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原文摘要

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.