From Dialogue Systems to Autonomous Agents: A Modeling Framework for Ethical Generative AI in Healthcare

The advancement of generative artificial intelligence (GAI) in healthcare is driving a transition from dialogue-based medical chatbots to workflow-embedded clinical AI agents. These agentic systems incorporate persistent state management, coordinated tool invocation, and bounded autonomy, enabling multi-step reasoning within institutional processes. As a result, traditional response-level evaluation frameworks are insufficient for understanding system behavior. This review provides a conceptual synthesis of the evolution from conversational systems to agentic architectures and proposes a system-level modeling framework for ethical clinical AI agents. We identify core architectural dimensions, including autonomy gradients, state persistence, tool orchestration, workflow coupling, and human–AI co-agency, and examine how these features reshape bias propagation pathways, error cascade dynamics, trust calibration, and accountability structures. Emphasizing that ethical risks emerge from longitudinal system interactions rather than isolated outputs, we argue for embedding fairness constraints, transparency mechanisms, and lifecycle governance directly within AI design. By outlining trajectory-level evaluation strategies, equity-aware development approaches, collaborative oversight models, and adaptive regulatory frameworks, this paper establishes a foundation for the responsible and trustworthy integration of agentic AI in healthcare.