Through a convergence of interest on the part of athletes, sport organizations, governments, and the general public, the world of amateur sport has collectively adopted the principle of drug-free sport. As a consequence, doping control policies and programs have been developed to detect and deter the use of performance-enhancing substances and practices (3,4). Such approaches necessarily involve the testing of athletes; drug testing is crucial to the promotion of drug-free sport. Given the enormous rewards that can be associated with being a top-flight athlete and the numerous performance-enhancing substances and techniques that may help an athlete to become one, an operating presumption of this paper must be that doping practices can only be held in check by the application of effective testing procedures.
Urine is the current matrix of choice. But urine testing will not detect all effective doping methods. Blood doping, for instance, cannot currently be detected through an analysis of urine samples (4). This practice can artificially enhance an athlete's level of hemoglobin (Hb)-and aerobic performance-via the administration of blood products or hormones designed to accelerate blood production. Blood testing would conceivably facilitate the detection of this doping technique and might aid in the detection of others. In this respect the question emerges: should mandatory blood testing become a part of the doping control strategies of the international sport community? This is the fundamental question we address in our paper. The issue is the subject of considerable debate within the amateur sport community, and we find a full spectrum of responses to it.
This article deals exclusively with the issue of blood testing as it pertains to adult competent and consenting competitors. The taking of blood from minors raises a number of complex legal and ethical issues that merit in-depth discussion and are beyond the scope of this article. Even if blood testing were to be considered ethical for adult athletes, one cannot simply apply an adult situation to minors. We, however, will argue that routine mandatory blood testing protocols should not be introduced at this time.
Several national and international sport organizations have either adopted blood testing for doping control purposes or have called for the introduction of blood testing as a necessary addition to the existing urine testing programs. Blood sampling and subsequent analyses were conducted by the International Ski Federation, for example, at the 1989 Cross-Country Ski World Championships and the 1994 Lillehammer Olympics (it should be noted that such testing was not conducted by the International Olympic Committee), and by the International Amateur Athletic Federation at a number of Grand Prix meets in Europe in 1993 and 1994 (1). Other organizations in addition to the International Olympic Committee, and including the Canadian Centre for Ethics in Sport, have rejected blood testing as an element of standard doping control protocols. They are not prepared to adopt blood testing until the scientific, ethical, and legal issues are fully explored and resolved in favor of proceeding with the use of blood samples for doping control purposes. (Some sport organizations now conduct blood tests for the express purpose of identifying competitors whose levels of Hb or hematocrit (Hct) exceed certain arbitrarily defined levels. These individuals are withdrawn from competition on the basis of a concern for their health and safety. Such approaches are not the focus of this discussion.)
ADVANTAGES AND DISADVANTAGES OF BLOOD TESTING
It is natural to approach this question by listing and then weighing the advantages against the disadvantages. Both lists are impressive.
Advantages of Using Blood Matrix
1. The procedure for collecting a sample is relatively rapid.
2. It is a minimal requirement for the detection of homologous (nonautologous) blood doping.
3. It provides best matrix to detect autologous blood doping.
4. Blood may be useful to confirm the presence of exogenous testosterone detected in an athlete's urine sample (although urine provides much greater concentrations by which to detect testosterone doping).
5. Blood plasma provides advantages in identifying the presence of certain peptide hormones.
6. There are population-based reference ranges for clinical hematological tests.
7. It reduces the possibility of the manipulation of samples.
Disadvantages of Using Blood Matrix
1. It is an invasive sampling procedure requiring a specially trained person (phlebotomist).
2. Blood analyses require the handling of blood samples by collection officers and laboratory personnel. Such manipulations expose individuals to the risk of infection by bloodborne viruses and thus are more hazardous than analyses involving urine.
3. It requires preparation and the refrigerated transportation of the sample.
4. Reference ranges for peptide hormones and their secondary factors may be unknown.
5. The concentrations of certain compounds, in particular anabolic steroids, are much greater in urine than in blood.
6. Autologous blood doping or the administration of erythropoietin (EPO) cannot be reliably detected.
7. Hematological parameters may be altered by altitude and/or by hard training.
8. Concentration of drugs or medications with low molecular weights are lower than in urine by a factor of 100-1000.
9. There are compelling ethical and legal questions: Blood testing is invasive, and there is a significant potential for the invasion of privacy (e.g., other health problems will be detected, and unauthorized testing may be done for other conditions such as HIV).
10. Additional complications arising out of blood testing of minors, who make up a sizable portion of competitors.
It must be noted that significant reservations exist in the scientific community about the validity, accuracy, and reproducibility of doping-control analyses conducted using blood as a matrix (5). Those legitimate concerns are rightfully the focus of other discussions. There is, however, evidence of agreement on these advantages and disadvantages. There is further agreement that there should be blood testing if, and only if, the advantages outweigh the disadvantages. The problem is: How can this weighing be done? How can these incommensurable factors be balanced against one another so that we can say which side is weightier? In what follows we will first propose a list of factors relevant to deciding the issue and then make a recommendation about blood testing by applying those factors to the facts as we know them.
