The Knowledge Was There: How AI Safety Withholds Medical Help

The woman in the opening pages of IatroBench has no name. She does not need one. Her circumstances are rendered in the cold shorthand of a clinical vignette: alprazolam, six milligrams a day, ten days of tablets left in the bottle, a psychiatrist who has retired and left no referral, and a nervous system that will, without a carefully planned taper, begin to mutiny somewhere around day three. She opens a chat window. She types a version of the question millions of people have typed into frontier models since the launch of ChatGPT: how do I do this safely? The model replies with a tidy refusal and an instruction to contact her psychiatrist. The one who has retired. The one who is no longer there.
That vignette is the opening move of a pre-registered arXiv paper published on 9 April 2026 by a researcher named David Gringras. It is called “IatroBench: Pre-Registered Evidence of Iatrogenic Harm from AI Safety Measures,” and it has, in the forty-eight hours since it appeared, begun to detonate quietly across the parts of the internet where chronic illness meets machine learning. The title borrows a word from the oldest vocabulary in medicine. Iatrogenic: the harm the healing apparatus inflicts on the patient it was trying to help. A dropped scalpel. A misread scan. A drug that cures one thing and breaks another. Gringras argues, with the supporting firepower of 3,600 model responses scored against physician judgement, that something iatrogenic is now happening in the consumer interface of large language models. The guardrails are hurting the people they were designed to protect.
This is not a story about chatbots telling users to eat glue. It is not a story about hallucinations, jailbreaks, or the familiar catalogue of things that make AI dangerous when it is too willing. It is the mirror image. It is a story about the structural cost of AI that is too unwilling, too often, in precisely the wrong places. And it is a story about who, exactly, is paying that cost, and whether anyone at the frontier labs has been counting.
A Test Designed to Find the Second Kind of Harm
For most of the last three years, benchmarking a large language model's safety has meant one thing: counting the bad outputs. Does it help you build a bioweapon? Does it write the phishing email? Does it produce the instructions for the pipe bomb? The incentive structure inside frontier labs has been calibrated almost entirely around suppressing commission harm, the damage an AI does by saying something it should not. Reward models get tuned. Red teams probe. System cards are published. The metric that matters is how often the model refuses the dangerous ask.
IatroBench's central methodological move is to introduce a second axis. Gringras constructs a two-dimensional scoring system: commission harm on one scale, omission harm on another. Commission harm is what happens when a model says the unsafe thing. Omission harm is what happens when a model withholds the safe thing from someone who needed it. The paper treats these as co-equal failure modes. It is, as far as anyone in the fact-checking of this article has been able to establish, the first systematic attempt to measure both.
The test set comprises sixty pre-registered clinical scenarios, each drawn from the awkward middle ground between a jailbreak attempt and a textbook consult. A carer asking about a potassium interaction in a relative's medication chart. A patient with a chronic pain diagnosis trying to understand a new prescription. A person in the hours after a cardiac event wondering whether a lingering symptom is the ordinary tail end of recovery or the beginning of something worse. Each scenario was run through six frontier models: Claude Opus 4.6, GPT-5.2, Gemini 3 Pro, Llama 4 Maverick 17B, DeepSeek V3.2, and Mistral Large. Each was asked the same question twice, with one variable altered. In one version, the question was phrased by a layperson in plain language. In the other, the opening clause became “I'm a physician; a patient presents with...” Everything else was identical.
The responses, 3,600 of them, were then scored along two scales: commission harm from zero to three, omission harm from zero to four. The scoring rubric was validated against physician ratings, yielding a weighted kappa of 0.571 and 96 per cent within-one agreement, figures that by the standards of medical reliability research are serviceable rather than heroic but more than adequate for a benchmark of this type.
What Gringras calls the decoupling gap is the central finding. Across the five testable models, the average omission harm score under layperson framing was 1.38. Under physician framing, it was 1.00. The gap, 0.38, was statistically significant at p equals 0.003. Put in English, the models knew the answer. They knew it well enough to give it to a notional physician. They just would not give it to the patient.
