To remedy the impact of bias, we must consider factors that can be changed and improved, such as opportunities for quality education, good paying jobs, access to quality clinical care, healthy foods, green spaces, and secure and affordable housing. Unfair policies and practices at many levels and over many decades have affected the health of people with lower incomes and communities of color.

10.1 Implicit Bias

Humans have developed many automatic responses that can help us move through our daily lives efficiently and without conscious thought. We don’t think about how our bodies maintain balance, when to withdraw our hand from a hot stove, or why it is important to avoid rotten food. We have developed automatic and reflexive responses that allow us to function efficiently, without conscious thought.

Implicit biases might be viewed in this light. They occur below the level of consciousness, using information developed from our life experiences and habits. They help us to make sense of the world, allowing us to classify individuals into categories quickly and automatically. Although efficient and easy, biases have caused considerable harm to people who are their target, leading to discrimination and lack of access to the benefits available to members of society who do not experience these biases.

Implicit bias affects a person’s perception, action, or decision-making in an unconscious manner. It can contribute to unequal treatment based on characteristics such as race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, or disability.

Decades of research has demonstrated that discrimination, driven by implicit bias, impacts healthcare access, trust in clinicians, care quality, and patient outcomes (Dirks et al, 2022). Implicit bias is widespread, even among individuals who explicitly reject prejudice (Payne et al., 2019).

The troubling thing for healthcare professionals is the possibility that biased judgment and biased behavior can affect patient care (FitzGerald et al., 2019).

10.2 Decision Making and Diagnostic Bias

The use of racial terms to describe epidemiologic data perpetuates the belief that race itself puts patients at risk for disease, and this belief is the basis for race-based diagnostic bias. Rather than presenting race as correlated with social factors that shape disease or acknowledging race as an imperfect proxy for ancestry or family history that may predispose one to disease, the educators we observed portrayed race itself as an essential—biologic—causal mechanism.

Amutah, et al., 2021
New England Journal of Medicine

Healthcare providers are vulnerable to a range of biases when making decisions, particularly diagnostic and treatment decisions. Many biases have been described in the healthcare literature, and many of these have been shown to influence decisions (Featherston et al., 2020).

Patient-provider interactions, treatment decisions, patient adherence to recommendations, and patient health outcomes can be influenced by bias. This can lead to an unintentional form of discrimination that affects decision-making structurally and systematically and is hard to identify and uncover (Nápoles et al., 2022).

Studies have shown that implicit racial bias profoundly influences clinical decision-making. Its affects nonverbal behaviors such as eye contact and posture and has been shown to influence the quality of physicians’ interpersonal communication with Black patients and, in turn, patients’ trust and perceptions of their physicians (van Ryn et al., 2015).

10.3 The Impacts of Bias in Child Welfare

Significant disparities exist throughout the child welfare system. Research has shown that mandated reporters' decisions to report a family to the Statewide Central Register (SCR) is often influenced by biases and personal beliefs. An implicit bias may even sway you to make a report against one parent/caregiver and not another even when the objective facts and information are the same.

Research also shows that these biases contribute to a disproportionate number of reports being called into the SCR on specific individuals or groups—including communities of color and Black communities in particular—far more than others. This leads to a disproportionate level of Child Protective Services (CPS) involvement in certain communities that can have long-lasting and devastating impacts on families and communities (NYSOCFS, 2024).

Once reported, cases with Black children are more likely to be accepted for investigation, be confirmed, be brought to court, result in removal of the children from their families for longer periods of time, and take longer to be closed, possibly related to surveillance bias. Multiple points in this process are subject to bias, but the process begins with reporting (Palusci and Botash, 2021).

When assessing information received about a child and their family, instead of making assumptions or jumping to conclusions that a child is being maltreated or abused, mandated reporters must evaluate potential biases that affect their decision to report (NYSOCFS, 2024).

For example, would my decision to call the Statewide Central Register with a report of suspected child maltreatment or abuse change if any of the following were different (NYSOCFS, 2024)?

• primary spoken language
• age
• neighborhood where they reside
• presence of a disability
• socioeconomic status of the family
• race
• gender or gender identity
• sexual orientation or sexual expression
• culture and/or immigration status
• religion

When considering a mandated report for suspected child abuse or neglect, consider the following questions (Palusci and Botash, 2021):

• Why do I suspect maltreatment?
• What is the objective evidence?
• If the family does not look like me, share my values, or lives on the “other” side of town, is that affecting my thinking?
• If my gut is telling me to report, why is that?

Similarly, when making a decision not to report, check if these thoughts are coming up: “they are such a good family,” “I have known them since they were children,” “my patients would never do that,” or similar emotional reasoning (Palusci and Botash, 2021).