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Racial disparities of medical care have been well documented for decades. That much is clear. Less clear are the cause or causes. By the time of the historic 2003 report by the Institute of Medicine (IOM), investigators had uncovered a pervasive pattern of disparities – often, however, without access to clinical or socioeconomic data which might help explain them. It was in these circumstances that the authors of the IOM report adopted the theory of unconscious bias as the ultimate explanation of observed disparities of care. The theory of a profound bias working outside the holder’s awareness and control seemed to many to account for patterns of disparate treatment as nothing else could. However, to this day there exists little good evidence that such bias warps clinical decisions – certainly not enough to bear out the sweeping theory of a psychological mechanism that operates automatically. Impressive in principle but doubtful in practice, the theory of unconscious bias does not account for the evidence but covers its absence, just as it did when it was enshrined in the IOM report in 2003.

Keywords: Unconscious bias; racial disparities; unequal treatment; clinical decisions