A Concrete Introduction
Each of us, at least once in our lives, has found ourselves telling a so-called “white lie.” If we were to rephrase this expression, we would say it is a lie that conceals a benevolent intention. For example, imagine a family member bakes a cake for us with great effort, but the taste is not particularly good. When asked about the cake’s flavor, we respond with feigned enthusiasm, saying it’s delicious, so as not to hurt their feelings. The lie’s intent is kind—but is the goodness of the intention enough to generalize the principle that lying is right? Certainly not. We would rather say that lying is wrong, but in this specific case, weighing the situation, the lie was (probably) the better choice.
This seemingly trivial dilemma, which every child and adult has encountered in some form, represents and exemplifies some of the most complex issues in modern applied ethics. In other words, when what’s at stake is no longer a cake but a person’s health, the seemingly simple dilemma can turn into a real Rubik’s cube.
Let’s imagine a moderately problematic situation. An elderly woman lives alone. Although she is no longer as independent as she once was and struggles with some daily tasks, she has no intention of hiring someone to help her during the day. She believes that having her own space is essential for her mental well-being. Moving in with her children is not an option either: she loves her home, and abandoning her habits would make her feel anguished and disoriented. Her children thus face a decision: force her to move in with them or allow her to continue living independently, hoping she will eventually agree to some daily or occasional assistance.
Analyzing the structure of this common situation, it’s easy to see that the uncertainty about what decision to make arises from a conflict between distinct values. The two options are mutually exclusive, but neither is entirely satisfactory from a moral standpoint. Whatever choice is made, some ethical aspect will inevitably be sacrificed. Forcing the elderly woman to move in with her children would protect her health but simultaneously deny her the ability to make decisions for herself—a factor equally central to a comprehensive ethical evaluation. So what should be done?
The Theory Behind the Practice
Unfortunately, there is no definitive answer. However, we can attempt to analyze the situation using different conceptual tools to gain a clearer understanding and perhaps derive some general guidance. In philosophical terms, the scenario we have described involves two distinct conflicts. Let’s explore them.
The first conflict is between two different principles within the same ethical theory: principlism.
Officially coined in 1990, principlism describes the ethical approach formulated by Tom Beauchamp and James Childress in their influential work Principles of Biomedical Ethics, first published in 1979. The two philosophers outlined a model based on four fundamental principles, intended to provide a shared foundation for moral analysis in healthcare. The approach also draws inspiration from the Belmont Report (1979), a document drafted by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which established three core ethical principles—autonomy, beneficence, and justice—to ensure the protection of individuals involved in scientific research. Rather than offering definitive solutions, principlism aims to provide a minimal shared “vocabulary” to navigate ethical dilemmas.
The first principle is autonomy. The subject’s self-determination—the ability to decide independently regarding their life and body—is a fundamental criterion to consider in evaluating a concrete case within bioethics. This is not surprising, as bioethics deals with life (bios, in Greek) and health. In this sense, the elderly woman should have the right to choose for herself.
The second principle, which conflicts with the first, is beneficence, which holds that the morally right action is the one that provides the greatest benefit and the least harm. It draws inspiration from utilitarianism, the broader theory stating that an action is morally right if it produces the greatest benefit for the greatest number. Unlike other theories, such as Kantian deontology, utilitarianism is based on a concrete and contingent fact: how many people benefit or are harmed by a given action. However, unlike utilitarianism, which looks at the overall outcome, the principle of beneficence can also be applied to the individual.
In the case of the elderly woman, acting in her best interest would mean first defining how beneficence should be interpreted here: medically or more broadly. For example, we could say that from a strictly physical standpoint, she would benefit from having a live-in assistant to help with daily tasks. However, from a psychological standpoint, this might undermine her quality of life by depriving her of peace of mind. Thus, applying the principle of beneficence already presents internal difficulties, besides contradicting, in this case, the principle of autonomy.
The third principle is non-maleficence, which is similar to beneficence. Whereas beneficence requires actively doing good, non-maleficence imposes a passive duty: to refrain from causing harm. As might be expected, the same dilemma of interpreting beneficence—whether medically or more broadly—also arises with non-maleficence.
The fourth principle is justice, associated with fairness and impartiality. It involves the balanced distribution of benefits and burdens. In the situation under analysis, justice could come into play because if the woman refuses preventative home assistance, she might eventually require more intensive and costly care, raising issues of sustainability and distributive justice in the healthcare system.
