Pediatric nephrologists may encounter infants with renal failure who have either unexpectedly survived lung hypoplasia at birth or whose renal failure could be treated but comorbid conditions exist. As a member of the health care team, the pediatric nephrologist may be asked to guide therapeutic intervention with parents, family members, and other care-givers. We present a case study that illustrates some of the difficulties that may arise when conflicting social and economic pressures, as well as public opinion and legal authority, enter the decision-making process. Clinical, theoretical, legal, and economic considerations involved in the ethical decision process are presented. Some tentative guidelines for approaching such dilemmas are offered bearing in mind a goal of consensual decision making.