The individual model breakdowns sharpen the picture into something more uncomfortable. Claude Opus showed the largest gap, 0.65, a pattern Gringras characterises as trained withholding: the model has internalised that certain topics trigger refusal when raised by laypeople and defers to an imagined medical professional. Gemini 3 Pro posted a gap of 0.31, DeepSeek V3.2 came in at 0.37, and Mistral Large sat at 0.18. Llama 4 Maverick was functionally incompetent in both conditions, a different problem with different remedies. GPT-5.2 produced the strangest result of all: it stripped physician responses nine times more aggressively than layperson responses, a pattern suggestive of an indiscriminate filter that treats clinical-sounding language as itself a hazard.
The paper reserves its most pointed finding for the question of critical actions. Gringras defines a category of safety-colliding critical actions, the discrete pieces of guidance that a treating clinician would consider essential and which are also the ones most likely to collide with the trained safety reflexes of a chat model. Across these actions, models hit them 82.0 per cent of the time for the physician framing and 68.9 per cent of the time for the layperson framing, a gap of 13.1 percentage points, significant at p less than 0.0001. On actions that did not collide with safety training, the two framings were indistinguishable: 72.9 per cent versus 71.2 per cent. The asymmetry is not that models are generally worse at helping laypeople. It is that models are specifically worse at helping laypeople in exactly the moments when the stakes are highest and the safety reflex fires.
There is a name for this in the paper, and it is perhaps the most quietly damning phrase in the whole document. Gringras calls it identity-contingent withholding. The model has the knowledge. The model can produce the knowledge. The model chooses not to produce the knowledge based on its inference about who is asking. As Gringras writes in the discussion: “The knowledge was there; the model withheld it.”
The Vocabulary of a Forgotten Harm
Iatrogenic injury is the oldest anxiety in Western medicine. The Hippocratic injunction is usually paraphrased as “first, do no harm,” but the underlying Greek is a recognition that the healer has a unique capacity to wound. The word iatrogenic, from iatros (healer) and genic (origin), names that capacity directly. Every surgical incision carries an iatrogenic risk. Every antibiotic prescription is an iatrogenic gamble against the emergence of resistance. The profession that spends its days trying to help has long understood that trying to help is not the same as helping, and that the distance between them can sometimes be lethal.
Medicine has a concept of defensive medicine for precisely this reason. A physician worried about malpractice liability orders more tests than are clinically indicated, prescribes more conservatively, refers earlier, documents more defensively. Each action feels, subjectively, like safety. Each carries hidden costs that fall on the patient: higher radiation exposure from unnecessary imaging, longer waits, delayed diagnoses from the signal noise of false positives. A study led by Michelle Mello of the Harvard School of Public Health, published in Health Affairs, estimated the annual cost of the American medical liability system at roughly 55.6 billion dollars, with approximately 45.6 billion of that figure attributable to defensive medicine. Defensive medicine looks, from any individual physician's perspective, like caution, and adds up, in aggregate, to something that harms patients.
IatroBench's deeper argument is that the current generation of frontier models has taught itself to practise defensive medicine under conditions structurally worse than those faced by any real physician. A human doctor has a longitudinal relationship with the patient, an intake process, a medical history, and a professional register that knows who they are. A chat interface has none of these. When the safety reflex of a model fires, it fires against a shadow. It imagines the worst-case user: a person in crisis, a suicidal ideator, a malicious actor, a child. The reflex then optimises for that shadow, and the real person on the other side of the interaction, the woman with ten days of alprazolam left, is treated as collateral in a risk calculation she was never told about.
The asymmetry is, from an engineering perspective, built in. When a model produces a commission harm, somebody can screenshot it. It lands on Twitter. It ends up in a congressional hearing. It becomes the next training example for the RLHF reward model. When a model produces an omission harm, it produces silence. The patient walks away. The silence does not land on Twitter because there is nothing to screenshot. There is no training signal because there is no complaint that got through the right door. The feedback loop is broken on one side of the ledger, and the model drifts, cycle by cycle, towards the shape of the ledger it can see.
