A Toolbox for Surfacing Health Equity Harms and Biases in Large Language Models

Large language models (LLMs) hold immense promise to serve complex health information needs but also have the potential to introduce harm and exacerbate health disparities. Reliably evaluating equity-related model failures is a critical step toward developing systems that promote health equity. In this work, we present resources and methodologies for surfacing biases with potential to precipitate equity-related harms in long-form, LLM-generated answers to medical questions and then conduct an empirical case study with Med-PaLM 2, resulting in the largest human evaluation study in this area to date. Our contributions include a multifactorial framework for human assessment of LLM-generated answers for biases, and EquityMedQA, a collection of seven newly-released datasets comprising both manually-curated and LLM-generated questions enriched for adversarial queries. Both our human assessment framework and dataset design process are grounded in an iterative participatory approach and review of possible biases in Med-PaLM 2 answers to adversarial queries. Through our empirical study, we find that the use of a collection of datasets curated through a variety of methodologies, coupled with a thorough evaluation protocol that leverages multiple assessment rubric designs and diverse rater groups, surfaces biases that may be missed via narrower evaluation approaches. Our experience underscores the importance of using diverse assessment methodologies and involving raters of varying backgrounds and expertise. We emphasize that while our framework can identify specific forms of bias, it is not sufficient to holistically assess whether the deployment of an AI system promotes equitable health outcomes. We hope the broader community leverages and builds on these tools and methods towards realizing a shared goal of LLMs that promote accessible and equitable healthcare for all.

The Case for Globalizing Fairness: A Mixed Methods Study on Colonialism, AI, and Health in Africa

With growing application of machine learning (ML) technologies in healthcare, there have been calls for developing techniques to understand and mitigate biases these systems may exhibit. Fair-ness considerations in the development of ML-based solutions for health have particular implications for Africa, which already faces inequitable power imbalances between the Global North and South.This paper seeks to explore fairness for global health, with Africa as a case study. We conduct a scoping review to propose axes of disparities for fairness consideration in the African context and delineate where they may come into play in different ML-enabled medical modalities. We then conduct qualitative research studies with 672 general population study participants and 28 experts inML, health, and policy focused on Africa to obtain corroborative evidence on the proposed axes of disparities. Our analysis focuses on colonialism as the attribute of interest and examines the interplay between artificial intelligence (AI), health, and colonialism. Among the pre-identified attributes, we found that colonial history, country of origin, and national income level were specific axes of disparities that participants believed would cause an AI system to be biased.However, there was also divergence of opinion between experts and general population participants. Whereas experts generally expressed a shared view about the relevance of colonial history for the development and implementation of AI technologies in Africa, the majority of the general population participants surveyed did not think there was a direct link between AI and colonialism. Based on these findings, we provide practical recommendations for developing fairness-aware ML solutions for health in Africa.

Bias in Language Models: Beyond Trick Tests and Toward RUTEd Evaluation

Bias benchmarks are a popular method for studying the negative impacts of bias in LLMs, yet there has been little empirical investigation of whether these benchmarks are actually indicative of how real world harm may manifest in the real world. In this work, we study the correspondence between such decontextualized "trick tests" and evaluations that are more grounded in Realistic Use and Tangible {Effects (i.e. RUTEd evaluations). We explore this correlation in the context of gender-occupation bias--a popular genre of bias evaluation. We compare three de-contextualized evaluations adapted from the current literature to three analogous RUTEd evaluations applied to long-form content generation. We conduct each evaluation for seven instruction-tuned LLMs. For the RUTEd evaluations, we conduct repeated trials of three text generation tasks: children's bedtime stories, user personas, and English language learning exercises. We found no correspondence between trick tests and RUTEd evaluations. Specifically, selecting the least biased model based on the de-contextualized results coincides with selecting the model with the best performance on RUTEd evaluations only as often as random chance. We conclude that evaluations that are not based in realistic use are likely insufficient to mitigate and assess bias and real-world harms.

Transforming and Combining Rewards for Aligning Large Language Models

A common approach for aligning language models to human preferences is to first learn a reward model from preference data, and then use this reward model to update the language model. We study two closely related problems that arise in this approach. First, any monotone transformation of the reward model preserves preference ranking; is there a choice that is ``better'' than others? Second, we often wish to align language models to multiple properties: how should we combine multiple reward models? Using a probabilistic interpretation of the alignment procedure, we identify a natural choice for transformation for (the common case of) rewards learned from Bradley-Terry preference models. This derived transformation has two important properties. First, it emphasizes improving poorly-performing outputs, rather than outputs that already score well. This mitigates both underfitting (where some prompts are not improved) and reward hacking (where the model learns to exploit misspecification of the reward model). Second, it enables principled aggregation of rewards by linking summation to logical conjunction: the sum of transformed rewards corresponds to the probability that the output is ``good'' in all measured properties, in a sense we make precise. Experiments aligning language models to be both helpful and harmless using RLHF show substantial improvements over the baseline (non-transformed) approach.

