Pediatric intensivists face ethical challenges every day. In this chapter, we will highlight areas that are integral to the practice of pediatric critical care medicine, from informed consent to the provision of palliative care. We will describe situations where pediatric patients can make their independent decisions, as well as situations where parents are not the optimal decision maker. The doctrine of double effect will be described, along with other key elements to withdrawing and withholding technological support. We will review policy guidelines and consensus statements, and include resources for resolving difficult cases. Finally, we will address challenges for the caregiver, as not all difficult cases may be resolved. The goal is that this chapter will provide information to facilitate the practice of pediatric critical care medicine in challenging times.