A code of ethics for sports physicians needs to be clear, appropriate and practically useful to clinicians in everyday clinical circumstances and for situations that may be difficult or contentious. For a code of ethics to be so apposite requires that it have some basis in the ethical concerns of clinicians. This article reflects on the recent experience of rewriting the code of ethics for the Australasian College of Sports Physicians, describing the findings from the research, the processes and challenges that arose, and providing suggestions for other code writers in this field.
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The code of ethics for the Australasian College of Sports Physicians (ACSP) was recently rewritten based on research into the ethical concerns of sports doctors and physicians in New Zealand.i The research carried out by the author of this paper generated a number of findings. Further appraisal of the existing code in the light of these findings led to concerns about its adequacy. The previous ACSP code had not been updated in 25 years, and had gaps in topic areas and errors within it that made it potentially confusing. Once alerted to these major concerns the ACSP set up a code development group (primarily members of the ACSP Ethics Committee) to oversee the writing of a new code from scratch. Writing a new code required decisions about process, content and implementation.
This paper discusses the processes and principles in developing a new code of ethics as well as some practical issues important to the successful adoption, implementation and use of a code. The article then provides some lessons to others attempting to provide ethical guidance in sport in other settings and jurisdictions.
Any code written for a specialist group such as the ACSP code must acknowledge the context of its governance. In Australasia, as in other regions, there are a number of ethical codes and legislation that doctors working in sport will be subject to. By virtue of their medical registration, sports medical practitioners are required to comply with the code written for all registered medical practitioners in their local jurisdiction. They may also be subject to speciality codes written specifically for physicians who have received further training in sports medicine, and there may be consensus guidelines written on various topics, such as those of the American Orthopaedic Society for Sports Medicine or the American Medical Society for Sports Medicine. There are also international codes such as the World Medical Association Declaration on Principles of Health Care for Sports Medicine. The ACSP code of ethics was written for a group of doctors who have completed their specialist training in sports medicine and sits within a context of other codes and legislation.
A code of ethics with a foundation in evidence
To ensure that the new code met the needs of physicians and covered appropriate areas requires that it be informed by evidence.1 The author had previously carried out qualitative research with 16 sports medical practitioners working with elite athletes and teams in New Zealand.ii Sports medical practitioners were asked to identify and discuss a range of ethical concerns they experienced in their work. As well as qualitative research, an extensive literature search was undertaken to ascertain the ethical concerns already described for themes and suggested guidance.2 3 4 5 6 Many experienced sports physicians had written articles reflecting on their careers, and these were also scrutinised for ethical concerns.7 8 9 10 11 12 13
There were three key findings from this research that will be explored in more detail below. (1) Sports medical practitioners work within a complex and pressured environment that has the potential to compromise patient welfare and limit a doctor’s ability to provide quality care or demand better conditions for their patients. (2) Sports medical practitioners may have multiple obligations to others including individual patients and employers. At times these responsibilities may conflict when meeting one obligation will result in neglecting others. (3) Sports medical practitioners vary widely in their perceptions in two particular aspects of practice.
The complex environment of elite sport
Sports medicine at the elite level occurs within a complex setting that may include the pressure of large amounts of money riding on results, together with a high level of media attention into the wellbeing of athletes. Those two elements are further intertwined as media attention can attract sponsorship and advertising and even greater medical services if the athlete/team is successful. Coaches, team management and sponsors can seek to transfer this financial pressure to sports doctors. Although some coaches respect the doctor’s knowledge and experience, this was not the case among all medical practitioners interviewed. Some sports medical practitioners have fought difficult battles with coaches, sponsors and governing bodies, sometimes dealing with entrenched views about the nature of injury and rehabilitation. Some participants described situations in which their decisions were overridden, disrespected and in which the athlete’s wellbeing was overlooked by others with divergent aims. In this kind of environment sports medical practitioners may lack the independence and support required to attend to the needs of their patient group.
Multiple obligations are most obvious when sports medical practitioners have an employment relationship that places demands on them while traditional obligations to their patients remain. For example, the desire of the coach to succeed can result in pressure on a sports medical practitioner to return an athlete to the field of play before medically indicated. Here the medical practitioner has an obligation to his employer, but also to the athlete.
Inconsistencies in actions among sports medical practitioners
Individual sports physicians varied in their perceptions and management of the complexity of their environment and their multiple obligations; this was particularly evident in two situations.
