Background: Perinatal hypoxic brain damage is one of the most devastating complications in neonates. In such cases, treatment teams and families can encounter many ethical dilemmas regarding the initiation, continuation or withdrawal of life-sustaining treatment, not only in the acute neonatal phase but also in the course of the evolving severe neurological impairment. Method: During a pro-contra session at the 49th Annual Meeting of the Society for Neuropediatrics (Gesellschaft für Neuropädiatrie) in 2024, more than 100 participants could interactively communicate via smartphones their assessments and treatment decisions for various hypothetical ethical dilemmas in the course of the disease in a child with severe perinatal asphyxia. Results: In a neonatal scenario, for which 77% of the participants expected long-term survival with severe neurological impairment (84% expected cerebral palsy level 5 in the gross motor function classification system, GMFCS), 39% of the participants voted for the termination of mechanical ventilation (compassionate extubation) on the 5th day of life. In a scenario of an acute respiratory tract infection with respiratory insufficiency several months later in the same child, 93% voted for the initiation of noninvasive ventilation (NIV) but only 11% would have intubated the child in the case of respiratory failure during NIV. Summary: This article highlights the diagnostic, prognostic and therapeutic challenges in children with severe brain damage in the field of tension between medical feasibility, ethical responsibility and humane care.