MedConstBench: Benchmarking How Constitutions Steer LLMs in Medical Ethics

Abstract

As large language models advance rapidly, they are increasingly used to answer medical questions, and many such models are now deployed locally. Once a model is deployed, its behavior is governed mainly by the ethical policy written into its constitution. However, most existing work focuses on factual correctness rather than the trade-off between competing ethical values. Even benchmarks that do evaluate ethics treat it as a fixed property of the model rather than as a variable, so how a constitution reshapes medical-ethics behavior remains largely unexplored. We introduce MedConstBench, a medical-ethics benchmark that treats the deployment constitution as a controlled variable, is organized around Beauchamp's four principles, and is scored by human-calibrated multi-model peer review. It includes MedDilemma, our own dataset of clinical dilemmas, and supports a systematic analysis of how constitutions steer LLMs. Evaluating ten open-source LLMs under four constitutions, we find that the effect of a constitution is dimension-selective and model-dependent, and that no constitution is universally optimal. Motivated by these findings, we propose a do-no-harm adaptive selector that chooses a constitution per model, matching the per-model oracle while guaranteeing a worst-case floor and generalizing to unseen models at low cost.