Ethical Issues in Sports

Original Editor - Wanda van Niekerk

Top Contributors - Wanda van Niekerk and Tarina van der Stockt  

Introduction

In it's most simple form, ethics is the study of what makes a particular action in a particular situation the right thing to do.[1] In the world of sports medicine there are unique challenges to the practice of ethics by health care professionals due to the unusual clinical environment of taking care of athletes in team scenarios with winning being the primary goal.[2] The traditional health care professional-patient relationship is often replaced with the healthcare professional-patient-team triad and as such creates a scenario in which a team's priority can be in conflict with a health care professional's obligation to the athlete's well-being.[3] As a result many of the ethical norms that regulate cthe linical practice, such as autonomy and confidentiality, are not easily translated to sports medicine.[1]

Health care professionals in sports, such as doctors, physiotherapists, psychologists are constantly under pressure to keep athletes on the field of play and to improve performance as well as allow the athlete to return to play in the shortest possible amount of time. This pressure usually comes from team management, such as coaches, trainers, agents; the athletes themselves or even parents in the case of younger athletes. This constant pressure may compel health care professionals to rather focus on the short-term solutions to injury rather than consider the long-term effects of such solutions and decisions.[4] In sports medicine a wide variety of ethical dilemmas may be found and unfortunately ,there are no unique right answers for many of these situations.[1] Knowledge of the principles and exposure to the practice of ethics are helpful in the decision-making process.

Ethical Problems in Sports Medicine

The unique and dynamic relationship between the various stakeholders associated with sports franchises and even local clubs or school teams and athletes are one of the biggest causes of the many ethical issues that are encountered in the care of athletes.[5] The stakeholders can include:[5]

  • Health care professionals (doctor, physiotherapist, athletic trainer, etc)
  • The athletes themselves
  • Team management (coaches, general manager)
  • Team owner (in professional sport)
  • Other stakeholders such as agents, family (parents), the media and the sports fans

Conflicts of Interest

With this multitude of stakeholders involved, each with their own different interests and goals, health care professionals are often conflicted about the proper course of treatment and rehabilitation for an injured athlete.[5]

Types of ethical issues experienced by health care professionals working in sports include:[6]

  • Interdisciplinary conflicts such as miscommunication about roles
  • Conflict of interest due to divided loyalties
  • Conflicts in acting in the athlete's best interest
  • Pressure to return to play from a coach, parent, athlete or administration

In sports medicine, conflicts of interest often arise in two areas; confidentiality and clinical decision making.[7] Often confidentiality is challenged by the responsibilities of the health care professional to both the athlete as well as to the team.[7] Clinical decision making, normally associated with an athlete's long-term health and well-being, can be complicated by short-term interests leaning towards the pursuit of winning.[7]

Most patients want to reduce their pain/suffering and live a health life. Athletes on the other hand also have as a priority the drive to perform at the highest level possible.[8] A big role of the sports health care professional is to support this athletic achievement.[9] In the world of professional sports and even in lower levels of sport these days, the dynamics of competitive sport can affect medical decision making. Most of the time these factors are not normally encountered in standard practices.

Health care professionals in sport should be aware of the various potential influences that can affect ethical medical decision-making. Pressure can come from various sources that can influence the health care professional and the athlete. This pressure can come from the athlete, the coaching staff, management and even the health care professionals themselves.[5]

Some examples of sources of pressure that a team clinician may come under:

  • Allowing an athlete to return to play[5][8]
    • pressure from the athlete is usually the greatest potential source of pressure
    • athletes are extremely motivated people and may prefer to risk their health for the sake of taking part and having success
      • this is usually motivated by factors such as pride, peer pressure, institutional pressures and financial considerations.
    • coaches, teammates, parents, team management can put the clinician under pressure in several ways:[8]
      • the coach may put pressure on the athlete, who will in turn put pressure on the clinician
      • questioning of the clinician's decision making and sometimes even involving the media
      • management can threaten to replace clinician

Sports health care providers should be aware of these powerful motivators and bear them in mind when determining the extent of an injury and the time needed for recovery and return to play.

  • A team clinician can also fall victim to "fan syndrome". This is when the clinician's clinical judgment is influenced by his/her desire to see the team win or succeed.[5][8] Some ways that this can happen in are:
    • allowing a player to return to play too soon
    • team clinician wants to stay in good favor with team management - clinician provides advice that will please, instead of what is rational advice
  • Health care professionals in professional sport do benefit from the team's success and achievements:[8]
    • there are financial benefits as staff earn performance bonuses
    • clinicians can have contract renewals for the next year
    • travelling with the team
    • increased media exposure
    • enhanced professional reputation

The accumulation of these types of pressure can create a conflict of interest and may even affect the clinician's critical thinking and judgement.

Where lies the sports clinician's duty?

Health care professionals in sport inadvertently have an inherent conflict of interest when they are employed by or under contract with a team or organisation. The question arises as to where the primary duty of the clinician lies...to the athlete or the team?

