained by cultural, political, and economic factors that, if uninterrupted, will perpetuate current biases and stereotypes. Left unaddressed, these biases and stereotypes may be indistinguishable in impact from the bigotry and racism of our nation's past. Individual-level cognitive solutions are likely too narrow in scope to effectively address such broad-sweeping constraints. Thus, true and lasting change should be made with reference to the context in which physicians' attitudes develop and behaviors occur.

Because discriminatory conduct is socially determined, I propose that we look to legal interventions that are both grounded in social science evidence and strive toward changing the social and political context in which health care is delivered, as well as the environments in which patients live, work, and play. Further research is needed to flesh out the full range of options that are likely to be necessary to achieve the type of structural change that will in turn compel agency-level changes as well. Of course, there will be limitations to legal solutions as well. The law, to be sure, is a “blunt instrument” and therefore encounters considerable resistance when wielded. Moreover, there are limits on the law's ability to change values and attitudes. Nevertheless, we have seen law used to institutionalize racist values that produce health disparities, and likewise, we have witnessed law used to dismantle segregation in health care during the Civil Rights Era. Law is one of the strongest of American social tools to both reflect and influence changing social norms. As we work towards addressing the health inequities arising from implicit bias, we should remain cognizant of that tool's utility. Indeed, I believe it is now reasonable to employ legal avenues to implement structural change in socially determined discrimination. I propose a future approach that focuses on using legal remedies, informed by current social science and (of course) further research, to produce structural change and effectuate real health improvement for minority patient populations.

Professor of Law, Director, Health Law Program, University of Colorado Law School; J.D., University of Virginia Law School; A.B. Harvard-Radcliffe College.