California’s Forced Implicit Bias Training for Doctors Faces First Amendment Challenge 

Billion Photos /
Billion Photos /

Dr. Marilyn Singleton, a Black anesthesiologist practicing in Los Angeles, has filed a lawsuit over California’s forced implicit training requirement for healthcare professionals. The training has become a part of the state’s continuing education training for physicians, and it advises them on ways to stop unconsciously providing inferior levels of care for minorities. 

For Singleton, who teaches continuing education classes for healthcare professionals, forcing teachers to discuss implicit bias violates their First Amendment rights. 

Singleton’s suit is represented by Sacramento-based Pacific Legal Foundation (PLF), a national public interest law firm dedicated to safeguarding Americans’ liberties when faced with government overreach and abuse. Their mission involves defending constitutional rights through legal action. One of their clients is the activist group Do No Harm, established in 2022 to challenge affirmative action in medicine. Before this case, PLF and Do No Harm collaborated to file lawsuits against the Louisiana Medical Board and the Tennessee Podiatry Board, challenging their practice of reserving board seats exclusively for racial minorities. 

The lawsuit doesn’t address the state’s right to require implicit bias training, but it challenges the state’s requirement that all doctors teaching continuing education classes must include it as part of their class.  

Implicit bias is nonconscious or automatic feelings and beliefs about others, which can differ from conscious attitudes. Some believe these implicit biases significantly impact patient-physician interactions and outcomes in healthcare.  

Healthcare professionals exhibit similar levels of implicit bias as the general population, and that bias may be associated with lower-quality care. Providers with more bias may demonstrate unequal treatment recommendations, disparities in pain management, and a lack of empathy toward minority patients. 

Conversely, patients’ views of their healthcare providers can be influenced by implicit bias. Factors like physicians’ language use and a patient’s experiences with discrimination affect how they perceive providers and the quality of care they receive. A study found that black patients felt most negatively toward physicians who were low in explicit bias but high in implicit bias. 

Research shows that racial and ethnic minorities receive lower-quality healthcare, even when access-to-care barriers are removed. An Institute of Medicine (IOM) report highlights disparities for minorities, and a systematic review within the medical profession shows a prevalent negative bias toward non-White patients, as measured by the Implicit Association Test (IAT). This bias significantly affects treatment adherence, decision-making, and patient outcomes. 

Several states have passed a continuing education requirement for all doctors to take implicit bias training. Maryland, Michigan, and Washington have also passed the requirement, which California took on in 2022 alongside Massachusetts. 

Singleton’s lawsuit was initially filed in December 2023, but U.S. District Judge Dale S. Fischer dismissed it. In his ruling, he acknowledged that teachers have a right to tell students they don’t believe in implicit bias’s role in healthcare disparities, but ultimately, the state has the right to mandate the training. 

It all comes down to not who is speaking, in this case, but who they represent while speaking. Fischer explained in his ruling that those who teach courses “must communicate the information that the legislature requires medical practitioners to have” and noted that “when they do so, they do not speak for themselves, but for the State.” 

The PLF was given time to file an amended complaint, which it has updated to argue that its clients teach as private citizens and are covered under their First Amendment rights. If the judge disagrees again, lead attorney Caleb Trotter plans to appeal the decision and, if needed, take the case to the Supreme Court. 

Implicit bias may influence physician decisions in patient care, but critics of the mandated training point out that the IoM report found that training healthcare providers does not help. In fact, the report found that it could worsen the situation. 

It’s a battle unlikely to be won at the state level, with both sides firmly dug in and the battle lines drawn. State Attorney General Rob Bonta argues that Singleton and her co-plaintiffs are wrong, stating that “there can be no dispute that the State shapes or controls the content of continuing medical education courses.” 

Trotter and his team, however, believe that implicit bias training is not “government speech” but private speech protected by the First Amendment. If a teacher doesn’t want to discuss implicit bias in the classroom, they should not be forced to do so. 

This case has far-reaching implications. If it can be proven that teachers are protected under the First Amendment and cannot be forced to teach a topic, does this mean that some of the insanity happening in children’s classrooms can be stopped? It’s an interesting case that will likely make waves when it is heard later this month.