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
All rapid responses
Regarding the anti boxing stance of the BMA,1 Sokol suspiciously wonders if medical harm alone is the issue, why the BMA does not call for a ban on other risky sports, such as skiing and taekwondo.2 Part of the answer can be found (in the same issue of the BMJ) in Schachter’s attack on the attitude of some of the medical profession’s intelligentsia concerning the pharmaceutical industry,3 which I think is a generalised attitude applicable to other distasteful concepts such as boxing. A change of one word in Schachter’s statement expresses my point: “Although to some extent based on valid ethical considerations, much of it seems to be the prissy, sanctimonious snobbery of much of the English professional middle class, who do not want to be associated with those frightfully vulgar people in boxing.” The BMA admit to disliking the intent of the boxer to cause harm and this value judgement makes perfect sense to the medical profession who of course must do no harm. But is it right to impose a negative judgement of this intent on the consenting sportsman undertaking his sport of choice, who blends his intent to harm with respect for his opponent? To assume that rugby or motor racing injuries are devoid of intent to harm or to win at any cost is naïve and unscientific. Sokol reminds us that medical best interest does not equate to best interest and discusses the ethical concept of the boxer’s autonomy. These important issues were not adequately expanded apon in BMA: boxing. The scientific case against boxing is real and is well set out by the BMA in BMA: boxing, but it can be undermined by middle class value judgements of our profession. Ethically, the boxer would benefit more from the legal need to make a capacitous decision of informed consent or informed discontinuation rather than a paternalistic ban bypassing his or her autonomy, which is inconsistent with the ability to refuse treatment. The medical case against boxing is stronger if it is not contaminated by elitist value judgements. 1.BMA. Boxing, 2008. www.bma.org.uk/health_promotion_ethics/sports_exercise/boxing.jsp 2. Sokol D. Boxing, mixed martial arts, and other risky sports: is the BMA confused? BMJ 2011; 343:d6937 3. Schachter M. Spare me the English middle class’s snobbery about trade [Letters] BMJ 2011; 343:d7026.
Competing interests: David Ingle has boxed as an amateur and is a member of the medical profession.
In our medical philosophy is beneficence, no maleficence, but everything is subordinate to the autonomy that each patient as a person has. Risks and benefits form part of every decision, and given that we offer advice to people from every risk group in our city, so do we to boxers or martial arts sportsmen. They have a tendency to suffer from cerebral disorders of intense or chronic evolution.
In the same way that patients with terminal illnesses have to make a decision between agreeing or not to chemotherapeutic treatment, we help to determine the road that each person desires to live his or her life assuming risks or accepting the benefits that we can offer.
Competing interests: No competing interests
As someone who has been involved in the martial arts for 35 years,
including participation in Mixed Martial Arts (MMA) and its sub-
disciplines - boxing & Olympic freestyle wrestling - for the past
decade, I concur wholeheartedly with Sokol's analysis of the BMA's
The BMA's policy is not evidence based, and as Sokol has ably pointed
out, is based on a partial interpretation of ethics. Indeed, given the
current epidemic in obesity & physical inactivity, you would have
thought that the BMA would be actively supporting endeavours such as MMA
which promote determination, persistence and above all physical fitness.
The MMA gym that I train at has members from a wide range of ages and
includes a number of female members. It is open 6 days a week and many of
the younger members train every day. MMA is one of the fastest growing
sports in the world and is inspiring a whole generation of young people to
become physically active. Many of the current British MMA stars, including
Michael Bisping, Dan Hardy and my own coach Paul Taylor have become strong
positive role models - indeed for many young people MMA is their first
introduction to strenuous physical exercise.
MMA disciplines will also have longer term benefits. My original
wrestling coach, now in his 70's, is still going strong, as are a number
of wrestling coaches in the North of England who are well into their 80's
and who are still teaching the "youngsters" a thing or two.
It has recently been announced that the Summer Olympics of 2012 will
include female boxing for the first time. I would suggest that this
provides a good opportunity for the BMA to review its current position
with regard to MMA and the fighting arts.
Competing interests: Active martial artist & MMA practitioner
Re Paul Pharoah's response - "seems offensive" is surely a personal
belief rather than an absolute certainty? The whole point of the well-
written article is that it is for Mr Smith to decide for himself whether
he wishes to take risks, and not for people who have a different viewpoint
to tell Mr Smith what he can and cannot do to and with himself (and any
other competent and consenting adult).
