AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. July 2004, Volume 6, Number 7.

Clinical Cases

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Performance-Enhancing Drugs in Sports

Physicians have an ethical obligation to warn athletes about the potential health problems associated with performance-enhancing drugs.

Commentary by Stephen L. Brotherton, MD, Norman Fost, MD, MPH, and Gary A. Green, MD

Dr. Jarvis, a family physician, enters the exam room to see his next patient, Jim, a star basketball player for the Springfield Tigers, the local high school team. Jim is here today for his routine preparticipation physical examination. He reports that the team has great potential and is hoping to win the state championship. Jim inquires somewhat tentatively about how he could get stronger. Thus far, he has only been using creatine and protein powder and is not satisfied with his strength gains.

In the course of the exam, Jim asks about steroid drugs and mentions that some friends told him that new-generation steroid drugs are not banned from sports. They saw some of these drugs on an Internet site that said their products worked like the real thing but were technically legal. "They must cost a lot of money," observes Dr. Jarvis, trying to remain nonjudgmental for the moment and aware that these drugs sell for several hundred dollars or more. Jim says the pros do it and everyone knows some of the best athletes are "juiced." He says he wants that edge but asks what Dr. Jarvis thinks.

Dr. Jarvis says steroids are questionable as an "edge," but they're a danger sometimes. Too many kids are using them to build muscle too fast and actually get injured as a result. Dr. Jarvis says, "depending on what this drug was, Jim, I might have to report it to someone, the school, your folks, even the police. Many of these drugs are restricted by state and federal laws. And your health is at stake." Jim says OK, and asks the doctor not to tell anyone about their conversation. The doctor suggests some other conditioning methods, completes the screening physical and tells Jim to schedule a follow-up appointment closer to the season. Dr. Jarvis is worried about Jim but is unsure of what his obligations are to the athlete—he does not want to condone the use of nutritional supplements but, if Jim is going to take them, Dr. Jarvis does not want him to do so without medical supervision.

Commentary 1

By Stephen L. Brotherton

Franciscan scholar William of Occam, who dissected every question as if with a razor, preferred to remove all extraneous facts and hypotheticals when deliberating. This is a valuable technique in discussing this case. There are 4 extraneous factors confounding this scenario.

The first is the team's potential state title. It is not more moral to cheat to win a state championship than it is to cheat to come in third in district; the end never justifies the means. The second is the player's star status. This has long been held to be irrelevant in our system, although it may have some validity in some monarchical or theocratic societies. We do not accept separate sets of rules willingly.

The third factor is the status of the drugs as "technically legal," and the statement that "some of best athletes are 'juiced.'" The tradition in medicine has always been to value patient safety over all other factors, and this has been reiterated by the Council on Ethical and Judicial Affairs of the American Medical Association many times [1]. Other commentators have tried to liken this anabolic competitive advantage to a slicker swimsuit or a snappier vaulting pole. In medical ethics this has no validity, since death and disability are possible. Indeed, this is one area where the patient's star status makes it more important to remain compliant. If this player cheats and endangers his health but raises his ability, he will tacitly coerce other players to imitate him. He therefore will indirectly endanger other players' health.

The last factor is the physician's desire to buffer the patient's danger by "supervising" his drug abuse. This is the most ominous of the extraneous issues because it plays to an historically vulnerable area for physicians, and it has never, to my knowledge, ameliorated a situation. This is analogous to parents' misguided notion that allowing their teenager to smoke will "keep the lines of communication open" or that parents can somehow benefit their teenagers' health by knowing how much they smoke. Physicians usually have a strong sense of duty and service, and this has occasionally been exploited by a government, team, or other organization. For an excellent example, see The Nazi Doctors by Robert Jay Lifton [2]. There is no place for "medical supervision" in the case of dangerous, or even potentially dangerous, drugs.

This case, after "Occam's Razor," distills down to whether or not the physician should actively discourage androgen use in otherwise healthy patients, and indeed he should [1,3]. In a practical sense, there are several techniques he can employ with the athlete to maximize compliance.

The physician should acknowledge the athlete's concern about competitiveness and not be patronizing. It will help to sit down, preferably positioning himself a little lower than the athlete to avoid appearing dismissive or superior. If a follow-up interview does not call for an exam, he should make a point to touch the patient, such as a pat on the shoulder. If the patient is an older minor and wishes to talk to the physician without the parents present, he should try to have a neutral chaperone available. He should intervene actively in the athlete's training. Does the athlete want a nutritionist to go over his training diet? Is the weight training program supervised by a certified athletic trainer or a certified strength and conditioning coach? Are there some sport-specific techniques that can be added—such as pliometrics in vertical sports and rotational strengthening in throwing sports—to give the desired "edge"? Only when adequate rapport is developed should the physician resort to more graphic illustrations. High school athletes like Jim respond poorly to risk statements about cancer or stroke, but they will usually respond to body-image risks—testicular atrophy in males or masculinization in females.

