Nonadherence to a medical treatment regimen, a pervasive problem across pediatric chronic illnesses, is a common reason for referral to pediatric psychology. In the area of pediatric solid organ transplant, demonstrated adherence to a treatment regimen is often required for transplant listing because of significant medical risks associated with nonadherence to posttransplant treatment regimens, in addition to the scarcity of organs available. The current article details the psychological treatment course of an adolescent with end-stage renal disease and nonadherence to an aspect of his treatment regimen, which led to inability to be listed for transplant. Despite extensive intervention efforts guided by the adherence literature base, treatment success was not consistently maintained. The ethical questions and clinical decision-making that arose throughout the course of treatment as providers weighed risks and benefits of transplant listing are detailed.