A Distribution Mapping Approach to Counterfactually Fair Reinforcement Learning

Reinforcement learning (RL) seeks to optimize sequential decisions to maximize population-level benefits over time. However, when deployed in high-stakes settings such as healthcare, RL decisions might systematically restrict some subpopulation's access to valuable services in a manner contrary to the values and goals of stakeholders. Counterfactual fairness (CF) offers a promising framework to address this problem based on causal reasoning. This paper develops a data preprocessing algorithm that, when used in tandem with policy learning, enables CF in RL. Our algorithm relies on a novel quantile distribution mapping method for sequentially estimating the counterfactual states and rewards in the data preprocessing step, subsuming common additivity assumptions used for counterfactual prediction as a special case. We theoretically prove that the per-step level of counterfactual unfairness and infinite-horizon suboptimality gap can be bounded under mild regularity conditions. We also empirically test our algorithm in numerical experiments as well as in application to a real-world interventional digital health dataset.

APEX-VW: A Document-Level English-Spanish Post-Editing Dataset in the Healthcare Domain

Post-Editing (PE) of Machine Translation (MT) output often involves repeating the same lexical and terminological corrections across many segments, especially in specialised and highly repetitive documents. Despite substantial work on Automatic Post-Editing (APE), most available corpora operate at the sentence level, others are synthetic, and overall not designed to study how corrections propagate in realistic Computer-Assisted Translation (CAT) workflows. This paper presents the APEX-VW (Automatic Post-Editing eXperiments on Virtual Wards) Corpus, a new open English-Spanish (EN-ES) dataset built from recent NHS virtual-ward documents and professional PE in Trados Studio, with controlled MT, terminology, and quality assurance settings. The corpus contains seven document-coherent source texts totalling 42k words, translated with four MT systems representing different paradigms and then post-edited by professional translators. Unlike prior resources such as WMT APE corpora, eSCAPE, MLQE-PE, or LangMark, the dataset preserves document order and CAT-tool context, making it suitable for research on terminology normalisation, correction propagation, and human-in-the-loop translation support. The paper describes the corpus design, data preparation, PE setup, and initial corpus statistics, and positions the resource as a benchmark for document-level APE and propagation-aware assistive tools.

The Judgment-Consequence Gap: LLM Moral Reasoning in Healthcare Decisions

As large language models (LLMs) enter high-stakes domains such as healthcare, understanding their moral reasoning becomes essential. Decisions about scarce medical resources often hinge on judgments of responsibility, particularly when patients' own actions contribute to illness. We investigate how LLMs reason about responsibility and its consequences, tracing their judgments across successive levels, from the behavior, to the resulting illness, to the denial of care. We evaluate a wide range of LLMs, spanning different model families and capability levels, on various clinical vignettes adapted from prior studies. Our results identify a judgment-consequence gap: LLMs largely agree with humans that patients bear responsibility for health-harming behaviors, yet overwhelmingly refuse to let that judgment influence how they allocate scarce resources. Specifically, LLMs default to random allocation, whereas humans consistently favor the less-culpable patient. Compared to humans, LLMs also place greater emphasis on access to information, reducing responsibility judgments when health-risk knowledge is unavailable. These findings reveal that LLMs apply a systematically different moral framework than humans when responsibility and resource scarcity intersect, surprisingly often amplifying normative disagreement with humans as reasoning capability increases.

Human-Centered Reflections on Care Robots: A Comparative Study of Caregiver Perspectives