In most scenarios the team interests and the interests of the athlete are the same. So whatever is the best option or course of treatment for the athlete is also best for the team. However, there are instances where sthe hort-term benefit to the team, might be disadvantageous to the athlete. Regardless of the amount of pressure that a sports health care professional faces, their primary duty is always to the athlete. It is the responsibility of the sports clinician to always fully disclose to the athlete (and the parents, in the case of minors) the extent of the injury, the nature of the injury, the proper rehabilitation as well as the various consequences of injuries and return to play.[8]

The well-being of the athlete is always most important, especially if there is a conflict of interest with a third party.[7] One way of minimizing potential conflicts between the sports medical team and coaches and management is to instate a policy that the medical team has the final say regarding an athlete's participation after injury. In situations where the sports clinician have fully disclosed everything to the athlete and the athlete (or parents of athlete) still insists on going against medical advice, it is recommended that the clinician ask the player (or parent) to sign an exculpatory waiver.[8]

"Physicians and other health care professionals must always act in the best interest of the patient whether she or he is an athlete or not, regardless of setting, and irrespective of incentives."[5]

[10]

Informed Consent

Informed consent is the voluntary agreement by a patient to a proposed health care management approach after proper and adequate information is conveyed to the patient about the proposed management, including potential risks and benefits and alternative management options.[11] There are various challenges around informed consent in the context of athletes. Issues such as pressure from coaches, parents, or that the athlete feels forced to do "what is best for the team." Should an athlete make decisions such as seeking outside advice or refuse to play while injured, he/she is often labeled as "uncommitted." Another challenge is the huge amount of information that is freely available from various sources. Athletes need to realise that there is not always ways to separate unscientific information from information with sound scientific evidence and that "personal testimonies" from other players should not influence the advice given by their health care professional.[5]

Keeping record of all discussions between the athlete and the health care professional is paramount. Ideally, it would be best if athletes are provided with documentation regarding the planned course of action as well as the risks and benefits. It is also recommended that both athlete and clinician sign a document stating that the athlete has received the relevant information before making a decision and giving consent. It is always the athlete's decision on what course of treatment he would prefer. If this is different from what the clinician advised, it is essential to document that the athlete is acting against the advice of the clinician.[8]

Confidentiality

Sports health care professionals work in an area that is distinct from many other areas of medical practice.[12] Maintaining confidentiality is shaped by various responsibilities or obligations, the physical environment and practice and policy contexts of sports medicine.[12] As a result confidentiality has been identified as one of the most important ethical issues in sports medicine[13] and is onof e the most frequent ethical dilemmas experienced in sports medicine.[14]

The principles of confidentiality

Confidentiality is the concluding item of the Hippocratic oath, The notion is that health care professionals should always exclusively act on behalf of their patients and it is therefore intricately linked to privacy, patient autonomy and informed consent.[12] However, the sharing of information with other health care professionals directly involved with the treatment or care of the patient is ethical behaviour.[12] Other mitigated circumstances that might require non-consented disclosure is:

  • incapacity of patient[15]
  • medical emergencies[15]
  • legal obligation to state law (but not to sport-specific regulations)[15]
  • protecting patient's health and well-being[15]
  • protection of a third party from serious harm[15]

From the available literature it is evident that there are difficulties in simply conveying medical ethical conventions into the area of sports medicine.[16] The International Federation of Sports Physical Therapy (IFSPT) clearly states in their Code of Ethics that: "The physical therapist's duty to the athlete must be his/her first concern and contractual and other responsibilities are of secondary importance. A physical therapy decision must be taken honestly and conscientiously."[17]

The sports health care professional and the athlete do have a confidential clinician-athlete relationship, but when a team clinician is employed by the team management this may change this relationship as the team clinician now have two obligations, one to the athlete and one to their employer. Testoni et al (2013)[13] suggests the term "clinician covering the team" rather than "team clinician" in an attempt to clarify the obligations that the clinician's role should entail.[13] British and Australian researchers and ethics codes express the view that the team clinician role is "discrete in practice." The British Olympic Association released a position statement on athlete confidentiality in 2000.[18] In this statement it is argued that a coach or management can only be informed of an athlete's issues (e.g. injury or illness) if the athlete gives consent to this. In contractual scenario's, where a health care professional has signed a contract with a sporting governing body or team, they may very well be in breach of their professional code of conduct hould they breach heir responsibilities of confidentiality.[5] It is suggested that athletes who have signed a general consent form may still refuse consent for any specific procedure, treatment nd test or for information to be shared with other parties.[8]

In the United States the legal structure allows for management to be allowed access to athletes' medical records. This is because of the scholarships and salaries that athletes receive, either at pthe rofessional level or collegiate team level.[5][12] The Health Insurance Portability and Accountability Act suggests that the medical records of athletes can be seen as part of their employment records rather than privileged health information. Therefore it is allowable to be shared with parties within the specific sporting organisation.[12] These ethical codes that operate within the legal systems are also usually state bounded. As a result ,there are variations in the maintenance of confidentiality and the idea of anuniversal code of ethics in sports medicine may still be only a dream.[12]

