Ketamine is a medication used for starting and maintaining anesthesia. It induces a trance-like state while providing pain relief and memory loss. Other uses include sedation in intensive treatment of pain and depression. Heart function and airway reflexes remain functional. Effects begin within five minutes when given by injection, last up to 25 minutes. Common side effects include confusion, or hallucinations as the medication wears off. Elevated blood pressure and muscle tremors are common. Spasms of the larynx may occur. Ketamine is an NMDA receptor antagonist, but it may have other actions. Ketamine was discovered in 1962, first tested in humans in 1964, approved for use in the United States in 1970, it was extensively used for surgical anesthesia in the Vietnam War due to its safety. It is on the World Health Organization's List of Essential Medicines, the safest and most effective medicines needed in a health system, it is available as a generic medication. The wholesale price in the developing world is between US$0.84 and US$3.22 per vial.

Ketamine is used as a recreational drug for its hallucinogenic and dissociative effects. Uses as an anesthetic: To prevent opioid-induced hyperalgesia Since it suppresses breathing much less than most other available anesthetics, ketamine is used in medicine as an anesthetic. Ketamine is used in injured people and appears to be safe in this group. A 2011 clinical practice guideline supports the use of ketamine as a dissociative sedative in emergency medicine, it is the drug of choice for people in traumatic shock. Low blood pressure is harmful in people with severe head injury and ketamine is least to cause low blood pressure even able to prevent it; the effect of ketamine on the respiratory and circulatory systems is different from that of other anesthetics. When used at anesthetic doses, it will stimulate rather than depress the circulatory system, it is sometimes possible to perform ketamine anesthesia without protective measures to the airways. Ketamine is considered safe because protective airway reflexes are preserved.

It has been used to prevent postanesthetic shivering. Ketamine is used as a bronchodilator in the treatment of severe asthma. However, evidence of clinical benefit is limited. Ketamine is sometimes used in the treatment of status epilepticus that has failed to adequately respond to standard treatments. Ketamine may be used for postoperative pain management. Low doses of ketamine may reduce morphine use and vomiting after surgery. Ketamine has similar efficacy to opioids in a hospital emergency department setting for management of acute pain and for control of procedural pain. If given intrathecally, its adverse cognitive effects are avoided at analgesic doses, it may be used as an intravenous analgesic with opiates to manage otherwise intractable pain if this pain is neuropathic. It has the added benefit of counteracting spinal sensitization or wind-up phenomena experienced with chronic pain. At these doses, the psychotropic side effects are less apparent and well managed with benzodiazepines. Ketamine is an analgesic, most effective when used alongside a low-dose opioid.

A review article in 2013 concluded, "despite limitations in the breadth and depth of data available, there is evidence that ketamine may be a viable option for treatment-refractory cancer pain". Low-dose ketamine is sometimes used in the treatment of complex regional pain syndrome. A 2013 systematic review found only low-quality evidence to support the use of ketamine for CRPS. Ketamine has been found to be a rapid-acting antidepressant in depression, it may be effective in decreasing suicidal ideation, although based on lower quality evidence. The antidepressant effects of ketamine were first shown in small studies in 2000 and 2006, they have since been characterized in subsequent studies. A single low, sub-anesthetic dose of ketamine given via intravenous infusion may produce antidepressant effects within four hours in people with depression; these antidepressant effects may persist for up to several weeks following a single infusion. This is in contrast to conventional antidepressants like selective serotonin reuptake inhibitors and tricyclic antidepressants, which require at least several weeks for their benefits to occur and become maximal.

Moreover, based on the available preliminary evidence, the magnitude of the antidepressant effects of ketamine appears to be more than double that of conventional antidepressants. On the basis of these findings, ketamine has been described as the single most important advance in the treatment of depression in over 50 years, it has sparked interest in NMDA receptor antagonists for depression, has shifted the direction of antidepressant research and development. Ketamine has not been approved for use as an antidepressant, but its enantiomer, was developed as a nasal spray for treatment-resistant depression and was approved for this indication in the United States in March 2019; the effectiveness of esketamine is limited however, with significant effectiveness for treatment-resistant depression seen in only two of five clinical trials. Although there is evidence to support the effectiveness

Consequentialist justifications of the state are philosophical arguments which contend that the state is justified by the good results it produces. The justification of the state is the source of legitimate authority for the government. A justification of the state explains why the state should exist, what a legitimate state should or should not be able to do. Consequentialist justifications of the state focus on the results that are achieved when certain institutions are put in place, they are based on consequentialist theories such as utilitarianism. Consequentialism is sometimes confused with utilitarianism, but utilitarianism is only one member of a broad family of consequentialist theories. Consequentialist theories maintain that the rightness or wrongness of an action depends on whether the results of the action are desirable, they are contrasted to deontological theories of morality, which hold that certain actions are either forbidden or wrong per se. In law and political theory, a state or sovereign is an institution that legitimates a particular government.

