Fuzzy Logic Approaches for Causal Inference in Health Care: Systematic Review.

Abstract

<h4>Background</h4>Fuzzy logic has been progressively investigated as a viable alternative to traditional statistical and machine learning methods in health care modeling, especially in environments marked by uncertainty, nonlinearity, and missing information. Although its use in prediction, classification, and risk stratification is well established, its application to explicit causal inference remains limited, varied, and methodologically premature.<h4>Objective</h4>This systematic review aimed to examine how fuzzy logic frameworks have been used to address causal questions in health care, focusing on their methodological characteristics, comparative performance, and degree of integration with formal causal inference approaches.<h4>Methods</h4>A systematic search across 6 databases (PubMed, Web of Science, ScienceDirect, SpringerLink, Scopus, and IEEE Xplore) identified peer-reviewed studies published between 2014 and 2025 that applied fuzzy modeling in health care settings with explicit or implicit causal objectives. The review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines and used a modified PICO (population, intervention, comparator, and outcome) framework for study selection. Data were extracted on the health care domain, fuzzy method, comparator use, and causal framing. Risk of bias was evaluated using the Joanna Briggs Institute (JBI) checklist and the PROBAST+AI tool, according to study design.<h4>Results</h4>A total of 37 studies met the inclusion criteria. The most frequently applied approaches were fuzzy inference systems, fuzzy cognitive maps, and neuro-fuzzy models, with applications spanning infectious diseases, cancer, cardiovascular health, mental health, and occupational health. Fourteen studies included comparator models; among these, 5 reported superior performance of fuzzy approaches, 3 showed comparable results, and 6 lacked sufficient detail for a robust comparison. Only 2 studies explicitly implemented formal causal inference frameworks, while most relied on predictive or associative modeling with implicit causal assumptions. Overall, the risk of bias was moderate to high.<h4>Conclusions</h4>Fuzzy logic offers interpretability and flexibility well suited to complex health care problems, yet its application to explicit causal inference remains fragmented. Greater methodological transparency, systematic benchmarking, and integration with formal causal designs-such as counterfactual and target trial frameworks-are required to establish fuzzy logic as a robust paradigm for causal inference in health care.