Sharing personal information about athletes with others
Employment contracts commonly oblige medical practitioners to share health information with coaches and team management. Correspondingly, employment contracts between athletes and team management make similar demands to share health information. Despite this, athletes may request sports medical practitioners to withhold health information from the coach and management. Five of the participants interviewed were prepared to disclose information against the wishes of the athlete but in line with contractual expectations. Ten of the 16 would keep such information confidential, citing a commitment to traditional obligations to confidentiality.iii 14
Risk taking by athletes
When an athlete wished to take a course of action with a significant risk to health, all sports medical practitioners took an educational role seriously, but there was a lack of consistency about whether to support or limit an athlete’s ability to assume risk. For example, one doctor said he would do whatever the patient requested so long as it was not illegal, whereas another has it written into the athlete’s contract that the sports medical practitioner has the final say on who can play. Although these responses may be acceptable depending on the individual clinical situation faced, ambiguity exists about how medical practitioners should respond.
Aims for a new ACSP code of ethics
A code of ethics serves a number of purposes. These include articulating professional standards for its members, ensuring the protection of the public and to enhance the trust society has in this group.15 Codes provide an opportunity to express the shared values of the group and the profession.16 On a practical level, codes can be used to support members with ethical decision making, and can act as a shield to protect practitioners from unacceptable demands and external pressures. Codes of ethics also set out standards of behaviour to be used as a yardstick against which to measure the actions of its members.
The aims of the new ACSP code of ethics were to: express the shared values of the ACSP; standardise behaviour between sports physicians; clarify expectations of sports physicians and shield members from pressure from coaches, governing bodies and others.
The new ACSP code was considered an important way to create support for individual practitioners and to promote a professional community. The creation of a professional community led to other advantages being envisaged. For example, as a more organised group with clear expectations and limits sports physicians could respond more effectively to new developments in sport that have the potential to affect athlete wellbeing negatively, including new forms of high-risk sport, new cell technology and genetic enhancement.
Key requirements of a code
Before writing the code, decisions were needed on some key requirements of a coherent code, these include the following.1
A code of ethics is, in part, a form of communication between the general public and the profession, and as such it needs to be accessible to both patients and clinicians. The document must therefore be written without jargon and in plain language.
A code of ethics must avoid confusion so it must be plainly expressed, clear in its requirements and not contain unintended double meanings.
Compatible with existing codes and laws
A code of ethics should seek to be compatible with legislation governing the practice of medicine in the relevant country or state. Although medical codes should always reserve the right not to comply with any law considered unjust, in general codes should comply with legislation. A code of ethics written for a specialist medical group should also be compatible with relevant codes written for all registered doctors in that jurisdiction.
A search for a template
Other extant codes were examined for templates. International sports medicine codes, baseline medical codes and codes written for other clinical specialities in Australia and New Zealand were examined.17 18 19 20 21 22 23 24 25 26 27 28 29 The Royal Australasian College of Physicians (RACP) was identified as a code with particular features that made it ideal for the ACSP. First, it was written for Australasian specialists, so some content was readily transferrable. Second, the RACP document used a “must” and “should” structure that allowed for an expression of rules and aspirations.
Armed with the RACP code as a template and the research findings referred to above, the code writing group produced a set of agreed topic areas. The list of topics included many new areas generated by the research, including: consent, record keeping, caring for children, risk taking by athletes, performing enhancing drugs, relationship with industry and dealing with the media. One new area of note was the section on “employment structure and relationships”. The aim of this section was designed to clarify divided loyalty concerns raised by the research, but also to highlight this as an area of ethical concern. In this section a distinction was made between being employed for therapeutic purposes or assessment-only purposes. When a sports physician is employed in a therapeutic role certain obligations to the patient remain including acting in the patient’s interests, and not being party to a contract that forces or encourages the abandonment of a commitment to the patient.
The must/should structure identified in the RACP code was favoured because it allowed the document to set minimum standards expected of all physicians expressed through the term “must”, whereas the term “should” was used to convey aspirational aims of the college. The use of “should” statements allows for guidance in situations in which no strict rule would be appropriate or possible. Problems exist in deciding where to place the division between “must” and “should”. Setting expectations for behaviour too high will result in “must” statements that are unachievable. The use of the word “should” in the wrong place would result in a failure to impose minimal standards.
The next issue is how much detail to include within a code. Excessive detail renders the code long and unwieldy and threatens its usefulness. It is impossible to imagine every clinical scenario. Any attempt to do so within a code will inevitably lead to some unconsidered possibility being overlooked, leaving the clinician unsure how the code applies. If the code is too general we also run into problems.30 A code that has grand statements such as “always act for the good of the patient” or “always act with the highest integrity” without further detail can be banal and of little practical use. It is hard to know how such general statements apply in specific situations. Such injunctions also fail to provide standards to measure a physician against.
