Abstract. Individuals who reside in a country without regular authorisation generally find it difficult to access public medical services beyond emergency treatment. Even in countries with universal healthcare, there is often a gap between rights on paper and their implementation. Civil society organisations (CSOs) fill this gap by providing medical services to vulnerable populations, including irregular migrants. What, if any, are the ethical dilemmas that arise for CSO staff when delivering such services in countries with universal healthcare? Under what conditions do these dilemmas arise? And what strategies do CSO staff use to mitigate them? We answer these questions using 40 semi-structured interviews with CSO staff working in two European countries with high levels of irregularity, universal healthcare provisions on paper, and significant differences in approaches and availability of public services for irregular migrants: Italy and Spain. We show that CSO staff providing medical services to irregular migrants in places with universal healthcare coverage face a fundamental dilemma between humanitarianism and equity. CSO staff respond to the humanitarian belief in the value of taking all possible steps to prevent or alleviate human suffering, thus promoting a decent quality of life that includes access to both emergency and non-emergency care. In doing so, however, they run the risk of substituting rather than complementing public provisions, thereby preventing governments from assuming responsibility for these services in the long term. Individuals who acknowledge the existence of this dilemma generally oppose the creation of parallel structures; that is, services specifically developed for irregular migrants outside the public system; while those who ignore it essentially subscribe to a tiered system, giving up on considerations of equity. We argue that CSOs involved in the provision of healthcare to irregular migrants do not simply provide services; they also play an inherently political role