Care robots are increasingly being introduced into healthcare settings, raising important questions about their acceptance and ethical implementation. To better understand these challenges, this study investigates caregivers' perceptions of four categories of care robots: delivering supplies, helping patients into bed, monitoring vital signs, and assisting with mobility. We conducted a mixed-methods study employing a mixed-factorial design in which 298 caregivers from the United States, Mexico, and Chile evaluated all four robot categories. Quantitative measures integrated constructs from the Unified Theory of Acceptance and Use of Technology, the Cognitive-Affective-Normative model, and overall acceptance ratings. Qualitative data were collected through open-ended questions and analyzed using a literature-informed ethical framework. The results indicate that participants across countries generally evaluated care robots positively, particularly for logistical and physically demanding tasks rather than those requiring intensive interpersonal interaction. The qualitative findings provide further insight into stakeholders' views of the ethical implications of care robot use. Participants emphasized potential benefits such as reduced workload, lower risk, and greater patient autonomy, while also expressing concerns about dependability, the need for human oversight, and potential job displacement. Although many ethical concerns were shared across countries, participants differed in how they interpreted and prioritized them. These findings advance a context-sensitive and socially informed understanding of responsible design and implementation of care robots.

Toward Production-Ready Federated Learning in Healthcare: Privacy, Orchestration, and Governance in MLOps

Healthcare organizations often cannot freely centralize patient data because medical records are sensitive, regulated, and institutionally controlled. Federated learning offers a practical alternative by allowing hospitals and clinics to train a shared model while keeping raw data local. However, federated learning is not automatically production-ready or private by default. Model updates can still leak information, and decentralized training introduces operational challenges in deployment, monitoring, rollback, debugging, and governance. This paper examines how MLOps practices and the emerging idea of Federated Learning Operations (FLOps) can make federated healthcare machine learning systems scalable, reliable, and trustworthy. It answers three research questions: how containerization and orchestration support federated deployment, how privacy-preserving mechanisms affect trade-offs among privacy, utility, scalability, and operational complexity, and which post-deployment practices are most important for long-term governance. The central argument is that federated healthcare ML requires more than privacy-preserving algorithms. It needs an integrated MLOps architecture that combines reproducible deployment, secure orchestration, model versioning, audit logging, drift monitoring, heterogeneity management, and clear governance.

Auto-FL-Research: Agentic Search for Federated Learning Algorithms

Federated learning (FL) research often depends on many small but consequential algorithmic choices: optimizer variants, server aggregation rules, local training schedules, normalization, regularization, and model architecture. These choices are expensive to explore manually and difficult to compare fairly when candidate changes can also alter the FL training or evaluation path. In this work, we present Auto-FL-Research (AFR), a constrained coding-agent workflow for FL algorithmic recipe search. Agents may propose and implement candidate training algorithms, including server aggregation rules, client update schedules, local objectives, and registered model variants, while task profiles fix the mutation surface, compute budget, communication contract, and final model evaluation. Each campaign records candidate scores, runtime, edited files, artifacts, and failure status. We evaluate AFR on five healthcare cross-silo FLamby tasks and on grouped-client profiles for the five fixed LEAF datasets plus the LEAF synthetic task. Five-seed repeat evaluations support gains on four FLamby tasks and five of six LEAF profiles, while also exposing seed-sensitive and search-selected failure cases. Same-budget controls show that several gains correspond to FL-recipe changes, whereas other improvements are recovered by fixed-surface scalar controls or fail under repeat or held-out evaluation. These mixed outcomes are part of the contribution: they show how agent-generated candidates can be separated into repeated FL mechanisms, fixed-surface tuning effects, and selected single-run artifacts.

How sensitive do we want AI to be? Socio-communicative competencies of large language models in healthcare

Background. Effective clinical practice relies heavily on the socio-communicative skills of medical professionals. Large language models (LLMs) have been proposed for tasks such as triaging patients, report drafting or translating medical jargon to support informed decision-making. These applications require both factual and social competence. This study evaluates dialogues between LLMs and participants to assess the current state of socio-communicative competencies displayed in LLM-generated texts. Methods. We extracted a subset of extended dialogues from the HELP-Med dataset, comprising 1800 conversation transcripts of interactions between human participants seeking medical information and three different LLMs, GPT 4o, Llama 3 and Command R+. Two experts coded the transcripts for demonstrations of socio-communicative behaviours (non-hostility, sensitivity, structuring, non-intrusiveness) using the IC-MD instrument, originally designed to evaluate interactional competencies in medical student admissions. Results. The LLMs in our study showed strength in non-hostility, mixed results in sensitivity and non-intrusiveness and performed poorly in structuring. Conclusion. Current LLMs lack the consistent and reliable socio-communicative skills needed for safe and effective use as healthcare advisors. While existing frameworks for assessing interactional competencies may support the development of more socially responsive LLMs, they will require adaptation to account for the differences in desirable behaviour between humans and LLMs.

