Unmasking Toxic Mimicry in Medical Offline Reinforcement Learning for ICU Sepsis Management via Counterfactual Clinical Audits

Offline reinforcement learning (RL) offers considerable promise for optimizing ICU treatment decisions, yet standard evaluation metrics Mean Squared Error (MSE) and Fitted Q-Evaluation (FQE) assess only behavioral imitation and cannot detect Toxic Mimicry, a failure mode in which agents replicate harmful patterns such as treatment withdrawal during comfort-care transitions. Using the MIMIC-III database, we propose the Counterfactual Clinical Audit (CCA) framework, which stress-tests RL agents through physiological perturbations anchored in Surviving Sepsis Campaign (SSC) guidelines. We audit a Medical Decision Transformer (MedDT) and a Historical Causal Transformer (HCT-RL), the latter employing Causal Action Shielding, propensity-based importance weighting, and Conservative Q-Learning. CCA reveals that MedDT paradoxically reduces vasopressor dosage as lactate escalates, contradicting resuscitation guidelines, while HCT-RL maintains physiologically consistent responses. These findings expose a systemic misalignment between statistical fit and clinical safety, supporting counterfactual audits as a necessary evaluation standard for medical RL.

Do Audio Language Models Use Paralinguistic Evidence? Counterfactual Audits for Response Evaluation

Audio-language models (ALMs) are increasingly used as judges for speech-to-speech systems, but a judge that receives audio may not actually use paralinguistic evidence. We introduce counterfactual audits for paralinguistic response evaluation. Each audit item holds the transcript fixed while varying affect, prosody, or the timing of an affective shift, forcing a valid judge to track the audio cue rather than lexical content or response style. We evaluate ALM judges using a native one-context judgment protocol and a contrastive recoverability control, then further decompose each item into its constituent perception and response-mapping skills. This yields useful diagnostic states that identify different sources of judge failures. Across Gemini, GPT, and open audio models, we find that contrastive success often overstates native judge reliability, and that similar aggregate accuracies can hide different failure modes. These results suggest that ALM judges should not be evaluated by accuracy alone, instead requiring thorough behavioral audits before deployment.