Content Warning: This section of the guide includes discussion of mental illness, illness, death, substance use, sexual content, sexual violence, rape, ableism, and racism.

In The Medicine Woman of Galveston, Dr. Tucia Hatherley, a licensed doctor and single mother, joins a medicine show out of desperation to provide for herself and her young son. The book revolves around the context of this medicine show, an inherently unethical enterprise that dupes people into buying a so-called patent medicine with fraudulent claims about its efficacy. Thus, the central premise of the book lends itself to the exploration of the ethics of survival.

The first aspect of ethicality that Skenandore examines is the role of circumstance. While the medicine show is a fraudulent enterprise, none of the performers in the show are there voluntarily—each of them has been coerced into it by means of blackmail. Fanny, Cal, Lawrence, Darl, and Tucia each have secrets in their past that Huey, their boss, uses to keep them tied to the show. Additionally, their secrets are also misfortunes of circumstance: Fanny did not mean to kill Bruno, but her act of self-defense accidentally led to his death.