Intended for healthcare professionals


Ethics in sports medicine

BMJ 2009; 339 doi: (Published 29 September 2009) Cite this as: BMJ 2009;339:b3898
  1. Søren Holm, professor of bioethics12,
  2. Michael McNamee, professor of applied ethics3
  1. 1Centre for Social Ethics and Policy, School of Law, University of Manchester, Manchester M13 9PL
  2. 2Section for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway
  3. 3Department of Philosophy, History and Law, School of Health Science, Swansea University, Swansea SA2 8PP
  1. Correspondence to: S Holm soren.holm{at}

    Professional standards need to be clarified and acted on

    Doctors and other healthcare professionals have been involved in facilitating both legitimate and illegitimate performance enhancement in sport.1 2 The recent “bloodgate” affair in Rugby Union shows that healthcare professionals can be involved in producing fake injuries in situations where the apparent “injury” creates an advantage for the team.3

    The incident happened last April at the semifinals of the European Rugby Cup match between Harlequins and the eventual winners Leinster. Normally in Rugby Union players cannot return to play once they have been substituted except to replace a player who has a “blood injury.” A Harlequins player produced an apparent blood injury through the use of a fake blood capsule so that a specialist goal kicker could be brought back on to the field to try to secure victory in the last few minutes. At the behest of the head coach, the team physiotherapist had purchased fake blood capsules in advance of the game and had delivered one to the player during the match. At the European Rugby Cup hearing he admitted having done this on four previous occasions.3 The physiotherapist has received a two year worldwide ban from the sport. It is also alleged by the player that the team doctor reluctantly cut his lip with a scalpel after the incident to produce a real injury, although the European Rugby Cup panel declined to consider the allegation on the grounds it had no jurisdiction to do so. The doctor has since been suspended by the General Medical Council, pending investigations.4

    Further underhand practices have emerged since the Rugby Union incident. Players have told of the deceptive use of blood soaked towels and the opening up of stitches in previous minor wounds to obtain an illicit blood injury substitution.5 What can we learn about the ethics of sports medicine from the bloodgate case and other instances of cheating facilitated by healthcare professionals?

    That healthcare professionals are involved in such activities is no surprise, unless we believe that healthcare professionals involved in sport have ethical standards that diverge radically from the ethical standards of players. Players feign pain and injury in many competitive football matches, for example, only to recover miraculously once a foul has been awarded. Ethical standards may be higher and more deeply entrenched among healthcare professionals than among professional footballers, but healthcare professionals are not all saints.

    We should focus attention on the complex environment inhabited by healthcare professionals who work in elite sport. They may overidentify with the goals of the team. They are also working in contexts where health promotion is often a secondary concern, both for their employers and for the clients they treat. Participating in elite sports is not health promoting in general. It very often leads to long term health problems, such as irreparable joint injuries or arthritis,6 7 and athletes will sometimes trade their immediate ability to perform against increased risks of long term injury and ill health when they can no longer command high salaries.

    In exploring the ethical issues raised in elite sports medicine, it is useful to draw on experience from other areas of health care that involve inherent conflicts of interest in complex settings—for example, prison medicine and military medicine. Comparing and contrasting patient power in cosmetic medicine with athletes who seek medical interventions that are deleterious to their present or future welfare might also help to frame the discussion better.

    What should be done to ensure that healthcare professionals in elite sports balance possible conflicting interests with the health interests of their clients? Reformulating professional guidelines or teaching ethics using abstract examples is unlikely to be sufficient. Ethical failings do not typically arise from a lack of knowledge about what is the right action. Instead, reconfiguration of the relationship between elite sports organisations and sports medicine is required so that unprofessional action becomes less acceptable. Complicity with the excesses of elite sports by healthcare professionals—for example, by helping athletes to fake injuries or by encouraging them to “play through” real injuries with deleterious long term effects—must be replaced by norms that reinforce commitment to the long term welfare of the athlete and the defining rules of sports. This process could involve securing the independence of healthcare professionals from the clubs and other sporting organisations that employ them and providing forums where healthcare professionals from different organisations can exchange experiences in a non-judgmental setting that encourages professional and ethical reflection.

    Healthcare professionals in younger branches of medicine such as sports medicine might not have had the time to reflect critically on the adequacy of their professional norms. But this can function as a legitimate excuse only for so long. Interestingly, the athletic equivalent of the Hippocratic oath, the Beroia law,8 has existed since the 3rd century BC. The need for ethical standards in sports medicine has not just recently been sprung on us. The Rugby Union scandal has highlighted the need for greater clarity about the nature and purposes of sports medicine, especially in the pressured arena of elite, commercialised sports.


    Cite this as: BMJ 2009;339:b3898


    • Competing interests: None declared.

    • Provenance and peer review: Commissioned, not externally peer reviewed.