Rural physicians face the personal and professional challenges that come with working in small communities where privacy is hard to come by, and confidentiality, hard to preserve. Their patients may be friends or relatives with concerns that range from the exercise of reproductive rights to the stigma still associated with psychiatric care. With few specialists nearby, rural primary care physicians are often called upon to work at the edges of their expertise. The authors in this month's issue have been there and report to us on the ethical complexity of medical care in small-town America.