Principal Fairness with Optimal Transport for Heterogeneous Population
Algorithmic fairness has attracted growing attention as data-driven decision systems are increasingly deployed in high-stakes domains such as healthcare. Most existing work focuses on associational fairness or counterfactual fairness grounded in structural causal models. Yet in clinical decision-making, fairness should be judged by actions: who receives which treatment and how those choices causally shape benefits and harms across groups. Associational criteria can hold while treatment allocation remains inequitable, and counterfactual notions often rely on strong, untestable modeling assumptions. We propose a two-stage framework that first predicts individual potential outcomes and then enforces a causal fairness constraint on treatment recommendations by aligning decision-relevant representations across sensitive groups within strata defined by predicted potential outcomes. Simulations show near-perfect principal fairness with predictive performance close to the first-stage estimators despite information loss from transport-based alignment. We further apply the method to the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and obtain clinically plausible predicted strata proportions. Because true strata are unobserved, we assess fairness using surrogate criteria, including statistical parity and a decomposition-based estimate of the direct causal effect of the sensitive attribute on treatment assignment, and observe improved parity under these measures. Overall, our results support causal fairness as a practical objective for equitable clinical decision policies under complex time-series data.