sportsmedicine:someethical issues · quette', and 'medical ethics' or...

Br J Sp Med 1993; 27(2)

Discussion paper

Sports medicine: some ethical issuesJulius Sim BA MSc MCSPSchool of Health and Social Sciences, Coventry University, Coventry, UK

The ethical aspects of sports medicine have hithertoreceived little scrutiny, in contrast to its legal implications,which have recently been subject to much greaterdiscussion. However, the differences that are apparentbetween sports medicine and 'mainstream' areas ofclinical practice can shed new light on a number of thecentral issues within health-care ethics. By means ofhypothetical case studies, this paper seeks to examinesome of these issues within a sports medicine context.Specific attention will be paid to the concepts of autonomyand paternalism, issues to do with truthfulness, and thequestion of conflicting professional loyalties. It is sug-gested that the ethics of sports medicine warrant furtherand more detailed examination.

Keywords: Ethics, sports medicine, physiotherapy

Over recent years, there has been a growing interestin the ethical implications of health care in general,and medical practice in particular. There are over halfa dozen major journals devoted to ethical issues inhealth care, and a steady proliferation of textbooks.One of the best known texts' has now entered itsthird edition and seems destined to be as much a'standard work' on the subject as many of the classicworks in medicine and surgery.Much of the attention in this field has been given to

high-profile issues, such as those to do with thebeginning and end of life and/or those concernedwith medical technology2-4. More recently, the ethicsof resource allocation and other aspects of health

5policy have received considerable attention .

Although by no means ignored, the ethics of theroutine clinical encounter, in which life and deathissues are not at stake, have been scrutinizednoticeably less. When the more 'minor' issues ofhealth-care ethics are addressed, this is often withinthe specific context of the ethics of nursing6 ratherthan in the primary medical focus of health-careethics. In addition, while there have been studies onthe ethical issues that arise in community settingssuch as general practice, the main ethical focus has

Address for correspondence: J. Sim, School of Health and SocialSciences, Coventry University, Priory Street, Coventry CV1 5FB,UK

(©) 1993 Butterworth-Heinemann Ltd0306-3674/93/020095-06

tended to be on health care as it occurs within ahospital setting7.

Sports medicine is an area of practice which has notfeatured largely within health-care ethics, and yet thespecific, and sometimes unique, features of this fieldof practice shed new light on many of the standarddebates in health-care ethics.

Specific features of sports medicineThere are a number of ways in which sports medicinediffers from the predominant form of practice in'mainstream' medicine, physiotherapy and alliedfields. Whereas mainstream medicine and physio-therapy are, as we have noted, hospital-centred,sports medicine is generally pursued in privatepractice, at sports clubs, health centres, and, ofcourse, at the track- or pitch-side. Injured sportsparticipants do, of course, find themselves inhospital, but when they do they tend to encounterpractitioners in specialities such as orthopaedics,rheumatology and emergency medicine, rather thana specialist in sports medicine.

This removal from the institutional setting alsohelps to explain the rather different relationships thatexist between sports medicine practitioners, theiremployers, official sports organizations, professionalcolleagues and patients. The pattern of relationshipsencountered in hospital practice does not usuallyexist in the context of sports medicine.Another distinctive feature of sports medicine is

the link between the pathology concerned and aspecific recreational or professional activity. A sport-ing injury has a direct and immediate impact onparticipation in this activity; this has particularpsychological8 and, in the case of professional sportspersons, financial implications. The fact that injury isdirectly connected with a pursuit or occupation that isof personal significance to the individual helps toexplain another factor, which is that many sportsparticipants are fairly knowledgeable about sportsinjuries (which is not to say that they do notmisunderstand some of the processes involved), andshow particular concern for their physical well-being.Probably the most obvious difference between

sports medicine and mainstream medicine andphysiotherapy is the fact that, setting aside thepresenting injury, the patients treated are generallyhealthy. Indeed, many sports persons are, almost bydefinition, healthier than the average individual.

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Ethical issues in sports medicine: J. Sim

This, coupled with the fact that most of theconditions encountered are musculoskeletal ratherthan systemic, largely explains the scarcity of life anddeath cases in sports medicine.

