Worst-Group Equalized Odds Regularization for Multi-Attribute Fair Medical Image Classification

Diagnostic performance in medical AI varies systematically across demographic groups, yet subgroup AUC can mask clinically important disparities. At a fixed inference-time operating point, some groups may exhibit over-diagnostic behaviour, characterized by elevated true and false positive rates, while others show under-diagnostic patterns with reduced true and false positive rates. These opposing tendencies can cancel in aggregate AUCs while producing meaningful inequities in clinical decision-making. Motivated by the need to assess and mitigate such disparities at the operating point and across multiple demographic attributes simultaneously, we propose a worst-group equalized-odds margin regularizer. The proposed regularizer explicitly targets subgroup-level deviations on both the true positive and false positive sides at inference. At each update, the method identifies subgroups defined by explicit demographic attributes (e.g., age, sex, and race) that exhibit the most extreme margin deviations and applies a unified penalty, enabling fairness optimization across multiple demographic axes without requiring explicit intersectional constraints. Across two medical imaging datasets in realistic multi-label settings, our method consistently reduces disparities in Equalized Odds and Equalized Opportunity with minimal impact on AUC, preserving diagnostic performance while improving fairness.

Improving the Fairness of Chest X-ray Classifiers

Deep learning models have reached or surpassed human-level performance in the field of medical imaging, especially in disease diagnosis using chest x-rays. However, prior work has found that such classifiers can exhibit biases in the form of gaps in predictive performance across protected groups. In this paper, we question whether striving to achieve zero disparities in predictive performance (i.e. group fairness) is the appropriate fairness definition in the clinical setting, over minimax fairness, which focuses on maximizing the performance of the worst-case group. We benchmark the performance of nine methods in improving classifier fairness across these two definitions. We find, consistent with prior work on non-clinical data, that methods which strive to achieve better worst-group performance do not outperform simple data balancing. We also find that methods which achieve group fairness do so by worsening performance for all groups. In light of these results, we discuss the utility of fairness definitions in the clinical setting, advocating for an investigation of the bias-inducing mechanisms in the underlying data generating process whenever possible.