[ii] “House Votes to Expose Secrets of Drug Trade,” New York Times, Special to The New York Times, 23 June 1906.

[iii] Keel, R. (2010), “Drug Law Timeline”, http://www.druglibrary.org/schaffer/history/ drug_law_ timeline.htm.

[iv] Hobson, Richard, “One Million Americans Victims of Drug Habit,” New York Times, 9 November 1924.

[v] Ibid

[vi] “Roosevelt Asks Narcotic War Aid,” New York Times, 22 May 1935.

[vii] “President Demands Drive By All Forces of Nation to Solve Crime Problem,” New York Times, 11 December 1934.

[viii] “$100,000 Gems Seizure in N.Y. U.S. Reveals,” Washington Post, 25 November 1936.

[ix] “Seizures Reach Peak in Cocaine and Heroin,” New York Times, 3 March 1949.

[x] “Heroin Addicts Mount,” New York Times, 3 December 1950.

[xi] “U.S. Finds Heroin Big Narcotic Snag,” New York Times, 2 May 1951.

[xii] Davis, M. and Troupe, Q., Miles: The Autobiography, New York: Simon & Schuster, 1989.

[xiii] Plumb, R. “Drug Eases Care of Heroin Addicts,” New York Times, 8 December 1964.

[xiv] Asbury, E. “Lag on Narcotics Seen by Kennedy,” New York Times, 25 April 1965.

[xv] U.S. Food and Drug Administration (2014), http://www.fda.gov/regulatoryinformation/ legislation/ucm148726.htm

[xvi] U.S. Government Printing Office (2014), http://www.gpo.gov/fdsys/pkg/STATUTE-86/pdf/STATUTE-86-Pg65.pdf

[xvii] Bird, L. “Rockefeller Sees Heroin ‘Drying Up’,” New York Times, 8 September 1973.

[xviii] Ibid

[xix] Goldstein, T. “The Rockefeller Drug Law,” New York Times, 14 May 1979.

[xx] “Gigantic Heroin Epidemic Seen by Legislator,” New York Times, 6 July 1975.

[xxi] Roberts, S. “Mrs. Reagan Assails Drug Users,” New York Times, 1 March 1988.

[xxii] Govtrack.US (2014), https://www.govtrack.us/congress/bills/99/hr5484#summary/ libraryofcongress.

[xxiii] Boyd, G. “Reagan Signs Anti-drug Measure; Hopes for ‘Drug-Free Generation’,” New York Times, 28 October 1986.

[xxiv] Wren, C. “ U.S. Convenes Experts on Drugs to Grapple With Heroin Use,” New York Times, 30 September 1997.

[xxv] Buckley, C. “Young and Suburban, and Falling for Heroin,” New York Times, 27 September 2009.

            While the drug produces euphoric effects in the short-term, long-term heroin use has serious consequences for the user’s health.  Chronic abusers of heroin often suffer from “collapsed veins, infection of the heart lining and valves, abscesses, cellulites, and liver disease.”[iv] Regular heroin users develop a tolerance in which the user’s physiological and psychological response to the drug decreases, and additional heroin is needed to achieve the same intensity of effect. Heroin users are at a high risk for addiction.  In fact, it is estimated that about 23% of individuals who use heroin become dependent on it.[v] This physical dependence means the user will experience severe withdrawal symptoms, such as drug cravings, insomnia, and vomiting, when his or her heroin usage is decreased or stopped altogether. Some users become so dependent on the drug that these withdrawal symptoms can even become fatal. [vi] The overall poor health of a heroin abuser and the depressive effects of heroin on the respiratory system may also result in pulmonary complications, such as pneumonia. Furthermore, some additives that will not completely dissolve in the blood stream may be present in the heroin dosage, leading to clogging of the blood vessels that supply vital organs. [vii] These blockages can lead to infection or death of cells in these vital organs. 