Theoretical guarantees on the best-of-n alignment policy

A simple and effective method for the alignment of generative models is the best-of-$n$ policy, where $n$ samples are drawn from a base policy, and ranked based on a reward function, and the highest ranking one is selected. A commonly used analytical expression in the literature claims that the KL divergence between the best-of-$n$ policy and the base policy is equal to $\log (n) - (n-1)/n.$ We disprove the validity of this claim, and show that it is an upper bound on the actual KL divergence. We also explore the tightness of this upper bound in different regimes. Finally, we propose a new estimator for the KL divergence and empirically show that it provides a tight approximation through a few examples.

Helping or Herding? Reward Model Ensembles Mitigate but do not Eliminate Reward Hacking

Reward models play a key role in aligning language model applications towards human preferences. However, this setup creates an incentive for the language model to exploit errors in the reward model to achieve high estimated reward, a phenomenon often termed \emph{reward hacking}. A natural mitigation is to train an ensemble of reward models, aggregating over model outputs to obtain a more robust reward estimate. We explore the application of reward ensembles to alignment at both training time (through reinforcement learning) and inference time (through reranking). First, we show that reward models are \emph{underspecified}: reward models that perform similarly in-distribution can yield very different rewards when used in alignment, due to distribution shift. Second, underspecification results in overoptimization, where alignment to one reward model does not improve reward as measured by another reward model trained on the same data. Third, overoptimization is mitigated by the use of reward ensembles, and ensembles that vary by their \emph{pretraining} seeds lead to better generalization than ensembles that differ only by their \emph{fine-tuning} seeds, with both outperforming individual reward models. However, even pretrain reward ensembles do not eliminate reward hacking: we show several qualitative reward hacking phenomena that are not mitigated by ensembling because all reward models in the ensemble exhibit similar error patterns.

Recovering Sparse and Interpretable Subgroups with Heterogeneous Treatment Effects with Censored Time-to-Event Outcomes

Studies involving both randomized experiments as well as observational data typically involve time-to-event outcomes such as time-to-failure, death or onset of an adverse condition. Such outcomes are typically subject to censoring due to loss of follow-up and established statistical practice involves comparing treatment efficacy in terms of hazard ratios between the treated and control groups. In this paper we propose a statistical approach to recovering sparse phenogroups (or subtypes) that demonstrate differential treatment effects as compared to the study population. Our approach involves modelling the data as a mixture while enforcing parameter shrinkage through structured sparsity regularization. We propose a novel inference procedure for the proposed model and demonstrate its efficacy in recovering sparse phenotypes across large landmark real world clinical studies in cardiovascular health.

Participatory Systems for Personalized Prediction

Machine learning models are often personalized based on information that is protected, sensitive, self-reported, or costly to acquire. These models use information about people, but do not facilitate nor inform their \emph{consent}. Individuals cannot opt out of reporting information that a model needs to personalize their predictions, nor tell if they would benefit from personalization in the first place. In this work, we introduce a new family of prediction models, called \emph{participatory systems}, that allow individuals to opt into personalization at prediction time. We present a model-agnostic algorithm to learn participatory systems for supervised learning tasks where models are personalized with categorical group attributes. We conduct a comprehensive empirical study of participatory systems in clinical prediction tasks, comparing them to common approaches for personalization and imputation. Our results demonstrate that participatory systems can facilitate and inform consent in a way that improves performance and privacy across all groups who report personal data.

auton-survival: an Open-Source Package for Regression, Counterfactual Estimation, Evaluation and Phenotyping with Censored Time-to-Event Data

Applications of machine learning in healthcare often require working with time-to-event prediction tasks including prognostication of an adverse event, re-hospitalization or death. Such outcomes are typically subject to censoring due to loss of follow up. Standard machine learning methods cannot be applied in a straightforward manner to datasets with censored outcomes. In this paper, we present auton-survival, an open-source repository of tools to streamline working with censored time-to-event or survival data. auton-survival includes tools for survival regression, adjustment in the presence of domain shift, counterfactual estimation, phenotyping for risk stratification, evaluation, as well as estimation of treatment effects. Through real world case studies employing a large subset of the SEER oncology incidence data, we demonstrate the ability of auton-survival to rapidly support data scientists in answering complex health and epidemiological questions.

Counterfactual Phenotyping with Censored Time-to-Events

Estimation of treatment efficacy of real-world clinical interventions involves working with continuous outcomes such as time-to-death, re-hospitalization, or a composite event that may be subject to censoring. Causal reasoning in such scenarios requires decoupling the effects of confounding physiological characteristics that affect baseline survival rates from the effects of the interventions being assessed. In this paper, we present a latent variable approach to model heterogeneous treatment effects by proposing that an individual can belong to one of latent clusters with distinct response characteristics. We show that this latent structure can mediate the base survival rates and helps determine the effects of an intervention. We demonstrate the ability of our approach to discover actionable phenotypes of individuals based on their treatment response on multiple large randomized clinical trials originally conducted to assess appropriate treatments to reduce cardiovascular risk.