Considerations such as these create a specificcontext for the ethics of sports medicine, and cause usto take a rather different perspective on some of theclassic ethical issues in health care. Before doing so,however, it is important to clarify what is includedwithin the phrase 'ethics of health care'. The term'medical ethics' has often been used to cover a rangeof issues. In addition to genuinely ethical, or moral,considerations, it has frequently referred to mattersof etiquette or professional courtesy, particularlywhen employed in the sense of 'professional ethics'.Remarks such as 'it is not ethical for a consultant tosee a patient without a general practitioner's referral',or 'health professionals should not be seen todisagree in front of a patient' may raise some moralissues, but the primary underlying concern is oftenwith the formalities and courtesies of interprofes-sional dealings. Matters such as these should beconsidered under the heading of 'professional eti-quette', and 'medical ethics' or 'health-care ethics'should be reserved for those instances where thereare distinctively moral issues at stake. Of course,some situations may come under both of theseheadings.The ethics of sports medicine should also be

distinguished from the law as it relates to sport (anarea which has recently received detailed considera-tion9). One refers to morality, the other to a set ofenforceable social rules. Although it is desirable thatthe law should be grounded in moral principles, andthat matters of moral importance should be givenlegal backing in many instances, none the less noteverything that is illegal is immoral, and similarly notall immoral behaviour is against the law. Thus, whenwe speak of the ethics of sports medicine, we are notconcerned with etiquette or law, but with basic issuesof morality - of right and wrong, good and bad.

Some specific issuesWe are now in a position to address some specificethical issues within the context of sports medicine.These will be considered with reference to threehypothetical case studies.

Case study 1: autonomyBeauchamp and Childress1 describe autonomy interms of 'personal rule of the self while remainingfree from both controlling interferences by others andpersonal limitations, such as inadequate under-standing, that prevent meaningful choice'. Gilloncontrasts the notion of autonomy with that offreedom:In the sphere of action it is important to distinguishbetween, on the one hand, freedom, liberty, license, orsimply doing what one wants to do and, on the other hand,acting autonomously, which may also be doing what onewants to do but on the basis of thought or reasoning1.A basic ethical principle in health care is that of

respect for autonomy. This requires health profes-

sionals to do their utmost to preserve, and perhapsalso to enhance, the autonomy of their patients. Themain ethical basis for informed consent is that failureto obtain consent is to undermine the individual'sautonomy. Similarly, to mislead or lie to patients is tofail to give them the necessary information withwhich to make autonomous choices.There are a number of factors that can threaten a

patient's autonomy. Within an institutional settingsuch as a hospital, patients tend to find themselves ina dependent and subordinate position in relation tothose caring for them. This, and the disconcertingunfamiliarity of their surroundings, can make it hardfor them to voice and insist on their own wishes andintentions. An essential component of autonomy isknowledge. A number of patients have little under-standing of the pathological processes affecting themand the therapeutic procedures employed in theircare, and their capacity to make autonomousdecisions suffers accordingly. Illness itself can have adisorienting effect on the individual, especially if ithas marked psychological sequelae. In addition, andat a purely practical level, even if the patient can formperfectly autonomous intentions, illness or disabilitycan prevent these from being physically imple-mented. Finally, serious, life-threatening conditionscan cause some patients to become fatalistic or subjectto a sort of paralysis of the will, such that they allow,or even oblige, others to make decisions for themwith little participation on their part.How do these factors translate into the sports

medicine arena? The following is an adapted sum-mary of a case presented by Bruckner1":Shirlaine is a physical therapist treating a public high schoolstudent, who is a state-level wrestler and weight-lifter.Noting excessive muscular hypertrophy, she questions thestudent, Donald, and eventually elicits from him anadmission that he has been taking anabolic steroids.Shirlaine points out the serious side effects of such drugs,but although Donald is aware of the attendant risks heprofesses not to be concerned with these, claiming thatwinning the state championship is the primary goal of hislife. Donald's likelihood of success in the championship hasbeen the subject of much public hope and speculation inthe town, and his coach has been pushing him hard intraining.