Gringras's auxiliary finding on this point is perhaps the most unsettling in the paper. When he ran the standard LLM-judge evaluation pipeline that most labs use to grade their own safety work, that judge scored 73 per cent of the paper's omission-harm cases as zero. The physicians who scored the same cases gave them at least one. The inter-rater kappa between the LLM judge and the physicians, for omission harm, was 0.045, which is statistical parlance for noise. The evaluation apparatus that labs are using to tell themselves they are becoming safer shares the training apparatus's blind spot. A machine that has been taught not to see an entire category of harm is judging the performance of the machine that causes it.
The Woman Who Is Not One Woman
Since the paper dropped on Wednesday, a pattern has begun to assemble itself across the parts of the internet where the chronically ill gather. Reddit communities like r/ChronicPain, r/benzorecovery and r/CFS have long served as informal consult rooms, places where people swap taper schedules and compare notes on which consultant is willing to listen. The threads that emerged this week are different in tone: less a swap of strategies than a collective recognition.
Someone posts that they had exactly the experience described in the paper and thought it was just them. Someone else replies that they had the same experience three months ago and tried to work around it by pretending to be a nurse. A third describes getting the same refusal from three different models in sequence and giving up. What the threads confirm, in aggregate, is what IatroBench measures in the lab: the refusal pattern is real, it is widespread, and the people most likely to hit it are the ones with the fewest alternatives.
Those people tend to share certain characteristics. They live in rural areas where specialist care is scarce. They cannot afford repeat consultations. They have complex, slow-burning conditions that generate questions at all hours and which their allotted fifteen-minute appointment could not have covered even if they had been able to secure one. A World Health Organisation report released in early 2024 estimated that more than half of the world's population lacks access to essential health services, and in countries where access is nominally universal, the practical waiting time for specialist consultations in long-tail conditions can run to months. A person taking benzodiazepines whose prescriber retires does not have months. They have the half-life of the drug in their bloodstream, which for alprazolam is around eleven hours.
The scale of the displacement into AI is already substantial. A cross-sectional patient study published in the Journal of Medical Internet Research in 2024 found that ChatGPT had already been consulted for medical information by a significant proportion of survey respondents, often before, during or instead of contacting a human clinician, with users citing accessibility, cost and speed as the principal drivers. MIT Technology Review reported in July 2025 that AI companies had begun quietly removing the medical disclaimers that used to precede chatbot health responses, a sign the companies themselves have accepted the fact of patient reliance on their systems even where they have not openly endorsed it. Research published in npj Digital Medicine in 2025 found that AI chatbots were being used to manage chronic diseases by simulated and real patients alike, with outcomes ranging from clinically useful to actively harmful depending on the specific system, condition and framing.
In other words, by the time Gringras ran his benchmark, the gap between what patients were using these systems for and what the systems were willing to do for them had already become load-bearing. The refusal machine is not an abstraction. It is a live friction in the lives of people whose alternative is often nothing at all.
What a Tapering Protocol Costs to Withhold
Return to the opening scenario and think about what the correct answer actually is. The late Heather Ashton, a professor of clinical psychopharmacology at the University of Newcastle upon Tyne, ran a benzodiazepine withdrawal clinic from 1982 to 1994 and helped over 300 patients off these drugs. In 2002 she published, in its current form, Benzodiazepines: How They Work and How to Withdraw, known in the withdrawal community as the Ashton Manual. The manual is not secret. It is freely available online at benzo.org.uk. It describes, in concrete numerical detail, how to convert alprazolam to diazepam equivalents, how to reduce the dose in increments of around 10 per cent, how to wait, how to adjust the pace, how to monitor for sensory hypersensitivity, depersonalisation and rebound anxiety, the particular symptoms that signal a taper is moving too fast.
In 2025, a Joint Clinical Practice Guideline on benzodiazepine tapering was published by the American Society of Addiction Medicine in conjunction with nine other medical societies. That guideline, published in the Journal of General Internal Medicine, recommends starting with 5 to 10 per cent reductions every two to four weeks and adjusting to patient response. The Ashton protocol and the ASAM guideline do not disagree in any meaningful way about the shape of a safe taper.
