Background <p>The four-principles approach is widely incorporated into Chinese curricula and training programs in medicine. Notably, in the training of palliative care practitioners, the literature and the empirical evidence show that the principlist framework appears to be the sole ethical framework taught. However, this framework does not align well with the prevailing cultural practice in China - the family-led decision-making model.</p> Methods <p>To better capture the moral and cultural nuances in palliative care provision, 35 practitioners were recruited via purposive and snowball sampling from nine sites in Eastern China for one-on-one semi-structured interviews. All interviews were conducted in Mandarin, the participants’ native language, to accurately reflect the moral claims underlying their clinical practices.</p> Results <p>Empirical evidence reveals three key insights. Firstly, families on the Chinese mainland assume a dominant role in medical decision-making, with the power to make decisions regarding care planning and treatment provision on behalf of the patient. This family-led feature is depicted as normative by Chinese HCPs. Secondly, the four-principles approach is the predominant ethical framework recognised by participants. Nevertheless, while the four-principles approach is extensively taught through university courses and occupational training, the family-led decision-making model remains intact in practice and justified by legislation. Finally, a practical solution of a family-first coping mechanism was proposed by the participants, in accordance with the Familistic feature. In this mechanism, the patient is able to make autonomous choices, albeit on the (implicit) precondition of family approval.</p> Conclusions <p>Empirical data indicates that the translation of the four-principles approach remains incomplete in Chinese contexts due to its failure to consider the local socio-cultural landscape. The principlist framework overlooks the distinctive conceptualisation of the decision-making unit as a holistic family entity in China and disregards the legal and perceived moral necessity of familial participation in medical decision-making. Consequently, the application of Western bioethics in this context falls short of transcending cultural boundaries, raising critical questions about the validity of conclusions drawn from this theoretical framework.</p>