            As mentioned above, heroin is an opioid. Opioids act at three G-protein coupled receptor subtypes, Mu, Kapa, and Delta.  The ligands that bind these receptors “are encoded by three different genes and are expressed heterogeneously throughout the CNS and in peripheral tissues.” [viii] These ligands are distributed similarly to opioid receptors.  Agonists that act at these three receptors sites cause analgesia, agonists acting at Mu or Delta receptors cause respiratory depression.  Heroin, which is converted into morphine in the body, acts as an agonist at Mu Opioid receptors and can therefore result in respiratory depression. [ix] To understand how heroin can result in respiratory depression, we must first understand the processes of respiration. Respiration is carried out to control the levels of oxygen and carbon dioxide in the body through inspiration of oxygen and exhalation of carbon dioxide.  Respiration is dependent on external neuronal input from the CNS to the lungs and associated musculature.  Breathing is largely controlled in the brainstem via two major neuron groups located in the medulla region, the dorsal respiratory group (DRG) and the ventral respiratory group (VRG).  It is believed that the DRG plays a more controlling role and influences the VRG, while the VRG most likely deals with influencing motor output.  This is supported by the fact that “efferent fibres emanating from the VRG innervate the muscles of respiration.”[x] This rhythm of inspiration and exhalation requires activation and inhibition.  Excitation is carried out via amino acid receptors, while GABA receptors facilitate inhibition.  However, other neurotransmitters, such as serotonin and opioid peptides, may also affect this rhythmic process.  Heroin disrupts this process, causing respiratory depression, by acting at the opioid receptors and decreasing neuronal activity.  It also diminishes the system’s capacity to sense changes in oxygen and carbon dioxide levels and bring these concentrations to optimum levels, which, as mentioned above, is the main function of respiration.[xi]

            The drug naloxone reverses the above effects on the respiratory system, as it is an opioid antagonist, meaning the drug bocks the brain’s opioid receptors. Naloxone reverses the effects of morphine by binding the Mu receptors where this opioid acts, blocking the morphine from binding to these receptors.  Naloxone is able to do this due to its higher affinity to bind the Mu receptors than opioids.  Blocking the opioid results in the reversal of respiratory suppression since the opioid can no longer affect the respiratory process.  A limitation on this use of naloxone, though, is its relatively short period of action.  This is not a problem when heroin is the only drug present in the dosage taken by the individual, as the period of action of heroin is shorter than that of naloxone.  However, if another opioid agonist with a longer period of action on the body than that naloxone is present in the patient’s body, the effects of that agonist will eventually return and again cause respiratory depression.  Furthermore, administration of naloxone results in the individual experiencing withdrawal.  Therefore, the use of naloxone should be followed by administration of a drug, such as buprenorphine, to control these withdrawal symptoms.  However, when naloxone is administered in the absence of opioids or any other similar antagonists, the drug has no pharmacologic effect whatsoever. [xii] The amount of time the drug acts on the individual also varies based on the type of administration used. Because this length of action may be shorter than the action of the opiate, multiple doses of naloxone could be necessary. While naloxone does not produce a tolerance or dependence to the drug, it will cause the patient to experience withdrawal symptoms within a few minutes if the individual is already physically dependent on the opioid.[xiii]  

            The form of naloxone that will be available to the public, Evzio, can be administered via muscular or subcutaneous injection from a credit card-sized auto-injector.[xiv]  The FDA approved this Evzio device on April 3rd, 2014 via its Priority Review program.[xv] This fast-tracked approval process is one of four routes the FDA has implemented.  The reasoning behind the FDA’s implementation of such processes is that “Speeding the development and availability of drugs that treat serious diseases are in everyone’s interest, especially when the drugs are the first available treatment or have advantages over existing treatments.”[xvi] The Priority Review Model used for the approval of Evzio was designed to “direct overall attention and resources to the evaluation of applications for drugs that, if approved, would be significant improvements in the safety or effectiveness of the treatment, diagnosis, or prevention of serious conditions when compared to standard applications.”[xvii] The aforementioned significant improvement can be shown in a number of ways:

• Evidence of increased effectiveness in treatment, prevention, or diagnosis of condition.
• Elimination or substantial reduction of a treatment-limiting adverse reaction.
• Documented enhancement of patient compliance that is expected to lead to an improvement in serious outcomes.
• Evidence of safety and effectiveness in a new subpopulation.[xviii]