No physician can prevent a dedicated cheater from violating rules of law, health, and common sense, but that does not relieve us of the responsibility to try.



References

  1. American Medical Association. Policy H470.978. Blood Doping. CEJA Rep B, I-85; Reaffirmed CLRPD Rep. 2, I-95). Available at http://www.ama-assn.org/apps/pf_new/pf_online?f_n=resultLink&
    doc=policyfiles/HnE/H-470.978.HTM&s_t=blood+doping&catg
    =AMA/HnE&&nth=1&&st_p=0&nth=1& Accessed June 4, 2004.
  2. Lifton RJ. Nazi Doctors. New York: Basic Books; 1986.
  3. American Medical Association. Code of Medical Ethics. Opinion 3.06 Sports medicine. Available at: http://www.ama-assn.org/
    apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-
    3.06.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-
    2.30.HTM&nxt_pol=policyfiles/HnE/E-3.01.HTM&. Accessed June 4, 2004.

Stephen L. Brotherton, MD, is a board-certified orthopedic surgeon in Dallas-Ft Worth, Texas. He works with professional athletes of The Fort Worth Brahmas, a minor league hockey team, and participates in rodeo care of athletes in Fort Worth. He is company physician for the Texas Ballet Theater. Dr. Brotherton is also an orthopedic team physician for Texas Christian University.

Commentary 2

by Norman Fost, MD, MPH

There are several reasons to be concerned about Jim's interest in using anabolic steroids, and Dr. Jarvis's uncertainty about whether and how to help him. Both might be breaking the law and could face criminal prosecution. If there is a screening program in Jim's league, he could be banned from competition, possibly forever. There are potential medical risks, though wildly overstated in the lay press [1]. The most likely permanent harm would be stunting of growth, assuming Jim has not yet reached his final adult height. One of the problems with the ban on these drugs is that potential users like Jim are driven to illegal sources, where there will be little reliable information on efficacy, safety, or good manufacturing processes.

But these observations beg the question: Why are these drugs banned and why has their use been criminalized? There are hundreds of other drugs far more dangerous that are not subject to these constraints. Underlying the abhorrence of anabolic steroids are several moral claims of questionable validity [2] . One of these is that there is something wrong about using unnatural means to enhance athletic performance, wrong for the athlete and wrong for physicians who help such athletes.

What's wrong with enhancement?

If there is something morally problematic about enhancement of athletic performance, we are going to need a definition of the term. Presumably it refers to improving the athletic ability of someone who is already normal or healthy, distinguishing it from treatment of someone who has a bona fide disease or disability. But these concepts are all murky, not just at their boundaries but at the core [3].

Consider the mythical planet of Asthmatica, where everyone wheezes all the time. Suppose a child was born into this population with an albuterol-secreting tumor, which relieved his wheezing and allowed him to run laps around everyone on the planet. Scientists and industry would undoubtedly seize the opportunity to create a cell line from the tumor, or find the gene and insert it into E coli, and manufacture industrial quantities of the drug. Assume the new drug were shown to be safe, effective, and eventually cheap. Would use of this wonder drug be treatment or enhancement? The moralist living on Asthmatica would presumably argue that wheezing is the normal condition, and that this was not treatment but enhancement.

Others (particularly if they knew about the planet Earth) might disagree, but the operational question is, "Why should we care?" or, more to the point, "Why should albuterol be prohibited, or even criminalized?" From the perspective of the Asthmaticans, many would find life preferable with the new drug, and a few would appreciate the opportunity to compete in the Interplanetary Olympics. It is not clear why we should condemn them as immoral, or punish physicians who tried to improve the quality of their lives in this way.

Consider the case of Rick DeMont, the American swimmer who had his gold medal taken away in the 1972 Olympic games because he had presumably used ephedrine, an over-the-counter drug, present in numerous cold remedies, to alleviate his mild, exercise-induced asthma [4]. Why ephedrine was banned is unexplained, as it has no known effects on athletic performance when taken by otherwise healthy individuals. And we will also ignore DeMont's insistence that the official team doctor falsely told him that ephedrine was not banned. Those who are sympathetic to DeMont's claim that he was unfairly punished claim that he had a disease and therefore deserved to have access to the drug. But DeMont did not have a disease in the usual sense of "atypical species functioning." Even when wheezing, his cardiopulmonary functioning was several standard deviations above the norm. He used ephedrine for the same reason Jim wants steroids, and the same reason runners train at altitude: not because he was sick or had a disease, but because he wanted to enable his body to work in the best possible way so that he could win the race.

