The Bloodgate saga is finally being resolved for the two medical team members involved (the doctor was given a warning, while the physiotherapist was initially struck off). But were the differences in punishments justified, and by focusing on the individuals, are we missing the real problem?

The term Bloodgate was given to events that occurred in April 2009 when, during a rugby match between Leinster and Harlequins, a Harlequins player (Tom Williams) faked a blood injury in order to be replaced by a specialist kicker in an attempt to win the match. The physiotherapist and doctor were both closely involved in the scam. At the behest of the coach, the physiotherapist (appointed England Rugby team physiotherapist) gave the blood capsule to Williams.1 The doctor later cut the inside of Williams' mouth to ‘demonstrate a real injury’.2 Their actions were brought to the attention of their respective professional bodies. In August 2010, Dr Wendy Chapman was given a warning by the General Medical Council (GMC) (listed on her registration).2 In September 2010, the Health Professions Council (HPC) struck off physiotherapist Stephen Brennan.3 This decision was overturned by the High Court in January 2011.4

The initial penalties for each seem inequitable. Chapman caused physical injury to Williams and she and Brennan both engaged in deception after the event.1 2 Yet, Chapman emerged with a significantly lighter penalty. Physiotherapists and doctors in sport work under similar circumstances, and yet the decisions by their respective professional bodies indicate that the norms to which they are held differ.

The GMC regarded Chapman as a reluctant party to this event, having been placed under pressure from Williams to cut his mouth.5 Furthermore, in Chapman's defence, her lawyers are reported as presenting a number of mitigating factors to her decision making including depression and breast cancer tests (now both resolved).6 These do look like contributing factors but Chapman showed poor judgement in submitting to pressure from Williams, and arguably by not removing herself when her own health concerns could impact on decision making.

The HPC, on the other hand, decided Brennan displayed a degree of premeditation in his actions by purchasing the blood capsules. He also ‘took an active role in the drafting of false witness statements’ to sustain the deception.1 However, the act of removing someone from a professional register is a serious matter and should be limited to certain criteria, including threats to public health and safety posed by malicious or incompetent practitioners, and should be used as a last resort. Mr Justice Ouseley, in his judgment, considered that the HPC ‘had gone for the ultimate sanction without explaining why in the light of the evidence, a lesser sanction, whether conditions of practice or suspension was not appropriate’ (4 at para 27). His Honour quashed the HPC decision stating that their ‘reasoning is legally inadequate, failing to deal with the issues properly raised for its consideration by Mr Brennan’ (4 at para 55). The judgment of Mr Justice Ouseley has the effect of reducing the apparent inequity between the penalties imposed by the GMC on Chapman and by the HPC on Brennan (although the HPC is yet to determine what new sanction will be imposed).4

So were these just two flawed individuals and do the final disciplinary decisions conclude this matter? The concerns raised by Bloodgate have not been resolved, and the actions of these two are symptomatic of the pressures of medicine in top-level sport.7 Being a doctor or physiotherapist is ethically fraught in an employment setting where health is not of central concern,8 and conflict ensues between meeting obligations to an employer and caring for players.9 Professional sport is a highly pressurised commercial environment with sponsorship tied to success, and winning therefore hugely important. This has a subsequent impact on the attitudes of coaches, managers and players seeking new contracts and they may place pressure on team health professionals. Coaches and managers may pressure health professionals to supply confidential health information,10 return athletes to play before medically indicated or apply medical services inappropriately. Some coaches respect the team doctor or physiotherapist, others do not and there are concerns that careers may be short where people oppose the coach's aims.11 Conflicts also exist for health professionals in dealing with athletes willing to trade long-term health for short-term gains.

Some health professionals may be willing to compromise professional integrity for corporate aims, others may wish to resist but may find it too difficult when working under time pressure and unsupported. It is perhaps understandable that health aims of doctors and physiotherapists may be distorted by the environment of professional sport.

A 1997 BJSM editorial rather prophetically stated: ‘Sporting doctors may in the future earn money from sport, but at a price. Could that price be their personal and professional integrity?’12 We should not be surprised that the integrity of sports health professionals may slip under the intense pressure of professional sport. But as some authors suggest, teaching ethics and creating professional guidelines may not be enough.7 Until we recognise the pressures and provide adequate support and protection to sports health professionals, scandals like Bloodgate are likely to recur.