Ethics in Sports Medicine, Information Every Athlete Should Have…

Dr. Sanders and the Sanders Clinic team put the physical well being of the athlete above all else and believe that every athlete should be aware of their medical options and responsible for their long-term health, while pursuing their sport.

A recent article published in the American Journal of Sports Medicine outlines many of the challenges sports medicine doctors and athletes face in the sports arena - information every athlete should have.

Only a portion of this article has been printed, though the article in its entirety can be obtained online at the American Journal of Sports Medicine website.

Click here for access.



Ethics in Sports Medicine
Warren R. Dunn, MD, MPH,*, Michael S. George, MD , Larry Churchill, PhD and Kurt P. Spindler, MD

From the Vanderbilt Sports Medicine Center, Nashville, Tennessee, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, KSF Orthopaedic Center, Houston, Texas, and The Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville

* Address correspondence to:
Warren R. Dunn, MD, MPH, Center for Health Services Research,
1215 21st Ave. South, 6007 MCE, Nashville, TN 37232-8300
(e-mail: warren.dunn@vanderbilt.edu).

Abstract

Physicians have struggled with the medical ramifications of athletic competition since ancient Greece, where rational medicine and organized athletics originated. Historically, the relationship between sport and medicine was adversarial because of conflicts between health and sport. However, modern sports medicine has emerged with the goal of improving performance and preventing injury, and the concept of the "team physician" has become an integral part of athletic culture. With this distinction come unique ethical challenges because the customary ethical norms for most forms of clinical practice, such as confidentiality and patient autonomy, cannot be translated easily into sports medicine. The particular areas of medical ethics that present unique challenges in sports medicine are informed consent, third parties, advertising, confidentiality, drug use, and innovative technology. Unfortunately, there is no widely accepted code of sports medicine ethics that adequately addresses these issues. Key Words: ethics
• team physician
• informed consent
• confidentiality

Introduction

Physicians have struggled with the medical ramifications of athletic competition since ancient Greece, where rational medicine and organized athletics originated. Historically, the relationship between sport and medicine was somewhat adversarial due to rival objectives. The goal of sport is triumph, whereas the goal of medicine is well-being and the pursuit of victory can threaten health. Two physicians commonly referred to as fathers of sports medicine—Galen, who started clinical practice as a physician for gladiators, and Hippocrates—were both critical of the lifestyle of professional athletes. Rational medicine was deeply rooted in the notion of moderation; hence, the immoderate lifestyle of athletes, which involved intense training, excessive diets, and obsession with victory, was viewed as unhealthy and potentially dangerous behavior. In accordance with this disapproval, sports medicine served more of an observational role and, perhaps reluctantly, a restorative role in the "premodern" period, which continued throughout the 19th century.

The evolution of sports medicine in the 20th century brought about significant change; modern sports medicine emerged with the goal of improving athletic performance, accompanied by newfound physician endorsement. Sports medicine physicians are now an integral part of athletic culture, with the distinction of "team physician," and often serve in a variety of roles. Many of these roles are purely voluntary, especially at the high school or recreational level; at the collegiate or professional level, however, team physicians may serve as either consultants or employees of the team, which can be associated with significant prestige and market power. The 21st century transformation of the sports medicine doctor into the team physician creates some unique ethical challenges. The most basic of these challenges is to beneficence, the physicians' traditional obligation to seek the well-being of their patients above other goals, even at some cost or inconvenience to themselves. In other words, the ethics of the classic doctor-patient dyad, in which the physician has a primary obligation to the patient's well-being, is challenged by the emergence of the doctor-patient-team triad, in which the team's priorities can conflict with or even replace those of the patient-athlete. This means that the customary ethical norms for most forms of clinical practice, such as confidentiality and patient autonomy, cannot be translated easily into sports medicine. Furthermore, this more complex triadic relationship creates unique ethical dilemmas in areas such as advertising and third-party influence. Unfortunately, there is no widely accepted code of ethics for sports medicine that adequately addresses these questions. The reader is referred to Mathias, to whom we are intellectually indebted, for a more detailed description of the history of ethics in sports medicine and the irony of sport and health.

