An intravenous (IV) drug abuser underwent repeated valve replacements because of recurrent infective endocarditis. Is it ethically permissible to withhold valve surgery in a recalcitrant, noncompliant IV drug abuser? We believe so, and in our analysis, discuss the principles of futility, rationing, personal responsibility, and justice. Because of her continued drug abuse, the patient is responsible and accountable for the medical consequences. The consequences are that physicians will not be able to provide her with beneficial treatments without disproportionate harm, and that society will no longer be able to provide resources for her treatment without unfairly jeopardizing the availability of resources for other members of society. Although valve surgery does not constitute futile treatment, maximizing and egalitarian principles of societal justice support the withholding of such an expensive intervention. The patient should be jointly evaluated by the physician, social worker, and psychiatrist. The medical team will emphasize patient compliance and willingness to undergo drug rehabilitation, and will offer the first valve replacement. The recidivist abuser with demonstrable non-compliance who sustains a second episode of endocarditis need not be offered another valve. To avoid bedside rationing, we recommend the formulation of such a policy by nations and professional bodies.