Globalisation of anti-doping: the reverse side of the medal

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a584 (Published 4 July 2008)
Cite this as: BMJ 2008;337:a584

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In their timely and thought provoking article Bengt Kayser and Aaron Smith seek to challenge the traditional anti-doping position by certain skeptical strategies and in doing so believe they have put forward a robust anti anti-doping position. I contend that they have not. Their argumentative strategy is that sport should just be considered one among many social practices and regulated by the same arguments, supported by or detracted from the same evidence base And they ask that ruling principles be applied consistently across them all. At first sight this seems reasonable enough. Allow me to point to a few examples, among many possible ones, where this is not good enough. Sports are after all, fabulously peculiar affairs, and doping is after all against the rules of the activity.

First, in their opening postulate they assert that "The reasons advanced for anti-doping policy are flawed and do not warrant strong punishment and costly repression of doping practices" but without argument they assume the very thing they should be arguing for. They offer a caricature of the anti-doping arguments toward the end of the paper but dismiss all possible arguments on the basis of that caricature. It is true that many anti-doping lobbyists or ethicists have real concerns about spiralling costs but this fact does not justify the dismissal of all anti- doping policies.

Secondly, their third postulate declares another important point: "Testing for doping in bodily specimens will never uncover all use of forbidden substances or methods" but it does not follow from the fact that not all cheats will be caught, or that the occasional non-cheat will wrongly be accused, that we therefore ought to abandon the entire anti- doping policy. By analogy consider the traffic laws on speeding which many and perhaps most drivers flout on a regular basis. Extending their logic would warrant the repealing of most criminal laws.

Thirdly, it is true that the whereabout system appears to be an unreasonable restricttion of athlete's individual rights to freedom. Athlete's are not very fond of it yet they recognise that it is the price to pay for "clean" sport. Just like their submission to all rules of sports, athletes accept the restriction of their liberties (if you want to win a boxing match you forego the use of the most effective ways of rendering your opponent defenseless (knives, handguns, etc) for 10 seconds. That is sport for you. It is an exercise in perfecting inefficient means to the desired end.

Fourthly, and this is really the rub, from the fact that certain enhancement technologies are accepted in other parts of society it does not follow that we should allow them in sports. This is partly due to the rule-governed nature of sports alluded to above (they just are socially conservative social practices) and partly because nothing follows from the mere growing acceptance of any given practice for our reflective ethical responses to it. Were, heaven forbid, racist and sexist practices to return to their earlier levels in the UK it would in no way justify their acceptance in sports or anywhere else for that matter. Sports, however jaded in practice, represent genuinely virtuous ideals such as commitment, courage, dedication and honesty. If you don't like that you just don't like idealism.

This is why skepticism just is not enough for Kayser and Smith. What I would like to hear once and for all from the would-be sports libertarians (whose position Kayser and Smith share to an important degree) is a substantial argument as to why governing bodies in national and international sports should accept the line that, after all, if an athlete consents to doping (or any other potentially harmful practice) it is their body and they should be allowed to dispose of it as they see fit with or without the sports medics' assistance. They offer no such argument.

Sports medicine professionals have obligations not merely their profession (that is to the health of their athlete/patient) but also to the integrity of the sports practices in which they ply their trade. Despite the many interesting and valid points the authors raise, many of us still believe in the soundness of the ethics of anti-doping and dismissing it by poor argument or skeptical posture just does not cut the mustard.

Competing interests: The author is Principal Investigator for a project on the attitudes and values of talented young athletes.

Competing interests: None declared

Michael McNamee, Professor of Applied Ethics

Swansea University

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13 August 2008

Having read the article I have difficulty understanding how people could hold such views so opposite to my own (and I suspect the large majority of people). Having served for 10 years on the IOC Medical Commission and Sub-Commission 'Doping and Biochemistry in Sport' and having been undertaking research to develop new methods of detection of growth hormone abuse since 1996 I have quite a wide knowledge of the subject. Have the authors forgotten that 'anti-doping' activities by the IOC were introduced as a result of the death of two cyclists from abuse of amphetamines (one in front of a large audience in an Olympic venue and the other in full view of the media in the Tour de France)? Drug abuse is not only cheating but is not uncommonly life threatening. Surveys have shown that a majority of elite athletes are so driven that they would willing take a drug that would end their life prematurely, so long as they win and don't get caught!

I'm very much in favour of carefully developed and validated drug testing regimes and have published more than 20 peer-reviewed papers on our own research (that has not yet been implemented) and accept that false positives are inevitable but with professional statistical advice (as we have always had) these can be kept to an acceptable level. The sports authorities have never published what they consider an 'acceptable risk' (for a false +ve) but a workshop in our GH-2000 project that included a senior IOC lawyer settled on a risk of 1:10,000 as being 'acceptable' and this figure has subsequently been used in many discussions and publications.

Quot homines, tot sententia!