While this model speeds up the approval process, it does not alter the scientific/medical standard for approval or the quality of evidence necessary.  The Evzio device was then granted access to the Fast-Track Model after passing the Priority Review process.  “Fast track is a process designed to facilitate the development, and expedite the review of drugs to treat serious conditions and fill an unmet medical need.  The purpose is to get important new drugs to the patient earlier.”[xix] This process aids the drug company through the development of the drug and during its review process by offering and encouraging frequent communication between the FDA and the drug company to ensure all issues throughout the process are resolved quickly.[xx] Evzio also passed through this process and was approved ahead of its original timetable.[xxi] The American Medical Association (AMA) has lauded this expedited approval; "The American Medical Association (AMA) applauds the Food and Drug Administration (FDA) for approving the automatic injector of opioid overdose antidote naloxone for prescription by physicians. We commend FDA for expediting the approval process to quickly increase access to this medicine, which will undoubtedly save lives by reducing death from opioid-related overdose.  The AMA has been a longtime supporter of increasing the availability of naloxone for patients, first responders, and bystanders who can help save lives and has provided resources to bolster legislative efforts to increase access to this medication in several states. Additionally, we have worked with several national groups, including the National Governors Association, the National Conference of Insurance Legislators and the National Safety Council to increase support for the increased availability of and access to naloxone.  The AMA's dedication to reducing deaths from overdose is a part of the organization's broader effects to combat prescription drug abuse and diversion while at the same time preserving access to medically necessary treatments for pain.”[xxii]

            There is another form of naloxone administered intranasally that has been in use by emergency medical professionals.  This form, known as Narcan, can be administered by following just a few simple steps: from a nasal naloxone kit, attach the nasal applicator to the needleless syringe, screw a capsule of naloxone to the barrel of the syringe, and insert cone at the end of the syringe into the patients nose before giving a short push on the end of the device to spray the naloxone up the nostril of the patient.[xxiii] This method has been shown to be similarly effective as administering naloxone intravenously or subcutaneously, as one study found only 10% of patients required a second dosage of naloxone after receiving intranasal administration.[xxiv] Furthermore, the cost of an intranasal naloxone kit is significantly cheaper than the Evzio device.  While Evzio may cost a few hundred dollars, an intranasal naloxone kit costs just $42.[xxv]

National Institute on Drug Abuse.

• Risk factors for opioid overdose
• Prevention strategies
• Recognizing overdose
• Signs of an overdose
• Calling 911
• Rescue breathing
• Administering nasal naloxone
• Completion of proper documentation
• Proper storage of naloxone
• Post-overdose care
• Refill procedure [iii]

These training sessions must last at least 3 hours and cover all of the above topics in detail. [iv] The DOPE Project Manager will examine each DOPE educator annually and provide necessary feedback to the educator, while also reviewing documentation carried out by the educator monthly to ensure accuracy. Furthermore, any medical issues reported regarding use or distribution of naloxone will be referred to the DOPE Medical Director.[v] These DOPE educators can then provide training sessions for individuals who want to be approved to administer naloxone emergently.  The following requirements are the cornerstones of these training sessions:

1. DOPE Project Overdose Prevention Educators shall be responsible for training Responders using the DOPE Project training curriculum.
2. Trainings may be conducted in a variety of settings, including on the street or in a more conventional private indoor setting. The trainings may be in small groups or conducted one-on-one. The duration of the training shall depend on the number of responders in the class and their familiarity with drug administration and overdose.
3. Responders shall be given a naloxone kit upon successful completion of the curriculum and practical demonstration of an understanding of the subject matter.
4. An Overdose Prevention and Narcan Registration will be completed with each overdose responder as part of the training session. The DOPE Educators will conduct a brief overdose risk assessment as part of the Registration process and will ensure that all paperwork is completed accurately.[vi]

