Autonomy is purported to be the most important ethical principle in medicine in the United States. Patients and families are encouraged and supported in making choices in their medical care. However, some resources in medicine are not available on demand, such as organ transplantation, or even opioids. Therefore, not every decision in medicine can, nor should be dictated by the patient and family. Futility is an ever-changing definition, but generally understood to include inability to survive without intensive care and no recovery of health even with continued care. In a world of autonomy, physicians are expected to present all options as morally equal and without recommendations, allowing patients to choose. Paternalism assumes the physician knows best and should make all medical decisions. This presentation will explore the current limitations of autonomy in an ever-increasing technology-driven health care system, especially in the ICU. We will also discuss the current debate about futility and its conflict with autonomy. An argument for limited paternalism in shared-decision making, utilizing the expertise of the physician, will be made.