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Time out: ethical reflections on medical disqualification of athletes in the context of mandated pre-participation cardiac screening
  1. Emma Forton Magavern1,
  2. Gherardo Finocchiaro2,
  3. Sanjay Sharma2,
  4. Michael Papadakis2,
  5. Pascal Borry1
  1. 1 Centre for Biomedical Ethics and Law, University of Leuven, Kapucijnenvoer, Belgium
  2. 2 Cardiovascular Research Centre, St. George’s University of London, London, UK
  1. Correspondence to Dr Emma Forton Magavern, Centre for Biomedical Ethics and Law, University of Leuven, Kapucijnenvoer, 3000 Leuven, Belgium; emma.magavern{at}

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Sudden cardiac death (SCD) in any young person is a devastating event. The value of cardiac pre-participation screening (PPS) in young athletes has been intensely debated in the medical community and public health arena.1 One of the shortcomings of attempts to identify athletes with heart disease is the lack of established risk stratification protocols. Consequently, athletes are offered a ‘blanket approach’, with a considerable number of athlete disqualifications to save the few at high risk of exercise-associated arrhythmias.

This analysis considers the ethical implications of disqualification of athletes with heart disease from competitive sport in the context of available evidence, contemporary medical recommendations and legal structures, as well as emerging genetic diagnostics.

Eligibility recommendations for athletes with heart disease

There is a lack of consensus in eligibility recommendations for athletes with heart disease aimed at medical practitioners. The discrepancies are due to multiple factors including: (1) the lack of evidence base relating to risk stratification of athletes for most conditions predisposing to exercise-related SCD(as a consequence, the recommendations are expert opinion based (level of evidence C)), (2) Cultural differences, and(3) Differences in legal contexts (if physicians are legally liable, disqualification decisions tend to be more conservative as physicians can be held accountable for adverse events).2 In addition, the label of ‘disqualification’ can be tantamount to loss of employment or ‘being fired’ when the athlete receives substantial financial remuneration or has a professional status.

Is medical disqualification ethically justified?

Ethical arguments in favour of medical disqualification


Disqualification of athletes with heart disease from competitive sport as a precautionary measure relies heavily on evidence that disqualification of at-risk athletes improves morbidity and mortality. In the 36th Bethesda conference, the authors state: ‘The increased risk of sudden death associated with intense athletic participation is a controllable risk factor, and the devastating impact of even infrequent sudden deaths in this young population underscores the wisdom of the conservative nature of these recommendations’.3

The …

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  • MP and PB contributed equally.

  • Handling editor Karim M Khan

  • Contributors EFM wrote the analysis in collaboration with MP, GF, SS and PB. MP, GF and SS were involved in pre-participation cardiac screening organised by the charity Cardiac Risk in the Young (CRY). MP and PB contributed equally as senior authors.

  • Funding EFM was funded by a European Commission Bioethics Fellowship. MP, GF and SS are funded by research grants from the charitable organisation Cardiac Risk in the Young (CRY), which supports pre-participation screening in young athletes.

  • Competing interests None declared.

  • Patient consent None.

  • Provenance and peer review Not commissioned; externally peer reviewed.