Extracorporeal membrane oxygenation (ECMO) provides lifesaving support for patients with cardiopulmonary failure but poses complex ethical challenges that may generate moral distress for clinicians, patients, and families. We convened a multidisciplinary panel of experts in cardiothoracic surgery, critical care, and palliative medicine to identify recurring ethical issues. The panel includes ECMO specialists working in the US, Canada, and the UK. The panel was nominated by organizers of a national critical care meeting. We analyzed four domains of ethical tension: 1) equitable ECMO candidacy decisions; 2) integration of palliative care and clinical ethics; 3) preservation of patient autonomy when institutional or benchmarking pressures influence care; and 4) responding to requests to continue ECMO when there is no exit strategy. Consensus recommendations emphasize transparent, team-based decisions, early involvement of ethics and palliative care, and consistent processes for ongoing review of candidacy and continuation of ECMO. Programs should recognize and mitigate institutional pressures that may undermine patient-centered care. As ECMO use expands, the development of ethical care frameworks is essential to ensure equity, uphold autonomy, and align treatments with patients’ goals and values. This work provides a practical, consensus-based guide for addressing the ethical complexities of ECMO in contemporary critical care.