A Causal Framework for Mitigating Data Shifts in Healthcare

Medical imaging models frequently fail when deployed across hospitals, scanners, populations, or imaging protocols due to domain shift, limiting their clinical reliability. While transfer learning and domain adaptation address such shifts statistically, they often rely on spurious correlations that break under changing conditions. On the other hand, causal inference provides a principled way to identify invariant mechanisms that remain stable across environments. This survey introduces and systematises Causal Transfer Learning (CTL) for medical image analysis. This paradigm integrates causal reasoning with cross-domain representation learning to enable robust and generalisable clinical AI. We frame domain shift as a causal problem and analyse how structural causal models, invariant risk minimisation, and counterfactual reasoning can be embedded within transfer learning pipelines. We studied spanning classification, segmentation, reconstruction, anomaly detection, and multimodal imaging, and organised them by task, shift type, and causal assumption. A unified taxonomy is proposed that connects causal frameworks and transfer mechanisms. We further summarise datasets, benchmarks, and empirical gains, highlighting when and why causal transfer outperforms correlation-based domain adaptation. Finally, we discuss how CTL supports fairness, robustness, and trustworthy deployment in multi-institutional and federated settings, and outline open challenges and research directions for clinically reliable medical imaging AI.

The problem of domain generalization concerns learning predictive models that are robust to distribution shifts when deployed in new, previously unseen environments. Existing methods typically require labeled data from multiple training environments, limiting their applicability when labeled data are scarce. In this work, we study domain generalization in an anti-causal setting, where the outcome causes the observed covariates. Under this structure, environment perturbations that affect the covariates do not propagate to the outcome, which motivates regularizing the model's sensitivity to these perturbations. Crucially, estimating these perturbation directions does not require labels, enabling us to leverage unlabeled data from multiple environments. We propose two methods that penalize the model's sensitivity to variations in the mean and covariance of the covariates across environments, respectively, and prove that these methods have worst-case optimality guarantees under certain classes of environments. Finally, we demonstrate the empirical performance of our approach on a controlled physical system and a physiological signal dataset.

Domain generalization has become a critical challenge in predictive healthcare, where different patient groups exhibit shifting data distributions that degrade model performance. Still, regular domain generalization approaches often struggle in clinical settings due to (1) the absence of domain labels and (2) the lack of clinical insight integration. To address these challenges in healthcare, we aim to explore how medical ontologies can be used to discover dynamic yet hierarchy-grounded patient domains, a partitioning strategy that remains under-explored in prior work. Hence, we introduce UdonCare, a hierarchy-pruning method that iteratively divides patients into latent domains and retrieves domain-invariant (label) information from patient data. On public datasets (MIMIC-III, MIMIC-IV, and eICU), UdonCare shows superiority over eight generalization baselines across four representative clinical prediction tasks with substantial domain gaps, highlighting the potential of medical knowledge for enhancing model generalization.