Ethics in sports medicineBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3898 (Published 29 September 2009) Cite this as: BMJ 2009;339:b3898
All rapid responses
Dr Nicholas S Peirce and the other honourable gentlemen from the
medical panel of the England and Wales Cricket Board claim that we base
our editorial almost entirely on a single case and that ethical standards
in sports medicine are high, well developed and routinely adhered to.
But they seem to have misread our editorial and also not to be aware
of the revelations of sharp practice that have come to light in the
aftermath of the Bloodgate incident in Rugby Union, or of the more general
involvement of health care professionals in securing victory for their
team in ethically problematic ways.
With regard to the misreading they read “medical doctor” where we
wrote “health care professional”. In the Bloodgate incident there were two
health care professionals involved (1). The physiotherapist who supplied
the fake blood capsule to the player to produce a “blood injury” on the
playing field and the medical doctor who allegedly cut the player’s lip
afterwards to produce a real injury and prevent detection of the fake.
Both were health care professionals bound by ethical codes of conduct.
The investigation into the Bloodgate incident found that the team had
produced similar fake injuries before. And other evidence shows that other
methods for producing blood injuries were common in high level rugby,
including making incisions that could be opened if the production of a
blood injury was needed (2). What happened was not a unique incident and
we have no reason to believe that other health care professionals were not
involved, for instance in the incision and suturing involved in preparing
potential injuries. Nor is there any reason to suspect that rugby union
is alone in suffering such ethical problems, it is after all the form of
Rugby played by gentlemen and not by working class Northerners (sic!).
Professor Galasko sadly makes the same error as the Gentlemen from
the ECB in that in response to our pointing out various ethical issues
faced by healthcare professionals in sports he goes on to discuss only the
role of the team doctor (complex as it is).
Moreover, his suggestion that “The fact that players feign pain and
injury in many competitive football matches , for example, only to recover
miraculously once the foul has been rewarded has nothing whatsoever to
with Sport and Exercise Medicine . This is a decision made by a player on
a field without any intervention of medical staff.” is easily rebutted as
the “bloodgate” affair showed. There are also more mundane or at least
less dramatic ways in which to collude in unethical behaviour.
We know from other sports than rugby that health care professionals have
been involved in activities that, although not harming the player had as
their only goal to benefit the team in an illegitimate way, for instance,
by time-wasting when their team or player is in a winning position.
The rules of football (soccer) now for instance contain rules requiring
the immediate removal of an injured player to minimise any potential for
time wasting by players and team doctors:
“The referee must adhere to the following procedure when dealing with
• play is allowed to continue until the ball is out of play if a
player is, in the opinion of the referee, only slightly injured
• play is stopped if, in the opinion of the referee, a player is
• after questioning the injured player, the referee may authorise
one, or at most two doctors, to enter the field of play to assess the
injury and arrange the player’s safe and swift removal from the field of
• the stretcher-bearers should enter the field of play with a
stretcher at the same time as the doctors to allow the player to be
removed as quickly as possible
• the referee must ensure an injured player is safely removed from
the field of play
• a player is not allowed to receive treatment on the field of play”
(FIFA Rules of the Game 2009/2010, p. 67).
And tennis, hardly a sport for ruffians, has strict rules concerning
the time limits for medical assistance before the player has to retire and
forfeit the game.
Now it is a fact of almost all medical practice that there are
ethical pressures and that these are “routinely managed without incident”
as pointed out by the honourable gentlemen. But “routinely managed” does
not entail that the ethical pressures do not sometimes lead to unethical
behaviour in medicine. Apart from the honourableness of the gentlemen of
the ECB medical panel we have no reason to believe that sports medicine
differs in this regard.
Is it also worth pointing out that the example they use, that
specialists in sports medicine keep medical information confidential when
asked by journalists, is not an example of a serious ethical conflict. In
these cases the doctor’s self-interest and the ethically right action
align themselves. Any team doctor who spoke too much to journalists would
soon be out of a job.
Finally, we are well aware of the existence of a new more broadly
focused Faculty of Sports and Exercise Medicine. We simply wished to
focus our Editorial on the narrower aspect of sports medicine as a branch
of occupational medicine applied to elite sports. There are, of course,
any number of issues arising in public health ethics that may impact upon
sports and exercise medicine professionals. They were simply not our
concern here, hence the deliberately restricted title of the Editorial.
Like Professor Galasko we very much look forward to contributing to the
consultative process of a new Professional Code.
1 European Rugby Cup Decision of Appeal Committee in Appeal by Roger
O’Connor, ERC Disciplinary Officer. 17 August 2009.
2 The Telegraph. Bloodgate: scandal opens the doors to a world of
sinister practice in rugby.
Competing interests: No competing interests
Re: Ethics in Sports Medicine . Professional Standards need to be
clarified and acted on .
By: Holm and McNamee, BMJ, 2009;339:b3898
This article is out of date. Sports Medicine in the UK has been
taken over by the new medical speciality of Sport and Exercise Medicine.
Although the new specialty was only recognised in 2005 and the Specialist
Medical Order was amended by Parliament in 2005 to create the new
speciality the term, “Sport Medicine” was replaced in the UK by “ Sport
and Exercise Medicine” many years ago. For example BASM ( The British
Association for Sport and Medicine” changed to BASEM ( The British
Association for Sport and Exercise Medicine) in 1995 as did the Institute
of Sport Medicine , becoming the Institute of Sport and Exercise
Medicine. This is because of the recognition of the importance of
exercise not only in promoting health but in treating a number of
The medical care of elite athletes is one branch of Sport and
Exercise Medicine and it is unfortunate that in the title of their
editorial Professors Holme and McNamee do not appear to be aware of
the developments that have occurred in the UK over more than a decade.