Thus, the first contradiction arises between two different principles within principlism itself: autonomy and medically-interpreted beneficence. However, considering the situation globally from a principlist perspective, assisted living seems to be the fairer solution.
At this point, we can observe that applying the principles of principlism to real-world cases often encounters significant difficulties, as it does not inherently account for the specifics and idiosyncrasies of each situation.
In response to the intrinsic limitations of this model, an alternative approach emerged in the 1980s, primarily thanks to Carol Gilligan through her book In a Different Voice: the ethics of care. Rather than relying on abstract principles and universal rules, care ethics aims for a relational and contextual approach, necessary to appropriately evaluate each specific case. It places vulnerability and interdependence at the center of ethical assessment. The underlying idea is that the fundamental criterion for resolving moral conflicts is the need for care and the protection of relationships. In other words, since human relationships are unique and care needs are always personally defined, attention to specific circumstances becomes essential: understanding morality means understanding connection with others.
Applying this model to our hypothetical case would reveal an additional layer of conflict. Beyond the elderly woman’s physical and psychological well-being, other factors should be considered. For example, she might have deep emotional ties to her home and neighborhood. How could these ties be preserved if she were forced to move? What about family routines? Do relatives visit her regularly? Could moving in with her children strain their relationship due to the proximity? How crucial is preserving her own space for her emotional well-being? And to what extent should her care involve allowing her to maintain her autonomy at the expense of physical safety?
Integration or Opposition?
Considering these aspects, determining the most ethical choice becomes even more complex—especially when the two paradigms are used together, as we have done here, to interpret a situation holistically. It seems that the two models suggest different courses of action. The first seeks to solve the dilemma by adhering to universally accepted principles but leaves room for differing interpretations when applied to practice. The second model is less prescriptive but has its own limitations. For example, it tends to set aside justice, which considers the impact of individual choices on the community. Furthermore, “care” can be interpreted in purely physical or emotional terms. And once again, in situations like this, physical well-being often seems to come at the expense of emotional well-being.
However, integrating the two approaches could also lead to a solution. For instance, by jointly considering the importance of prevention—highlighted by the principle of justice—and the elderly woman’s emotional well-being, we could explore a possibility that reconciles both. If the children patiently found a discreet and affectionate caregiver with whom the elderly woman could build a relationship of trust, she might accept sharing her space without too much resistance.
This kind of integration, although complex, represents a valid theoretical—and practical—remedy for balancing the limits of both models.
There are real examples of this approach, such as the COMFORTage project [1], one of the initiatives funded by the European Union under research and innovation programs aimed at promoting shared solutions to major social, health, and technological challenges. COMFORTage seeks to develop holistic healthcare models for the prevention and personalized management of dementia and frailty in the elderly, promoting both physical and emotional well-being. In a context where available therapies are still limited, the project aims to bridge the research gap, often focused solely on genetics, neglecting modifiable factors like lifestyle, nutrition, or relational well-being.
The project involves experts from various fields—medicine, engineering, sociology, and bioethics—to create inclusive and sustainable solutions, supported by Artificial Intelligence and guided by a strong ethical awareness. COMFORTage integrates both principlism and care ethics in its analyses, recognizing that beyond preventing physical risks and considering collective justice aspects, it is essential to address emotional and relational needs. The adoption of combined solutions represents one of the project’s ethical foundations, where AI systems must not only meet practical and legal requirements but also respect the emotional well-being of those involved.
In this context, the research and development team at CyberEthics Lab. has developed a specific methodology for AI Ethics (ETHAI). ETHAI is not merely a tool to evaluate AI systems according to established principles, like those outlined in the EU Guidelines for Trustworthy AI; it also facilitates value-sensitive design adapted to specific domains such as healthcare. By integrating broad ethical principles with the particular needs of each project, ETHAI offers a more adaptable and fluid approach, responding effectively to the dynamic nature of applied ethics. This methodology, combining general ethical principles with specific project needs, reflects the integration of care ethics and principlism.
Naturally, combining the two models often generates contradictions and complications, increasing the complexity of each individual case. But it is worth it. Even though the approaches may seem opposed and conflicting, it is precisely in their painstaking harmonization that something greater is born: a more solid, fairer, and less biased agreement than would ever have been possible by rigidly following just one perspective.
[1] This work was supported by the COMFORTage project (Grant Agreement No. 101137301), which received funding from the European Union’s Horizon Europe research and innovation programme.
