The increasing application of artificial intelligence (AI) to healthcare raises both hope and ethical concerns. Some advanced machine learning methods provide accurate clinical predictions at the expense of a significant lack of explainability. Alex John London has defended that accuracy is a more important value than explainability in AI medicine. In this article, we locate the trade-off between accurate performance and explainable algorithms in the context of distributive justice. We acknowledge that accuracy is cardinal from outcome-oriented justice because it helps (...) to maximize patients’ benefits and optimizes limited resources. However, we claim that the opaqueness of the algorithmic black box and its absence of explainability threatens core commitments of procedural fairness such as accountability, avoidance of bias, and transparency. To illustrate this, we discuss liver transplantation as a case of critical medical resources in which the lack of explainability in AI-based allocation algorithms is procedurally unfair. Finally, we provide a number of ethical recommendations for when considering the use of unexplainable algorithms in the distribution of health-related resources. (shrink)

There is a current debate about if, and in what sense, machine learning systems used in the medical context need to be explainable. Those arguing in favor contend these systems require post hoc explanations for each individual decision to increase trust and ensure accurate diagnoses. Those arguing against suggest the high accuracy and reliability of the systems is sufficient for providing epistemic justified beliefs without the need for explaining each individual decision. But, as we show, both solutions have limitations—and it (...) is unclear either address the epistemic worries of the medical professionals using these systems. We argue these systems do require an explanation, but an institutional explanation. These types of explanations provide the reasons why the medical professional should rely on the system in practice—that is, they focus on trying to address the epistemic concerns of those using the system in specific contexts and specific occasions. But ensuring that these institutional explanations are fit for purpose means ensuring the institutions designing and deploying these systems are transparent about the assumptions baked into the system. This requires coordination with experts and end-users concerning how it will function in the field, the metrics used to evaluate its accuracy, and the procedures for auditing the system to prevent biases and failures from going unaddressed. We contend this broader explanation is necessary for either post hoc explanations or accuracy scores to be epistemically meaningful to the medical professional, making it possible for them to rely on these systems as effective and useful tools in their practices. (shrink)

The counterfactual approach to explainable AI (XAI) seeks to provide understanding of AI systems through the provision of counterfactual explanations. In a recent systematic review, Chou et al. (Inform Fus 81:59–83, 2022) argue that the counterfactual approach does not clearly provide causal understanding. They diagnose the problem in terms of the underlying framework within which the counterfactual approach has been developed. To date, the counterfactual approach has not been developed in concert with the approach for specifying causes developed by Pearl (...) (Causality: Models, reasoning, and inference. Cambridge University Press, 2000) and Woodward (Making things happen: A theory of causal explanation. Oxford University Press, 2003). In this paper, I build on Chou et al.’s work by applying the Pearl-Woodward approach. I argue that the standard counterfactual approach to XAI is capable of delivering causal understanding, but that there are limitations on its capacity to do so. I suggest a way to overcome these limitations. (shrink)

We argue that the trend toward providing users with feasible and actionable explanations of AI decisions—known as recourse explanations—comes with ethical downsides. Specifically, we argue that recourse explanations face several conceptual pitfalls and can lead to problematic explanation hacking, which undermines their ethical status. As an alternative, we advocate that explanations of AI decisions should aim at understanding.

This paper argues that one problem that besets black-box AI is that it lacks algorithmic justifiability. We argue that the norm of shared decision making in medical care presupposes that treatment decisions ought to be justifiable to the patient. Medical decisions are justifiable to the patient only if they are compatible with the patient’s values and preferences and the patient is able to see that this is so. Patient-directed justifiability is threatened by black-box AIs because the lack of rationale provided (...) for the decision makes it difficult for patients to ascertain whether there is adequate fit between the decision and the patient’s values. This paper argues that achieving algorithmic transparency does not help patients bridge the gap between their medical decisions and values. We introduce a hypothetical model we call Justifiable AI to illustrate this argument. Justifiable AI aims at modelling normative and evaluative considerations in an explicit way so as to provide a stepping stone for patient and physician to jointly decide on a course of treatment. If our argument succeeds, we should prefer these justifiable models over alternatives if the former are available and aim to develop said models if not. (shrink)

The need for fair and just AI is often related to the possibility of understanding AI itself, in other words, of turning an opaque box into a glass box, as inspectable as possible. Transparency and explainability, however, pertain to the technical domain and to philosophy of science, thus leaving the ethics and epistemology of AI largely disconnected. To remedy this, we propose an integrated approach premised on the idea that a glass-box epistemology should explicitly consider how to incorporate values and (...) other normative considerations, such as intersectoral vulnerabilities, at critical stages of the whole process from design and implementation to use and assessment. To connect ethics and epistemology of AI, we perform a double shift of focus. First, we move from trusting the output of an AI system to trusting the process that leads to the outcome. Second, we move from expert assessment to more inclusive assessment strategies, aiming to facilitate expert and non-expert assessment. Together, these two moves yield a framework usable for experts and non-experts when they inquire into relevant epistemological and ethical aspects of AI systems. We dub our framework ‘epistemology-cum-ethics’ to signal the equal importance of both aspects. We develop it from the vantage point of the designers: how to create the conditions to internalize values into the whole process of design, implementation, use, and assessment of an AI system, in which values (epistemic and non-epistemic) are explicitly considered at each stage and inspectable by every salient actor involved at any moment. (shrink)

Assistive systems based on Artificial Intelligence (AI) are bound to reshape decision-making in all areas of society. One of the most intricate challenges arising from their implementation in high-stakes environments such as medicine concerns their frequently unsatisfying levels of explainability, especially in the guise of the so-called black-box problem: highly successful models based on deep learning seem to be inherently opaque, resisting comprehensive explanations. This may explain why some scholars claim that research should focus on rendering AI systems understandable, rather (...) than explainable. Yet, there is a grave lack of agreement concerning these terms in much of the literature on AI. We argue that the seminal distinction made by the philosopher and physician Karl Jaspers between different types of explaining and understanding in psychopathology can be used to promote greater conceptual clarity in the context of Machine Learning (ML). Following Jaspers, we claim that explaining and understanding constitute multi-faceted epistemic approaches that should not be seen as mutually exclusive, but rather as complementary ones as in and of themselves they are necessarily limited. Drawing on the famous example of Watson for Oncology we highlight how Jaspers’ methodology translates to the case of medical AI. Classical considerations from the philosophy of psychiatry can therefore inform a debate at the centre of current AI ethics, which in turn may be crucial for a successful implementation of ethically and legally sound AI in medicine. (shrink)