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INTRODUCTION Physicians must satisfy two competing expectations: advocate for patients and serve as stewards of resources. No guidelines exist for surgeons on resolving this conflict. We surveyed surgeons' perceptions regarding these dual obligations. METHODS We conducted our study at two large university hospitals in three distinct steps, each built on the previous one. First, we surveyed forty surgery residents and medical students using a ten-question assessment tool as the quantitative portion of our analysis. Next, a focus group of attending surgeons was surveyed to identify themes for the qualitative part of our study. Based on these, five attending surgeons from varying specialties were interviewed in a semi-structured format. We used the Wilcoxon signed rank-test for quantitative analysis and content analysis to report our qualitative findings. RESULTS Students and residents did not feel they faced resource allocation decisions; however, they observed attending surgeons face them regularly (p=0.0003). Attending surgeons from various specialties agreed that they felt obligated both to provide excellent care and serve as a steward of resources. All surgeons agreed these obligations may conflict. Individual practices varied with all erring on the side of patient care. Concern about being an outlier in one's section was a greater motivator to alter practice than was fear of litigation. No surgeon thought that patients had an adequate understanding of surgeons' dual agency. CONCLUSION Surgeons balance the responsibilities of patient-care and stewardship of resources with great variability. Diverse practices likely add to inequalities in healthcare delivery and increase mistrust. Surgeons' social contract with patients call for transparent strategies to address their dual agency.