In America competent adult patients have a right to refuse unwanted medical treatments. For incompetent patients who have made no advance directive, the family ordinarily makes decisions about medical treatments. But in many healthcare facilities, problems arise in choosing a surrogate to make decisions for an incompetent patient and in working with that surrogate. Concrete, step-by-step procedures for resolving conflict are needed. Every effort should be made to have competent patients fill out advance directives or indicate their treatment preferences in the event of loss of competence. Family members may not override decisions made by competent patients, but anyone closely involved with the patients' care may question their competence. The physician generally assesses the patients' competence, but sometimes the courts are involved. The physician may be the appropriate person to choose a surrogate for a patient with limited competence or to make decisions for a totally incompetent patient. The surrogate may be a relative, close friend, physician who knows the patient well, or someone provided by the hospital or government. Treatment decisions are made within the surrogate-patient-physician triad. When different value judgments about the proper treatment conflict, the surrogate may have to mediate to restore physician-patient communication, or institutional proceedings through the ethics committee may be needed to resolve disputes quickly, amicably, and at low cost. As a last resort, the case may be referred to the courts.