On Hallucinations in Inverse Problems: Fundamental Limits and Provable Assessment Methods

AI systems are being deployed across medical imaging faster than their failure modes are understood. At this point in time, the failure of greatest clinical concern is hallucination: clinically plausible but factually incorrect outputs, including fabricated anatomical structures, missed findings, incorrect laterality, and invented measurements in generated reports, with direct consequences, for example, for biopsy decisions, staging, and treatment planning. This structured narrative synthesizes peer-reviewed studies, benchmark datasets, and FDA regulatory guidance across five imaging modalities to produce a cross-modality analysis of hallucination taxonomy, etiology, detection, and mitigation. Specifically, we address three questions in this study: (1) how can existing taxonomies be unified across modalities?, (2) how do medical-specialized foundation models hallucinate less than general-purpose ones?, and (3) which mitigation strategies are effective and compatible with FDA lifecycle oversight? We note that three taxonomic frameworks together cover the imaging pipeline in a way no single framework does alone. We also highlight that general-purpose foundation models outperform medical-specialized models on hallucination-specific benchmarks, indicating that narrow domain fine-tuning can introduce overfitting-induced confabulation. At the same time, the oversight of radiologists remains essential; for instance, a very high percentage of of AI-generated flags required expert correction before clinical use. Physics-informed architectural constraints, Chain-of-Thought prompting, and human-in-the-loop safeguards each address different failure modes and is effective when combined. All findings are mapped to the FDA's Total Product Lifecycle and Predetermined Change Control Plan frameworks, which treat hallucination management as a lifecycle obligation rather than a pre-deployment checklist.

Recent inference-time hallucination mitigation methods for large vision-language models (LVLMs) report strong gains on hallucination benchmarks. However, it remains unclear whether lower hallucination scores reflect improved multimodal grounding or more conservative generation. We evaluate six mitigation methods across three LVLMs and four benchmarks, including hallucination-focused evaluation and the diverse capability benchmark MMStar. Our analysis reveals two consistent patterns. First, hallucination reduction is often coupled with reduced informativeness: methods that lower hallucination rates also reduce object recall, visual coverage, or response detailedness. Second, improvements on hallucination benchmarks do not reliably transfer to broader multimodal capabilities, with methods showing inconsistent or degraded performance on fine-grained perception and reasoning tasks. Our findings suggest that current evaluation protocols may overestimate progress by rewarding conservative generation. We argue that hallucination mitigation should be evaluated as a faithfulness--informativeness--capability trade-off rather than through hallucination scores alone.

Diffusion-based inverse problem solvers can produce realistic reconstructions, but realism alone does not ensure that the recovered details are supported by the measurement. We study this failure as measurement-conditioned hallucination: visually meaningful content that is either implausible or inconsistent with the measured instance. Our analysis separates Bayes-rule-based diffusion inverse solvers into a prior update and a measurement-conditioning step, showing that hallucinated content can enter through the prior-side proposal before the measurement correction is applied. Motivated by this view, we propose Robust Prior Update (RPU), a solver-level module that probes the local stability of the diffusion prior update, re-anchors the resulting displacement at the current iterate, and leaves the measurement update unchanged. We instantiate RPU in DPS and evaluate it on FFHQ and ImageNet inverse problems using automatic metrics and human faithfulness studies. On FFHQ, RPU improves PSNR and LPIPS over DPS across box inpainting, Gaussian deblurring, and motion deblurring. In human judgments, RPU receives 91.9% of blind non-tie majority preferences and 91.1% of ground-truth-assisted non-tie preferences on FFHQ box inpainting, while the ImageNet Gaussian reader study is tie-heavy but favors RPU among non-tie cases. These results support a targeted claim: robustifying the prior update can improve instance faithfulness in diffusion inverse solvers, especially when the prior shapes weakly constrained content.