In a society supporting the individual's right to decide the course of his or her own life or death, affirmed by the Patient Self-Deterrnination Act (PSDA), critical illness may create conflict at a number of levels. The proposals made in this article respond to the message of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) and to recent consensus statements of two major medical societies regarding futile treatment and fair allocation of resources in the intensive care unit They are based on our observations of the diversity in individual personal wishes under extreme medical circumstances. Prior inpatients from our 513-bed inner-city teaching hospital, hospitalized before and after implementation of the PSDA, were interviewed regarding their attitudes toward advance directives and end-of-life decisions. Patient behavior regarding advance directives and personal wishes under extreme medical conditions are variable and socioculturally based. Patient preferences may not match medical realities. Patient or proxy expectations may either under- or overvalue the actual skill of medical science in controlling the forces of nature and of spirit At the border between the real limitations of medicine and the overpowering forces of nature lies an area where the physician may invoke “medical futility.” Medical practice in this area resembles the practice of magic The effect of magical beliefs and the relationship between magic and medical science are explored. The fuzzy concept of futility is challenged within this context A process is proposed to balance medical decision-making under conditions of apparent futility, external economic constraint, and individual human belief.