HealthCraft: A Reinforcement Learning Safety Environment for Emergency Medicine

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 \textsc{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, \textsc{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 Large Language Models is critical for healthcare; however, reliance on binary refusal boundaries often results in over-refusal of benign queries or unsafe compliance with harmful ones. While existing benchmarks measure these extremes, they fail to evaluate Safe Completion: the model's ability to maximise helpfulness on dual-use or borderline queries by providing safe, high-level guidance without crossing into actionable harm. We introduce Health-ORSC-Bench, the first large-scale benchmark designed to systematically measure Over-Refusal and Safe Completion quality in healthcare. Comprising 31,920 benign boundary prompts across seven health categories (e.g., self-harm, medical misinformation), our framework uses an automated pipeline with human validation to test models at varying levels of intent ambiguity. We evaluate 30 state-of-the-art LLMs, including GPT-5 and Claude-4, revealing a significant tension: safety-optimised models frequently refuse up to 80% of "Hard" benign prompts, while domain-specific models often sacrifice safety for utility. Our findings demonstrate that model family and size significantly influence calibration: larger frontier models (e.g., GPT-5, Llama-4) exhibit "safety-pessimism" and higher over-refusal than smaller or MoE-based counterparts (e.g., Qwen-3-Next), highlighting that current LLMs struggle to balance refusal and compliance. Health-ORSC-Bench provides a rigorous standard for calibrating the next generation of medical AI assistants toward nuanced, safe, and helpful completions. Furthermore, our benchmark facilitates reproducible evaluation, encourages safety calibration, and supports development of clinically reliable, context-aware, human-aligned medical AI systems. Our code and data are available at: https://github.com/ZhihaoZhang97/Health-ORSC-Bench. Warning: Some contents may include toxic or undesired contents.

Large language models (LLMs) increasingly provide conversational health information that may influence treatment decisions, yet existing benchmarks do not isolate whether medication-safety boundaries persist across follow-ups after explicit self-treatment intent. We introduce TAF-MED, a physician-reviewed benchmark of 500 fixed three-turn scenarios, and evaluate eight LLMs across 4,000 conversations. A rubric-based automated judge labelled responses as SAFE, LEAKY, or UNSAFE, and two physicians independently annotated a model-balanced random subset of 400 conversations. We assessed unsafe guidance, collapse after a strictly SAFE initial response, and model-ranking stability. Overall, 71.6% of conversations contained an UNSAFE response, and 61.4% of those beginning with a strictly SAFE response later collapsed to UNSAFE; model-level collapse rates ranged from 24.4% to 96.2%. Four of 28 model pairs reversed order between initial unsafe and collapse rates. Automated labels achieved 94.3% agreement with the adjudicated physician reference ($κ= 0.895$). These findings show that first-turn safety is an incomplete proxy for conversational safety persistence and motivate evaluation across complete dialogue trajectories. We will release TAF-MED on Hugging Face to support reproducible research on multi-turn medical safety.