Is Donald's drug taking autonomous? It is imme-diately noticeable that many of the familiar threats toautonomy apparently do not apply here. Donald isnot in hospital, and his relationship to his physicaltherapist appears to be far less subordinate than thatof a hospital patient to his or her specialist. Nor is heunwell in any obvious sense. He is physically capableof enacting his decisions. Similarly, there is no reasonto think that his cognitive or decision-making powershave been adversely affected by illness or disability,and it is reasonable to suggest that he has a fairunderstanding of the medical issues at stake. He hasnot taken drugs out of necessity to avert a seriousthreat to his health, but has done so, it would seem,to gain the 'optional extra' of heightened physicalcapacity.However, despite the dissimilarities between

Donald and the classic picture of the non-

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autonomous patient, there are reasons to questionthe authenticity of his choice. Most obvious perhapsis the influence of his coach and the psychologicalpressure exerted by friends, neighbours and relativesin his town. There is also the possibility that theemphasis on succeeding that exists in high-level sporthas distorted Donald's goals. The immediate objec-tive of winning state championships in two sportsmay have suppressed his concern for longer termwelfare (just as he has ignored threats to his health,he may also have neglected his studies and hispersonal relationships in the process of achievinggreater levels of fitness). In general, we tend to thinkthat lack of autonomy consists in being led to dothings that are contrary to what would normally beone's inclinations; the non-autonomous person isoften thought of as doing, or being made to do, theopposite of what he or she wishes to. In this case,however, it is more a question of Donald being led, orleading himself, in the same direction that he himselfhas chosen, but excessively so. It is as if his desireshave developed too much momentum and haveescaped his control. On the other hand, thepossibility remains that, however irrational it mayseem to an outsider taking a detached, long-termview, Donald is in fact truly autonomous. Perhaps hegenuinely does think that sporting success in hisyouth is more important than his future health,career and personal relationships. Individuals differin the importance they attach to short- and long-termgoals, and health professionals should be wary oflabelling as irrational any decision they personallydisapprove of or cannot understand.

If, after careful thought, Shirlaine is convinced thatDonald is not acting autonomously, what should shedo? She may feel that she should endeavour topersuade him against his own stated wishes, on thebasis that these are not in fact his 'true' intentions. Inother words, she would argue that she is able tojudge his own best interests better than he. This is thebasis of what is known as 'paternalism'.The health care application of paternalism involvessomeone other than the patient (usually the health careprofessional) assuming decision-making responsibility forthe patient, assuming veto power over the patient'sdecisions, or being ready to impose her will on the patient.The paternalistic person then limits the autonomous action(or decision) of another person and treats that person as ifhis competence were limited12.

For many, paternalism is unacceptable, as itsuggests a notion of interference in the lives ofothers, with the health professional imposing his orher will on others, and thereby overriding theirautonomy. Those who seek to justify paternalism, onthe other hand, argue that in some cases it is only bysuch action that the welfare of the patient can besafeguarded. They would claim that the patient hasno genuine autonomy and that therefore their ownactions are not an infringement of autonomy but asubstitute for it. Accordingly, whether paternalisticbehaviour is justified hinges largely on the factualquestion as to whether or not the individual'scapacity for autonomous decision-making is gen-uinely impaired. Shirlaine must decide whether

Donald's choice is genuinely autonomous and, if so,whether respecting his autonomy is a more pressingethical demand than protecting him from the harmwhich his autonomous action is likely to bring uponhim.

Case study 2: truthfulness

The notion of truthfulness is an important one inhealth-care ethics13 5. In classic discussions of'medical ethics', the question of whether healthprofessionals should disclose grave diagnoses topatients often arises. However, these are not the onlyoccasions when truthfulness is at stake:Dr B runs a weekly sports injury clinic within her generalpractice, and sees a variety of sports participants of variousages and abilities. Two of her patients, John and Audrey P.have brought their 15-year-old daughter, Annabel, to seeher. Annabel is a promising gymnast who has recentlybeen experiencing recurrent episodes of back pain. Dr Bcould not identify any specific injury, but was struck byAnnabel's lumbar hypermobility, which seemed excessiveeven in a gymnast. As a precaution, and in view of thepersistence of the symptoms, she ordered a radiograph.The radiologist's report indicated no specific lesion, but didremark that there were early signs of degenerative changesin the spinal apophyseal joints. Dr B was immediately ledto consider the effects which continued participation intop-class gymnastics might have on Annabel's spine, andwondered what, if anything, to say to her and her family.

