Surgical Ethics and Diversity

  • Judith C. French
  • R. Matthew WalshEmail author


Surgeons have an ethical obligation to ensure all patients, regardless of their personal characteristics, receive the same quality of care. Established surgeons also have an obligation to ensure equal treatment for their peers and for those who would like to join the field. The commitment to ethical hiring and working standards entails making certain all individuals have the same opportunities free from discriminatory practices. The world of business has long realized the positive implications of having a diverse and inclusive workforce. Studies have shown a positive correlation between increased racial and gender diversity and company performance. Diversity can lead to an increase in knowledge by sharing ideas with individuals who come from different life experiences and breakdown cultural barriers. We have already begun to see the impact of ignoring the importance of diversity within healthcare, including surgery. Healthcare disparities are defined by the NIH (National Institutes of Health) as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.” Healthcare disparities persist despite decades acknowledging their existence, and they are pernicious and prevalent in surgery. One proposed method to help reduce or eliminate healthcare disparities is to increase the diversity of the workforce treating the patients, which would in turn reduce potential bias the patients face in the healthcare setting. Implicit bias can play a key role in interactions with patients and colleagues and needs to be explored on an individual basis. Cultural competence training can also provide surgeons the ability to effectively communicate with not only a diverse population of patients but also a diverse surgical workforce. All surgeons regardless of their role can have a positive impact on diversity as it relates to patient care and the surgical workforce.


Healthcare disparities Surgical workforce diversity Implicit bias Cultural competence 




Equity, comparability of opportunities to learn and demonstrate abilities, and equality, equal practice or treatment.

Cultural competence

The awareness of one’s own cultural viewpoint, attitude toward differences in other cultures, knowledge of different cultural practices, and the skills to interact with other cultures.

Cultural sensitivity

An awareness of differences in cultures alone but still treating others with respect and dignity.


A social construct created through identification of similar characteristics in individuals.

Healthcare disparities

Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups based on race, ethnicity, gender, sexual orientation, age, geographic location, socioeconomic status, and disability.

Implicit bias

Unconscious associations everyone possesses toward people’s characteristics such as race, gender, and age.


