Ethical issues in multi-agent AI systems for healthcare: a narrative review

Introduction: Multi-agent AI systems are believed to bring significant improvements in digital health, but it also brings new and more serious ethical issues. Such systems distribute the decision-making process among multiple interacting agents, and this decentralized decision-making system has raised ethical concerns in the medical field. On the one hand, it continues the ethical issues of traditional AI tools; on the other hand, the interaction processes within complex systems have also brought about new dilemmas. This narrative review aims to synthesize the ethical issues related to multi-agent AI systems in healthcare presented and explore the corresponding mitigation strategies. Methods: The study outcomes were synthesized using a narrative approach. Relevant records were gathered through Boolean searches in databases such as PubMed, Scopus, and Web of Science. A total of 21 articles related to multi-agent AI, healthcare, and ethical issues are included in this review. Results: Seven key ethical challenges were identified: (1) compound opacity, where interacting AI agents create layers of inscrutable decision-making; (2) error propagation and attribution difficulties, complicating accountability for clinical harm; (3) increased clinician dependence and automation bias, leading to potential deskilling and overreliance; (4) erosion of human oversight, as multi-agent AI systems operate beyond effective human control; (5) privacy and data security risks, stemming from complex data flows among agents; (6) threats to patient autonomy and informed consent, due to opaque or paternalistic AI recommendations; and (7) contextual blindness, reflecting a loss of individualized patient understanding in modular AI workflows. Furthermore, this review also summarized solutions proposed in the existing literature for these ethical issues. Conclusions: Multi-agent AI systems intensify existing ethical concerns in healthcare by distributing decision-making and blurring responsibility. To mitigate these issues, recent research advocates for the development of adaptive governance models, clear accountability frameworks, human-AI collaboration structures that preserve clinician authority, enhanced systems for explainability, and privacy-centered designs. In order to successfully incorporate agentic AI into healthcare, it is essential to maintain transparency, protect patient rights, and ensure that human-centered values continue to guide clinical decision-making in an era dominated by autonomous, interacting AI systems.