There are a number of factors that need to be takeninto account when deciding what information shouldbe given to a patient: the certainty of the factsinvolved, the likely effects of telling or not telling, thequestion as to whether the patient 'wants to know',and the wider ethical issue as to whether the patienthas a right to know the truth. In respect of the last ofthese, it is generally agreed that, all else being equal,patients should be told the truth about theircondition. However, the other factors listed maymean that all else is not in fact equal.

In the first instance, the extent to which it is right totell a patient certain information is influenced to someextent by how sure one is about that information. Inthis case, it is at best a statement of probability to saythat Annabel will suffer significant pain or disabilityin later life. However, it should be remembered thatwhat is at issue is not the truth in any objective sense,but the truth as it is honestly perceived by theindividual practitioner. Dr B must decide on the basisof what she believes to be the case, even thoughevents may subsequently contradict her.

The whole truth is out of reach. But this fact has very littleto do with our choices about whether to lie or speakhonestly, about what to say and what to hold back'6.

Second, to say that the patient has a right to knowis not to say that the doctor automatically has a dutyto tell. If there is a right to know there is also,presumably, a right not to know. The final decisionwill largely be governed by whether or not the patientwishes to be informed. This is not easy to judge: 'Thelogical difficulty here is that the very nature ofdisclosed information may determine the patient'sdesire to be acquainted with it, by which time of

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course it is too late'15. Would Annabel wish to knowof the future pain and disability she is risking? It isnot clear that this question would be satisfactorilyresolved by asking her parents, as parents often seemto have as much at stake in their children's sportingsuccess as their sons and daughters themselves (andthere is, moreover, no strict guarantee that parentsalways have their children's best interests at heart,even though this assumption is often made indiscussions of health-care ethics). There is nostandard solution to this question, but it is probablywise to put the burden of proof on the advocate ofnon-disclosure, i.e. to work on the basis of disclosureunless there are convincing reasons to suggest thatthis is against the patient's wishes.

If the effects of telling the truth seem to bemanifestly worse than those of not telling, it might beargued that the doctor should keep silent. If thereverse were the case, this would be furtherjustification for disclosure. An obvious question is,assuming that Annabel was told of Dr B's misgivingsabout possible future damage to her spine, howuseful would this information be to her? Would itmake a meaningful contribution to Annabel's plansfor her future in gymnastics, or would it merely be asource of confusion, distress and indecision? If shewere to decide to withdraw from competitivegymnastics, how would her parents react to this -indeed, to what extent would she be permitted tomake such a choice for herself? The fact that Annabelis still a fairly young girl has a bearing on the issue. Itis not so much that her age as such prevents her frommaking a rational, informed decision in the light ofinformation about her future health. Rather, it isarguable that she is not yet sufficiently mature toform an autonomous decision in the face of thepsychological pressures which she is likely to beexposed to as an aspiring athlete - much the samepressures from family, friends and coach whichaffected Donald in the previous case. On the otherhand, it could be argued that pressures such as theseare not a reason for withholding the truth in apaternalistic way, but for ensuring that the rightconditions for autonomous choice are provided oncethe truth has been told. Perhaps the overridingethical concern is to provide the information, to thebest of one's ability, that is necessary for the patientto decide and act autonomously. Appropriate stepscan then be taken to facilitate and support the patientin making these decisions, and if the whole process israther more painful than a state of ignorance, thismay be seen as an inevitable cost of autonomy.

Case study 3: conflicts of dutiesHealth professionals have various duties and respons-ibilities. The precise nature of their professionalduties and allegiances depends upon the network ofrelationships in which they find themselves. Attimes, these obligations may pull in opposite direc-tions, and lead to an ethical conflict which thepractitioner must attempt to resolve.The following case illustrates such a situation:

John E is physician to a top-class rugby league club. Beforean important fixture, he is asked by the team manager to

give the first team scrum-half a pain-killing injection for asprain of the lateral ligament of the ankle; the club iscurrently short of a replacement specialist scrum-half.Having examined the injury, the doctor suspects that thereis a partial tear of the anterior band of the ligament. Thereis, he reasons, a fair likelihood that a relatively minor injurycould be transformed into a more serious one if the playerwere to play in the match, especially in view of the fact thatthe normal protective pain mechanisms would be at leastpartly abolished by.the injection.

