Fair Foundation Models for Medical Image Analysis: Challenges and Perspectives

Ensuring equitable Artificial Intelligence (AI) in healthcare demands systems that make unbiased decisions across all demographic groups, bridging technical innovation with ethical principles. Foundation Models (FMs), trained on vast datasets through self-supervised learning, enable efficient adaptation across medical imaging tasks while reducing dependency on labeled data. These models demonstrate potential for enhancing fairness, though significant challenges remain in achieving consistent performance across demographic groups. Our review indicates that effective bias mitigation in FMs requires systematic interventions throughout all stages of development. While previous approaches focused primarily on model-level bias mitigation, our analysis reveals that fairness in FMs requires integrated interventions throughout the development pipeline, from data documentation to deployment protocols. This comprehensive framework advances current knowledge by demonstrating how systematic bias mitigation, combined with policy engagement, can effectively address both technical and institutional barriers to equitable AI in healthcare. The development of equitable FMs represents a critical step toward democratizing advanced healthcare technologies, particularly for underserved populations and regions with limited medical infrastructure and computational resources.

Does Data-Efficient Generalization Exacerbate Bias in Foundation Models?

Foundation models have emerged as robust models with label efficiency in diverse domains. In medical imaging, these models contribute to the advancement of medical diagnoses due to the difficulty in obtaining labeled data. However, it is unclear whether using a large amount of unlabeled data, biased by the presence of sensitive attributes during pre-training, influences the fairness of the model. This research examines the bias in the Foundation model (RetFound) when it is applied to fine-tune the Brazilian Multilabel Ophthalmological Dataset (BRSET), which has a different population than the pre-training dataset. The model evaluation, in comparison with supervised learning, shows that the Foundation Model has the potential to reduce the gap between the maximum AUC and minimum AUC evaluations across gender and age groups. However, in a data-efficient generalization, the model increases the bias when the data amount decreases. These findings suggest that when deploying a Foundation Model in real-life scenarios with limited data, the possibility of fairness issues should be considered.

Using Backbone Foundation Model for Evaluating Fairness in Chest Radiography Without Demographic Data

Ensuring consistent performance across diverse populations and incorporating fairness into machine learning models are crucial for advancing medical image diagnostics and promoting equitable healthcare. However, many databases do not provide protected attributes or contain unbalanced representations of demographic groups, complicating the evaluation of model performance across different demographics and the application of bias mitigation techniques that rely on these attributes. This study aims to investigate the effectiveness of using the backbone of Foundation Models as an embedding extractor for creating groups that represent protected attributes, such as gender and age. We propose utilizing these groups in different stages of bias mitigation, including pre-processing, in-processing, and evaluation. Using databases in and out-of-distribution scenarios, it is possible to identify that the method can create groups that represent gender in both databases and reduce in 4.44% the difference between the gender attribute in-distribution and 6.16% in out-of-distribution. However, the model lacks robustness in handling age attributes, underscoring the need for more fundamentally fair and robust Foundation models. These findings suggest a role in promoting fairness assessment in scenarios where we lack knowledge of attributes, contributing to the development of more equitable medical diagnostics.