Virtue Ethics in a Value-driven World: It’s Always with Me

On June 7, 2019, I sat in a crowded auditorium in Chicago, IL, USA at the Annual Meeting of the American Medical Association where Dr. Jerome Adams—the Surgeon General of the United States—was set to give a lecture during the Young Physicians’ section of the meeting. Dr. Adams opened his lecture by asking how many people in the room know CPR, and every hand went up. He then asked who in the room had naloxone with them. Naloxone is used to treat narcotic overdoses in emergency situations. Only his hand went up. He removed a small intranasal injector—about the size of a dental floss container—from his coat pocket. “Today, you are more likely to save a life with this [naloxone] than CPR,” Dr. Adams said.

He grounded his lecture within his own family’s struggles; he mentioned his brother, who had a history of substance abuse. He issued a formal advisory on the use of naloxone [8] and encouraged all the physicians in the room to carry the opioid antagonist.

I was moved by his lecture, and I planned to order naloxone so I could carry it with me. I live in Baltimore City, and the city health commissioner has a standing order, which serves as a blanket prescription, allowing any city resident to carry the medication. But as things do, the lecture faded from my memory.

About a year later, I received a terrible telephone call. A family member had died suddenly, most likely from a fentanyl overdose. After the funeral, I went to the pharmacy for my naloxone prescription, which I now carry with me at all times. At first I carried it for self-preservation; I didn’t think I would be able to survive the trauma of witnessing an overdose without helping. Over time, my views have evolved. I now believe it is my duty to carry naloxone.

There is a compelling altruistic argument that everyone should carry naloxone, given the scope and impact of the opioid epidemic. A community-wide response of individuals carrying naloxone would be similar to the increasing availability of automated external defibrillators in public spaces. Community access to naloxone is already increasing, thanks to widespread harm-reduction efforts of health departments, non-profits, and individual healthcare practitioners [5]. Additionally, the Food and Drug Administration (FDA) has recommended coprescribing naloxone with all opioid prescriptions [10] and has required opioid labels to include information on naloxone [3]. Many localities have a standing naloxone order for community members similar to Baltimore’s so that anyone can obtain naloxone at a pharmacy [7]. Naloxone is both safe and easy to administer. There are no adverse effects to giving naloxone to a person who is not overdosing from an opioid. There is an intranasal delivery system, which enables administration of the medication to an unconscious individual. Naloxone is an ideal public-health intervention, because inappropriate usage is not harmful and appropriate usage has tremendous potential benefit.

As part of the general public, physicians likewise could have altruistic reasons for carrying naloxone. But do they have greater obligations than the general public to act during life-threatening emergencies? In this way, Dr. Adams’ CPR analogy is a good one. If a passenger on an airplane requires CPR, it is reasonable to believe that a physician on the flight—aware of the need for assistance—provides it. Physicians have a special obligation to provide emergency care outside of their workplace beyond any lay person’s obligation.

One could argue that it is not appropriate to expect physicians to carry life-saving medications at all times, because this would be an unending obligation. Should physicians be expected to carry insulin wherever they go, in case they witness a diabetic emergency? The rates of death from hyperglycemic crises is less than 2500 a year [11]. In contrast, the Centers for Disease Control & Prevention projected 70,980 overdose deaths in 2019, exceeding the previous record of 70,699 set in 2017 [2]. In the Vietnam War, 58,220 service members died [6]. If more Americans were going to die from hyperglycemic crisis this year than died in the Vietnam War, I would similarly argue that physicians have a professional obligation to carry insulin because of their positions as stewards of public health. The breadth of the opioid crisis requires broad action, both from professionals and the lay public.

Finally, physicians have a backward-looking obligation to carry naloxone because of our historical role in creating the opioid crisis. The history of the opioid crisis has been well-documented elsewhere [9]. Although pharmaceutical companies and the adoption of pain as the “5^th vital sign” drove the epidemic, we physicians also had an active role [4]. Physicians in general, and surgeons in particular, continued to overprescribe opioids even as the crisis raged [1]. Opioid overprescribing by physicians created much of the crisis, and the crisis will end only with the full engagement of physicians.

Ending the opioid epidemic will require a multifaceted approach, and much of the heaviest lifting will be done by our colleagues in pain and addiction medicine. As orthopaedic surgeons, we have two obligations. First, as opioid prescribers, we must coprescribe naloxone with any opioid as the FDA suggests. This is analogous to our responsibility to prevent deep vein thrombosis after surgery. When our treatment includes the potential for harm, we must use risk mitigation strategies. Second, orthopaedic surgeons have an obligation—as physicians and public health stewards—to carry naloxone. Just as we would render aid in an emergency situation by providing CPR, we should be ready to provide naloxone to someone who has overdosed.

I clearly feel strongly about this issue in large part because the professional has become personal. Before I lost a family member, I was invested in improving outcomes from the opioid crisis as a physician who prescribes opioids and has patients with opioid use disorder. Yet, it was only after a personal loss that I opted to carry naloxone at all times. As physicians first, we orthopaedic surgeons promote public health through other mechanisms—encouraging smoking cessation to promote fusion, working on diabetic control to improve wound healing, and recommending weight loss to improve arthritis. Carrying naloxone is an extension of our physician-derived obligations to promote the health of our patients and our community. We can save lives by carrying a floss-sized container. We are obligated to do so.