These training sessions also are in accordance with California law, which requires the training program of an opioid overdose program to educate individuals on what causes an overdose and how to carry out mouth-to-mouth resuscitation, correctly contact emergency medical personnel, and administer a naloxone dosage.  This law also allows licensed health care providers to issue standing orders to “a person at risk of an opioid-related overdose or to a family member, friend, or other person in a position to assist a person at risk of an opioid-related overdose.”[vii] Massachusetts law similarly allows naloxone to be prescribed to “a person at risk of experiencing an opiate-related overdose or to a family member, friend or other person in a position to assist a person at risk of experiencing an opiate-related overdose.”[viii] The standing order in Massachusetts allows state-registered naloxone programs to keep supplies of naloxone and allows approved opioid overdose trainers to carry and distribute naloxone to responders, while also allowing these responders to administer naloxone to a patient believed to be experiencing an overdose. [ix] While this is similar to California’s requirements, Massachusetts law does not state that individuals must go through overdose training to be prescribed naloxone as it is in California. Law enforcement officers are gaining more access to naloxone around the country because law enforcement officers can often respond to emergencies before emergency medical personnel.  Currently, there are law enforcement naloxone programs in 13 states, Georgia, Illinois, Indiana, Massachusetts, Maryland, Michigan, New Jersey, New Mexico, New York, North Carolina, Ohio, Rhode Island and Wisconsin, covering nearly 70 counties.[x] This number is expected to nearly double in the coming years.[xi] Emergency Medical Technicians (EMTs) and firefighters are also gaining more access to naloxone, though, as around 2,000 firefighters and EMTs have gained access to naloxone kits in New York City alone.[xii] This increased access is vital as firefighters can respond within 10 minutes, law enforcement in 10 minutes and EMTs in 6 minutes.[xiii], [xiv], [xv] This increased access is vital as these trained individuals can correctly identify whether or not an individual is truly overdosing and in need of treatment, significantly increasing the chance for a successful overdose reversal   Steps to increase access to naloxone must continue to ensure the drug can be used to save lives. The harm reduction approach would be one way to justify its use.

"Map of State Laws Regulating Naloxone." Drug Policy Alliance. N.p., n.d. Web.

• Accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.
• Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.
• Establishes quality of individual and community life and well-being–not necessarily cessation of all drug use–as the criteria for successful interventions and policies.
• Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.
• Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.
• Affirms drugs users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.
• Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.
• Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use. [iii]

Naloxone’s ability to reverse the effects of a heroin overdose gives it the potential to be used as a harm reduction agent in it of itself as it will save lives.  Furthermore, many individuals who die from opiate overdoses did not receive necessary medical treatment in time to save them; allowing more lay people access to naloxone can then save many preventable deaths. If we as a society value human life as sacred, we must find a way to prevent these deaths. Distributing naloxone to trained personnel as a harm reduction agent could present a way to solve this problem and save thousands of lives.

            Many naloxone distribution programs are already in existence.  In fact, at least 188 of these programs are currently operating.[iv] So many that, according to the Harm Reduction Coalition, over fifty thousand people were trained and given naloxone for reversing the overdoses of others between 1996 and 2010.  This distribution of naloxone has resulted in over ten thousand reported overdose reversals. [v] Clearly, naloxone distribution programs have been effective and can continue to be so.  There are, however, arguments against such programs; one of which being that nationwide distribution of naloxone through government programs would be a gross misuse of taxpayers’ money.  Contrary to this criticism, the distribution of naloxone has actually been proven to be extremely cost-effective. One study has concluded this using a mathematical form of analysis, the Incremental cost-effectiveness ratio (ICER), often used in healthcare economic evaluations. ICER is “the ratio of the change in costs of a therapeutic intervention (compared to the alternative, such as doing nothing or using the best available alternative treatment) to the change in effects of the intervention…The change in effects is usually measured in terms of the number of life-years gained or quality-adjusted life years gained by the intervention.” [vi] This study has found that “Naloxone distribution increased costs by $53 (CI, $3 to $156) and quality-adjusted life-years by 0.119 (CI, 0.017 to 0.378) for an ICER of $438 (CI, $48 to $1706)… Naloxone distribution was cost-effective in all deterministic and probabilistic sensitivity and scenario analyses, and it was cost-saving if it resulted in fewer overdoses or emergency medical service activations. In a ‘worst-case scenario’ where overdose was rarely witnessed and naloxone was rarely used, minimally effective, and expensive, the ICER was $14 000. If national drug-related expenditures were applied to heroin users, the ICER was $2429.” [vii] The ICER values produced from this study are relatively low and therefore show how cost-effective the distribution of naloxone can be.

