Advancements in perinatal care have improved survival rates of extremely preterm infants born at 22 to 23 weeks of gestation, thus introducing new ethical challenges associated with their treatment. Therefore, we reviewed the epidemiological prognosis, treatment evolution, and ethical considerations associated with the care of preterm infants at the limit of viability. We comprehensively searched PubMed to find relevant English-language articles published between January 2014 and July 2024. Survival rates of infants born at 22 to 23 weeks of gestation have improved but remain low. Proactive treatment can result in survival rates exceeding 50% for infants born at 22 weeks; however, these infants are at high risk for complications and neurodevelopmental impairment. Advancements in obstetric and neonatal care have contributed to improved outcomes. Ethical challenges include balancing survival with the disability risk, managing patients with uncertain prognoses, and considering parental wishes.Conclusion: The care of preterm infants at the limit of viability presents complex ethical dilemmas. Shared decision-making between healthcare providers and families as well as engaging in societal discourse are crucial to addressing these challenges.