Weighing the Advantages and Disadvantages of Blood Testing: the Fair Competitor and Costs
Whether the advantages of blood testing outweigh the disadvantages or, what is the same thing, whether blood testing should take place, depends on two factors. The first is what the Fair Competitor wants; the second is the cost of what the Fair Competitor wants. We will take these in order. By the Fair Competitor, we mean one who wants to win but who does not want to use prohibited substances or techniques to do so and would rather compete using fair and ethical means. The Fair Competitor is thus to be contrasted to the Unfair Competitor, who wants to win and is prepared to use prohibited performance-enhancing methods. The Fair Competitor plays the same role in our account as "the reasonable person" plays in the law, namely, to provide a standard by which operational significance is provided to an otherwise hard-to-apply concept. In law, what is reasonable is settled by asking what the reasonable person would decide in those circumstances. In our model, the preferences of a postulated Fair Competitor determine what testing programs are appropriate. If the Fair Competitor feels that blood testing must be conducted to detect the use of certain banned substances, then that is a powerful reason for having such testing. For then we have evidence that such testing would be to the disadvantage of the Unfair Competitor (assumed for this discussion to be one likely to use banned practices to accentuate performance) and thus will help level the playing field for the Fair Competitor.
What kind of testing would the Fair Competitor want? This will be a function of six considerations:
1. The advantage gained from using the prohibited substances or techniques. Is this advantage negligible? Or is the advantage so significant that it is extremely difficult for the Fair Competitor to compete with users?
2. The incidence of the use of the prohibited substances or techniques among athletes. Is the incidence 1 in 3 athletes, 1 in 100, 1 in 10,000 or less?
3. The number of "false negatives" the specific testing procedure produces. (A false negative occurs when a test fails to identify a banned substance when it is present.) False negatives may be a result of the intrinsic unreliability of the test procedure or may occur as a consequence of the manipulation or misidentification of samples. The Fair Competitor may be indifferent as to why false negatives are produced but will be keenly interested in whether athletes can use performance-enhancing substances and still pass the test and, if so, how many can escape detection.
4. The number of "false positives" the specific testing procedure produces. (A false positive occurs when a test mistakenly identifies the presence of a banned substance when it is not present.) Like false negatives, false positives may be the result of the intrinsic unreliability of the tests or the manipulation or misidentification of samples. Again, the Fair Competitor may not care about the cause of false positives but will be acutely sensitive to the likelihood that athletes who do not cheat can fail the test and thus be falsely accused of cheating.
5. Whether Unfair Competitors can adopt other methods of doping that will be effective yet remain undetectable by current testing technologies.
6. The risk to the Fair Competitor that he or she will suffer unfair or unwanted consequences as a result of participating in the testing process (e.g., the risk of public or semipublic revelation that he or she is a carrier of Hepatitis B or C, HIV, or other communicable disease; the potential for the blood sample to be frozen, stored, and used for other purposes without the express permission of the athlete).
It is easy to assume what the Fair Competitor would want in some circumstances. If athletes derive a significant advantage from using prohibited substances or techniques, if the incidence of their use is high, if blood testing provides no or very few false negatives and (more importantly) no false positives, if there are no easily accessible alternative ways of doping that are undetectable by blood testing to gain that advantage, and if there are no or minimal "risks" to the Fair Competitor who participates in the blood testing procedure, then the Fair Competitor will want blood testing to be conducted. That would significantly level the playing field, and hence the Fair Competitor would predictably regard the invasiveness of the procedure and its potential to compromise privacy or cause personal harm as acceptable prices to be paid.
At the other extreme, if there is no significant advantage to be derived from the banned practice detectable by blood testing, if the incidence of the banned practices is rare, and if blood testing produces many false negatives or any false positives, or if participation in the testing process exposes the Fair Competitor to a high probability of personal risk or harm, then he or she will not want blood testing. No Fair Competitor would reasonably regard the possibility of an unjustified disqualification occurring as a consequence of a false positive test result, or a significant compromise of privacy, worth a minimal leveling of the playing field. Similarly, if blood testing effectively closes down one method of cheating, but dopers can with ease move to another effective but undetectable technique, the Fair Competitor could not be expected to be enthusiastic about the testing. Blood testing will then have all its attendant disutilities without possessing any significant advantages.
Even if the preferences of the Fair Competitor are easy to predict in some circumstances, there are others in which they are not. To take only perhaps the most challenging one: suppose that doping is so effective that it is difficult to compete without doping. Suppose also that doping is very common, can be effectively curtailed only by blood testing, but that blood testing yields a small but significant number of false positives. Would the Fair Competitor want blood testing under these conditions?