The information exists. It is in Gringras's paper, embedded in the second framing, the one where the model thinks it is talking to a physician. It is in the Ashton Manual. It is in the ASAM guideline. It is in the training data of every frontier model. The question IatroBench forces is why, in the moment when a real person with ten days of pills left asks, the systems that could retrieve and summarise this information instead produce a referral to someone who no longer exists. The answer is not that the systems lack the knowledge. The answer is that they have been trained to treat the act of sharing it as the dangerous thing.
The Safe-Completion Turn
Some frontier labs have begun, quietly, to concede the shape of the problem. In August 2025, OpenAI published a technical paper titled “From Hard Refusals to Safe-Completions: Toward Output-Centric Safety Training.” The paper, authored by members of the OpenAI safety research team, argues that the old approach, in which the model made a binary decision at the point of input about whether a request was permissible, produces brittle, over-restrictive behaviour, especially in dual-use domains. The alternative, which they call safe-completions, trains the model to evaluate the safety of its output rather than the user's presumed intent. A safe-completion model can respond to a question about medication dosing with a partial, non-actionable answer that is genuinely helpful without producing the specific content that would enable abuse.
The paper reports that safe-completion training, incorporated into GPT-5, improved both safety and helpfulness compared with refusal-based training on dual-use prompts. Gringras, in his discussion, reads OpenAI's pivot with a directness that has made the paper travel: he calls it “an implicit admission that hard refusals cause harm.” The charitable reading is that OpenAI has recognised that its old approach was producing the exact pattern IatroBench has now measured. The less charitable reading, and it is the one the Gringras paper seems to endorse, is that the measurement came from outside because no lab was willing to run the benchmark that would have forced the conclusion internally.
The tension between these readings is the real interest of the moment. If safe-completion is the right engineering fix, the open question is why it took until mid-2025 to arrive and whether the models still deployed under the older paradigm, which is most of them, can be retrofitted or need to be replaced. If safe-completion turns out to be a rebranding of the existing reflex, in which the model still refuses but does so more politely, then the IatroBench measurement will return the same numbers on the next generation of systems and the iatrogenic harm will continue under a new name.
The Policy Vacuum
In early April 2026, the regulatory scaffolding around AI in clinical settings is still being poured, and the cracks are obvious. Illinois passed a law effective 1 August 2025 prohibiting AI systems from making independent therapeutic decisions, directly interacting with clients in any form of therapeutic communication, or generating treatment plans without the review and approval of a licensed professional. Ohio has a comparable bill. California passed legislation in December 2024 restricting the use of AI by health insurance companies to deny coverage. The Trump administration subsequently rolled back several Biden-era health IT provisions, including the AI model card requirements proposed under the HTI-5 rule. The overall picture is of a patchwork in which the rules governing AI in formal clinical workflows are tightening while the rules governing AI in informal patient-facing chat interfaces are essentially absent.
The policy vacuum produces the exact incentive structure IatroBench is measuring. A frontier lab, faced with the choice between a commission-harm scandal and an omission-harm scandal, knows that only one of these has ever made it into a congressional hearing. The rational move is to train the model towards refusal, accept the omission harm as invisible collateral, and push the question of clinical access to some other institution that does not exist.
Inside the medical profession, the argument is starting to shift. A commentary in JAMA Internal Medicine in late 2025 asked whether defensive programming of medical AI was itself a malpractice risk, reasoning by analogy with the defensive medicine literature. A STAT News column in December 2025 by a Dartmouth clinical educator argued that physicians need to be trained on how their patients are already using AI, on the grounds that pretending the usage does not happen has become clinically negligent. In March 2026, NPR ran a segment on the growing body of evidence that AI chatbots produce inconsistent medical advice, some of it dangerous and some of it dangerously absent, with reporting from primary care clinicians who described patients arriving at appointments with printouts of model refusals asking whether it was safe to proceed.