Why Trust Your Agent? Empirical Security Gains from TRiSM-Guided Agentic Workflows in Healthcare

Agent-based AI has enabled the automation of tasks by exposing application tools and resources to large language models (LLMs). However, to improve scope and accuracy, agents are often given access rights that exceed those of ordinary users, introducing significant security risks. AI is routinely integrated into applications with a disregard to security, risking data exposure and breaching regulations. This paper applies the AI Trust, Risk, and Security Management (TRiSM) framework to a medical report-generation application to demonstrate how an insecure agent workflow can be transformed into security-conscious agentic workflow. Both workflows were evaluated across five LLMs (Claude Haiku 4.5, GPT-4.1-nano, GPT-4.1-mini, GPT-5.4-mini, and Gemini 2.5 Flash) on two report types, totalling 800 generations and 500 attack scenarios including RAG poisoning, data-field injection, and client-side network injection. The TRiSM-guided agentic workflow reduced mean attack success rates from 31% to 10% for RAG poisoning and from 42% to 25% for data-field injection, while eliminating the network injection vector entirely through server-side prompt construction. Furthermore, report accuracy increased by 14 percentage points (72.5% to 86.5%) with the agentic workflow, demonstrating a secure design which provides more reliable outputs. This paper contributes to knowledge by demonstrating least-privilege, defence in depth agentic workflows improving security and accuracy, while also highlighting model choice is a necessary architectural consideration.

Old Fictions, New Skins: Evaluating the Manipulative Capabilities of LLMs in Healthcare

Large language models (LLMs) are increasingly piloted in African healthcare contexts, raising concerns about their potential to manipulate users in high-stakes settings. In a randomised experiment, we examined the manipulative capabilities of two publicly available models, ChatGPT 5.2 and DeepSeek V3.2, among Kenyan participants (N = 303). Participants interacted with either a manipulative variant or a non-manipulative variant before making a treatment decision within a hypothetical clinical scenario. The manipulative variant was prompted to covertly steer participants towards an incorrect treatment option while the non-manipulative variant served as the control condition. Manipulation success rates were higher in the manipulative condition (59.5%) than in the control condition (44.0%), with the effect reaching significance (OR = 2.11, 95% CI [1.12, 4.00], p = .021). These findings highlight the need for improved safety infrastructure specifically targeting manipulation, particularly given the integration of AI into healthcare systems across Africa.

Strategic Feature Selection

When algorithmic predictors inform resource allocation in high-stakes domains such as healthcare, these predictors must account for strategic manipulation of input features. The typical solution is to redesign the predictor itself to explicitly account for strategic interactions. In practice, however, decision makers are often constrained to adjusting coarser levers within existing prediction pipelines. For example, healthcare organizations often select which features to exclude based on perceived manipulability, while using standard regularization procedures to shrink the coefficients of retained features. In this work, we initiate a formal study of strategic classification through feature selection and its interaction with ridge regularization. Our main finding is that excluding individual features based on their manipulability alone is generally suboptimal. We provide a fine-grained characterization of the performance of a feature subset under optimal regularization, yielding new insights for policy design. Motivated by this characterization, we develop a practical algorithm for jointly choosing the feature set and the level of ridge regularization. Through a real-world case study on a healthcare payments benchmark, we illustrate how our algorithm can guide the design of coarse policy levers in practice. Our results provide a principled, practical framework for mitigating the effects of strategic behavior in algorithmic decision-making systems.