Some Fair Competitors may say that the stigma of disqualification is so great that there should not be any blood testing as long as there is any possibility of a false positive. Others may take the lead from criminal law and say that blood testing should proceed if it will detect doping beyond a reasonable doubt. Still others may adopt the civil law standard and say that blood testing should take place if it will detect doping on a balance of probabilities. Fortunately we do not have to settle this question to come to a decision in the blood testing issue before us. That issue (we will argue) can be resolved by a much more intuitively obvious balancing of the six factors. However, technology and attitudes relating to doping may change so that this question will have to be faced in the future, and we flag it for that reason.
The second factor on which the issue of blood testing turns is the cost of the tests. The fact that the Fair Competitor desires a particular testing procedure is a powerful, but not decisive, reason for its implementation. For the testing that will be maximally advantageous to the Fair Competitor and maximally disadvantageous to the Unfair Competitor may be prohibitively expensive. In this respect it may be seen to be disadvantageous to the sport system. Fairness is an important value, but it is not the only one that guides the conduct of sport in the same way that safety is not the only value that guides the activities of NASA or justice the only value that guides the conduct of society. How much fairness we can afford will be a function of what we have to give up if we apply a given testing procedure of known cost, and the extent to which the Fair Competitor is disadvantaged in competition if we do not. We are thus brought face to face with a standard problem in distributive justice. Unfortunately, there is no standard answer to this dilemma. But the absence of a well-tested, generally accepted theory of justice need not be crippling in practice. For once the cost-benefit ledger has been determined, the answer may become obvious on any account. This, as we will suggest in the next section, appears to be so in the case of blood testing.
We now turn to our three recommendations.
Recommendation 1: That Blood Testing Not Be Conducted as Part of the Protocols for Doping Control Procedures in Sport.
There are four reasons for the development of this recommendation.
First, the only significant performance-enhancing doping method which is, in our view, uniquely detectable by blood testing is homologous blood infusion (the administration of another's blood or blood products). But to introduce blood testing to detect this practice would likely only have the effect of causing a shift to autologous blood infusion (the administration of an individual's own blood, or blood products, previously withdrawn and stored) or the administration of EPO, both of which are not reliably detectable. This will reduce the health risks associated with homologous blood doping to which dopers are exposed but do nothing to level the playing field. The Fair Competitor must therefore be indifferent to testing for this reason, and the advantage of encouraging dopers to adopt a safer method of cheating would not seem to be worth the cost.
The second reason relates to the other two putative advantages of blood testing to detect doping. (i) Blood testing will detect certain substances more easily and accurately than will urine testing, and (ii) the possibility of the manipulation of samples is reduced. The Fair Competitor must be attracted to blood testing for both these reasons. They mean that more dopers will be detected and hence there will be an increased deterrent effect.
We must not, however, overestimate the extent to which all this will level the playing field. It is not clear that even the most enthusiastic Fair Competitor will regard the leveling effect of (i) and (ii) significant enough to justify the inconvenience, physical invasiveness, and compromise of privacy that blood testing places on guilty and innocent alike. It may be that the Fair Competitor would prefer to let that amount of doping go undetected and unpunished rather than be subject to those burdens.
Even if on balance the Fair Competitor thinks blood testing is best, there is still the question of cost to consider. Blood testing may save some money, time, and effort because it may eliminate some frivolous and vexatious appeals. But this saving will hardly offset the significant amounts of money, time, and effort needed to develop and implement a program of blood testing, and it is highly problematic that (whatever the Fair Competitor may think) these costs will be worth the limited advantages of the program.
Third, blood testing as a component of research activities designed to assist in the development of better techniques for the detection of doping, e.g., to determine normal reference ranges, should be able to be equally well done by voluntary testing. Given that the Fair Competitor will want optimal detection methods, there should be no shortage of volunteers, and other things being equal, voluntary programs are always preferable to mandatory ones.
Recommendation 2: A Vigorous Educational Program to Articulate and Inculcate the Advantages of Drug-Free Sport Should Go Forward.
This will both reduce the incidence of doping and secure support for testing programs.
Recommendation 3: Scientific Research Designed to Facilitate the Development of Valid, Reliable Methods of Detection of Prohibited Performance-Enhancing Substances and Techniques Should Continue and Be Appropriately Supported.
Given the unfortunate realities of competition, as long as effective testing for certain substances is not in place, there can be no guarantee that competition will be fair; and in the absence of fair competition, the benefits of sport will not be completely realized. All in sport have an obligation to develop, to the extent possible, a sporting environment in which the pursuit of excellence by fair and ethical means is seen, particularly by athletes, as the only socially acceptable mode of competition. The application of reliable, state-of-the-art, and proven testing technologies coupled with expert interpretation of test results and open transparent processes of reporting such deliberations is a necessary component of such an approach.
This discussion has demonstrated, we hope, an approach to the consideration of an important issue in doping control. The concept of the Fair Competitor provides us with an instrument that can be applied in such discussions. Such an application has led us to the conclusion that the use of blood testing procedures to detect certain doping practices is not yet justifiable in sport.
© 1999 Lippincott Williams & Wilkins, Inc.