Pediatric surgeons take part in the care of children across a wide spectrum of development and maturity. The relationships between patients, their families, and their surgeons can form an inclusive and supportive team to help children navigate complex health concerns. However, these relationships can also form the basis of complex ethical challenges. The care of children involves an understanding of the development of a child’s maturity and subsequent ability to participate in medical decision making. Under specific circumstances, adolescents can become fully independent to make medical decisions. But in the vast majority of instances, children and adolescents require surrogate decision makers to choose for them. This chapter explores several of the tensions that may arise when considering medical and surgical care for children.