PUBLISHED: 30-09-2019

Holier than thou: are we all biased?

Mark Ashton MBBS MD FRACS,1,2,3 Mark Lee MBBS FRACS1,4


Australasian Journal of Plastic Surgery
St Leonards, New South Wales, 2065



Clinical Professor of Surgery
Department of Surgery 
University of Melbourne 
Parkville, Victoria


Chairman, Professorial Plastic Unit
Epworth Freemasons Hospital
East Melbourne, Victoria



Specialist Plastic Surgeon
Subiaco, Western Australia

Name: Mark Ashton
Address: Editor-in-Chief
Australasian Journal of Plastic Surgery
Suite 503, Level 5, 69 Christie Street
St Leonards, New South Wales, 2065
Phone: +61 (0) 418 566 620
Citation: Ashton M, Lee M. Holier than thou: are we all biased? Aust J Plast Surg. 2019;2(2):1–3.https://doi. org. /10.34239/ajops.v2n2.164
Accepted for publication: 12 August 2019
Copyright © 2019. Authors retain their copyright in the article. This is an open access article distributed under the Creative Commons Attribution Licence which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

Topic: Ethics
Keywords: conflict of interest, decision-making, bias

Life is meant to be fair but it isn’t.

Unfortunately, all too often we encounter people who are, in one way or another, conflicted in their work, behavior or allegiances. Worse, sometimes their actions impact upon us, our workplace or colleagues, confronting our perception of what is fair and reasonable and what is ethical. In some situations this conflict is clear and obvious and we, as outsiders, can readily identify the biased behaviour: perhaps someone is having a relationship with a trainee they are supervising then giving them glowing references, or a lecturer is advocating for a new product they received via a research grant, or a senior manager is promoting a friend or family member into a job they control. In these instances, we can see the conflict of interest clearly and if the person is close to us, we will try to guide them to see that their judgment is impaired and that they should remove themselves from the decision-making process. Not infrequently, this is easier said than done and our friend or colleague is blind to their own conflict.

Why is it that we, as outsiders, can spot conflict of interest so easily—almost transparently—and yet the individuals involved are unable to see their underlying bias?

David Robson’s recent book, The intelligence trap: why smart people do stupid things and how to make wiser decisions1 provides unique insight into the decision-making process of people with high IQs and why they are more likely to make certain types of mistakes. Robson claims that it is ‘falsely…assumed that intelligence is synonymous with good thinking’ and that an individual’s heightened ‘factual recall, analogical reasoning and vocabulary reflect an innate general intelligence that extends to all kinds of learning, problem solving, and decision-making’.2 Robson’s research has shown that intelligent educated people are less likely to learn from their mistakes or take advice from others. When they do err, they:

…are better able to build an elaborate argument to justify their reasoning, meaning that they are at risk of becoming more dogmatic in their views. Worse still, intelligent people appear to have a bigger ‘bias blind spot’; meaning they are able to see others’ flaws, while being oblivious to the prejudices and errors in their own reasoning.3

In their book, The responsible public servant, Kernahan and Langford state that conflict broadly falls into seven categories:

While potential conflict of interest is omnipresent in business and the public service, it is also fundamental to medicine, influencing our ethics, our behaviors and the trust that is placed in us by the community we serve. We are continuously surrounded by potential conflicts of interest—in how we treat our patients, the advice we provide, and the treatments we implement. Some is more straightforward and easier to identify, other requires skill and good judgement to recognise that we have a conflict of interest in a particular situation.5

Examples of more subtle conflicts of interest—but none the less still conflicts—involve situations where our decisions indirectly, but absolutely, influence our current lifestyle or workplace. What if you are asked to adjudicate on a proposal that will indirectly impact upon your university, hospital or clinic, and therefore you? We are all trained to quickly identify threats to our well-being and this naturally extends to our home and family. But it also extends to our work environment and, more broadly, to our lifestyle. In these situations, the boundary between professionalism, advocacy and self-interest is more complex and less clear.

The most difficult component of conflict of interest, therefore, is to realise that we can all be blinded by our own bias that we naturally bring to any conversation, assessment or adjudication. And because as surgeons we are decision makers, these preconceptions influence our behavior, our assessment and hence the outcome.6

The understanding that our preconceptions can bias our assessment of a situation is a much more difficult lesson to learn. We often fail to appreciate how bias or conflict of interest works upon us. Our belief that we are doing ‘the right thing’—that we are forwarding research, public knowledge, surgery, advancing the public good—blinds us.

Perhaps, therefore, the real challenge facing us is identifying potential conflict of interest in the first place and recognising that we are all vulnerable to influence—either consciously or subliminally. We need to set in place a series of checks and balances that allow us to recognise unintended conflict or bias and then to prevent this bias from influencing our behaviour.

There are three key elements to conflict of interest. First, there is an individual’s personal or private interest. Second, there is a duty. That means there is an official act or responsibility in which an individual is acting in a formal capacity. And third, there is a conflict between an individual’s personal interest and their professional responsibilities that hinders an objective assessment or professional judgment.

It is said that good judgment without conflict of interest is what a reasonable person believes professional judgment is likely to be and whether an individual’s interest would plausibly influence the assessment. In other words, would someone else, who is similarly qualified, with access to the same information, deem your assessment to be objective and reasonable?

A simple way to test conflict of interest is the ‘trust test’ in which you divulge all your potential conflict of interest to the parties with whom you are dealing and then they, not you, decide if there is conflict.

It is much easier for others to recognise your conflict of interest than you, yourself. This suggests that it is worthwhile speaking to a trusted colleague or friend when you are in doubt.


The authors have no financial or commercical conflicts of interest to disclose.


  1. David Robson. The intelligence trap: why smart people do stupid things and how to make wiser decisions (London, UK: Hodder Stoughton Publishers, 2019).
  2. David Robson. The intelligence trap: why smart people do stupid things and how to make wiser decisions (London, UK: Hodder Stoughton Publishers, 2019) p 2
  3. David Robson. The intelligence trap: why smart people do stupid things and how to make wiser decisions (London, UK: Hodder Stoughton Publishers, 2019) p 3
  4. Kenneth Kernahan and John Langford. The responsible public servant (Canada: Institute for Research on Public Policy, Institute of Public Administration of Canada, 2014) p 142
  5. Lopez J, Samaha G, Purvis TE. The accuracy of conflict-of-interest disclosures reported by plastic surgeons and industry. Plast Reconstr Surg. 2018 Jun;141(6):1592–599. PMID: 29794718
  6. Lopez J, Prifogle E, Nyame TT. The impact of conflicts of interest in plastic surgery: an analysis of acellular dermal matrix, implant-based breast reconstruction. Plast Reconstr Surg. 2014 Jun;133(6):1328–334. PMID: 24867714