Context is all you need: A causal framework for governing bias in clinical AI

Clinical AI systems can produce different recommendations when a patient’s race, income, housing status, or gender identity changes, but a differential alone does not establish unjustified bias. What separates a clinically justified differential from an unjustified one is not its size or direction but its origin: whether the feature acts through a clinically justified pathway, or marks how patients of that group have been treated. That distinction is causal, and a model trained only to detect statistical association records that a feature carries information but never why. Existing evidence does not establish reliable recovery of this adjudication inside that model; we therefore argue for explicit causal and normative supervision, whether supplied by an external layer, built into training, or both. We set out a six-criterion rubric, four approaches to implementing it, and a two-sided evaluation reporting preserved clinical sensitivity alongside reduced bias.