Informed Consent and Third-Party Influences

Informed consent attempts to harness an otherwise complex and abstract issue of honoring the free will of others into a practical process that allows patients to choose their treatment with a full understanding of all the options. The purpose of consent is to respect patient autonomy, and to enable them to make decisions that reflect their values. At least one study suggests that this is one of the more difficult aspects of medical ethics for orthopaedic surgeons to grasp. The physician must work as both a patient advocate and an educator to ensure that the patient really understands the risks and benefits of all possible treatment options. All reasonable operative and nonoperative treatment options must be presented to the patient to obtain truly informed consent.

In sports medicine, this consent is threatened further by the fact that different parties in the triad of relationships may have different values and priorities, and therefore might choose different options. The following classic example addresses the issues of balancing medical risk with nonmedical benefit and balancing patient preferences with team priorities. An athlete sustains a potentially repairable meniscus tear that occurs a few weeks before the playoffs. An excision of the tear would permit participation, whereas meniscal repair would preclude participation. If the physician believes that meniscectomy increases the long-term risk of arthritis and that a successful meniscal repair may decrease this risk, then the physician's and the athlete's goals may diverge. The player's present desire to participate in the playoffs may outweigh future consequences to the knee. The physician's belief that excision may lead to arthritis in the future may outweigh the short-term benefit of the playoffs.

More subtle layers of complexity that can complicate medical decision-making can arise because physicians, as mortals, are affected (at least to some degree) by their personal history and can be influenced (consciously or unconsciously) by the psychosocial allure of prestige, gratitude, and admiration. A team physician in this situation may face implicit or explicit pressure from multiple sources, such as management, coaches, trainers, and agents, to improve performance now rather than preserve the long-term health of the athlete. Indeed, it could be argued that in the role of team physician, the physician owes both information and loyalty to team owners and coaches. Should the informed consent process be aimed at the team authority, such as the coach or owner, as well as the patient-athlete? In what ways can the sports medicine physician recognize that the team has a legitimate stake in the outcome and yet remain loyal to the patient? Should the physician ever seek a consensus about treatment among all the parties involved, or only treat this as an issue between physician and patient? We argue that the primary loyalty is still to the patient-athlete, but we recognize the extraordinary pressures to involve others and the special pressure on the athlete to choose in ways that balance team benefit in the short run with personal health in the long run.

The media further complicate matters. Media coverage introduces another distinctive aspect of decision-making in sports medicine because the physician's care comes under an added level of scrutiny that can have either positive or negative influence on the physician's practice and, consequently, his or her career. Unfortunately, public perception of the athlete's outcome may influence the public's perception of the physician's competence. Clearly, partial meniscectomy exposes the physician to less risk; it is an easier procedure to perform and the athlete would likely return to sport quickly, reflecting positively on the surgeon. Meniscal repair is technically more difficult, has a much longer convalescence, and the tear may not heal, which could lead to reoperation. Despite the fact that the success of the procedure depends on many factors other than the integrity of the surgical repair, which are beyond the control of the surgeon, meniscal repair would be season-ending and could lead to a second operation to address the "failure" of the first procedure. Reports of "successful" surgery returning athletes to sport quickly with a backdrop of marveling advances in surgical technology are common. It would be unusual to hear an account of a retired athlete without arthritis told in such heroic fashion. Nonetheless, it is normal for the physician to think about the public perception of the care he or she provides; however, this should in no way factor into the treatment options that are discussed with the athlete.

Patient autonomy is one of the basic tenets of medical ethics and always supplants the physician's partiality. In many respects, this unburdens the physician because it is the athlete's right to determine what is in his or her best interest. However, an athlete faces some unique challenges when making informed decisions regarding medical treatment. Athletes must tackle external pressure from coaches, teammates, and agents as well as internal drives and goals that may influence their treatment decisions. The American Medical Association (AMA) Code of Medical Ethics has a subsection on sports medicine that states "Physicians should assist athletes to make informed decisions about their participation in amateur and professional contact sports which entail risks of bodily injury." The International Federation of Sports Medicine (FIMS) offers position statements as guidelines in areas where clarity is lacking or controversy exists, and their code of ethics states, "Never impose your authority in a way that impinges on the individual right of the athlete to make his/her own decisions" and "A basic ethical principle in health care is that of respect for autonomy. An essential component of autonomy is knowledge. Failure to obtain informed consent is to undermine the athlete's autonomy."

