The decision-making process is central in medicine and surgery. When data is available, we can lean on that existing information as an aid in making a confident decision. However, in many areas of pediatric neurosurgery, data is sparse and often cannot be relied on. Moreover, does good data necessarily guarantee good decisions? Within this arena of uncertainty, decisions must be made before, during, and in the postoperative period. Personal experience and bias, knowledge of the literature, consultations with colleagues, and patient/family ideals must all be taken into account. Each of these variables adds a significant complexity to the decision-making process (DMP) both consciously and subconsciously. A thorough list of treatment options, each with pros and cons, can be developed at each stage, and nonetheless, a non-mathematical intuitive integration is often required. We train most meticulously for the technical aspects of our profession, which come with many complexities. In this chapter, we suggest that beyond this the decision before and during the incision may be far more difficult, distressing, and critical.