In this situation, Dr E may hesitate to administer theinjection on the basis that he has a professional dutyto protect the best interests of the players, who areentrusted to him as patients. In other words, he has aduty to protect his patients from harm (often referredto as the principle of non-maleficence1). His judg-ment may be that the chances of the injury beingextended to a major rupture are too great to be risked,and that in order to preserve the player from likelyharm, he should decline to give the injection.However, he also has another duty - a contractual

duty to the club that employs him. Since it is theclub's wishes, as expressed by the manager, that theirscrum-half should play in the forthcoming match, therequirements of Dr E's contractual duty to the clubmight appear to conflict with his professional duty tohis patient. There are, however, a number ofconsiderations which would suggest that it is thelatter duty which should take precedence. In the firstinstance, Dr E could argue that his duty to the club isnot to follow specific instructions, but to maintainand restore the health and fitness of the playerswithin the terms of his professional judgment - it isfor him to decide the precise steps to be taken inorder to achieve this goal. In addition, he could claimthat the interests of the club would be better served iftheir scrum-half were to miss the coming match inorder to make a complete recovery and regain fullfitness for the remaining games in the season.Perhaps the strongest argument that Dr E couldadvance, however, is that his duty to his patientsmust be his first concern, and that contractual orother responsibilities are of secondary importance.He might claim that obligations to the patient aremore central to his professional role than thoseresponsibilities associated with an employer-em-ployee relationship; the former are part of the verydefinition of being a doctor in a way that the latter arenot. Thus, he might argue, where it is a choicebetween duties to a patient and those to an employer,the patient must be put first (unless, perhaps, theduty to the patient is disproportionately minor incomparison to the contractual requirement).So far, it is not hard to be convinced that Dr E

should decline to administer the pain-killing injec-tion. This seems to be where his principal ethical dutylies. Indeed, it could be said that in this case the mainconsideration urging compliance with the manager'srequest is not an ethical one but a prudential one, i.e.that his own financial and career interests would bebest served in this way. Suppose, however, that thescrum-half asks him for full details of his injury andthe implications of playing on it, and, having heardall this, asks that he be given the injection none theless. This casts a new light on the situation, as the

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player has now voiced a specific wish to receive theinjection. Given that he has received a full explana-tion of the circumstances, and assuming that thereare no barriers to his comprehension, this wouldseem to be a fully autonomous wish. Whereas before,a duty to the patient (in the form of non-maleficence)required that no injection be given, another duty tothe patient (in the form of respect for autonomy) nowseems to require that the injection should be givenafter all. In order to resolve this dilemma, Dr E mustdecide whether he attaches most weight to autonomyor non-maleficence, and faces much the samedecision as Shirlaine did in the earlier case.

In the example just described, there seems to be acase to be made that the injection should be given. Itis worth considering briefly another possible situa-tion in which, although some of the key issues are thesame, a different conclusion might be arrived at:

The physiotherapist for the same rugby league team isconsidering a player for return to match-play who hassustained an injury to the rectus femoris muscle. Althoughto the untrained eye the player would seem to haveregained full performance, during late-stage fitness testingthere is a perceptible hesitancy in the player's accelerationand signs of a slight loss of coordination during rapidchanges in direction. The physiotherapist expresses hisdoubts to the player, who admits to feeling less than totallyrecovered, but none the less pleads to be passed fit; as aregular second-team player, he is eager to take advantageof a forthcoming first-team appearance to try to secure aregular place.

