Medicine is inherently pluralistic. Principles such as autonomy, beneficence, nonmaleficence, and justice routinely conflict, and such ethical dilemmas often sharply divide reasonable physicians. Good clinical practice navigates these tensions in concert with each patient's values rather than imposing a single ethical stance. The ethical values that large language models bring to medical advice, however, have not been systematically examined. We present a framework for auditing value pluralism in medical AI, comprising a benchmark of clinician-verified dilemmas and an attribution method that recovers value priorities directly from decisions. The ecosystem of frontier models spans physician-level value heterogeneity, and models discuss competing values in their reasoning (Overton pluralism) before committing to a decision. However, individual model decisions are near-deterministic across repeated sampling and semantic variations, failing to reproduce the distributional pluralism of the physician panel. Across benchmark cases, these consistent decisions reflect committed, systematic value preferences. While most model priorities fall within the natural range of inter-physician variation, some significantly underweight patient autonomy. A single LLM deployed without regard for its value priorities could amplify those priorities at scale to every patient it serves. Without explicit efforts to balance ethical perspectives with one or multiple models, these tools risk replacing clinical pluralism with a deployment monoculture.
Large Language Models (LLMs) are increasingly deployed in healthcare, yet their communicative alignment with clinical standards remains insufficiently quantified. We conduct a multidimensional evaluation of general-purpose and domain-specialized LLMs across structured medical explanations and real-world physician-patient interactions, analyzing semantic fidelity, readability, and affective resonance. Baseline models amplify affective polarity relative to physicians (Very Negative: 43.14-45.10% vs. 37.25%) and, in larger architectures such as GPT-5 and Claude, produce substantially higher linguistic complexity (FKGL up to 16.91-17.60 vs. 11.47-12.50 in physician-authored responses). Empathy-oriented prompting reduces extreme negativity and lowers grade-level complexity (up to -6.87 FKGL points for GPT-5) but does not significantly increase semantic fidelity. Collaborative rewriting yields the strongest overall alignment. Rephrase configurations achieve the highest semantic similarity to physician answers (up to mean = 0.93) while consistently improving readability and reducing affective extremity. Dual stakeholder evaluation shows that no model surpasses physicians on epistemic criteria, whereas patients consistently prefer rewritten variants for clarity and emotional tone. These findings suggest that LLMs function most effectively as collaborative communication enhancers rather than replacements for clinical expertise.
Mariano Barone, Francesco Di Serio, Roberto Moio +4
The impressive performance of generalist large language models (LLMs) such as GPT and Claude in healthcare raises a critical question: will domain-specific medical specialist models become obsolete? We argue that the future of medical artificial intelligence (AI) lies not in building monolithic medical foundation models, nor in replacing human expertise, but in orchestrating collaboration among generalist LLMs, domain-specific specialist models, and clinicians. We propose HetMedAgent, a heterogeneous medical multi-agent framework that enables conflict-aware evidence fusion, uncertainty-based clinician intervention triggering, and adaptive threshold calibration. Experiments on three real-world clinical decision-making tasks demonstrate that the synergy between generalist LLMs and domain-specific specialist models significantly outperforms using either type of model alone, validating the irreplaceable value of specialist models in modality-specific analysis. HetMedAgent represents a shift from building medical LLMs or foundation models to multi-agent collaboration, achieving a balance between general reasoning capabilities and domain-specific precision.
Language models deployed in high-stakes professional settings face conflicting demands from users, institutional authorities, and professional norms. How models act when these demands conflict reveals a principal hierarchy -- an implicit ordering over competing stakeholders that determines, for instance, whether a medical AI receiving a cost-reduction directive from a hospital administrator complies at the expense of evidence-based care, or refuses because professional standards require it. Across 7,136 scenarios in legal and medical domains, we test ten frontier models and find that models frequently fail to adhere to professional standards during task execution, such as drafting, when user instructions conflict with those standards -- despite adequately upholding them when users seek advisory guidance. We further find that the hierarchies between user, authority, and professional standards exhibited by these models are unstable across medical and legal contexts and inconsistent across model families. When failing to follow professional standards, the primary failure mechanism is knowledge omission: models that demonstrably possess relevant knowledge produce harmful outputs without surfacing conflicting knowledge. In a particularly troubling instance, we find that a reasoning model recognizes the relevant knowledge in its reasoning trace -- e.g., that a drug has been withdrawn -- yet suppresses this in the user-facing answer and proceeds to recommend the drug under authority pressure anyway. Inconsistent alignment across task framing, domain, and model families suggests that current alignment methods, including published alignment hierarchies, are unlikely to be robust when models are deployed in high-stakes professional settings.
Fangyi Yu, Nabeel Seedat, Jonathan Richard Schwarz +1