Sport physicians may become invested heavily in the success of their athletes, and even when there is no direct or indirect financial gain, the sport physician may push the boundaries of good medical practice (12). The ethical dilemmas of the sport physician with regard to return to play and conflicts of interest have been described elsewhere (4,11), and this commentary will focus on the issue of doping.
Over the years, physicians who were involved in the doping of athletes claimed that they were monitoring properly the athletes and simply assisting the body’s efforts at homeostasis. The argument was that if testosterone levels were low from overtraining or heavy competition, it could be boosted back up to “normal” levels. Fatigue in the setting of multiday endurance events could be cured with a small blood transfusion or the judicious use of erythropoiesis-stimulating agents. These doctors emphasized that their athletes were monitored strictly, and thus, any medical risks were minimal.
“Only with adequate safe controls can anabolic steroids be viewed in the same light as antibiotics, anti-asthmatic and other medications used in daily life,” stated U.S. physician Dr. Robert Kerr in 1982, 8 years after androgenic anabolic steroids were banned. He eventually reversed his position upon the realization that athletes often pushed drug use to the extremes (1). This conclusion should not have come as a surprise as illustrated by the British cyclist Tommy Simpson who died on Mont Ventoux during the 1967 Tour de France while under the influence of amphetamines and alcohol. “If ten pills will kill you, I will take nine,” he reportedly said, not calculating for conditions of extreme heat and dehydration (7).
The contested opinion of the relative harms of doping substances continued to be expressed. In 1994, Italian physician Dr. Michele Ferrari was quoted in L’Equipe, “EPO is not dangerous, it is the abuse that is. It is as dangerous to drink ten litres of orange juice” (2). Nevertheless erythropoietin (EPO) has been prohibited by the International Olympic Committee (IOC) since 1990.
Some physicians believed that they were operating in a gray zone of acceptable medical practice and in some historical contexts that may have been an argument. For example, in the early days of blood transfusions, there was little concern over the ethical implications as it was seen to be an extension of a training method rather than ingestion of a substance. At that time, the concept of a prohibited method had not been described in antidoping. Although the first study on blood transfusions was in 1945 (1), this method became more investigated widely in the 1970s at which time athletes began to see the performance-enhancing benefits (8). A steadying clamor arose to ban this practice for the same reasons as other substances are banned — for the health of the athletes and the fairness of the competition. This debate was summarized nicely in 1982 by Dr. N. Gledhill, who stated that although in athletes with low hemoglobin levels the use of blood boosting could be rationalized as being therapeutic, it was nevertheless analogous to the use of physiological substances to gain an artificial and unfair increase of performance. Therefore he recommended that the IOC prohibit it (3). Following the use of blood transfusions in the 1984 Los Angeles Olympics, which was publicly acknowledged by the U.S. Cycling team, the IOC Medical Commission made this the first-ever prohibited method (6). An increasing understanding of this and related prohibited methods developed over the years and is now defined in the World Anti-Doping Agency (WADA) Prohibited List under Section M1; Manipulation of Blood and Blood Components (9).
International sporting federations were the first organizations to ban the use of certain doping substances starting in 1928 with the International Amateur Athletics Federation. The IOC, spurred by the death of cyclist Knud Jensen in the 1960 Olympics games, took a leadership role in antidoping and harmonized a prohibited list for Olympic sports. After the Festina cycling scandal of 1998 and with the concerns of potential conflicts of interest, it became evident that there was a need for an independent global antidoping authority. WADA, created in 1999 and funded half by the sports and half by the governments, took over the responsibility from the IOC of maintaining the Prohibited List in 2004. It is published annually and is adopted by more than 600 signatories to the World Anti-Doping Code. This includes all Olympic sports and almost all the international federations. A few professional leagues have their own antidoping programs, but even these have many of the same principles and processes and dialogue with WADA.
Central to antidoping activities is the Prohibited List. This enumeration of prohibited methods and substances is an extension of the rules of sport. Fair play and concern for athlete’s health underlie the reason for the existence of these rules. Once a substance or method is prohibited, it becomes unequivocal and there is no gray zone for the athlete or sport physician. Athletes (and their physicians) may be found to have committed an antidoping rule violation regardless of their intentions according to the principle of strict liability (5). (In exceptional cases, sanctions may be reduced as per the World Anti-Doping Code.)
The claim that carefully monitoring and modifying an athlete’s physiology with prohibited substances or methods are acceptable professional behavior is a specious one (13). Although the risk to particular athletes may be low with some doping substances or methods, their use distorts the notion of a level playing field and sense of fairness that reverberates through all ranks of sport. Moreover, developing athletes may come to believe it is acceptable to engage in risky (and often unmonitored) behaviors to emulate the stars and/or attempt to reach the elite level of their sport.
The argument that elite sport itself is risky and in some cases far more dangerous than the practice of doping also is found wanting. Danger may be an inherent element in some sports, and although sport federations often wrestle with the rules to improve safety, there are not many who believe that allowing doping is desirable. Although there are no large-scale social science studies, most athletes accept and encourage the application of antidoping rules.
There is certainly a need to continue academic debates on what should or should not be prohibited and how best to apply antidoping rules. There are elaborate processes for stakeholders, as well as individuals, to suggest changes to the WADA Prohibited List as well as periodic revisions of the World Anti-Doping Code and Standards. Nevertheless the point remains; once a substance or method is prohibited, there can be no justification for a physician to assist or administer this to an athlete. For legitimate medical conditions, there are provisions where athletes may receive a Therapeutic Use Exemption (TUE), which are clearly defined criteria in the International Standard TUE (14).
Doping undermines not just fair play and health but attacks the values and beauty of sport — the challenges of pushing oneself to the limit, respect for others, teamwork, winning with honor, and the sadly diminishing art of losing with grace.
Sport physicians will always be challenged by difficult ethical/medical decisions beyond those related to doping, and not all issues can be resolved by verifying whether the substance is on the Prohibited List. For example, the use of local anesthetics (not prohibited) in different clinical/sporting situations as well as other return-to-play issues may be quite complex. “Do no harm” is still the ultimate maxim to guide physicians, but this principle must apply to the collective health of the athletes as well as to the individual. Physicians and other responsible leaders need to promote respect for the spirit of sport and the integrity of the rules, which exist to promote fair play and the health of the athletes.
The author declares no conflicts of interest and does not have any financial disclosures.
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