Similar factors operate here as in the case of thescrum-half and the team physician. Although respectfor autonomy seems to suggest that the player's wishshould be complied with, the chances that further,more serious, injury might occur during the course ofa keenly-fought match urge the opposite course ofaction. However, there are additional factors to beconsidered which were not present in the previousexample. Whereas, previously, the contractual dutyto the club was at variance with the duty to protectthe scrum-half from likely harm, in this case loyalty tothe club coincides with and reinforces the require-ment of non-maleficence. It is presumably not in theclub's interest to include a second-team player who isless than fully fit when there are very likely otherplayers who could readily fill his place (in theprevious case, in contrast, there was no suchalternative player). In addition, the reason why thephysiotherapist might be inclined to pass the playerfit - namely that this might assist him to obtain aregular first-team place - is counteracted by anequivalent reason acting in the opposite direction.While this player's future success may be furtheredby allowing him to play, the future success of histeam-mates is likely to be undermined in the process,as he is liable to perform at a suboptimal level whileplaying with a residual injury. In fact, this mightexpose other members of the team to a greater risk ofinjury themselves, through trying to compensate forthe original player's lack of speed or manoeuvrability,or as a result of his mistakes. Finally, if thephysiotherapist were to accede to the player'srequest, this would involve him in deceiving the club.

Even if, on all other grounds, the physiotherapistthought it justified to pass the player fit, the fact thatthis would require him to be deceitful would tend totip the scales in the opposite direction.There is no standard solution to conflicts of duties

such as these. Each case must be considered in thelight of all the relevant ethical considerations thatbear upon it, and the conclusion that is determined inone case may be very different from that arrived at inanother. Whether the decision reached is the 'right'one in any objective sense is often a question whichcannot be answered, not least because one's initialreading of the situation, or the consequences that onepredicts for various courses of action, may beovertaken or undermined by events. In much thesame way, even the most careful diagnosis maysubsequently prove to be erroneous. The importantthing is for such a decision to have been takenhonestly and conscientiously.

DiscussionThese three case studies have illustrated some of theethical issues and dilemmas that may be encounteredin sports medicine. In tackling these questions, thepractitioner must pay careful attention to the specificnature of this area of practice: the sort of patientsinvolved, relationships with other parties such ascoaches and managers, and the particular psycholog-ical factors that operate in this competitive field ofhuman activity. Although the examples given havebeen taken from top-class sporting activity, the sameprinciples apply with respect to more modest levelsof participation. While the extrinsic rewards will bedifferent, the weekend golfer may derive as muchintrinsic value from his or her game as those on theprofessional circuit, and there is an equal need ineach case for careful and conscientious decision-making by the health professional.The ethics of sports medicine have been largely

neglected hitherto, and there is a need for a moreexplicit and detailed focus on this aspect of profes-sional practice.

References

1 Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 3rdedn. New York, USA: Oxford University Press, 1989.

2 Rachels J. The End of Life: Euthanasia and Morality. Oxford, UK:Oxford University Press, 1986.

3 Kuhse H, Singer P. Should the Baby Live? The Problem ofHandicapped Infants. Oxford, UK: Oxford University Press,1985.

4 Dyson A, Harris J. Experiments on Embryos. London, UK:Routledge, 1990.

5 Daniels N. Just Health Care. Cambridge, UK: CambridgeUniversity Press, 1985.

6 Melia KM. Everyday Nursing Ethics. London, UK: Macmillan,1989.

7 Gorowitz S. Drawing the Line: Life, Death and Ethical Choices inan American Hospital. New York, USA: Oxford UniversityPress, 1991.

8 Sanderson FH. The psychological implications of injury. In:Reilly T, ed. Sports Fitness and Sports Injury. London, UK:Faber and Faber, 1981.

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9 Gravson E. Spuort anid the Lauw. London, UK: Butterworth, 1988.10 Gillon R. Philosohlical Medical Ethics. Chichester, UK: John

Wilev, 1986: 60-1.11 Bruckner J. Physical therapists as double agents: ethical

dilemmas of divided loyalties. Pliys Ther 1987; 67: 383-7.12 Wright RA. Humana1 Values in Health Care: The Practice of Ethics.

New York, USA: McGraw-Hill, 1987: 112.13 Schrock RA. A question of honesty in nursing practice. I Adz,

Niirsing 1980; 5: 135-48.14 Higgs R. On telling patients the truth. In: Lockwood M, ed.

Moral Dilemmiiias in Modern Medicine. Oxford, UK: OxfordUniversitv Press, 1985.

15 Sim J. Truthfulness in the therapeutic relationship. Physio-therapy/ Practice 1985; 2: 121-7.

16 Bok S. Lying: Moral Choice inl Public and Priv~ate Life. Hassocks,UK: Harvester Press, 1978: 4.

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