  1. 1.
    Forbes Insights. Global diversity and inclusion: fostering innovation through a diverse workforce. New York: Forbes; 2011.Google Scholar
  2. 2.
    Carter NM, Wagner HM. The bottom line: corporate performance and women’s representation on boards (2004-2008): New York: Catalyst Inc; 2011.Google Scholar
  3. 3.
    Desvaux G, Devillard S, Sancier-Sultan S. Women at the top of corporations: making it happen. New York: McKinsey and Company; 2011.Google Scholar
  4. 4.
    Herring C. Does diversity pay?: race, gender, and the business case for diversity. Am Sociol Rev. 2009;74:208–24.CrossRefGoogle Scholar
  5. 5.
    Noland M, Moran T, Kotschwar B. Is gender diversity profitable? Evidence from a global survey. Washington, DC: Peterson Institute for International Economics; 2016. p. WP16–3.Google Scholar
  6. 6.
    National Institute on Minority Health and Health Disparities. History. Retrieved 28 Aug 2017.
  7. 7.
    Greenwald HP, Polissar NL, Borgatta EF, McCorkle R, Goodman G. Social factors, treatment, and survival in early-stage non-small cell lung cancer. Am J Public Health. 1998;88:1681–4.CrossRefGoogle Scholar
  8. 8.
    Govindarajan R, Shah RV, Erkman LG, Hutchins LF. Racial differences in the outcome of patients with colorectal carcinoma. Cancer. 2003;97:493–8.CrossRefGoogle Scholar
  9. 9.
    Cykert S, Dilworth-Anderson P, Monroe MH, Walker P, McGuire FR, Corbie-Smith G, Edwards LJ, Bunton AJ. Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. JAMA. 2010;303:2368–76.CrossRefGoogle Scholar
  10. 10.
    Lee SL, Yaghoubian A, Stark R, Shekherdimian S. Equal access to healthcare does not eliminate disparities in the management of adults with appendicitis. J Surg Res. 2011;170:209–13.CrossRefGoogle Scholar
  11. 11.
    Okafor PN, Stobaugh DJ, van Ryn M, Talwalkar JA. African Americans have better outcomes for five common gastrointestinal diagnoses in hospitals with more racially diverse patients. Am J Gastroenterol. 2016;111:649–57.CrossRefGoogle Scholar
  12. 12.
    Ojinnaka CO, Luo W, Ory MG, McMaughan D, Bolin JN. Disparities in surgical treatment of early-stage breast cancer among female residents of Texas: the role of racial residential segregation. Clin Breast Cancer. 2016;17:e43–52.CrossRefGoogle Scholar
  13. 13.
    Fedewa SA, Flanders WD, Ward KC, Lin CC, Jemal A, Goding Sauer A, Doubeni CA, Goodman M. Racial and ethnic disparities in interval colorectal cancer incidence: a population-based cohort study. Ann Intern Med. 2017;166:857–66.CrossRefGoogle Scholar
  14. 14.
    Lassiter RL, Talukder A, Abrams MM, Adam BL, Albo D, White CQ. Racial disparities in the use of laparoscopic surgery to treat colonic diverticulitis are not fully explained by socioeconomics or disease complexity. Am J Surg. 2017;213:673–7.CrossRefGoogle Scholar
  15. 15.
    Gahagan JV, Hanna MH, Whealon MD, Maximus S, Phelan MJ, Lekawa M, Barrios C, Bernal NP. Racial disparities in access and outcomes of cholecystectomy in the United States. Am Surg. 2016;82:921–5.PubMedGoogle Scholar
  16. 16.
    US Surgeon General. Elimination of health disparities. Retrieved 23 Oct 2017.
  17. 17.
    American Medical Association. Reducing disparities in health care. Retrieved 23 Oct 2017.
  18. 18.
    US Census Bureau. QuickFacts 2016. Retrieved 25 Oct 2017.
  19. 19.
    Association of American Medical Colleges. Diversity in the physician workforce: Facts & Figures 2014. AAMC 2014.Google Scholar
  20. 20.
    Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Int Med. 2013. Retrieved October 25, 2017 from
  21. 21.
    Lupkin S. Deep roots for lack of minorities in American medical schools. MedPage Today 2016. Retrieved 25 Oct 2017.
  22. 22.
    Freeman BK, Landry A, Trevino R, Grande D, Shea JA. Understanding the leaky pipeline: perceived barriers to pursuing a career in medicine or dentistry among underrepresented-in-medicine undergraduate students. Acad Med. 2016;91:987–93.CrossRefGoogle Scholar
  23. 23.
    Association of American Medical Colleges. Altering the course: Black males in medicine. AAMC 2015. Retrieved 25 Oct 2017.
  24. 24.
    Sexton KW, Hocking KM, Wise E, Osgood MJ, Cheung-Flynn J, Komalavilas P, Campbell KE, Dattilo JB, Brophy CM. Women in academic surgery: the pipeline is busted. J Surg Educ. 2012;69:84–90.CrossRefGoogle Scholar
  25. 25.
    Association of Women Surgeons. Female chairs of departments of surgery. Retrieved 23 Oct 2017.
  26. 26.
    French JC, O’Rourke C, Walsh RM. A current assessment of diversity characteristics and perceptions of their importance in the surgical workforce. J Gastrointest Surg. 2014;18:1936–43.CrossRefGoogle Scholar
  27. 27.
    Elam CL, Johnson MMS, Wiggs JS, Messmer JM, Brown PI, Hinkley R. Diversity in medical school: perceptions of first–year students at four southeastern U.S. medical schools. Acad Med. 2001;76:60–5.CrossRefGoogle Scholar
  28. 28.
    Society for Surgery of the Alimentary Tract. Diversity & inclusion liaison committee. Retrieved 25 Oct 2017.
  29. 29.
    American Society for Metabolic and Bariatric Surgery. Committees. Retrieved 25 Oct 2017.
  30. 30.
    American Society of Transplantation. Women’s health community of practice. Retrieved 25 Oct 2017.
  31. 31.
    National Institute on Minority Health and Health Disparities. NIH announces Institute on Minority Health and Health Disparities. Retrieved 25 Oct 2017.
  32. 32.
    National Institute on Minority Health and Health Disparities. NIH launches research program to reduce health disparities in surgical outcomes. Retrieved 25 Oct 2017.
  33. 33.
    FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18:19.CrossRefGoogle Scholar
  34. 34.
    Project Implicit. About us. Retrieved 24 Oct 2017.
  35. 35.
    Madera JM, Hebl MR, Martin RC. Gender and letters of recommendation for academia: agentic and communal differences. J Appl Psychol. 2009;94:1591–9.CrossRefGoogle Scholar
  36. 36.
    Meyerson SL, Sternbach JM, Zwischenberger JB, Bender EM. The effect of gender on resident autonomy in the operating room. J Surg Educ. 2017. In press;
  37. 37.
    Flyckt RL, White EE, Goodman LR, Mohr C, Dutta S, Zanotti KM. The use of laparoscopy simulation to explore gender differences in resident surgical confidence. Obstet Gynecol Int. 2017;
  38. 38.
    Mueller AS, Jenkins TM, Osbourne M, Dayal A, O’Connor DM, Arora VM. Gender differences in attending physicians’ feedback to residents: a qualitative analysis. JGME. 2017;9:577–85.CrossRefGoogle Scholar
  39. 39.
    Colbert CY, French JC, Herring ME, Dannefer EF. Fairness: the hidden challenge for competency-based postgraduate medical education programs. Perspect Med Educ. 2017;6:347–55.CrossRefGoogle Scholar
  40. 40.
    Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118:293–302.CrossRefGoogle Scholar

Suggested Literature

  1. Association of American Medical Colleges. Diversity learning series.
  2. Banaji MR, Greenwald AG. Blindspot: hidden biases of good people. New York: Bantam; 2016.Google Scholar
  3. Dreachslin JL, Malone B. Diversity and cultural competence in health care: a systems approach. San Francisco: Jossey-Bass; 2013.Google Scholar
  4. National Institute on Minority Health and Health Disparities. Overview.
  5. Think Cultural Health. Culturally and linguistically appropriate services.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of General SurgeryCleveland ClinicClevelandUSA

Personalised recommendations