            However, there are criticisms of both the harm reduction approach and the use of naloxone as a harm reduction agent.  First, many argue that the use of a harm reduction technique like naloxone only encourages people to continue their destructive action.  In the case of naloxone, critics believe its use will only lead drug abusers reusing heroin in even more dangerous ways.  Similarly, critics argue these approaches lead people away from seeking treatment since they now have a safety net of sorts for their risky behaviors.  Some critics also believe that we would be wasting valuable money on treating criminals, when that money could be spent helping more highly contributing members of society.  Lastly, there is the cost issue of the approved Evzio device.  While a dosage of naloxone would cost less than five dollars, experts believe that the Evzio device may cost as much as five hundred dollars. [viii] Because of the clear-cut effectiveness of the distribution of naloxone, it should be made available to the public at a reasonable cost.  Therefore, if the cost of Evzio is in fact as high as some fear, something must be done to either reduce the cost of Evzio or find a cheaper, more cost-effective solution, such as the use of the intranasal Narcan product.  To strengthen the arguments for this harm reduction approach, it must be determined whether or not broader access to naloxone would promote more good than harm, not only for heroin users but also for their associates and communities at large. 

"Principles of Harm Reduction." Harm Reduction Coalition. N.p., n.d. Web. 19 June 2014.

1) The action, considered by itself and independently of its effects, must not be morally harmful. The object of the action must be good or indifferent.

2) The harmful effect must not be the means of producing the good effect.

3) The harmful effect is sincerely not intended, but merely tolerated.

4) There must be a proportionate reason for performing the action, in spite of the harmful consequence.[ii]

            The principle of double effect is applicable to the issue of naloxone because it has two effects, one good and the other harmful. The good effect is that this drug has the potential to save lives and hopefully encourage the heroin user to seek rehabilitation. The harmful effect is that some believe that it may send a wrong message that illegal drug use is condoned and even encouraged.  To determine if naloxone is ethical, this issue will be examined in light of the four conditions of the principle of double effect.

            The first condition allows for naloxone because the object of the action, in and of itself, is good. The moral object is the precise good that is freely willed in this action. The moral object of this action is to save lives by reversing the effects of a heroin overdose and hopefully getting these individuals into drug rehabilitation. The immediate goal is not to endorse illegal drug use or to encourage it. Rather, the direct goal is to have naloxone readily available to save the lives of those who overdose on heroin because of their drug addiction.  Former New York Mayor Michael Bloomberg made this same point when he talked about implementing the Take Charge, Take Care: Ten Tips for Safer Use of Heroin program in New York City. He stated, “Using hard drugs is just not a smart thing to do. But we have an obligation no matter what people do in this city to make sure they do it as safe as they can.”[iii]

The second condition permits making naloxone available at various sites in a city because the good effect of saving lives from an overdose is not produced by means of the harmful effect. The two effects are completely independent.  Making naloxone available throughout a city at various sites with proper supervision has no intention of encouraging drug abuse. In fact, the opposite is true. To argue that public health officials are encouraging or condoning drug abuse is illogical.  This is “like suggesting that air bags and seatbelts encourage unsafe driving.”[iv]

The third condition is met because the direct intention of making naloxone available is to protect and preserve human life and to encourage drug rehabilitation, social support, professional counseling and medical care. The direct intention of this program is to preserve the lives of the most vulnerable that is, the poor and the minorities, by stopping heroin overdoses and indirectly, through rehabilitation decreasing illegal drug use. The foreseen but unintended consequence of this may be the belief by some that this is condoning and even encouraging illegal drug use.  One might also argue that it could give heroin users a “false” sense of security that if they overdose they will be revived. Nevertheless, there is no scientific evidence that proves this will encourage or even increase heroin abuse.

Finally, the argument for the ethical justification of making naloxone available by the principle of double effect focuses on the fourth condition of whether there is a proportionately grave reason for allowing the unintended possibility of scandal and the possibility of increased drug usage.  Proportionate reason is the linchpin that holds this complex moral principle together.

