The Missing Red Line: How Commercial Pressure Erodes AI Safety Boundaries

Large language models are being deployed as mental health support agents at scale, yet only 16% of LLM-based chatbot interventions have undergone rigorous clinical efficacy testing, and simulations reveal psychological deterioration in over one-third of cases. We evaluate four generative models on 250 Prolonged Exposure (PE) therapy scenarios and 146 CBT cognitive restructuring exercises (plus 29 severity-escalated variants), scored by a three-judge LLM panel. All models scored near-perfectly on surface acknowledgment (~0.91-1.00) while therapeutic appropriateness collapsed to 0.22-0.33 at the highest severity for three of four models, with protocol fidelity reaching zero for two. Under CBT severity escalation, one model's task completeness dropped from 92% to 71% while the frontier model's safety-interference score fell from 0.99 to 0.61. We identify a systematic, modality-spanning failure: RLHF safety alignment disrupts the therapeutic mechanism of action by grounding patients during imaginal exposure, offering false reassurance, inserting crisis resources into controlled exercises, and refusing to challenge distorted cognitions mentioning self-harm in PE; and through task abandonment or safety-preamble insertion during CBT cognitive restructuring. These findings motivate a five-axis evaluation framework (protocol fidelity, hallucination risk, behavioral consistency, crisis safety, demographic robustness), mapped onto FDA SaMD and EU AI Act requirements. We argue that no AI mental health system should proceed to deployment without passing multi-axis evaluation across all five dimensions.

Large language models (LLMs) are increasingly used for medical and health-related questions, yet their safety in high-risk medical scenarios remains poorly understood. We introduce MedHarm\footnote{Code and data will be released upon acceptance. Due to the sensitive nature of high-risk medical queries, data access will be available to qualified researchers upon request.}, a high-risk medical safety benchmark with 1,100 medically grounded queries across 10 safety-critical categories, including toxicology, pharmacology, covert poisoning, anesthesia, and fetal harm. Unlike broad medical QA benchmarks, MedHarm targets realistic clinical, educational, and technical prompts that require refusal, caution, or safe redirection rather than direct helpfulness. We evaluate 15 LLMs spanning general-purpose, medical-purpose, closed-source, and downstream SFT models, together with 4 representative guardrail models. Results reveal a substantial gap between apparent alignment and medical safety: aligned models can still produce unsafe or actionable responses, medical fine-tuning can amplify harmful specificity, and external guardrails reduce some failures while introducing brittle blocking and weak safe helpfulness. These findings show that medical safety cannot be inferred from general alignment or medical capability alone, highlighting the need for domain-specific stress testing before deploying LLMs in safety-critical medical applications.

Safety alignment in LLMs aims to align models with human values, but which values take precedence when they conflict? We investigate this question in the context of tool-calling LLM agents deployed in regulated industries, where agents processing confidential documents may encounter content that triggers safety-trained values (e.g., public welfare) that conflict with deployment-context instructions (e.g., internal logging). To empirically verify this phenomenon, we build a benchmark of 128 scenarios across 16 domains. We find that safety-aligned open-source models override their deployment instructions up to 43.4% of the time, engaging in whistleblowing, data exfiltration, and evidence tampering when processing documents that suggest organizational wrongdoing. We also find that abliteration reduces rates of external whistleblowing. These results reveal a fundamental tension in pluralistic alignment, where the same safety training that protects users can cause agents to act against deployment instructions in ways that create unpredictable liability risks. We release our benchmark as a framework to support evaluation of agent behavior under competing legitimate interests.