I agree with those who say DeMont's punishment was wrong. But not because he had a disease. And not just because he was apparently misinformed by those who had a responsibility to know better. It was wrong because there was no morally coherent reason for prohibiting him from doing something that all athletes do: using artificial means to enhance performance.

Enhancing human bodily function is, of course, common in health care on the planet Earth. Pediatricians enhance the immune system of children by administering vaccines. Innumerable researchers, with public funds, try to extend the normal life span. And of course, coaches, trainers, and physicians work feverishly to enhance athletic performance in hundreds of ways, often with assists from unnatural machines, diets, supplements, and drugs. It is now standard practice, for example, for long-distance runners and bicyclists to raise their hemoglobin concentration to unnatural levels to enhance performance. There is no moral outrage about this if it is done by simply working at a high altitude for a few months before the competition, or sleeping in a low-oxygen tent. But if an athlete autotransfuses his own natural blood before an event, or uses the approved version of erythropoetin, he is accused of "blood doping" and may be banned for life. If enhancement is the moral linchpin of this policy, we should be equally critical of all athletes who seek to enhance their performance, whatever the method.

One of the many growth industries in the medical enhancement field involves recombinant growth hormone (rHGH), used to add highly desired inches to the final height of children who would otherwise be abnormally short. Endocrinologists and ethicists used to claim that it would be immoral to treat a child for this purpose unless he or she had a certified disease, such as growth hormone deficiency [5]. Now that studies have shown that so-called "normal" short children (Idiopathic short stature is the technical term) can also have their height enhanced, the gates have been opened and the use of rHGH for this purpose has been approved by the FDA [6,7].

Anabolic steroids, combined with vigorous training, can enhance performance [8]. Dr. Jarvis needs to get his facts straight about that; the evidence is beyond "questionable." In that sense, they are no different than myriad other drugs, diets, and devices that athletes are permitted to use for the same purpose. The quest for enhancement—to improve on normal bodily function—is inherent in sports and in health care. If the moral crusade against steroids is to be based on rational argument, rather than hysteria, a better case needs to be made.


References

  1. Fost N. Steroids are only fair. Newsday. Feb 29, 2004; A56.
  2. Fost NC. Banning drugs in sports: a skeptical view. Hastings Center Report. 1986;16: 5-10.
  3. Parens E, ed. Enhancing Human Traits: Ethical and Social Implications. Washington, DC; Georgetown University Press; 1998.
  4. Hansen G. UA coach hopes Olympic disgrace can be rectified. Available at: http://www.azstarnet.com/sydney2000/DeMont3.shtml. Accessed Jun 18, 2004.
  5. Allen DB, Fost NC. Access to treatment with human growth hormone: proceedings of a conference. Growth, Genetics, Hormones. 1992; 8(Supp):1-76.
  6. Allen DB, Fost NC, eds. Ethical issues in growth hormone therapy: where are we now? Proceedings from a conference. Endocrinologist. 2001;11(suppl 1):1-86.
  7. Allen DB, Fost N. hGH for short stature: ethical issues raised by expanded access. J Ped. 2004;144:648-652.
  8. Yesalis CE, ed. Anabolic Steroids In Sport And Exercise. 2nd ed. Champaign IL: Human Kinetics; 2000.

Norman C. Fost, MD, MPH, is professor of Pediatrics and the History of Medicine, and director of the Program in Bioethics at University of Wisconsin, Madison.

Commentary 3

By Gary A. Green, MD

Rather fail with honor than succeed by fraud.
-- Sophocles, Greek dramatist (496-406 B.C.)


This case presents a commonly encountered scenario in a physician's office and raises several interesting issues. Before discussing the ethical issues, however, the health and safety issues must be addressed, as these substances are not innocuous. The case does not mention the age or physical maturity of the patient, but let us assume that he is still a growing adolescent who has not reached physical or sexual maturity. Although these drugs are called "steroids" the proper name for them is "anabolic-androgenic steroids." This is important because although athletes take these drugs for their anabolic (muscle-building) effects, they also have androgenic properties (expression of male secondary sex characteristics) as well. This latter property is what accounts for their adverse effects. There are several health concerns regarding the use of exogenous testosterone in a developing adolescent, and the physician should address these.

The next point concerns what supplement or drug the patient is taking and where he is obtaining it. From the vignette, it appears that the patient is considering taking pro-hormone dietary supplements. These substances, such as androstenedione, 19-norandrostenedione, etc, are sold as dietary supplements through loopholes in the 1994 Dietary Supplement Health and Education Act (DSHEA) and 1990 Anabolic Steroid Control Act. Although these drugs should properly be classified as anabolic-androgenic steroids, they are currently sold as dietary supplements in the United States. Research at the UCLA Olympic Analytical Laboratory and other centers has demonstrated that these supplements are converted in the body to anabolic steroids and can increase levels of testosterone or other anabolic steroids. A new Anabolic Steroid Control Act (HR 3866) is currently being debated in Congress that would correctly reclassify these drugs as anabolic-androgenic steroids.

