# False Confidence: Automated Labels Confound Fairness Audits in Cervical Spine Segmentation

arXiv: https://arxiv.org/abs/2607.07852 · HTML: https://mlsanity.com/paper/2607.07852/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 10 of its 22 references that are in the map.
- First posted on arXiv 8 Jul 2026.

## Builds on (most cited first, 10 of 10)

- [Quantifying the Carbon Emissions of Machine Learning](https://mlsanity.com/paper/1910.09700/) (2019)
- [Embracing Imperfect Datasets: A Review of Deep Learning Solutions for Medical Image Segmentation](https://mlsanity.com/paper/1908.10454/) (2019)
- [nnU-Net Revisited: A Call for Rigorous Validation in 3D Medical Image Segmentation](https://mlsanity.com/paper/2404.09556/) (2024)
- [Fairness in Cardiac MR Image Analysis: An Investigation of Bias Due to Data Imbalance in Deep Learning Based Segmentation](https://mlsanity.com/paper/2106.12387/) (2021)
- [FairMedFM: Fairness Benchmarking for Medical Imaging Foundation Models](https://mlsanity.com/paper/2407.00983/) (2024)
- [Tackling Bias in the Dice Similarity Coefficient: Introducing nDSC for White Matter Lesion Segmentation](https://mlsanity.com/paper/2302.05432/) (2023)
- [Investigating Label Bias and Representational Sources of Age-Related Disparities in Medical Segmentation](https://mlsanity.com/paper/2511.00477/) (2025)
- [Investigating Demographic Bias in Brain MRI Segmentation: A Comparative Study of Deep-Learning and Non-Deep-Learning Methods](https://mlsanity.com/paper/2510.17999/) (2025)
- [Towards Fairness under Label Bias in Image Segmentation: Impact, Measurement and Mitigation](https://mlsanity.com/paper/2605.06891/) (2026)
- [Who Does Your Algorithm Fail? Investigating Age and Ethnic Bias in the MAMA-MIA Dataset](https://mlsanity.com/paper/2510.27421/) (2025)

## Abstract (arXiv)

Automated segmentation of cervical-spine MRI is increasingly used in clinical workflows, yet no fairness audit exists for this anatomy. We show that auditing these segmentation tasks is complicated by a common property of modern segmentation datasets: expert-annotated gold labels are expensive, so abundant machine-generated (silver) labels are added to limit annotation cost. This matters because the reference used to judge a model can itself be biased. In this study, we present the first fairness audit of cervical-spine MRI segmentation across sex, age, and race using the CSpineSeg dataset. We observe that the deployed model is demographically fair, but the choice of reference label, however, is not neutral. Because a dataset's silver labels are generated by a model trained on its gold labels, any new model trained on those same gold labels agrees more with the silver labels than with expert truth: scoring identical predictions against silver rather than gold overestimates performance by ~8 Dice points and turns the fairness verdict for age from non-significant to significant - not by the gap inflation Parikh et al. report (which we term false magnitude) but by collapsing within-group variance (which we term false confidence). Reference-label provenance is thus a first-order confounder in segmentation evaluation: performance and fairness should be reported against expert labels, and any fairness claim stated together with the provenance of its reference.