At first glance, the process of informed consent can seem rather straightforward; however, depending on how much emphasis is placed on the athlete's comprehension and knowledge of the issue, a first-glance understanding may be far too simplistic. It can be a struggle at times to preserve autonomy when considering the external pressures on the athlete such as financial gain, coaching, and teammate expectations, and particularly in game situations, when the player's desire to return may overwhelm common sense. It has been argued that in these situations, education of the athlete and informed consent are meaningless. Despite the convolution of game situations, return to sport decisions are somewhat simplified when constrained by the physician's assessment of the risk of reinjury, or the risk placed on other athletes (for example, blood-borne infections). The subsection on sports medicine from the AMA Code of Medical Ethics states, "The professional responsibility of the physician who serves in a medical capacity at an athletic contest or sporting event is to protect the health and safety of the contestants. The desire of spectators, promoters of the event or even the injured athlete that he or she should not be removed from the contest should not be controlling. The physician's judgment should be governed only by medical considerations."The FIMS code of ethics regarding return to play states, "It is the responsibility of the sports medicine physician to determine whether the injured athletes should continue training or participate in competition. The outcome of the competition or the coaches should not influence the decision, but solely the possible risks and consequences to the health of the athlete."

Sports medicine physicians may feel pressured by coaches, agents, teammates, and other third parties regarding certain treatment recommendations. The orthopaedic surgeon should not allow outside pressure to obviate meeting the moral and ethical obligations of the medical profession. The physician has an obligation to protect the athlete from potential dangers and to ensure the patient's autonomy. According to the Committee on Ethics of the American Academy of Orthopaedic Surgeons (AAOS), such conflicts of interest must be resolved in the best interest of the patient (athlete); otherwise, the orthopaedic surgeon must withdraw from the care of the patient. We concur with this priority.

Advertising

Medical advertising, including sports team affiliations, raises particularly difficult ethical questions in sports medicine. Given the tremendous popularity, prestige, and revenue associated with college and professional sports, serving as team physician at this level has marketing advantages. Medical advertising was considered unprofessional and illegal in the United States until about 25 years ago when these regulations were lifted. Capozzi and Rhodes raise important questions of whether there are ethical reasons for physicians to avoid advertising and whether there are certain moral boundaries that should not be crossed. Of particular concern in sports medicine are ethical concerns surrounding relationships between team physicians and professional sports teams that are contingent upon ongoing corporate sponsorship. For instance, the reported annual cost for being Major League Baseball team physicians for New York's Yankees and Mets was $1.5 million per team. As many as 7 teams in the National Football League and 12 teams in the National Basketball Association have a marketing agreement with their current team physician that, on occasion, has supplanted a previous physician who was unwilling to engage in a bidding war. Teams in the National Football League have placed the team physician position up for bid; however, this practice does not appear to be widely accepted.

Confidentiality

The relationships between the sports medicine physician, the athlete, and the team create special ethical issues regarding patient confidentiality. The Committee on Ethics of the AAOS states that the orthopaedic surgeon must respect the rights of patients and safeguard patient confidences within the constraints of the law.

Drugs in Sports

Athletes may rely on sports medicine physicians for guidance on performance-enhancing substances. The involvement of sports physicians with the "doping" of athletes dates back more than 100 years. Despite the fact that it is unethical to encourage the use of banned substances, there have been well-documented cases of physician involvement with the doping of athletes.

Emerging Technology

Sports medicine is a field of particularly rapid technological advancement. Innovations in operative techniques, medications, and rehabilitation regimens create an environment in which evidence-based medicine lags behind the most recent developments.

Conclusion

Many ethical issues are unique to sports medicine because of the unusual clinical environment of caring for athletes within the context of a team whose primary goal is to win. The tension that can arise when trying to balance medical means with nonmedical ends can be challenging. In fact, the medical treatment of athletes may fall under special legal and ethical guidelines. The sports medicine physician must carefully examine these continually changing ethical standards and direct the care of the athlete accordingly. Ongoing awareness of national organization recommendations and legal changes and the policies and debates of sports medicine governing bodies is important to provide the best, most ethical care for the athlete.

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