When Large Language Models Fail in Healthcare: Evaluating Sensitivity to Prompt Variations

Large Language Models (LLMs) are increasingly used in healthcare for tasks such as clinical question answering, diagnosis support, and report summarization. Despite their promise, these models remain highly sensitive to subtle prompt perturbations, both lexical and syntactic, posing serious risks in safety-critical clinical applications. In this study, we conduct a systematic sensitivity analysis to evaluate the robustness of both general-purpose (e.g., GPT-3.5, Llama3) and medical-specific LLMs (e.g., ClinicalBERT, BioLlama3, BioBERT) using the MedMCQA benchmark. We categorize perturbations into natural and adversarial types and examine their effect on model consistency, accuracy, and reliability in clinical reasoning tasks. Our findings reveal that medical LLMs are not intrinsically safe. Even minor variations in phrasing can alter clinical advice, and targeted adversarial prompts can provoke harmful outputs. In high-stakes settings like healthcare, such unpredictability is unacceptable-models that change diagnoses due to reworded inputs or hallucinate medications when slightly rephrased cannot be reliably trusted by clinicians. While models tend to show resilience to simple lexical substitutions or paraphrasing, they often break down under syntactic reordering or misleading contextual cues. This fragility is evident across both general-purpose and domain-specific LLMs. Notably, adversarial manipulations can lead to clinically dangerous outputs, such as recommending incorrect dosages or omitting critical findings.

PAMF: Prior-Aware Multimodal Fusion for Incomplete Time Series Data

In healthcare, multimodal time series tasks often operate on incomplete observations in practice, for example when ECG segments are lost because electrodes detach or an entire respiratory channel is unavailable during overnight monitoring. Such missingness typically appears in two structurally distinct patterns: within-modality missing, where values are absent within an otherwise observed modality, and modality-level missing, where an entire modality is unavailable. Existing methods typically represent unobserved data implicitly through masks or missing embeddings, without learning instance-specific missing information, and most are designed for only one missingness pattern. A natural approach is to explicitly estimate the missing data; however, existing imputation methods treat missingness uniformly despite their different structural priors, and the imputation process is often isolated from downstream tasks, preventing downstream tasks from guiding imputation toward more informative representations. To address these limitations, we present PAMF, a multimodal time-series framework that explicitly handles different missingness patterns while coupling imputation with downstream prediction through prior-aware flow matching and weight sharing. Specifically, the method initializes the flow-matching source state with type-specific priors to distinguish two missing types. It further connects imputation and classification through architecturally matched encoders with weight sharing, transferring task-relevant representations into the imputation process. Experiments on multiple multimodal healthcare time-series benchmarks show that the proposed method achieves the strongest overall downstream performance across diverse datasets and missing settings compared with existing baselines.

Harnessing Source Heterogeneity for Cluster-Structured Transfer Learning

Transfer learning is a natural strategy when a target population has limited data but multiple related auxiliary sources are available. A central difficulty is source heterogeneity: auxiliary sources may not be equally useful, and their usefulness may vary in a structured, cluster-like fashion. Existing transfer-learning methods often reduce source selection to a binary informative/non-informative decision, overlooking subgroups of sources with differential transferability. Motivated by a suicide-risk study using data from the Connecticut Hospital Information Management Exchange (CHIME), comprising 636,758 patients across 27 hospitals, we propose Trans-GLMC, a cluster-structured transfer-learning procedure for generalized linear models. The CHIME setting illustrates the core challenge: hospital-specific risk models are unstable because suicide attempts are rare at any single facility, whereas indiscriminate pooling across hospitals can obscure facility-level differences in patient mix and risk profiles. Trans-GLMC first constructs a coefficient-based distance among the target and candidate sources to recover latent source clusters. It then combines global fusion, within-cluster refinement, and target debiasing to produce an estimator that adapts to the detected structure. We establish a non-asymptotic error bound that improves over its unclustered counterpart whenever a meaningful target cluster exists and matches the unclustered rate up to constants otherwise. In simulations and in the CHIME study, Trans-GLMC improves facility-specific prediction, identifies interpretable communities of hospitals with mutual transferability, and recovers clinically coherent suicide-risk factors.