Catastrophic burn injuries often leave patients in shock or incommunicative, creating complex ethical situations. Patient autonomy and the ability to make competent decisions become key issues. Although patient surrogates may aid in decision making, few patient advocates possess appropriate perspective of burn injury, management options, and likely outcomes. An informed decision requires informed perspective. In addition, debates over futility of care evoke strong emotion. At what point does caring for the severely burned patient become futile, and who defines it as such? Whereas formulas and algorithms guide medical management, very few well-defined principles direct ethical decision making in severe burn management. The physician must rely on his or her understanding of medical ethics to marshal a complex team of burn personnel, maintain institutional protocol, and work closely with patients and patient advocates. Only thorough, thoughtful rational application of ethics can one provide maximal respect for patient autonomy while optimally managing the severe burn injury.