Refusal of a medical act is one of the most complex ethical dilemmas in contemporary practice, positioned at the intersection of patient rights, physician autonomy, and the moral obligations embedded in the therapeutic relationship. In family medicine—where continuity, trust, and long-term engagement define care—situations requiring a justified “no” may generate significant ethical tension. Increasing social, legal, and administrative pressure on clinicians further complicates these situations, making it essential to clarify the ethical boundaries of refusal to protect professional integrity and maintain high-quality medical care.To analyse the conditions under which refusal of a medical act is ethically justified in family medicine, to differentiate ethical refusal from abusive or discriminatory denial, and to propose a practical decision-making framework to support clinicians facing such dilemmas.A narrative analysis of national and international literature was conducted, including WONCA statements, the Romanian College of Physicians’ Code of Ethics, and key World Medical Association declarations. Three illustrative case scenarios from everyday family medicine practice were examined: requests for non-evidence-based prescriptions, patient demands conflicting with the clinician’s moral or religious convictions, and expectations for interventions beyond the physician’s competence or legal remit. These cases helped identify recurrent ethical criteria relevant to refusal.The analysis suggests that ethical refusal may be justified when the requested act contradicts scientific evidence or accepted standards of practice, poses a credible risk of harm to the patient or others, exceeds the physician’s competence or legal authority, or conflicts with the physician’s deeply held moral convictions, provided a reasonable alternative ensuring continuity of care is available.Ethical refusal emerges as a form of professional responsibility, ensuring that clinical decisions remain aligned with evidence, patient safety, and the physician’s moral integrity. Maintaining transparent communication and offering reasonable alternatives allows physicians to preserve trust while upholding the ethical standards of family medicine.Ethical refusal, when exercised within legal and ethical boundaries, represents a legitimate expression of professional judgment and respect for both patient welfare and the integrity of medical practice. A simplified ethical decision-making model is proposed to guide family physicians when a justified “no” constitutes the most responsible clinical response.