We read with interest the article by Browne et al. (3) in which they state their intention to discuss the ethics of blood testing in sport. The paper begins with an assertion of the convergence of interest by athletes, governments, sports organizations, and the general public in having drug-free sport. Not discussed is that the groups listed adopted the principle of drug-free sport several decades ago, but have been unsuccessful in ensuring its practice. There is relevance to the divergence between principle and practice.
Television and Sponsors
Left unmentioned in the article is a group without which there would be no television sport. Television networks and corporate sponsors now pay staggering sums to harness the marketing power of sport, especially the Olympics, which they have found to be the single greatest marketing vehicle of the century. With the growth of sport has come the increasingly vested but diverse interest of governments, national organizing bodies, corporate sponsors, and athletes. Some nations attach enormous prestige to the successful participation of their athletes in Olympic competition. Organizing bodies and athletes achieve enormous wealth and positions of stature through successful participation. Considering what is at stake, it is hardly surprising that these disparate groups converge on the principle of drug-free sport because that principle contains its cherished and mightily valuable essence. But current testing cannot detect all doping methods, leaving cynics to suggest that present antidoping testing serves primarily to provide a comforting public image of fair play.
Athletes’ Safety First
Sports physicians and scientists have observed for decades the increasing sophistication attached to enhancing athletic performance. Many advances in athletics have proceeded through a better understanding of training methods, and of other “legitimate” factors affecting performance. Other advances have accrued through the “illegitimate” use of drugs and, now increasingly, the supplementation of human physiologic substances (2,4,5). It is true that discussions of doping suffer from the inability to document completely either the scope or the effects of all doping methods. However, experience tells us that doping tests have always been years to decades behind the dopers. In part, the sports medicine community seems to underestimate the continuous development and use of new methods. Equally, there is a clear tardiness in the reaction of organizing bodies to this ongoing challenge. These issues are further complicated when discussing things like asthma medications, which have legitimate, as well as potentially illegitimate uses. Clearly, when our focus is legitimacy, establishing parameters is difficult. But it is safety, not legitimacy, which is every physician’s highest duty. This ethic dictates that we work to ensure that athletic endeavor is conducted as safely as our existing knowledge permits.
Are We Ensuring Safety at Present?
Documented hemoglobin levels in some athletes (up to 200 g·L−1) have reached dangerous proportions (7). Clusters of deaths in young, previously healthy elite male cyclists have raised concerns that exogenous utilization of rEPO may have been involved (6). Serious complications have been associated with blood transfusions reported in the print media (newspaper reports of a lawsuit filed against a physician for spreading hepatitis C to athletes from blood transfusions, and an athlete requiring dialysis in another widely known case unable to be officially confirmed. Testing for heterologous blood is possible, but testing for rEPO or autologous transfusion is problematic, to say the least (8). And it is likely that testing for other yet to be devised physiologic additives will be equally difficult. Because of this, Browne et al. conclude that “in their present state of development, blood tests should not be implemented” because they would “only have the effect of causing a shift to autologous blood or use of rEPO and that [ellipsis] the advantage of encouraging dopers to adopt a safer method of cheating would not seem to be worth the cost.” Here it is vital to ask, “What is the price of an athlete’s life, when already existing methods would preserve that life?”
Safety Procedures Have Already Been Successfully Tested
In 1988 the International Ski Federation (FIS) implemented a rule allowing heterologous blood testing and expanded the scope of testing before the 1997 season when they adopted an upper acceptable limit for hemoglobin. A review of the effect is enlightening. In 1989, the first Skiing World Championships permitting blood tests, but before the widespread use of rEPO became possible, mean values of hemoglobin were about 9% below the general population reference values for both male (reference 156 g·L−1) and female (reference 144 g·L−1) athletes (7). This is concordant with the plasma hemodilution well documented in endurance athletic training and explained in textbooks of exercise physiology (1). But by 1996, the last year before implementation of the “upper limit” rule, maximal values had risen to between 195 and 200 g·L−1 for both female and male athletes—values that were 25–35%above the reference populations. In 1997, one year into the rule implementation, the highest measured hemoglobin values dropped remarkably in men (to 180 g·L−1) and in women (to 155 g·L−1) (7). Perhaps equally important, by establishing the upper limit rule, discussions of the cause for “too high” values became moot. It is possible, as Browne et al. wrote, that testing for heterologous blood could prompt some shift to the use of rEPO or autologous transfusions (3). Such a shift is not easy. The high cost of rEPO is a limiting factor, and restoring autologous blood requires the collaboration of sophisticated laboratories. Even if such a shift occurred, the “upper limit rule” would eliminate or mitigate health concerns, especially when compared to the danger of heterologous transfusions.
Athletes Support Blood Tests
When the testing of urine samples was first proposed, there was a predictable outcry from indignant athletes and others about the embarrassment and invasiveness of this unseemly procedure. Interestingly, when the FIS first introduced antidoping rules to include blood testing, the athletes’ attitudes varied. However, after the first year, athletes strongly supported blood testing.
Discussions of legitimacy and fairness will no doubt proceed. Sport physicians and scientists contribute to these discussions most effectively by continuing to study the science of athletic performance. But the safety of those under our care demands that we ask, and ask continuously: “Can the safety of athletes competing today be assured under present testing methods?” If the answer is no, and we believe it is, we must recommend methods that do ensure safe competition. The challenge may be Olympian, but significant steps for athlete safety would be: 1) install increased, random testing for the most dangerous doping substances; 2) use the most ideal human sample in testing: blood, urine, hair, saliva, or other; and 3) apply upper physiologic limit rules for doping methods that cannot be controlled or for which there are no reliable tests.
Tapio Videman M.D., Ph.D.
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