Introduction

‘Bloodgate’ scandal

On 11 April 2009, in a Leinster versus Harlequins match in the quarter final of the European Rugby Cup (ERC), the Harlequin’s team used a fake blood capsule to secure the blood substitution of one of their players in order that a noted kicker, who had previously been substituted, could retake the field for a last-minute drop-goal attempt. As the drama unfolded, the opposing team became suspicious and made an official complaint. Following the game, the ERC launched an investigation. An independent appeal committee found the club, the player, the director of rugby and the physiotherapist all ‘guilty of misconduct.’1 Sanctions were imposed on the club, and each of the individuals involved received bans of varying lengths from the sport. The debacle became known as the ‘Bloodgate’ scandal.

As the hearing unravelled, allegations were also brought against the team doctor, who was alleged to have reluctantly cut the inside of the player’s lip in the medical room in order to fabricate a laceration, which the player claimed had been sustained during the game. The independent appeals committee could not pass judgement on the alleged role of the doctor in this case, due to issues concerning jurisdiction. The case was passed to the General Medical Council, and the doctor has since been suspended, pending investigations.2

This case serves as a salutary reminder of the intense pressure on sports-medicine doctors and draws attention to the peer pressure and bullying which can exist within a team environment. These events also highlight the ethical dilemmas that are unique to sports medicine because of the unusual clinical environment of caring for players within the context of a team whose primary objective is to win. Indeed, many of these ethical issues arise because the traditional relationship between doctor and patient is distorted or absent. The emergence of a doctor–patient–team triad has created a scenario in which the team’s priority can conflict with or even replace the primary obligation of the team doctor, which is to uphold the welfare of the player notwithstanding results or the success of the team. 3 As a result, the ethical norms that provide guidelines for most forms of clinical practice, such as patient autonomy and confidentiality, are not easily translated in the field of sports medicine.4

The team doctor, as an individual, is not infallible, and medical decisions may be influenced by the appeal of status, admiration and gratitude.5 Such behaviour is self-gratifying, and it should be remembered that passion must not be allowed to compromise judgement. In this article, a number of ethical principles and how they relate to sports medicine are discussed. To conclude, a list of guidelines has been drawn up to offer some support to doctors facing an ethical quandary.

Sport and the history of ethics in sports medicine

Sport has always played an integral role in society and naturally serves as a vehicle for education, health, leadership and fair play. Fairness is one of the core principles of sport and can be a metaphor for everyday behaviour in life and communities. Whether the principle is adhered to depends on how the sport is managed, taught and practised. Sport has clearly become a global enterprise as well as a recreation for billions.6 In the early Olympic Games, victors were crowned with wreaths from a sacred olive tree and marched around the grove to the accompaniment of a flute to bask in the admiration of the crowd. Nowadays, athletes can demand lucrative sponsorship contracts and appearance fees, and within moments of their triumph, their faces are found plastered on bill-boards and advertisements around the world endorsing some product or other.

International sport dates back to the 19th century, and the commercial exploitation of sport is even older than that. What is new is the degree of commercialisation and its spread to the emerging markets.6 As a result, the value of victory in monetary terms has never been greater. The pressure on athletes to win has increased considerably and so too have the demands on sports-medicine doctors to facilitate these victories through fair means or foul.

The adversarial relationship between sporting performance and patient welfare is not a new phenomenon and stretches back to early Greek and Roman civilisation. Aelius Galenus, one of the forefathers of sports medicine, served as a physician to the gladiators in Pergamum in AD 157. In this capacity, he learnt the importance of diet, fitness, hygiene and preventive measures, as well as living anatomy and the treatment of fractures and severe trauma. His fastidious attention to gladiators’ wounds resulted in a significant reduction in the mortality, when compared with his predecessor.7 In spite of this, he argued vehemently against the immoderate lifestyle of athletes and their obsession with victory, which he believed was unhealthy and potentially dangerous behaviour.4 He wrote a small work called ‘That the Best Physician is also a Philosopher,’ and he saw himself as being both.8 His theories dominated and influenced Western medical science for well over a millennium.

Application of ethical principles to sports medicine

There are a number of ethical approaches to the area of medicine and biological endeavours, and perhaps the most useful is the ‘principles’ approach. This approach is based on the four pillars of autonomy, beneficence, non-maleficence and justice. An understanding of these principles is useful in the field of sports medicine, particularly, when dealing with such an array of complex and challenging ethical dilemmas. These principles, however, do not provide an answer to every ethical conundrum, but provide guidelines and promote contemplation of the correct course of action.5 And of course, in individual cases, the principles may compete against each other.