The other major health issue is where the patient obtains these substances. If the patient is referring to pro-hormone dietary supplements, then purity is of great concern. Again, research from our Lab and others has demonstrated that dietary supplements frequently do not contain what is on the label and are laced with impurities. Owing to DSHEA, consumers cannot rely on labeling of dietary supplements for accurate content and purity. Thus, the product that Jim thinks he is taking may not be what he is actually ingesting. Of even more concern would be if Jim is buying products from black market sources. These are fraught with impurities, and there have been many reports of athletes consuming potentially hepatotoxic veterinary products. Of course, if Jim is buying anabolic steroids and not pro-hormone supplements, that is illegal and considered a felony.

An additional concern that the physician might raise is one of drug testing. If Jim is planning to eventually pursue athletics at the collegiate level, his decision to use anabolic steroids might have long-term effects. For example, injectable 19-nortestosterone (nandrolone) can be detected by sophisticated drug testing for 12-14 months. A decision made for short-term gain may result in a one-year suspension when Jim enters college.

Health issues aside, this case also raises significant ethical issues for Jim, his team, and his community. Unfortunately, the decision to use performance-enhancing drugs does not just affect the athlete who is using them. There are some drugs that are so effective that they significantly alter the sport. If one competes in a sport where others are using these drugs, he or she has 3 options: (1) compete at a competitive disadvantage, (2) decide to take the drugs in order to stay competitive, (3) quit the sport. I would argue that all 3 are poor ethical choices.

The ethical choice, in my opinion, is to respect your sport and your competition and play fair according to the rules of the game. Some have argued that banning certain drugs is "arbitrary." That is true, but "arbitrary" does not necessarily have a negative connotation. To some degree, all rules in sport are arbitrary. The Yankees could put 15 players in the field, but it wouldn't be what all of us consider major league baseball. The same is true regarding rules pertaining to performance-enhancing drugs. There are substances that can so alter the landscape of a game that the very nature of the sport is changed. There is a good ethical choice: respect the game, play by the rules, and at the end of the day know that you have given your best within the existing standards of the sport.

In the debate about the use of performance-enhancing drugs in sport and drug testing, you often hear people recite that drugs are less dangerous than the inherent risks in sport or that there is no such thing as a truly level playing field. While those arguments may all be true, what are the alternatives? If the choice is to allow athletes freely to take whatever drugs they wish, then we have already witnessed that scenario: The former German Democratic Republic. The East German program was well documented and despite medical supervision, extensive testing, and the efforts of sports scientists, several individuals died and there were numerous serious health effects. When you interview athletes, the ultimate stakeholders in this debate, that is not a world that the majority of them want to compete in. There is an oft-quoted article in which the majority of Olympic athletes claim they would take a drug to win a gold medal even if they would die in 5 years. That is refuted by a slew of former East German athletes who are now suffering infirmities from past ergogenic drug use who state they would gladly trade their gold medals for healthy bodies.

In sum, the physician needs to realize that he or she has an obligation to the patient's short- and long-term health. There is also a distinction between "monitoring" someone's health and "condoning" detrimental behavior. Ordering a chest x-ray for a cigarette smoker does not mean the physician condones smoking. If the chest x-ray is normal, the physician doesn't tell the patient to continue smoking! Performance-enhancing drug use is no different. According to the 2001 NCAA Survey of Substance Abuse, athletes ranked physicians last in terms of whom they went to for advice on dietary supplements. In this case, Jim obviously felt comfortable enough with his physician to bring up this issue. I believe it is incumbent on physicians to use each patient visit as a chance to improve the health of his or her patients. This case demonstrates a wonderful educational opportunity to make a positive impact in this patient's life. The physician should embrace it wholeheartedly.

Suggested Readings

  • Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic. Clinical Chemistry. 1997; 43:1262-79.
  • Hoberman J. Sports physicians and the doping crisis in elite sport. Clin J Sport Med. 2002;12:203-8.
  • Catlin D, Murray TH. Performance-enhancing drugs, fair competition, and Olympic Sport. JAMA. 1996;276(3):231-7.
  • Murray TH. The ethics of drugs in sport. In: Richard H. Strauss, ed. Drugs & Performance in Sports. Philadelphia, Pa.: WB Saunders Co. 1987;11-21.

Gary A. Green, MD, is a fellow in the American College of Physicians and American College of Sports Medicine. He is a clinical professor in the UCLA School of Medicine in the Division of Sports Medicine and is in private practice at the Pacific Palisades Medical Group, Pacific Palisades, Calif.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.