Also, even if sports clinicians have the legal right to inform team management about relevant injuries of an athlete, there is still a gray area about what is appropriate information to be shared - some issues such as drug or alcohol abuse, or psychological issues may influence an athletes' performance, but divulging this information to management might have a negative impact on the athlete's career. The sports clinician has the duty to clearly state the nature of his/her relationship with the athlete prior to any examination and to clearly indicate that the clinician is not the athlete's private health care professional and that confidentiality can not always be guaranteed.[5] It is strongly recommended that athletes and sports clinicians sign written agreements before the start of a season or term wherein it is made clear that the sports clinician does have the athlete's consent to share information with the coach or management team if need be and appropriate.[8] Unfortunately, these results often in athletes seeking medical advice outside of the team environment.[12]

Factors that influence confidentiality in sports

It is relevant to understand the social constraints on the maintenance of ethical principles of patient confidentiality. There are four main factors specifically relating to the sports medicine environment an context:[12]

Multiple and Conflicting obligations

These include:

  • Sports healthcare professionals being employed by sports organisations
  • Competitive nature of athletes overriding health concerns
  • Cost of injury prevention relative to short-term and long-term morbidity[12]
Physical Environment

Injury is common in sports, and it is so that some medical care is administered in front of coaches, team mates, etc. This exposes clinicians sometimes to questions from fellow tea mates or demands from management. Sometimes the design of treatment facilities in sport challenges confidentiality. Furthermore, sports medicine may be practsced on the playing field in front of spectators. These "easy ways" of access to information to an athletes medical information is just a few ways that constraints the clinicians' maintenance of patient confidentiality.[12]

Practice Context

Being involved in sports medicine usually means that the clinician is also part of a multidisciplinary team. This results in clinicians working in a environment "alongside colleagues whose degree of training, familiarity and concordance with medical ethical principles varies."[12]

Performance is paramount in sports and athletes are constantly undergoing performance testing. Often the health care professionals are required to be involved with these performance-based activities and they may be even included in performance-based financial reward systems.[12] This causes the medical and non-medical spheres in the practice context becoming blurry and this further complicates confidentiality issues with clinicians performing roles that not only cover health care but also performance.

Another area where the complexities of sports medicine are evident is in the system of transferring athletes between clubs or professional teams. The speed with which transfers sometimes occur makes it difficult to get signed and informed consent from athletes to release medical information. Other questions that arise in this field is: What information is owned by the sporting body and what belongs to the athlete. Furthermore, what is the duty of the club/college that is losing an athlete to divulge the medical condition of the involved athlete?[12]

Policy Context

Sports healthcare professionals work within the limits of various sports-specific policies that often require disclosure of privileged information. Athletes consent to these types of disclosure, usually because their desire to participate in sport overrides everything else. Policies that are problematic in the area of confidentiality are those relating to screening and policing of athletes.[12]

The testing for performance-enhancing drugs is justified on the basis that it protects individuals from harm, enforces equality and is in the economic interests of t.[12] However, there are ethical challenging issues such as:

  • athletes needing to disclose their whereabouts to enable no-notice, out of competition testing
  • testing for recreational drug use with no performance-enhancing effects, but which can bring the sport into disgrace
  • therapeutic use exemption system - athletes must declare their use of medications that may lead to positive tests - this may potentially divulge confidential medical conditions[12]

Other ethical issues relating to policies that can arise are:[12]

  • Sex segregation in sport - In the case of Caster Semenya, Olympic gold medalist in the 800m, it is shown that based on "nothing more than suspicion born of visual impression". athletes could be subjected to extensive medical and media scrutiny.
  • Cardiac screening - although these policies are designed to protect athletes from harm, there is resistance to this type of screening from athletes who have been forced to withdraw from sport following these tests.
  • The pre-fight and post-fight assessments of boxers involves the public disclosure of privileged medical information as well as the classification of athletes with disabilities.

Suggestions for Ethical Conduct

Ways to improve the ethical decision-making abilities of health care professionals involved in sports:

  • the inclusion of an ethics component in sports medicine/physiotherapy fellowship programs[5]
  • clear rules that govern relationships between sports clinicians and sports organizations or teams[5]
  • sports clinicians must be trained in the basic principles and concepts of applied ethics[5]

Guidelines for Sports Medical Personnel

  • Have a passion for the sport as well as a passion for the athletes' well-being
  • Be rational and impartial in carrying out medical duties
  • Keep a degree of professional distance from the management team
  • Be aware that informed consent is challenging in a highly charged game environment
  • Make sure that there are clear lines of reporting in place
  • Clinician first - Team Clinician second
  • Do not give up or forget your responsibility to the individual athlete[1]

Conclusion

Ethical decision-making can be challenging in the world of sports medicine. As advocates for our patients and athletes, we must remember the importance of ethical medical practice, remain professional and virtuous in all situations. At the end of the game, the only result that really counts is that the athletes' autonomy has been respected at all times.[1]

"A fit athlete is better than a injured star"[1]

Resources

References

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  18. 18.0 18.1 The British Olympic Association's position statement on athlete confidentiality. British Journal of Sports Medicine 2000;34:71-72.