Paternalistic decision making for the incompetent patient involves many ethical and legal issues. In the ophthalmic surgery setting, cataract surgery on the patient with dementia is a potentially harmful act that requires justification on the part of the delegated decision maker. Does the potential outcome of improved vision outweigh the patient's right to self-determination? This discussion covers some of the moral, legal, and ethical issues to be considered in analyzing this dilemma.