# MeCaMIL: Causality-Aware Multiple Instance Learning for Fair and Interpretable Whole Slide Image Diagnosis

arXiv: https://arxiv.org/abs/2511.11004 · HTML: https://mlsanity.com/paper/2511.11004/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 18 of its 58 references that are in the map.
- First posted on arXiv 14 Nov 2025.

## Builds on (most cited first, 18 of 18)

- [Attention Is All You Need](https://mlsanity.com/paper/1706.03762/) (2017)
- [An Image is Worth 16x16 Words: Transformers for Image Recognition at Scale](https://mlsanity.com/paper/2010.11929/) (2020)
- [DINOv2: Learning Robust Visual Features without Supervision](https://mlsanity.com/paper/2304.07193/) (2023)
- [SGDR: Stochastic Gradient Descent with Warm Restarts](https://mlsanity.com/paper/1608.03983/) (2016)
- [Attention-based Deep Multiple Instance Learning](https://mlsanity.com/paper/1802.04712/) (2018)
- [TransMIL: Transformer based Correlated Multiple Instance Learning for Whole Slide Image Classification](https://mlsanity.com/paper/2106.00908/) (2021)
- [Dual-stream Multiple Instance Learning Network for Whole Slide Image Classification with Self-supervised Contrastive Learning](https://mlsanity.com/paper/2011.08939/) (2020)
- [DTFD-MIL: Double-Tier Feature Distillation Multiple Instance Learning for Histopathology Whole Slide Image Classification](https://mlsanity.com/paper/2203.12081/) (2022)
- [Whole Slide Images based Cancer Survival Prediction using Attention Guided Deep Multiple Instance Learning Networks](https://mlsanity.com/paper/2009.11169/) (2020)
- [Benchmarking Self-Supervised Learning on Diverse Pathology Datasets](https://mlsanity.com/paper/2212.04690/) (2022)
- [Causal Attention for Vision-Language Tasks](https://mlsanity.com/paper/2103.03493/) (2021)
- [Interventional Bag Multi-Instance Learning On Whole-Slide Pathological Images](https://mlsanity.com/paper/2303.06873/) (2023)
- [Causal Attention for Unbiased Visual Recognition](https://mlsanity.com/paper/2108.08782/) (2021)
- [Mathematical Notions vs. Human Perception of Fairness: A Descriptive Approach to Fairness for Machine Learning](https://mlsanity.com/paper/1902.04783/) (2019)
- [DGMIL: Distribution Guided Multiple Instance Learning for Whole Slide Image Classification](https://mlsanity.com/paper/2206.08861/) (2022)
- [Shapley Values-enabled Progressive Pseudo Bag Augmentation for Whole Slide Image Classification](https://mlsanity.com/paper/2312.05490/) (2023)
- [Word Embeddings via Causal Inference: Gender Bias Reducing and Semantic Information Preserving](https://mlsanity.com/paper/2112.05194/) (2021)
- [Evaluate underdiagnosis and overdiagnosis bias of deep learning model on primary open-angle glaucoma diagnosis in under-served patient populations](https://mlsanity.com/paper/2301.11315/) (2023)

## Abstract (arXiv)

Multiple instance learning (MIL) has emerged as the dominant paradigm for whole slide image (WSI) analysis in computational pathology, achieving strong diagnostic performance through patch-level feature aggregation. However, existing MIL methods face critical limitations: (1) they rely on attention mechanisms that lack causal interpretability, and (2) they fail to integrate patient demographics (age, gender, race), leading to fairness concerns across diverse populations. These shortcomings hinder clinical translation, where algorithmic bias can exacerbate health disparities. We introduce MeCaMIL, a causality-aware MIL framework that explicitly models demographic confounders through structured causal graphs. Unlike prior approaches treating demographics as auxiliary features, MeCaMIL employs principled causal inference -- leveraging do-calculus and collider structures -- to disentangle disease-relevant signals from spurious demographic correlations. Extensive evaluation on three benchmarks demonstrates state-of-the-art performance across CAMELYON16 (ACC/AUC/F1: 0.939/0.983/0.946), TCGA-Lung (0.935/0.979/0.931), and TCGA-Multi (0.977/0.993/0.970, five cancer types). Critically, MeCaMIL achieves superior fairness -- demographic disparity variance drops by over 65% relative reduction on average across attributes, with notable improvements for underserved populations. The framework generalizes to survival prediction (mean C-index: 0.653, +0.017 over best baseline across five cancer types). Ablation studies confirm causal graph structure is essential -- alternative designs yield 0.048 lower accuracy and 4.2x times worse fairness. These results establish MeCaMIL as a principled framework for fair, interpretable, and clinically actionable AI in digital pathology. Code will be released upon acceptance.