Shared decision-making (SDM), which has become a core principle of patient-clinician communication, emphasizes respect for autonomy, partnership, and transparency. In neonatal practice—where decisions often carry profound ethical and emotional weight—SDM helps align medical recommendations with the family's values, fosters trust, and may reduce moral distress for both parents and clinicians. However, in Korea, the systematic recognition and formalization of SDM remains limited, underscoring the need for practical guidance and institutional support in neonatal and pediatric care. This review discusses key principles of SDM and illustrates their application in real clinical communication through hypothetical neonatal case vignettes. SDM is best understood not as a single model but as a continuum shaped by the balance between medical judgment and parental values. Drawing on Opel’s stepwise framework, SDM is most appropriate when more than one medically reasonable option exists and value considerations meaningfully influence the choice. Physicians must also remain aware of personal biases that can shape how options are framed and discussed. Building on this conceptual foundation, this paper describes how meaningful SDM can be practiced using the 4 conversational phases outlined by Madrigal and Kelly: (1) acknowledging the need for a decision and inviting participation; (2) sharing information while listening; (3) uncovering values, hopes, and fears; and (4) reaching a balanced and ethically grounded decision. Through clinical examples, these phases demonstrate how empathy, pacing, and reflective dialogue can transform information exchange into shared moral reasoning. Finally, structural and cultural barriers continue to hinder the implementation of SDM in Korea, including time constraints, limited training, and restrictive legal frameworks. Policy reform, education, and team-based strategies are essential to support its broader adoption. SDM ultimately offers an ethically robust and relational framework for navigating complex, value-laden decisions in neonatal and pediatric care that is grounded in communication that recognizes bias and engages families as true partners.