DARC: Dual Adjustment Reasoning with Counterfactuals for Trustworthy Chest X-ray Classification

Despite their impressive performance in multi-label classification of chest X-ray images (CXR), deep learning models are widely plagued by two types of spurious correlations: feature confounding arising from pathological co-occurrence and shortcut learning triggered by non-pathological visual confounders. These non-causal dependencies severely undermine the interpretability and robustness of models in real-world clinical settings. To address these challenges, we propose the Dual Adjustment Reasoning with Counterfactuals for Trustworthy Chest X-ray Classification (DARC) framework, the first to synergistically decouple both types of confounding sources from a causal mechanism perspective. At the data level, we construct CheXconf, the first pixel-level annotation dataset of non-pathological visual confounders in CXR, comprising 40,213 annotated instances across 11 categories. This provides a solid foundation for accurately modeling these confounders. At the methodological level, we design a novel dual-stream causal learning architecture. Its Global Stream leverages the back-door adjustment criterion with CheXconf to explicitly block spurious paths from non-pathological confounders. Concurrently, the Local Stream employs counterfactual reasoning, constrained by anatomical priors, to disentangle the visual coupling of co-occurring pathologies. Experiments on large-scale public benchmarks demonstrate that our method achieves significant improvements in task performance, interpretability, and robustness. All codes and datasets will be made publicly available upon the publication of this paper.