Rural health care ethics is becoming the subject of a growing body of literature [1-4]. This case is a classic example of a rural health care ethics situation; the rural context significantly influences the presentation of the ethical conflict, as well as the response [2]. Many of the characteristics of a rural community—limited access to specialists (including ethics consultants), professional and geographical isolation, local perceptions and expectations surrounding health, and overlapping personal and patient relationships [3, 4]—contribute to the case’s complexity. In many rural settings, family physicians tend to be the only doctors in a large area, with few specialists nearby to handle referrals. Dr. Burke practices in a small town, and when patients need hospitalization, they are probably cared for in a critical access hospital (CAH) with 25 beds or fewer. A recent national study noted that only 60 percent of CAHs have formally established ethics committees and ethics consultation services [5], so Dr. Burke may well lack a consult option nearby.