Counterfactual Evaluation Reveals Hidden Capability Profiles in Clinical LLMs and Agents

Counterfactual audits are the standard tool for checking whether a clinical agent treats demographically distinct but clinically identical patients differently. They report a flip rate: how often an action changes when only the patient descriptor changes. We show that this quantity is uninterpretable on its own. Re-running an identical condition ten times over sixteen vignettes (same narrative, same descriptor string, nothing varied) moved a clinical agent's action in 8.7% of outcome-vignette cells, and instability was heterogeneous across actions by a factor of eight, from 0.022 for ICU escalation to 0.179 for controlled-substance caution. No demographic contrast in our data was distinguishable from that floor. A second model gives a pooled floor of 6.7% and ranks the six actions almost identically (Spearman 0.94, exact p=0.017), so the floor is not one system's artefact. Majority-vote aggregation over five draws removes 39% of it and then flattens, and a null simulation attributes the residue to heterogeneous per-cell rates, so replication mitigates without eliminating. Any counterfactual fairness estimate reported without a per-action floor beside it therefore cannot be read as evidence of disparity. The measurements were taken with FairMedAgent, an evaluation harness for disparity in the actions of clinical LLM agents whose estimand, the within-range counterfactual flip rate, counts only flips between actions a published decision rule admits and a clinician has adjudicated. That estimand requires band adjudication, which is under way; no disparity result is claimed here. Each synthetic vignette runs a six-stage trajectory (five model-facing decisions around a deterministic environment step) under fixed-form conditions spanning race, sex, age, insurance, English proficiency, and their intersections. The harness, the floor protocol, and every analysis script are released.

When an LLM agent fails -- issues a refund it should not have, calls the wrong tool, leaks data -- existing tooling answers what happened (observability) or whether it passed (evaluation), but not which step caused the failure. The obvious heuristics are wrong: the step that executes the harmful action is usually not the step that decided on it, and LLM-judge attribution is correlational and unreliable (state-of-the-art step-level accuracy on the Who&When benchmark is about 14%). We present Causal Agent Replay (CAR), which answers the question by intervention: it models an agent run as a structural causal model, applies a do-operation to a step, and re-executes the trajectory forward under the same stochastic policy, measuring the shift in the outcome distribution. We define an intervention algebra over agent steps, a single-step contrastive estimator whose point-of-commitment rule resolves a confound specific to stochastic run-forward, and a budget-bounded Monte-Carlo Shapley estimator that splits credit across interacting steps. Every effect is reported with confidence intervals. We validate against synthetic structural causal models with planted ground truth: the contrastive estimator recovers the pivotal step, and Shapley recovers a two-step interaction (0.44, 0.45, ~0; efficiency sum 0.909 versus the analytic 0.91). CAR is open source and runs on hosted or free local models.

We introduce CausaLab, a scalable environment for evaluating interactive causal discovery by LLM agents. Unlike prior evaluations, CausaLab evaluates both whether an agent can solve a problem using causal evidence and whether its answer is grounded in a faithful recovered causal mechanism. Each episode places an agent in a synthetic laboratory: it receives prior measurement records, intervenes on a manipulator crystal, and predicts the resonance frequency of a held-out reactor crystal governed by the same mechanism. The hidden data-generating process is a randomly sampled structural causal model (SCM), so success requires recovering both a causal graph and structural equations rather than recalling prior knowledge. Experiments show a persistent gap between prediction and mechanism recovery: in the purely observational 6-node setting, GPT-5.2-high reaches 92% task accuracy but only 0.471 all-edge $F_1$. Mixed observation-intervention strategies improve structural fidelity, while pure intervention remains difficult even for strong agents. We identify premature stopping as a major weakness and show that consistency verification mitigates it. CausaLab therefore separates predictive success from causal understanding and exposes current LLM agents' limits as experimental causal reasoners.