Federated Learning in Healthcare Ethics: A Systematic Review of Privacy-Preserving and Equitable Medical AI

Background/Objectives: Federated learning (FL) offers a way for healthcare institutions to collaboratively train machine learning models without sharing sensitive patient data. This systematic review aims to comprehensively synthesize the ethical dimensions of FL in healthcare, integrating privacy preservation, algorithmic fairness, governance, and equitable access into a unified analytical framework. The application of FL in healthcare between January 2020 and December 2024 is examined, with a focus on ethical issues such as algorithmic fairness, privacy preservation, governance, and equitable access. Methods: Following PRISMA guidelines, six databases (PubMed, IEEE Xplore, Web of Science, Scopus, ACM Digital Library, and arXiv) were searched. The PROSPERO registration is CRD420251274110. Studies were selected if they described FL implementations in healthcare settings and explicitly discussed ethical considerations. Key data extracted included FL architectures, privacy-preserving mechanisms, such as differential privacy, secure multiparty computation, and encryption, as well as fairness metrics, governance models, and clinical application domains. Results: Out of 3047 records, 38 met the inclusion criteria. The most popular applications were found in medical imaging and electronic health records, especially in radiology and oncology. Through thematic analysis, four key ethical themes emerged: algorithmic fairness, which addresses differences between clients and attributes; privacy protection through formal guarantees and cryptographic techniques; governance models, which emphasize accountability, transparency, and stakeholder engagement; and equitable distribution of computing resources for institutions with limited resources. Considerable variation was observed in how fairness and privacy trade-offs were evaluated, and only a few studies reported real-world clinical deployment. Conclusions: FL has significant potential to promote ethical AI in healthcare, but advancement will require the development of common fairness standards, workable governance plans, and systems to guarantee fair benefit sharing. Future studies should develop standardized fairness metrics, implement multi-stakeholder governance frameworks, and prioritize real-world clinical validation beyond proof-of-concept implementations.