Patients in the emergency department frequently voice refusals of care or are unable or unwilling to consent to care. While general principles surrounding consent and refusal can be articulated in theory, it is often far more complicated in the real setting. Further, it is impossible to contemplate in advance every possible situation that might arise. In order to properly care for patients, the emergency physician has an obligation to understand ethical principles and the reasoning process one must go through to resolve an ethical dilemma. Emergency physicians face such complex decisions on a routine basis. Ethical reasoning skills are obviously a core competence in emergency medicine, even if easy answers are elusive. Two cases are presented that illustrate this complexity, and routes to resolution are discussed.