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Despite the vast quantity of information available to patients, parents and clinicians, high-quality information and knowledge remains in relatively short supply.1 The benefits of an active lifestyle are incontrovertible. However, youth athletes have substantial risk for sports-related injuries to the musculoskeletal system and the brain.2 3 These potential dangers are known to clinicians who are helping youth athletes and their parents make sound decisions about injury management and sports participation. In the face of these challenges, how does the clinician fulfil his or her duty of care to youth athletes?
The aim of this editorial is to illustrate how different ethical standards can help guide better shared decisions in sports medicine clinical practice. Youth athletes are a particularly vulnerable group because their life plans are still developing. Adding to this complexity is an increasing trend towards professionalisation in youth sport. When arriving at a decision in a clinical dilemma, one or several ethical standards may help the decision-making team evaluate if a decision is ethically justifiable. The 2018 International Olympic Committee consensus on paediatric ACL injury4 outlined six ethical standards (box 1) that may apply to different situations in sports medicine clinical practice.
Six ethical standards that can apply to sports medicine clinical scenarios
Best interests 5: what is in the youth athlete’s best long-term interests.
Harm principle 6: a threshold below which the clinician should not acquiesce to a parent-led decision, so that the youth athlete is not harmed.
Parental discretion 7 8: parent preference is accepted because the preferred course of action is not sufficiently harmful to the youth athlete for the clinician to dissent.
Costs–benefits 9: involve a risk assessment, but its application to the youth athlete means that the clinician may need to compare very different kinds of futures that may or may not eventuate.
Not unreasonable 10: focuses only on the appropriateness of decisions and decision-maker(s).
Reasonable choice 11: a decision method that attempts to incorporate the previous five standards into a single model or intervention.
The point of considering standards that range from what is in the child’s best interests to what is (not un)reasonable is to allow all interested parties to make an informed and ethically-justifiable shared decision.
An example from clinical practice
Eleven-year-old Martin is a promising football academy player with an acute ACL tear. There are no other knee structures involved, nor does he have any dynamic instability. Generally, Martin is well. He can run, change direction, kick and jump with no problem.
Here are two possible decision scenarios that could arise regarding the best management of Martin’s injury.
Scenario A: medical team advise ACL reconstruction, parents do not consent to surgery
The medical team’s rationale is: (1) Martin plays a high knee-demand sport where many athletes have ACL reconstruction if they sustain an ACL injury and (2) he has been identified as a talent with strong (preinjury) potential to be signed by the club and make the highest professional level. Martin’s parents do not want ACL reconstruction because they: (1) think that Martin is too young to have surgery and (2) have an older child who experienced serious complications from surgery. The medical team may have a conflict of interest because they do a lot of work for Martin’s club. The medical team are also under intense pressure from club administrators who want to sign Martin in the next few months before other clubs get his signature.
Scenario B: medical team advise against ACL reconstruction, parents want the club to pay for surgery
The medical team’s rationale is: the isolated ACL tear with no dynamic instability warrants a trial of high-quality rehabilitation (non-surgical treatment). Martin’s parents may be overinvested in his financial potential—their estimation of his abilities is unrealistic. When it comes to the final decision (around age 16 years) regarding a professional contract, the club is unlikely to sign a player with a previous serious injury, irrespective of whether he has had surgery or not.
Synthesising information and reaching a decision
Imagine being part of the medical team caring for Martin. How does the clinician confidently contribute to the shared treatment decision-making process? One place to start is by gathering the relevant facts. There are at least two facts that might influence shared decision-making in Martin’s case.4
Fact 1: we do not know whether youth athletes with ACL injury, with or without ACL reconstruction, can have a successful elite sporting career.
Fact 2: high-quality rehabilitation alone or in combination with ACL reconstruction are both acceptable treatment options for youth athletes with ACL injury.4
Next, we might consider the facts and decision-making context in light of ethical standards (box 1). These standards can help guide our actions and recommendations, especially when there is uncertainty around key issues. Working through the robustness of justification via the ethical standards requires sensitive handling of the key points that will differ from situation to situation.
Decision-making in light of ethical standards
In Martin’s case, there are at least three important uncertainties.
What are the chances of Martin making the highest level with non-surgical treatment?
If surgery is delayed, can Martin make it through the next few years and onto a professional football contract with an ACL-deficient knee?
How likely is the club to keep Martin in the football academy if he has an ACL reconstruction?
Best interests is hard to operationalise in Scenario A because there is so much uncertainty. It seems that Martin is at relatively low risk for harm and the medical team is confident of success. However, Martin can play without knee instability now, and the absence from football in order to have surgery could harm his athletic development.
The cost–benefit analysis in Scenario A could be: take Martin out of football training now for at least 9 months of surgery and rehabilitation (cost) balanced against early surgery possibly enabling him to have a financially successful career and protecting his knee from further injuries (benefit). In this situation, the cost is more certain while we lack the evidence to be confident about the benefit.
Without parental support and acknowledging the source of potential conflict, the medical team should acknowledge the child’s interest but accept parental discretion.
In Scenario B, the cost–benefit analysis is loaded against the decision to intervene. Even if successful, there are reasonable grounds to think Martin’s future football career might not be served by an ACL reconstruction. A serious consideration of alternative athletic and educational pursuits should be aired. Of course, facts alter cases: if football is the only avenue for socioeconomic success for Martin and his family, then weaker cost–benefit ratios may be acceptable as a justification.
Summary
Decision-making with youth athletes is complicated, especially when the outcomes of our treatment decisions have a high degree of uncertainty. The ethical standards set out in the 2018 IOC consensus statement on paediatric ACL injury,4 and briefly illustrated here, provide a framework that can help clinicians, and youth athletes and their parents/guardians weigh different treatment options and arrive at the best shared decision.
Footnotes
Contributors All authors made substantial contributions to overall conception, planning, drafting and critically revising the manuscript. CLA, HG and MMcN wrote the first draft. CLA is the guarantor.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.