AMA Journal of Ethics^®

Case

Dr. Robles is a sports medicine specialist in a group practice in a major urban area. While some of her patients compete in professional sports, she also serves many younger athletes. She is an active member of several local professional societies, and she often attends conferences with her colleagues in sports medicine around the country.

Today, she is asked to see 18-year-old Alison, a high school senior and a promising soccer player. Alison has an impressive record as a center forward, and her team is poised to enter a national championship. Alison feels her performance in this competition may also influence the scholarships she hopes to be offered when she enters college in the next academic year.

As Dr. Robles enters the room, she sees that Alison is obviously uncomfortable, holding an ice pack to her knee. After a brief history and physical exam, Dr. Robles concludes that Alison has injured her anterior cruciate ligament (ACL). She says that Alison cannot play a cutting and pivoting sport like soccer with an ACL-deficient knee because it could risk further, irreversible damage to the articular cartilage and menisci.

Alison leans forward. “I understand what you’re saying, but the championships are on the line. I have to play in this game. The school won’t let me play without a doctor’s note.”

Dr. Robles shakes her head and says, “I cannot recommend that you return to play with your knee injury.”

Alison thinks for a moment, and then asks, “Well, what if you write a note to the school saying that, although you don’t recommend that I play, I’m legally an adult now, and I accept the risks you’ve explained to me. Then I can just play with a knee brace—and all of the liability falls on me.”

Dr. Robles is taken aback, but quickly regains composure and reemphasizes her conservative recommendations. Alison repeats her suggestion—that Dr. Robles should write a note explaining that it’s okay for Alison to decide whether to play or not, so long as she assumes liability for playing on the injured knee. Dr. Robles wonders if Alison understands the long-term implications of further damage to her knee.

Commentary

Medical ethics are involved in almost every decision a physician makes. Fortunately, most decisions are simple and motivated by a desire to help the patient. Administer the appropriate antibiotic, or recommend and execute the correct surgical procedure, and there are no conflicts. The problems arise when ethical principles conflict with one another.

The four major ethical principles in Western medical ethics are respect for autonomy, beneficence, nonmaleficence, and justice [1]. Respect for autonomy is respect for a patient as a decision maker; an adult person of sound mind has the right to make decisions about his or her body. Beneficence is the obligation to do good on behalf of the patient. Nonmaleficence is the obligation to avoid harming the patient. And justice is fairness in the distribution of health care resources, as well as respect for the law.

This case demonstrates the tension between the ethical principles of autonomy and nonmaleficence. Autonomy again refers to the principle that an adult person of sound mind has the right to make decisions about the treatment of his or her body. At its core is respect for a patient’s dignity and ability to choose the best course of treatment. When beneficence is determined to outweigh respect for autonomy, we call this paternalism—the idea that the more educated and trained physician makes decisions on behalf of the patient to best further that patient’s interests.

Alison is a legal adult of sound mind who feels it is in her best interest to play soccer even though she has an ACL tear. She clearly understands that playing with a torn ACL puts her at risk for further injury, as she herself states that she will assume the risks for that potential scenario. For her, playing in a high-profile game could have many benefits, perhaps college scholarships and perhaps even a future in professional sports. In recent years we have seen professional athletes make such decisions, such as when quarterback Philip Rivers played in a National Football League game with a known ACL tear [2]. But Dr. Robles, mindful of nonmaleficence, is hesitant to leave the decision to Alison, because she is concerned that Alison will further damage her knee—suffer harm—and that she, Dr. Robles, will have allowed this to happen. Nonmaleficence trumps respect for autonomy. An extreme example would be a patient requesting the amputation of a healthy leg. Harming the patient is not permissible just because the patient wants it and is of sound mind.

If Alison wishes to play against medical advice, she can take that up with her athletic department. Dr. Robles, however, should not clear her for sport. Furthermore, Alison is asking Dr. Robles, in effect, to deceive in her professional capacity. Society and patients put their trust in physicians because of an expectation that physicians will be, among other things, truthful, and to deceive—even indirectly—would violate this trust. Dr. Robles cannot control what Alison does after she leaves the doctor’s office, but her obligation as a physician is to inform Alison of the risks of playing with an ACL-deficient knee and advise Alison against playing.