The movement toward increasing maternal age comes with many new challenges. As reproductive physicians now see increasingly older patients, they are also confronted with complex ethical questions regarding the medical, psychological, and psychosocial implications of providing services to this population. It is well established that increased maternal age is associated with many obstetric complications. These complications may have both short and long-term effects on the mother as well as the fetus and child. In addition to medical complications, many providers are concerned about psychosocial ramifications of pregnancies at the extremes of maternal age. These concerns largely pertain to the well-being of children born to older parents, and are often subject to societal and cultural norms. These factors combined have led many to question the ethics of providing ART to patients in their 40s and beyond, however most ethical scrutiny has been aimed at post-menopausal mothers and those greater than 50 years of age. This chapter explores the ethical issues and available guidance in relation to this group of patients and the practical application of medical ethics and the core ethical principles.