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Trisomy 18 (T18) is a disease with severe congenital anomalies that is typically fatal in the perinatal period or early infancy. This case report describes the care of one child with T18 who survived beyond her initially poor prognosis and whose parents requested cosmetic cleft lip repair that would confer significant perioperative risk without direct clinical benefit to the child. After extensive multidisciplinary consultation, shared decision-making via family meeting and a trial waiting period, the patient successfully underwent cleft lip repair with high parental satisfaction and no long-term postoperative complications. This case outlines the moral complexity of performing cosmetic surgery in high-risk patients, including those at the end of life, on hospice or with unknown prognoses, and highlights the range of ethically acceptable approaches to surgical care of children with T18.