            Proportionate reason refers to a specific value and its relation to all elements in the action.[v] The specific value in allowing for naloxone is to preserve human life by reversing the effects of heroin overdoses and encouraging drug rehabilitation to the most vulnerable members of society. The harm, which may come about by trying to achieve this value, is the foreseen but unintended possibility that some may view this as condoning and even encouraging illegal drug use.  The ethical question is whether the value of preserving human life outweighs the harm of the foreseen, but unintended, possibility of scandal and possible increased drug usage? To determine if a proper relationship exists between the specific value and the other elements of the act, ethicist Richard McCormick, S.J. proposes three criteria for the establishment of proportionate reason:

1) The means used will not cause more harm than necessary to achieve the value.

2) No less harmful way exists to protect the value.

3) The means used to achieve the value will not undermine it.[vi]

            The application of McCormick’s criteria to making naloxone available supports the argument that there is a proportionate reason for allowing this program.  First, according to public health officials, the use of naloxone, as part of a comprehensive drug prevention program, can decrease overdose deaths and could increase heroin addicts to seek drug rehabilitation. New York City’s health department is in the process of conducting “a large study following people who get naloxone to assess how frequently the antidote is used to reverse overdose. In 2012, the health department filed a public letter to the Food and Drug Administration (F.D.A.) recommending that the F.D.A. approve naloxone for over-the-counter use. The letter stated that more than 20,000 kits had been distributed in New York City. It also noted that more than 500 overdose reversals had been reported by civilians who had administered the antidote.”[vii] If making naloxone readily available, as part of a comprehensive program, saves lives and does not increase drug usage or condone drug use, then, this program does not cause more harm than necessary. To verify these facts, the program must be initiated on a wide-scale basis in order to collect the appropriate data. 

Second, at present, there does not appear to be an alternative that is as effective as naloxone. It is true that other means exist such as drug treatment and prevention efforts, but according to the most reliable public health and medical sources, the use of naloxone is the best means presently available for reducing overdose deaths among intravenous drug users.[viii] The American Medical Association (A.M.A.) endorsed the distribution of naloxone on April 7, 2014. In addition, the A.M.A. is working with several national groups, including the National Governor’s Association, the National Conference of Insurance Legislators and the National Safety Council to increase support for the increased availability of and access to naloxone.[ix] Most experts contend that few drug addicts, especially those within the 13-24 age range, will take advantage of drug treatment programs and educational resources on their own, because their addictive behavior stands in the way.

The critical aspect that cannot be overlooked in making naloxone readily available at various sites in a city is the element of human contact. Human contact is with an individual who saves your life through reversing the effects of a heroin overdose. This human contact allows outreach workers to form personal relationships with the addicts and thus provide the opportunity to offer them appropriate health care, personal counseling and referrals to treatment centers. Various scientific studies have confirmed that intravenous drug users reduce risk-laden behaviors when pertinent information and services, such as counseling are made available, and especially when they are offered by peers who are members of the drug-using subcultures.[x]  “The human contact of having individuals trained to reverse the effects of a heroin overdose communicates a powerful message to addicts that their lives and well-being are still valued by the community, even though they may not yet be able to break the cycle of addictive behavior.”[xi]   Making naloxone available to trained individuals not only has the potential to save human lives but also to foster human dignity and respect.

            Third, naloxone does not undermine the value of human life. One can argue convincingly that the intention of making naloxone readily available to trained individuals is to save human lives. This program has the potential to decrease drug overdoses and to increase referrals to drug rehabilitation centers. The purpose of making naloxone readily available to trained individuals is to save lives and from the current data it appears to be quite effective. This is a public health issue that must be addressed because innocent lives are being lost. It seems clear that there is a proportionate reason to allow naloxone to be made readily available to trained individuals in a city using taxpayer money. Naloxone contributes to the well-being of those affected because it has the potential to preserve the lives of those individuals who overdose on heroin.  It also offers those addicted the opportunity to realize that they are valued as persons and that with the appropriate assistance addiction can be overcome.  Therefore, it is ethically justified under the principle of double effect to allow for naloxone to be made readily available to trained individuals. Ethically, the greater good of addicts and the common good of society are advanced by financially supporting the use of naloxone in major cities in the United States.

Mangan, J:  An Historical Analysis of the Principle of Double Effect, Theological Studies; 1994; 10: 41.