Decision-making in oncology care is at best consequential and complex. This chapter explores a clinical ethics consultation exploring the difficult task of determining cancer directed therapy for a patient with a profound neurocognitive disability. The case highlights the ethics consultant’s and the multidisciplinary team’s missteps and failure to recognize that the true ethical question was not only “How can we ensure that this patient is treated equitably and receives the standard of care treatment,” but also “Is surgery really the right treatment option for this patient?” While disability rights activists have long proclaimed that all individuals should be granted equal access to healthcare, it is ethically permissible to tailor standards of care to meet the specific and unique needs of the patient sitting in front of you. This chapter illustrates the noble intent of clinicians and the limitations of substituted judgment in deciding for others.