Sometimes arguments about legitimacy have a mystical side as when kings claim divine right. Different political philosophies have distinct opinions concerning the state as a domestic organization monopolizing force; as an example, consequentialists might observe. They would ask whether those bridges would have been built in the absence of the state and whether those bridges are valued by those who use them. If the bridges would not have otherwise been built and they are valuable to those who use them the existence of the state is justified. A philosopher who doubts or denies the legitimacy of the state might respond by questioning the ethical premise, saying for example that the workers who built that bridge were exploited by the government that ordered it built, and/or by the investors in the private contractors who profited; the philosopher might have a deontological theory of exploitation. Alternatively, a skeptic might concede that the bridge is a good consequence but contend that on consequentialist grounds the argument fails.

He might argue that an better bridge might have been built under anarchist conditions. This counter-argument raises the issue of opportunity cost and the whole issue becomes an exercise in economic reasoning. Consequentialism Justification for the state Rule according to higher law Sovereign state

The Largo Public Library is one of the most used public libraries in Pinellas County, United States. It serves a community of over 75,000 residents; the city of Largo began as a grouping of loosely gathered communities of farmland around a large lake in the 1880s in the middle of what is today's Pinellas County. Due to railroad expansion and a growing community of residents, Largo became an incorporated town in 1905. In 1914, the Woman's Club of Largo began to create a small library for the community of 350 residents; this original Library Committee consisted of Mrs. D. F. Judkins, Mrs. W. F. Belcher, Mrs. J. T. Jackson, Mrs. W. M. Ulmer, Mrs. Ann McMullen. Efforts to begin the library started at the large Camphor Tree located at the center of downtown where residents left donations. Serving as a "Christmas Giving Tree", residents left books, magazines and other furnishings to help establish the first library of Largo; these donations were placed in the first library facility located in a downstairs room of the original, wood frame Town Hall building with a total of 560 books which opened to the community on April 7, 1916.

Marie Allen, was paid $2 weekly to serve as Largo's first librarian. Jennie Danforth Judkins, a strong Largo Library advocate, served as the library's second librarian; such was her dedication to the library that a local legend developed that Mrs. Judkins read every book, added to the library's collection before it was placed on the shelf. Due to the bustling population growth of the 1950s, Largo determined the need for a new library facility and town hall and began the project in 1960. December 15, 1961 the groundbreaking took place for the $36,000 new library and Ms. Helene Tilly served as the head librarian upon opening of the facility. By 1968, the current facility on West Bay Drive contained around 14,000 books. However, the city thereafter determined the need for a new, larger facility and in 1974 local businessman John Jenkins donated five acres of land for the new library. On May 15, 1977 the new $1 million library opened under the direction of Barbara Murphey with 30,000 books present.

In 1989 the facility expanded in size and totaled 250,000 volumes, serving an average of 1,500 visitors daily. In the middle of the 1990s concerns arose on how to deal with the issue of an awkward parking lot entrance, but morphed into the suggestion of a new library facility. After collecting funding from sales-tax through the "Penny for Pinellas" tax initiative, the new facility opened on July 31, 2005. To help define the overall goal of the institution within the community the official name of the facility was changed to Largo Public Library; the 90,300 square foot library opened under the direction of Casey McPhee and more than doubled the size of the previous facility. Within the first year of opening the library hired 72 staff, had 200 volunteers, welcomed more than 558,000 visitors, circulated 683,000 items, had 28,000 workshop attendees, answered 85,000 reference questions. Largo Public Library has a long history of "firsts" in technology; when the current library opened in 2005, patrons were able use RFID technology at four self check out stations located on the first floor.

This option is crucial to serving the huge influx of visitors that the library continues to assist each year. Starting in January 2008, library patrons had the added convenience of a full service Drive-Through window for returning materials, picking up hold requests and other library related transactions; the Drive-Through enables the library to serve a diverse group including the elderly, parents of young children and the mobility challenged. In 2013 the library upgraded its RFID system to comply with current standards and added an Automatic Materials Handler, which checks in and sorts materials; these additions have enabled Largo Public Library staff to re-focus on customer service and programming for their community, despite budget cuts that reduced staffing levels during the recession. This shift in focus was rewarded in 2018 when Largo Public Library was named The Florida Library Association Library of the Year; the Largo Public Library offers a diverse collection of materials available for checkout including DVDs, CDs, audiobooks, e-books, videos.

Through collaboration with the Pinellas Public Library Cooperative, the library offers a variety of digital content for check out from an e-reader or computer device through OverDrive's Libby platform. The physical library has computers for use, as well as study rooms, reference services, Children's Wing and the Teen Room. An ideaLAB with a 3D printer has been added outside the Teen Room as a place to develop creative ideas and explore new technology; the ideaLAB has not only a 3D printer, but iPads, MacBook Pros, LEGO Mindstorms EV3, a variety of MacBook software, iPad Apps. All of these services are free to use at the Largo Public Library, they host gaming, literary events and programs for adults and children. Specialized collections and resource centers are available for patron use in the form of the English Language Learning Center, e-Government resources and Genealogy collection; the library offers services beyond the physical library through the library's eBranch link. This link is the gateway to a wide variety of e-content including books, magazines, streaming video and databases.

Largo Public Library is designated as the center for genealogical research for the Pinellas Public Library Cooperative and partners with the Pinellas Genealogy Society to provide a permanent home for maps, journals, CD-