Competing interests: I currently hold research grants from WADA (jointly)

Competing interests: None declared

Peter Sonksen, Emeritus Professor of Endocrinology St Thomas' Hospital and King's College, London and Visiting Prof

Home SO32 1HP

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I am a signatory to the paper by Kayser and Smith and I plenty agree with the contents of this article (1). Nevertheless, I would like to add a further consideration on the topic of harm prevention in sports. Harm reduction strategy has proved useful and cost effective in the field of illegal drug use, and it is hence suggested as a viable approach to safeguard the athlete’s health towards harm from doping (1-3). It is to mention, however, that harm in sports not only results from doping, but also from an inappropriate management of athlete’s injuries and recovery after strenuous physical efforts (4). The leading role of sport physicians is to preserve athlete's integrity on a large scale. This concept also applies when training regimens, strenuous competitions or fastened recovery from injuries by administration of licit drugs to relief pain or inflammation conflict with the team strategy or the athlete’s wish to compete at any cost. All these issues are important to sports, but ethically irrelevant to medicine. Hence the practical strategy to identify and monitor abnormal and potentially harmful deviations of simple and inexpensive biochemical tests in athletes (the “harm reduction policy”) (1 -3) should be extended to embrace any condition that might be associated with risks for athlete’s health or fitness. Health is always more important than money and fame from success in competitions.

References.

1. Kayser B, Smith AC. Globalisation of anti-doping: the reverse side of the medal. BMJ. 2008 Jul 4;337:a584. doi: 10.1136/bmj.a584.

2. Kayser B, Mauron A, Miah A. Current anti-doping policy: a critical appraisal. BMC Med Ethics 2007;8:2.

3. Lippi G, Franchini M, Guidi GC. Doping in competition or doping in sport? Br Med Bull 2008;86:95-107.

4. Lippi G, Schena F, Salvagno GL, Montagnana M, Gelati M, Tarperi C, Banfi G, Guidi GC. Acute variation of biochemical markers of muscle damage following a 21-km, half-marathon run. Scand J Clin Lab Invest 2008 May 15:1-6.

Competing interests: None declared

Competing interests: None declared

Giuseppe Lippi, Associate Professor of Clinical Biochemistry

Sez. Chimica Clinica, Università di Verona

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I am a signatory to the paper by Kayser and Smith (BMJ 2008;337:a584) and wish to add the following to their critique of current policies restricting access to performance enhancing drugs and punitive sanctions for users.

The use of the word "doping" to refer to a wide array of performance enhancing technologies (drugs, genetic modifications, sleeping in a hypobaric chamber etc) contributes to the demonization and mass hysteria that have dominated this topic for over two decades. It is derived from a word ("dop") that referred to opium and other very dangerous drugs, and a person who used such drugs was referred to as a "dope." It is intentionally pejorative and misleading, and rational discourse would be facilitated if a more neutral term were used; e.g., "Globalisation of policies opposing performance enhancing technologies."

Editors should insist on value-neutral terms. "Doping" is no more appropriate to a dispassionate discussion of performance enhancement than "whoring" in a discussion of medical and social issues in prostitution.

Norman Fost MDF MPH
Professor, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin USA
Director, Program in Bioethics, UW-Madison
Vice-Chair, Department of Medical History and Bioethics, UW-Madison

Competing interests: I have published numerous articles on this topic over the past 20 years

Competing interests: None declared

Norman Fost, Professor

University of Wisconsin - Madison, USA

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12 July 2008

Kayser and Smith's article on doping in sport is thought provoking and interesting, but does appear to totally miss the point that doping is cheating, and the great majority of sportsmen and women are opposed to cheating. I would question that this is a "flawed reason" for trying to eradicate doping - I suspect the average person on the street would agree. It is difficult to combat doping; however Kayser and Smith appear to suggest that it actually doesn't matter too much, as long as people don't harm their health. Or am I missing something?

Competing interests: None declared

Competing interests: None declared

Christopher S Wayte, GP

No 18 Surgery, Bath BA2 3JZ

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This provocative paper challenges some fundamental beliefs about what sport means to participants and society but in doing so it assumes too much.

It assumes that, if doping was legal, elite athletes would have the autonomy to choose which drugs to take and at what dose. In reality, among cyclists at least, there has been tremendous pressure from peers and team officials to use drugs to get results. The current anti-doping culture appears to have banished this but who knows what unscrupulous sponsors would demand in an unregulated sport?

The paper assumes that social drug use is becoming acceptable. Maybe to some but not to me or many casual sports participants and supporters like me. Just because a few people use 'enhancement technologies' doesn't mean that many others accept it.

There is also an assumption that because we can't eradicate doping there is no point in having an anti-doping strategy. Surely its effectiveness lies in creating a culture where doping is not acceptable. This paper exaggerates its arguments ('anti-doping policy may encourage the use of substances in society at large') and in places loses touch with reality ('...[a] police state system where every citizen is regularly tested'). But mostly it forgets that excellence and ethics in sport do actually mean something to many people. In the 2007 Tour de France, the Kazakhstan cyclist Vinokourov scored a remarkable stage victory after having an infusion of someone's blood. Would this have been acceptable if blood doping was legal and his rivals had done it too? Not to me - after all, what would they have achieved?

Competing interests: Non-competitive cyclist and swimmer

Competing interests: None declared

Steve Chaplin, medical writer

Hexham NE46 3JH

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