AMA Journal of Ethics^®

Case

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 2

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.