How ethics operationalization breaks down in practice: expert perspectives from healthcare AI

Abstract Efforts to promote “Trustworthy AI” have focused on operationalizing high-level ethical principles through tools, standards, and governance mechanisms. Yet a persistent gap remains between ethical guidance and day-to-day development practice. We conducted semi-structured interviews with ten experts in AI ethics, healthcare AI, and socio-technical research to examine how ethical principles are operationalized in real-world AI development. Participants described several ways in which efforts to operationalize ethical principles break down in practice. While existing operationalization approaches were viewed as useful, participants discussed conceptual, epistemic, institutional, and socio-technical conditions that constrain their effectiveness. Our findings suggest that the operationalization gap cannot be understood independently of the broader contexts in which AI systems are designed, developed, and governed.