Same Evidence, Different Target: Decoding How Diagnostic Evidence Bears on Causal Questions from Language-Model States
Authors: Weiyi Kong, Zhuoran Li
Organizations: University of Toronto, Toronto, Canada · The University of Hong Kong, Hong Kong
Abstract
The same diagnostic result can support or challenge one causal claim yet fail to address another when the claims concern different populations, outcomes, estimands, pathways, or identifying assumptions. When the evidence and target vary together, a correct answer may reflect favorable or adverse wording, lexical overlap, or a familiar diagnostic pattern rather than matching the evidence to the causal question. We introduce paired prompts that repeat the same diagnostic evidence verbatim while changing the causal target. Each prompt is labeled Favors, Challenges, Unresolved, or Wrong Target according to how the evidence bears on the causal question. A pair is recovered only when both prompts are classified correctly. Using linear readouts trained on a separate development set, we analyze the final-token hidden state from the penultimate transformer block of Qwen2.5-7B-Instruct, Qwen3-8B, and Llama-3.1-8B-Instruct. On the 49-pair primary benchmark spanning nine diagnostic families, balanced accuracy ranges from 0.654 to 0.659 and 18-21 pairs are recovered. Two independent human reviewers assigned the same label to 95 of the 98 prompts (96.9%). Across checkpoints, balanced accuracy and complete-pair recovery exceed permutation nulls that preserve development scenario groups. In Qwen2.5, full-prompt balanced accuracy exceeds both restricted inputs, with paired-bootstrap intervals for both differences above zero. Readouts trained without development examples from the evaluated diagnostic family recover 21 pairs, including at least one in each of the nine families. The hidden-state readout exceeds a linear classifier on answer-option logits and text baselines in balanced accuracy and recovered pairs. These results show that the hidden state contains linearly decodable information about whether diagnostic evidence favors, challenges, or fails to address the causal target.
We find a mismatch between what large language models encode about a causal question and what they answer. On anti-commonsense CLadder items, a fixed linear probe recovers the evidence-supported answer from the model's hidden state (accuracy approximately 0.97), while the spoken Yes/No reverts to the commonsense one (accuracy approximately 0.5). We call this approximately +0.5 gap Causal Tongue-Tie: a wrong Yes/No decomposes into two separable failure modes: no internal signal versus a signal the verbal interface cannot say. The implication cuts both ways for output-only causal benchmarks: a benchmark "correct" need not mean the model has understood, and a benchmark "wrong" need not mean it cannot. Sweeping claims about whether LLMs can do causal reasoning, drawn from a single accuracy number, deserve a second look.
Instruction-tuned language models can answer the same causal-reasoning question differently after its English variable names are replaced by type-preserving placeholders, although the structural causal model and the gold answer are unchanged. We ask whether this lexical gap reflects information loss in the placeholder view or a misaligned read-out from a representation that still carries answer-relevant content. Vernier uses a paired-view weight update as an instrument and then inspects the mechanism left after the gap closes. In the working regimes, the evidence favours representational misalignment. A variable-name probe becomes more accurate on the placeholder view, and activation patching on Qwen-7B, Qwen-14B, and Llama-3.1-8B shows that the decision-token representation can transfer answer identity between views. The update that realigns the views is counterfactual augmentation over original and placeholder prompts, while the answer-subspace KL mainly sharpens intermediate answer-belief agreement. Success is bounded by model family, scale, and task. CRASS transfer is reliable across Qwen scales and Llama, e-CARE remains weak, and preliminary non-causal rename tasks show a similar qualitative pattern.
Medical LLMs are often evaluated by whether they select the correct diagnosis, but diagnostic accuracy alone does not show whether the model used the case evidence appropriately. We present a behavioral audit of evidence use in medical diagnosis. For each case, we decompose patient information into evidence units, score candidate diagnoses under controlled evidence subsets, and mine low-order interactions in diagnostic margins. Because medical evidence is diagnosis-relative, the audit separates interaction discovery from failure assignment: large or negative interactions can reflect plausible differential diagnosis, while suspicious interactions require robustness checks and clinical review. We evaluate five open-weight LLMs on DDXPlus, CupCase, and MedCase. Across datasets, faithful support and differential conflict or cancellation account for most interaction strength, showing that many evidence interactions are clinically plausible rather than failures. In a DDXPlus-focused blinded five-reviewer 130-item enriched review sample, invalid or shortcut-like cases concentrate in negated or absent findings and clinically local evidence. These results show that accuracy can hide candidate evidence-use failures and motivate role-aware audits for medical LLM evaluation.