Boxing, mixed martial arts, and other risky sports: is the BMA confused?BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6937 (Published 01 November 2011) Cite this as: BMJ 2011;343:d6937
- Daniel K Sokol, honorary senior lecturer in medical ethics, Imperial College London, and barrister
The BMA’s handbook Medical Ethics Today states unequivocally that “competent adult patients have the right to refuse any medical treatment, even if that refusal results in their permanent physical injury or death.”1 Yet the BMA’s latest statement on its proposed ban on boxing and mixed martial arts states with equal certitude that “the BMA’s opposition to boxing [and mixed martial arts] is based on medical evidence that reveals the risk not only of acute injury but also of chronic brain damage in those who survive a career in boxing.”2
These two statements are difficult to reconcile. On the one hand the BMA says that we should respect Mr Smith’s decision to refuse lifesaving antibiotics for his septicaemia but on the other that we should not respect Mr Smith’s decision to step into a boxing ring against a consenting opponent. The consequence of not intervening in the first case is probable death; in the second, perhaps injury and a minuscule chance of death.
The principle of respect for autonomy forms a cornerstone of modern medical ethics. The principle requires, subject to limited exceptions, that people be allowed to make decisions about how they want to conduct their lives. This principle underpins the BMA’s position that patients have a right to refuse treatment, a right that is itself anchored in the liberty principle, most clearly put by John Stuart Mill in On Liberty (1859): “The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.”3
For Mill, and for most democratic societies, this principle ensures that people can develop and flourish according to their own individuality. A democratic society thrives on this diversity. The liberty principle is entrenched in English law and embedded in many of the protections granted by the European Convention on Human Rights.
Why, then, should respect for autonomy, at work with Mr Smith the septicaemic patient, not apply to Mr Smith the boxer?
“The patient Smith harms only himself,” you might reply, “whereas the boxer Smith harms himself and his opponent.” This objection, however, is valid only if the opponent objects to stepping into the ring. Mr Smith’s opponent benefits from the liberty principle as much as he does. Yet there are limits, in law and in ethics, to what individuals can consent to. I cannot lawfully consent to someone causing me grievous bodily harm, unless the activity falls within an exception, such as surgery, tattooing, and boxing. In its call to remove boxing and mixed martial arts from the list of exceptions, the BMA invokes the risk of medical harm.
There is little empirical evidence on the dangers of mixed martial arts, in part because the sport is relatively new. More evidence may exist on other combat sports, such as judo and karate. Since its inception in 1993, when rules and safety precautions were few, mixed martial arts has sought to protect competitors by requiring the wearing of gloves, gum shield, and protective cup under the shorts.4 Competitors are also required to undergo a range of medical tests, including magnetic resonance imaging, HIV and hepatitis tests, and an ophthalmic examination.5 Contrary to common belief, the sport of mixed martial arts is not “no holds barred” but contains 31 possible fouls, including head butting, strikes to the groin, throat, and back of the head, and abusive language.
One study examined data from 635 mixed martial arts fights that took place in the state of Nevada between March 2002 and September 2007.6 It concluded that when regulated the sport has low rates of critical sports related injury and that rates of acute injury are similar to those in other combat sports. Mixed martial arts bouts have fewer rounds than boxing, and the focus on the whole body rather than the head and torso means that blows to the head are likely to be rarer than in boxing. If medical harm alone is the issue, it is curious that the BMA does not call for a ban on other risky sports, such as skiing and taekwondo.
In 2007 I attended as part of a research project a mixed martial arts championship. To my oafish eyes it was skilful, fair, and entertaining (although as a traditionalist I prefer boxing under the Queensberry rules). There was less blood on show than in many of the matches of the recent Rugby World Cup. Still, I can appreciate why others may find it offensive. If we accept the liberty principle, however, offensiveness to some does not justify banning it for others. In a free society there should be a gulf between disapproval of an activity and banning it. Tut-tutters need not watch the fights. They do not take place in public places.
If studies show that mixed martial arts, boxing, or indeed any other sport is dangerous, doctors should emphasise the dangers, insist on safety precautions, and even discourage participation on medical grounds. We should be wary, however, of assuming that a person’s best interests amount to no more than his or her or medical best interests. How impoverished life would be—and how much slower human progress—if our desire for health conquered all other desires. Would Mount Everest have been scaled, the oceans’ depths plumbed, or Antarctica explored?
Even if we concede the gravity of the physical harms of combat sports, it is Mr Smith who is normally best placed to decide whether the activity is, all things considered, in his best interests. The BMA’s stance on this issue, which seeks to impose its own moral value on others, is at odds with its emphasis on respect for autonomy.
In the debate on the fighting arts, Mill’s pithy statement is apposite: “Over himself, over his own body and mind, the individual is sovereign.”3 At present this is a philosophical knockout. Further empirical studies could change the outcome. There are limits beyond which a civilised society should not go. If two goliaths stepped into an arena, even with consent, and fought with clubs until one was dead, the liberty principle would give way. But we are not there yet.
Cite this as: BMJ 2011;343:d6937
Acknowledgements: Many thanks to Ronald Sokol, James Wilson, Georges Sokol, Samantha Sokol, and John Spicer for their helpful comments.
Competing interests: DS, in his capacity as a journalist and researcher, obtained a free standard ticket to the MMA competition in 2007. The organisers of the event imposed no conditions on the free entry.