This chapter, Autonomy and Ethical Dilemmas in Extreme Ends-of-Life Care, by Claudio S. Cinà stands at the intersection of scalpel and conscience, addressing two of medicine’s most ethically and emotionally charged topics: abortion and euthanasia. The chapter allows readers a close-up view of surgeons’ struggles in navigating between respect for patient autonomy, medical beneficence, and professional duty, often in the shadow of conflicting laws, cultural expectations, and personal values. At a time when rapidly advancing genetic technologies and shifting legislative terrains are reworking the ethical framework used in extreme ends-of-life decisions, the surgeon becomes not only, or even primarily, a technician, but also a moral arbiter, who wades through questions of conscientious objection, disparities in access to treatment, and the precariousness of the balance between family hopes and patients’ will. In extreme ends-of-life decisions, the chapter attempts to outline an argument in favor of an ethical approach that balances firm principles with adaptability to different contexts. To gain the moral wisdom to navigate these grey areas, medicine must require a new kind of surgical training, one that nurtures, not just skillful hands, but morally intelligent hearts and minds. Ultimately, the message expressed in this article is a simple one: ethics ought to remain our North Star, illuminating our way through changing laws, institutional regulations, and sometimes conflicting moral terrains in the protection of patient autonomy and the survival of medicine in an ever more pluralistic society.