The central argument that I see in the heart of the episode is making choices in a difficult scenario. There are at least two clear instances when this happens. One is of course the obvious one which involves Mal returning the medicine. Another more discrete one is Mal’s gesture to allow two fugitives actively sought by the alliance to use his ship to evade capture.
A simple answer would probably be that Mal being anti alliance would naturally do all in his power to help those who hinder the alliance. However a deeper analysis of this statement brings up two important contradictions. Mal is very self preserving. He would never take unnecessary risk. Mal also seeks gain and he doesn’t have much to gain from either a doctor with frozen accounts or his senile sister.
The other choice is much more direct than the former. Mal realizes what his action has caused; an epidemic amongst helpless children and civilians. He tales stock of his options and chooses to annul the deal. Again he chooses to do this in the way of least harm. He offers to return the money paid by his employer. So the captain in a way does this tightrope between what is necessary and what is right.
The sheriff at the end puts actual words to this when he says something to the effect of taking any job available in a hard time and yet presented with a choice when all the facts are made known. The train job displays the need for a feeling of goodwill behind every decision.
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