Fifty years ago, in May 1954, a young English medical student, Roger Bannister, transformed our understanding of human capacity when he became the first to run a mile in under 4 minutes. An accomplishment that many had deemed impossible was now a reality. As news of his record-breaking athletic achievement circled the globe, it was greeted with acclaim and astonishment. The human spirit and the power of human physiology were both celebrated in a singular sporting breakthrough. And as newspaper headlines and broadcasters brought the news of Bannister's feat to an amazed world, I am certain that no one asked, "I wonder what he was taking?" In the 50 years since Bannister's feat we have witnessed the erosion of something special in sport. No longer are spectacular sports performances assumed to be the result of drive and determination. Pharmacology and steroid biochemistry are now immediately suspected as the force behind any unusual accomplishment.
In a few weeks the Games of the Athens Olympics will begin. For months our attention has been drawn to the antics of a so-called nutritional consultant and the behaviour of athletes in his "care" as revelations and allegations of drug use swirl around US track athletes and professional baseball and football players. A "designer" steroid emerges as a factor in their training. In Europe, stories of the use of recombinant hormones and the role they play in modern endurance events are commonplace; in Australia, a doping scandal envelops a prestigious national training centre; and the public becomes increasingly cynical and dispirited about the state of contemporary sport. Olympic ideals, the spirit of fair competition, and principles of sportsmanship seem to be more remote than ever.
I wrote on this topic several years ago in my anniversary commentary for The Physician and Sportsmedicine, and my concern remains strong.1 "When will we face the fact that we're producing some really ugly, violent young men in sport?" asked a friend of mine, an internationally prominent basketball coach. Gratuitous violence; doping scandals; the antics of overzealous parents and unscrupulous officials; the perversities of some collegiate sport; the emotional, physical, and even sexual abuse of athletes; hazardous training practices—at times it seems as though the sports community is a nightmare of iniquitous, bizarre, and unethical behaviour. The bloated salaries of professional athletes and the machinations of team owners have only added to a growing sense of disenchantment and disillusionment.
Most of us who have become involved in sport as physicians have done so because of an athletic past, a concern with physical activity and the role it plays in securing and enhancing well-being, an appreciation of the important and positive cultural force that sport has represented in most societies, and a belief that sports experience can shape lives and mould values.
As sports medicine physicians, we have unique responsibilities to the athletes in our care, the sports organizations we work for, and the ideals of sportsmanship and fair competition. It is easy at times, when caught up in the pressure and excitement of competition, to lose sight of that full range of responsibilities. The temptation is to focus only on the individual athlete's capacity to perform, while ignoring the broader implications of the physician-patient relationship or the need for leadership in addressing the range of complex problems that bedevil contemporary sport.
A primary responsibility is to protect athletes' health and well-being in the broadest possible sense. Superficially, this role may seem perfectly compatible with the interests of the sports organization with which we and the athlete are associated. However, what's best for an athlete's long-term health may conflict with an organization's short-term interest in performance and victory. As a result, we may have a problem of divided loyalty, which raises significant questions about the ethical practice of our profession.
Given these trends, what are our responsibilities to athletes, athletic organizations, and the sports world? We must lend our training, experience, and scientific perspective to the identification and resolution of a range of sporting issues:
Intervene with patients. Physicians who care for high school or community-based athletes can help their patients—and often patients' parents—to place sports aspirations in a realistic perspective. Physicians who care for college athletes can intervene to minimize risk-taking behaviours and use their role and credibility to counsel on a range of health issues.
Speak out. We can be credible spokespersons for the elimination of gratuitous violence, the enhancement of safety, and the disavowal of harmful training practices and environments. An involvement with sport may endow physicians with enhanced leadership opportunities within the community. Use that credibility to encourage and support the development of sports programmes that emphasize participation, safety, and respect.
The high rate of athletic injury is a significant public health concern and remains a challenge for sports medicine organizations and their memberships. We have a particular responsibility to speak out about rules and behaviours that compromise health and safety or impose unrealistic demands on athletes.
Stand Up. Physicians must recognize their special obligation regarding doping. Antidoping rules should be clear, consistent, scientifically based, and focused on performance-enhancing substances. Sports should feature competition among athletes, not contests among biological preparations. It is clear that many of the doping practices which plague segments of modern sport could not take place without the involvement of misguided and malevolent physicians and scientists. The administration and titration of recombinant hormones, the development of "designer" steroids, and the supervision of strategies intended to deceive or distort doping control procedures are not the practices of an ethical sports physician or scientist. In the past, efforts to deter or detect doping have focused on athletes. Perhaps it is now time for greater scrutiny to be placed on the conduct of that small minority of our colleagues who are directly involved in doping practices. They should be removed from sport.
Exercise Leadership. A fundamental step to promote ethical conduct in sports medicine would be the development of a "Sports Medicine Code of Ethics." Such a code would illuminate our obligations, identify the tenets of responsible professional practice in the sports arena, and provide for the sanctioning of those who violated its fundamental, underlying principles. A commitment to such a code of ethics might be a prerequisite to any appointment to a sports medicine position, involvement in the care of athletes and teams, and a condition of membership in any sports medicine organization. Its development and application should be a priority.
Most of us continue to be involved in sports because of our own positive experiences. We understand the powerful role of sports in the physical and emotional development of youth, and recognize the importance of exercise to the health of the communities we serve. We also acknowledge that sports can be a powerful and positive cultural force that requires, and deserves, thoughtful stewardship. If we engage in that stewardship by helping sports institutions confront broad social issues and by lending our ethical perspective to the resulting debates, we can help create a sports culture that encourages fair competition and truly promotes the well-being of athletes and society.
Pipe A. Reviving ethics in sports: time for physicians to act. The Physician and Sportsmedicine. 1998;26:39. Available at: http://www.physsportsmed.com/issues/1998/06jun/pipe.htm. Accessed June 25, 2004.