Reflecting patient needs
Physicians as stakeholders in the new code will bear the greatest burden from any obligations set out therein, but patients are also stakeholders as they clearly have an interest in the behaviour and obligations of their physicians. No input was sought from patient groups in the development of the code, partly due to limited time, but also because it was considered that an improved code could only be an advance for athletes. It was thought that if physicians were strengthened in their ability to resist demands that eroded their commitment to patients then patients would ultimately benefit. Future reviews of the code could allow for soliciting patient input.
To implement the new code effectively will require member support of the code. To achieve this, members need to be informed about the existence of the new code and how their obligations may have changed. An education campaign of members must be undertaken. Because it is not possible to police every action taken by a physician we must rely on the commitment of members, so each individual member must feel that the code is appropriate and fits with the ethos of the group.
Administration of the code
Members will quickly lose respect for a code that is not applied appropriately, in a timely fashion, or fairly.30 Therefore any complaints must be dealt with in a procedurally just and appropriate manner and disciplinary action must be consistent, fair and in proportion with the breach by the member.31 Obviously, a good organisational structure is required to be able act on complaints about members. On occasions breaches may be dealt with by governmental bodies set up to deal with complaints regarding patient care and so the organisation needs to be aware of any legal obligations to direct complaints elsewhere.32
What is already known on this topic
A code of ethics for sports physicians needs to be clear, appropriate and practically useful to clinicians.
What this study adds
This paper presents the recent experience of rewriting the code of ethics for the ACSP and describes the process and challenges.
Practicalities and negotiating the politics
Not being a sports medicine physician created some advantages and disadvantages for the author in rewriting the code. One advantage was that the author had no investment in the old code so was able to start anew. Occasionally the author inadvertently stepped into areas of particular contention in sports medicine. Banned performance enhancing drugs in sport was one area where the author wished to clarify expectations but was unaware of the politics involved. This should not be interpreted to mean that the code development group did not want the area to be covered, but there were concerns about where such duties should originate from. Negotiation was rapid and resulted in a section acceptable to all.
Another matter that generated discussion was the inclusion of mental health and eating disorders. The reasons for including these two topics were based on the research. Some sports medical practitioners had expressed concern over dealing with them, particularly mental health issues. For example, some created fictitious physical injuries for their patients with mental health problems so that coaches would understand the patient needed to take time off. Some code development group members were not convinced that mental health issues should be represented separately from other illnesses and so this (along with eating disorders) was dropped from the final document. Although the author remains persuaded that mental health requires a separate section, it is more important that members felt the document was appropriate.
The new “ACSP code of ethics and professional behaviour” was adopted in April 2008.33 No claim is made that this code is somehow perfect or complete. Analysis will no doubt detect errors within the document or ways in which the ACSP code can be improved, and correcting these flaws will be an important part of the continual review process. Also, as medical practice evolves and new developments occur in sports science, sporting practices, or law that affects medical practice, such change will need to be reflected in the code.
In the end the new ACSP code is one that we hope is functional and clear and an improvement on the previous code. It is hoped that because the new ACSP code is based on research, it will be more relevant and useful to individual practitioners. We hope the new code will strengthen the resilience of individual practitioners to meet the challenges and pressures of modern clinical practice in sport in a professional manner.
The author would like to thank the following people for their support and guidance: Associate Professor Paul McCrory (past president of the ACSP), Dr Chris Milne (immediate past president of the ACSP), Dr Vince Higgins (chair of the ACSP Ethics Committee) and members of the ACSP Ethics Committee: Professor Donald Evans, Professor Grant Gillett, Professor Nicola Peart, Dr Neil Pickering, Dr Vanya Kovach, Professor John Saunders, Claire Gallop.
Competing interests None.
Ethics approval Ethics approval was received from the University of Otago Human Ethics Committee.
Provenance and Peer review Not commissioned; externally peer reviewed.
↵i Sports physician is a term limited to those who have trained and become Fellows of the Australasian College of Sports Physicians. Sports doctors are usually general practitioners with a particular interest in sports medicine who care for athletes or teams, sometimes at the highest level. The research was carried out on a mix of sports doctors and physicians and when both are referred to the term sports medical practitioners will be used.
↵ii Approved by the University of Otago Human Ethics Committee.
↵iii One research participant was unsure of what he or she would do under the circumstances.