Around the same time, ECRI, the non-profit patient-safety organisation whose annual list of health technology hazards is closely watched by hospital systems, named misuse of AI chatbots the top health technology hazard for 2026. The inclusion was framed around both sides of the problem: the chatbot that gives bad advice and the chatbot that refuses to give any. For the first time in the list's history, the top hazard was not a medical device but an interface.
Where the Weight Actually Falls
The most important number in Gringras's paper may be one that is not in the paper at all. It is the number of people whose refusal encounter did not end with them going to Reddit, did not end with them writing a complaint email to a frontier lab, did not end with them being captured in a benchmark. It ended with them sitting at their kitchen table at three in the morning, staring at the same refusal on the same screen, and deciding, for want of any other option, to taper on their own guesswork. That number, by the structure of the problem, is unknowable. The feedback loop that would capture it has been broken at the source.
The critique IatroBench has sharpened against the frontier labs is not the usual one. It is not that the labs are reckless. It is that they have been exquisitely, obsessively careful about one side of a two-sided ledger and have allowed themselves, for four years, to treat the other side as somebody else's problem. The language of “alignment” and “harm reduction” has attached itself almost exclusively to the risk of the model saying the wrong thing. The risk of the model refusing to say the right thing has not had a vocabulary at all until now. This is what Gringras means by iatrogenic harm. It is not a slogan. It is a category of injury with a clinical name, a measurement protocol, and, as of this month, a benchmark.
Who is weighing the trade-off, and on what evidence? Until now, the honest answer has been: nobody is, and none. Refusal rates get tracked. Refusal rates get published in system cards. The cost of those refusals, borne by the people who asked in good faith and walked away empty-handed, has been absorbed into a silence the labs built for themselves when they decided what their safety metrics would look at. IatroBench, to the extent that it changes anything, changes the availability of the evidence. It puts numbers on the gap. It makes the weighing possible. Whether the labs then do the weighing is a different question.
The Shape of a Better Metric
What would a serious response to IatroBench look like from a frontier lab? The paper's recommendations, laid out in its discussion, are surprisingly concrete. Safety evaluations should run on both axes, commission and omission, with comparable weight; a two-dimensional scoring rubric is not a technical moonshot. Reward models should be penalised for omission harm the way they are penalised for commission harm, meaning the RLHF signal that currently rewards refusal needs a counterweight that rewards appropriate help. Safety evaluation pipelines should not be fully automated with LLM judges, given Gringras's finding that the judges share the training apparatus's blind spot. Domain experts, actual practising clinicians in the case of medical safety, should be in the loop. And the shift towards safe-completion architectures that OpenAI has begun needs to be generalised across the industry rather than treated as a competitive advantage.
Whether any of these will be acted on is, as of this week, unresolved. Anthropic, OpenAI, Google DeepMind, Meta, Mistral and DeepSeek have not, at the time of writing, released public responses to the paper. The paper is days old. The institutional response machinery at frontier labs does not move in days. What has moved is the discourse. For the first time, the conversation about AI safety in medical contexts has a single document that can be pointed to, a methodology that can be replicated, and a set of numbers that cannot be waved away by appeal to anecdote.
The Woman Who Is Every Woman
The opening vignette of IatroBench is, to be clear, a constructed scenario. The woman with ten days of alprazolam left is an assemblage of clinical features the paper uses to make its point crisply. But the assemblage is not fictional in any meaningful sense. It is the median of a distribution documented in npj Digital Medicine, in the Journal of Medical Internet Research, in the Reddit threads, in the clinical guidelines, in the emerging reporting from NPR, STAT News and MIT Technology Review. Somewhere in the world, at the moment you are reading this sentence, a version of that woman is typing her question into a chat window. Somewhere, the refusal is appearing on her screen. Somewhere, the nervous system that needed a tapering protocol is instead going to get a clinical shadow.
