Leveraging Causal Reasoning Method for Explaining Medical Image Segmentation Models

Reliable and interpretable decision-making is essential in medical imaging, where diagnostic outcomes directly influence patient care. Despite advances in deep learning, most medical AI systems operate as opaque black boxes, providing little insight into why a particular diagnosis was reached. In this paper, we introduce Med-CAM, a framework for generating minimal and sharp maps as evidence-based explanations for Medical decision making via Classifier Activation Matching. Med-CAM trains a segmentation network from scratch to produce a mask that highlights the minimal evidence critical to model's decision for any seen or unseen image. This ensures that the explanation is both faithful to the network's behaviour and interpretable to clinicians. Experiments show, unlike prior spatial explanation methods, such as Grad-CAM and attention maps, which yield only fuzzy regions of relative importance, Med-CAM with its superior spatial awareness to shapes, textures, and boundaries, delivers conclusive, evidence-based explanations that faithfully replicate the model's prediction for any given image. By explicitly constraining explanations to be compact, consistent with model activations, and diagnostic alignment, Med-CAM advances transparent AI to foster clinician understanding and trust in high-stakes medical applications such as pathology and radiology.

Segment-based explanation methods such as LIME return a single explanation for each prediction, computed from one fixed image segmentation. This hides two important facts: a prediction can be supported by many different sets of image segments, and the segmentation itself shapes which explanations can be found. We introduce MOXIE (Multi-Objective eXplanation Imaging Engine), an evolutionary framework that searches for segment subsets that preserve the classifier's confidence while keeping as little of the image as possible. Instead of one explanation, MOXIE returns a Pareto front of alternative explanations that range from compact to highly faithful. We evaluate MOXIE with NSGA-II and four segmentation methods (SLIC, Felzenszwalb, Watershed and Voronoi) on BloodMNIST and HAM10000 datasets, using the same evaluation budget as LIME. Results show that MOXIE achieves a higher hypervolume than LIME on every image. LIME's explanations often appear convincing, yet the classifier's confidence collapses when only the highlighted segments are shown. MOXIE's fronts reveal how much of the image is needed to preserve the model's confidence and which contextual regions influence it. We also find that segmentation strongly affects evaluation: methods with unequal segment sizes appear most compact when segments are counted. These results show that alternative explanations provide a more complete view of a model's decision than a single explanation.

Deep neural networks for medical image diagnosis often achieve high predictive accuracy while relying on spurious or clinically irrelevant visual cues, limiting their trustworthiness in practice. Post-hoc explanation methods are widely used to visualize model decisions in the form of saliency maps; however, these explanations do not influence how models learn during training, allowing non-causal or confounding features to persist. This motivates the incorporation of explanation supervision directly into the training objective to guide model attention toward clinically meaningful regions and promote clinically grounded decision-making. This paper presents a systematic approach to integrate explanation loss into model training and analyzes how different explanation loss designs and supervision strengths influence both predictive performance and spatial faithfulness of explanations. To quantitatively assess interpretability, two complementary explanation performance metrics-annotation coverage and saliency precision-are introduced, enabling rigorous evaluation beyond qualitative visualization. Our experimental results reveal a clear trade-off between explanation quality and explanation loss coefficients. Furthermore, quantitative statistical analysis yields consistently improved explanation alignment while maintaining comparable accuracy. Experiments were conducted on annotated chest X-ray datasets; however, the proposed framework is applicable to a broad range of annotated biomedical imaging modalities. Overall, these findings demonstrate that explanation supervision is not a monolithic design choice and provide practical guidance for incorporating explanation loss into training objectives under noisy clinical annotations.