An equal argument could be applied to the compulsory wearing of
motorcycle helmets, and to any other activity in which an individual is
deprived of his/her autonomy to make his/her own risk assessment.
Competing interests: No competing interests
I am no ethicist, but it seems to me that the purpose or aim of an
activity are relevant. When Mr Smith chooses managment option A (no
treatment) over management option B, presumably the purpose of this is not
deliberate self harm. He may be misguided in his belief about the
outcomes of A and B, but that is not the issue. In contrast, the primary
aim of boxing is to cause your opponent brain damage - the primary aim of
boxing is to knock out your opponent. There does seem something rather
offensive about this. That other activities may result in greater harm is
irrelevant, provided that that harm is not the aim of the activity.
Competing interests: No competing interests
The gloves are off
Against the ropes, Professor Nathanson from the BMA is fighting
The bottom line is that the BMA is opposed to boxing on the ground
that it is medically contra-indicated, whatever the evident countervailing
benefits. Like it or not, it is a paternalistic position. I worry the
BMA will soon call for a ban on cheese.
In her response, Professor Nathanson conveniently ignores mentioning
other, more dangerous sports. It is this inconsistent approach and the
language used in their opposition to boxing that leads me to conclude that
the BMA's view is also affected by a perception of 'offensiveness'. One
can discern this from Professor Nathanson's remark that boxing is "a sport
whose goal is the physical degradation of an opponent".
Professor Nathanson comments that "autonomy is not a one-size-fits-all principle". For the BMA, the principle only protects what it
Competing interests: I am the author of the article
Somewhat naively, Dr Sokol assumes that John Stuart Mill's defence of
individual liberty clarifies the scope of state responsibility in relation
to its citizens. It does not and cannot. Mill's harm principle is
notoriously plagued by definitional difficulties. Most obviously, in
complex societies such as ours, the distinction between harms to self and
harms to others is far from clear. If individual autonomy is always to
trump collective interests we would have no motorcycle helmet legislation,
no seat belts and punitive taxation on harmful substance such as tobacco
would be ruled out of court. The clear benefits of these interventions
have meant that opposition to them has been muted.
Rhetorical appeals to liberty are easy to make, but reality is more
complex. The interests of individuals and of society cannot be so glibly
separated. We thrive as autonomous individuals because of, not in spite
of, collective social goods. The BMA's public health work - its campaigns
against smoking, alcohol abuse and boxing - draws on the fundamental
insight that a respect for individual autonomy requires attention to the
conditions that make autonomy possible. The state restricts our autonomy
in all kinds of ways in order to promote both our interests and the
interests of the community - that is why we pay income tax.
Somewhat tendentiously, Dr Sokol suggest that the BMA's call for a
ban on boxing is linked to its 'offensiveness', implying therefore that it
is a matter of individual taste. The BMA's opposition to boxing is based
on medical evidence. In 2007, the BMA Board of Science reviewed the
evidence and reaffirmed the BMA's position based on the injuries caused by
boxing, they include:
*Brain damage - the blows received during boxing cause the brain to
move with the skull, damaging blood vessels, nerves and brain tissue
*Acute brain haemorrhage - this is the primary cause of boxing-
*Eye, ear and nose damage - in some cases boxing causes permanent
sight and hearing loss
Sokol rightly points out that the BMA unequivocally supports a
respect for competent patients to refuse medical treatment, even if the
refusal results in their death. To treat a patient in these circumstances
would amount to assault. Granted this is an argument from legal reality
not principle. Autonomy however is not a one-size-fits-all principle. It
is of necessity expressed differently in different contexts. A refusal of
medical treatment is based on the requirement to respect bodily integrity.
It makes a very different demand on the principle than the 'right' to take
part in a sport whose goal is the physical degradation of an opponent. To
suggest here that Mill's harm principle is a 'knock-out' is to risk
reducing a matter of considerable public interest to philosophical
triteness. It is Sokol's simplistic appeal to the principle of autonomy
that is confused, not the BMA.
Competing interests: Professor Vivienne Nathanson is Director of Professional Activities at the British Medical Association