Autonomy

‘There’s no “I” in team’

This cliché is a frequent exhortation in prematch team talks. It advocates neutralising individualism which might detract from the team effort. While there’s no ‘I’ in team, there is an ‘a,’ and ‘a’ stands for autonomy. Respect for a patient’s autonomy is considered a fundamental ethical principle. Autonomy refers to the capacity of a rational individual to make an informed, uncoerced decision. This belief forms the central premise of the concept of informed consent. Included in this concept also is the principle of confidentiality. The player must give informed consent for confidential information to be divulged to the management team. This area is of particular relevance to sports-medicine doctors when dealing with an injured player who is faced with a treatment choice. The sports doctor must work as a patient advocate to ensure the player understands the risks and benefits of all possible treatment options.

The com mon cl i n ical vignet te used to i l lustrate t h is di lem ma is the young, professional soccer player who tears his medial meniscus midway through the season. The tear is in a region that could be repaired. The player is faced with two choices; he can undergo an arthroscopic meniscectomy and return to play relatively quickly or undergo a meniscal repair and be out for the rest of the season. The result of each procedure may have short-term and long-term consequences. In the short term, the player who chooses to have the meniscectomy may return to play more quickly, whereas the player who opts for a meniscal repair faces a longer period of rehabilitation and will miss more game time. In the long term, the player who opts for a meniscectomy substantially increases his chances of developing degenerative arthritis in his knee in the future, whereas the player who chooses a meniscal repair has the chance of pain free function in the longer term and probable avoidance of articular degeneration.9 10

Informed consent in clinical sports medicine takes on a greater level of importance than in normal clinical circumstance because of all the extra pressures and influences. The ramifications of the player’s decision extend further than his own well-being and have an effect on his team and coach. The consent process may be threatened by the fact that different parties in the triad of relationships may have different values and priorities, and therefore might choose different options.4

This case raises a number of important questions: should informed consent be aimed at the team authority, such as the coach or owner? In what ways can the sports-medicine doctor recognise that the team has a legitimate stake in the outcome and yet remain loyal to the player? Should the physician seek consensus with all the parties involved?5 Although these are all very relevant and sensible questions, the answer is simple. The primary obligation of the sports-medicine doctor is to the patient. Patient autonomy always supplants the doctor’s partiality.4 Although the paymaster in professional sport is the team, sports-medicine doctors cannot abdicate their responsibility to the individual player. The burden of obligation to the team should be removed from the team doctor, as it is the player’s right to determine what is in their best interest. However, as a patient advocate, the doctor must be cognisant of the fact that the player is often under external pressure from teammates, coaches and agents as well as internal drives and goals that may influence their treatment decisions.5 In fact, there is a responsibility on the team doctor to tease out the extent of influence on a player to make a certain decision in the process of informed consent. To further simplify the informed consent process, as it applies to the conventional doctor–patient relationship, Beauchamp divided it into three categories with seven elements (table 1).11 Application of this structured framework removes much of the ambiguity when faced with a complex ethical challenge or where controversy exists.

The International Federation of Sports Medicine guidelines also prove useful in such a scenario: ‘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 healthcare 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.’12

Beneficence

The second principle, beneficence, holds that healthcare professionals should aim to ‘do good’ and promote the interest of their patients. It is one of the core values of healthcare ethics and is important in elucidating the nature and goals of medicine as a social practice. Edmund Pelligrino argues that beneficence is the only fundamental principle of medical ethics, that healing should be the sole purpose of medicine and that endeavours like cosmetic surgery and contraception fall beyond its remit.13

The very nature of sport is that it can occasion harm and involves various degrees of risk, and thus raises the question of how of a doctor can stand idly by and watch this happen without intervening. This brings us back to the adversarial relationship between participation in sport and personal welfare. Players participate in sport of their own volition and need to be aware of the inherent risks they face. The principal motivation of the sports-medicine doctor is one of beneficence, and the primary aim is to ‘do good’ for the patient by treating any injuries that may occur and prevent any further harm.

Non-maleficence: primum non nocere (first, do no harm)

The third principle requires that doctors should do no harm. One can find conflicts between beneficence and non-maleficence in almost any clinical situation. The dichotomy between the two principles is the foundation for ‘risk/benefit’ analysis. The principle of beneficence and non-maleficence should be considered together and aim at producing a net benefit over harm, in keeping with traditional Hippocratic moral obligation.14 The obligation to provide net benefit to patients requires that there is a clear distinction between risk and probability when an assessment of harm and benefit is made.

Justice

The fourth principle is justice. Healthcare professionals should act fairly when the interests of different individuals or groups are in competition. The obligations of justice may be divided into three categories: fair distribution of scant resources (distributive justice), respect for people’s rights (rights based justice) and respect for moral acceptable laws (legal justice).14 Distributive justice is relevant to sports medicine in the context of limited resources. If resources are scarce, they should be distributed equally based on need and not on the basis of star talent.

Concerning rights-based justice, the team doctor should respect each individual’s right to treatment, should they require it. Failure to act because of personal bias or contrary beliefs would be unjust. Finally, the principle of legal justice holds that the team doctor must not willfully cause bodily harm to a player or do anything in contravention of morally acceptable laws.