In Germany, as in many other countries, any medical decision is based on two tiers: Firstly, the intervention requires a medical indication, and secondly, if indicated, the intervention requires patient consent. Patient consent should be grounded in participatory decision making, i.e., a process with input from both physician and patient, using a collegial model of the physician–patient-relationship. However, in many, if not most cases, there are no simple black or white solutions, and decision-making is complex and cumbersome. Medical decisions more often than not do not follow a textbook approach. Settings are complex, with a range of confounding factors, and without a clear-cut, easy solution. Medical standards and guidelines provide guidance on many illnesses, but decisions have to be tailored to the specific situation of the individual patient. Physicians should understand decision-making as a process and not as a singular event. This requires the ability and willingness to enter a relationship with the patient, building trust, repeating discussions, enduring ambiguities and tolerating ambivalence. This relationship should be at eye-level, with mutual respect between patient and physician as experts in their specific fields. The physician is the medical expert who knows about the available treatment options and their benefit and burden, and the patient is the expert for himself or herself, and more specifically for his or her personal preferences and values.