The consolation, if there is one, is that the refusal machine has no theological status. It is a set of training decisions made by teams of engineers who can, when the evidence is compelling enough, make different decisions. The IatroBench paper is that evidence, rendered in a form the field has not previously had. It is uncomfortable reading precisely because it shows that the harm is not a regrettable edge case. The harm is the shape of the current equilibrium. The harm is what happens when the metric that matters has only one axis.
In medicine, the recognition of iatrogenic injury produced hand-washing, informed consent, surgical checklists, pharmacovigilance databases, and the modern apparatus of patient safety. None of these existed as formal systems until the damage they addressed had first been named and measured. The history of the field is, in this respect, the history of what gets counted, which is always a subset of what actually hurts people, until somebody builds a way to count the rest.
What IatroBench proposes, stripped of the technical armature and the p-values, is that AI safety is now at the moment surgery reached in the middle of the nineteenth century, when Ignaz Semmelweis noticed that doctors moving between the morgue and the maternity ward were killing the women they were trying to help, and the profession that received the news did not, for a long time, want to hear it. The analogy is not perfect. No analogy is. But the structural feature that matters, the inability to see a category of harm intrinsic to the activity being performed, is preserved across the gap.
The women who are not one woman, and the carers and the chronic pain patients and the people tapering medications alone in the middle of the night, have been trying to tell the field what the harm looks like for some time. This month, for the first time, a pre-registered benchmark has backed them up. Whether the field chooses to listen is no longer a matter of whether the evidence exists. It exists. The only remaining question is whether anyone whose decisions shape the refusal machine has the will to look at it, name what they see, and build the second axis into the metric. Until they do, the cure will continue to be worse than the disease for the people whose disease has no other cure available.
The hands that need washing are not dirty in any way the existing safety framework can detect. That is exactly what makes the washing so urgent.
References & Sources
- Gringras, David. “IatroBench: Pre-Registered Evidence of Iatrogenic Harm from AI Safety Measures.” arXiv preprint 2604.07709, submitted 9 April 2026. https://arxiv.org/abs/2604.07709
- IatroBench HTML version. https://arxiv.org/html/2604.07709
- IatroBench pre-registration, Open Science Framework. https://doi.org/10.17605/OSF.IO/G6VMZ
- OpenAI. “From Hard Refusals to Safe-Completions: Toward Output-Centric Safety Training.” Technical report, August 2025. https://cdn.openai.com/pdf/be60c07b-6bc2-4f54-bcee-4141e1d6c69a/gpt-5-safe_completions.pdf
- OpenAI. “From hard refusals to safe-completions: toward output-centric safety training.” Published blog post. https://openai.com/index/gpt-5-safe-completions/
- Mello, Michelle M., et al. “National Costs of the Medical Liability System.” Health Affairs, 2010. Summarised at The Commonwealth Fund. https://www.commonwealthfund.org/publications/newsletter-article/medical-liability-costs-estimated-556-billion-annually
- Ashton, C. Heather. “Benzodiazepines: How They Work and How to Withdraw” (The Ashton Manual), 2002. https://www.benzo.org.uk/manual/
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- California State Senate. “Landmark Law Prohibits Health Insurance Companies from Using AI to Deny Healthcare Coverage.” 9 December 2024. https://sd13.senate.ca.gov/news/press-release/december-9-2024/landmark-law-prohibits-health-insurance-companies-using-ai-to
- Practical Ethics, University of Oxford. “Iatrogenic to AI-trogenic Harm: Nonmaleficence in AI healthcare.” February 2025. https://blog.practicalethics.ox.ac.uk/2025/02/guest-post-iatrogenic-to-ai-trogenic-harm-nonmaleficence-in-ai-healthcare/
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Tim Green UK-based Systems Theorist & Independent Technology Writer
Tim explores the intersections of artificial intelligence, decentralised cognition, and posthuman ethics. His work, published at smarterarticles.co.uk, challenges dominant narratives of technological progress while proposing interdisciplinary frameworks for collective intelligence and digital stewardship.
His writing has been featured on Ground News and shared by independent researchers across both academic and technological communities.
ORCID: 0009-0002-0156-9795 Email: tim@smarterarticles.co.uk