The fact that players feign pain and injury in many competitive
football matches , for example, only to recover miraculously once the foul
has been rewarded has nothing whatsoever to with Sport and Exercise
Medicine . This is a decision made by a player on a field without any
intervention of medical staff.
They are correct that the role of a Club doctor is a very complex
one. Often the Club doctor has 3 distinct roles because of his/her
responsibility to the Club which employs the doctor either on a full
time or part time basis. The first role is akin to that of occupational
medicine advising the Club about the health of their employee.
Secondly, the doctor has a responsibility to the sportsman/sportswoman
who has been injured and the prime responsibility must be the care of
the patient. Thirdly, the Club doctor may act as the General
Practitioner . Many footballers from abroad do not register with a
General Practitioner and rely on the Club doctor to undertake this role
in addition to the other two.
The Intercollegiate Faculty of Sport and Exercise Medicine (UK),
which was established once the speciality was recognised and is
responsible for setting the standards in the specialty, is aware of the
difficulties faced by doctors treating elite professional athletes and
has been working on a “ Professional Code” for some time , and which
should be available for consultation within a few weeks . It also
published, fairly recently, advice about indemnity for these doctors.
Professor Charles S B Galasko
Consultant Orthopaedic Surgeon
Emeritus Professor, University of Manchester
Faculty of Sport and Exercise Medicine(UK)
Competing interests: No competing interests
The article published in the BMJ by Søren Holm and Michael McNamee
raises important questions regarding medical standards but unfortunately
appears to have been written with little working knowledge of the field of
Sport and Exercise Medicine (SEM). Instead assumptions have been made,
based almost entirely on a single well publicised case, that of an
Accident and Emergency doctor, operating in isolation and neither
representative of nor trained as a Specialist in Sport and Exercise
Holm and McNamee acknowledge that the field of Sport and Exercise
Medicine is littered with ethical dilemmas, most notably the pressurised
arena that is elite sport. However, they show little appreciation of the
conduct of practitioners in this field, who have evolved into highly
experienced and skilled specialists. Even though the authors correctly
identify a number of pressures arising from athletes themselves, coaches,
agents, families and even, on occasion, other medical practitioners, they
fail to recognise how routinely these are managed without incident.
Sports medicine specialists frequently have to maximise patients care
while navigating carefully both in the public eye and with the potential
for conflicts of interest, whether it be the club, the player, an
international team or even other health care professionals. How common is
it for other specialties to be approached outside hotels, ground or on
occasion their own homes for an ‘off the record comment’? Therefore, to
meet these predictable ‘ethical situations’ the curriculum in SEM,
currently being undertaken by more than thirty higher specialist trainees,
looks to ensure these competencies are appropriately developed.
The authors of the piece suggest that the field of Sport and Exercise
medicine has not evolved professional ‘norms’. This is inaccurate. The ECB
Medical Panel and we expect many other Sporting bodies have a clinical
governance framework that address many of these ethical dilemmas.
Although SEM has only relatively recently been granted specialty status,
the expertise of its practitioners is well established. The ECB medical
panel demands individuals have a minimum of 10 years full-time experience
in elite sports medicine and a Fellowship of the Faculty of SEM, which
importantly is producing professional guidelines. Thus, we would argue
that in a situation where a doctor deliberately cuts a player to create an
injury there has been a breach of good medical practice, out with of any
answerability to SEM . Our paradigm is of course to do no harm and to this
end the professional code of conduct of a SEM practitioner is no different
to any other specialty.
Competing interests: No competing interests
Holmes and MacNamee’s timely editorial highlights the ethical
dilemmas that are unique to sports medicine because of the unusual
clinical environment of caring for players within the context of a team
whose primary objective is to win. This article is very welcome, however,
it pays insufficient attention to the very important area of patient
autonomy. In sports medicine, the traditional relationship between doctor
and patient may be distorted or absent. The emergence of a Doctor-Patient
-Team triad has created a scenario in which the team’s priority can
conflict with or even replace the doctor’s primary obligation to player
‘There’s no ‘I’ in team’
This cliché is a frequent exhortation in pre-match team talks. It
advocates neutralizing individualism which might detract from the team
effort. Whilst there’s no ‘I’ in team, there is an ‘a’, and ‘a’ stands for
autonomy. Respect for a patient’s autonomy is considered a fundamental
ethical principle. Autonomy refers to the capacity of a rational
individual to make an informed, un-coerced decision. This belief forms the
central premise of the concept of informed consent. Although the paymaster
in professional sport is the team, sports medicine doctors cannot abdicate
their responsibility to the individual player. They must be cognisant of
the fact that the player is often under external pressure from teammates,
coaches, and agents as well as internal drives and goals that may
influence their treatment decisions (2). In fact, there is a
responsibility on the team doctor to tease out the extent of influence on
a player to make a certain decision in the process of informed consent.
The sports team doctor should avoid becoming over-involved with the
team management to ensure that ethical principles do not get overlooked in
the pursuit of victory. It is imperative that a degree of professional
distance is maintained in order to achieve this. Clear lines of reporting
need to be established in professional sport, where the team doctor is not
answerable to the management team but reports directly to a medical
director or medical committee.
1. Johnson R. The unique ethics of sports medicine. Clin Sports Med.
2. Bernstein J, Perlis C, Bartolozzi AR. Ethics in sports medicine. Clin
Orthop Relat Res. 2000 Sep; 378; 50-60.
Competing interests: No competing interests