Should athletes be allowed to use performance enhancing drugs?
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6150 (Published 22 October 2013) Cite this as: BMJ 2013;347:f6150All rapid responses
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People are using performance enhancing drugs because they want to take unfair advantage over the competitors. It is a major problem and health hazard to the participants. We take punitive approach but and a lot of effort is spent in outsmarting the screening process. There is a possibility that many participants are and coaches not sure about the status of their opponents. So the bias is tilted towards taking the unfair advantage but a major effort is focused to evade detection.
We need to debate on an experimental new normal. Participants won't be punished if they fail drug screening test. They will be simply put to a new group. Let us see the preference of participants and difference in records. A lot of levers should be in a perfectly aligned position to give someone an unfair advantage over opponents. Performance enhancing drugs may be just one of these with very little positive impact on performance. Reliance on performance enhancing drugs may reduce the body’s natural ability to respond to demanding physical requirement.
We have no double blind, randomized, placebo-controlled study on this and we also understand the complexity of getting it approved by ethics committee. Let us take an alternative situation to shed some light on this situation.
It is now generally understood that high frequency traders (HFTs) are dominating the equity market, generating as much as 70% of the volume. According to one study, at the current phase of markets’ development, it is theoretically possible for algorithmic trading (and especially high- frequency strategies) to exceed the returns of index strategy. However, in terms of market volatility, it was not found any evidence for a detrimental impact of either algorithmic trading or high-frequency trading.
Well it is not a perfect analogy but we can debate on this unconventional or out of the box idea.
Competing interests: No competing interests
Savulescu makes the argument that athletes should be allowed to use performance enhancing drugs 1. He claims that current illegal methods of performance enhancement pose little harm to athletes and, further, that a regulatory framework (rather than one of prohibition) would enhance athlete safety. Savulescu specifically includes “blood doping” in his argument: “blood doping and erythropoietin could be dealt with at a stroke by allowing blood doping up to a blood cell count of 50”.
To include “blood doping” in this argument is misleading and potentially harmful. Blood transfusion carries health risks greater than the coagulopathic potential of an elevated haematocrit. ABO incompatibility, bacterial contamination and inadvertent viral transmission are amongst other potentially fatal outcomes2. Deaths occur every year even within the well-resourced, haemovigilant transfusion services of high-income countries3, 4. These risks are amplified in regions of socioeconomic deprivation and particularly for those with a high burden of transmissible disease where blood safety is a major public health issue5, 6. As described in a recent exposé on the Tour de France7, blood doping in sport frequently occurs ‘on site,’ further compounding the potential for contamination. Hence, the argument that blood doping would be safe within a ‘regulatory’ framework is misleading, fails to recognise that athletes from low income countries would be at greater risk and is naïve to the prohibitive financial and logistical resources required to provide a safe blood service.
Savulescu also contends that risk is inherent to sport and therefore it follows that any potential hazard posed by doping is acceptable. He cites the example of the morbidity and mortality caused by cycling accidents during the Tour de France. The comparison between doping and falling off a bike is, at best, an odd one given that the risk of injury is intrinsic to cycling. The risks of blood transfusion are not intrinsic to sport simply because blood transfusion is not a requirement for any sport; the risks of transfusion are extraneous, unnecessary and therefore avoidable. This remains an invalid comparison.
In summary, blood doping has the potential for significant harm and no regulation will change this. In the hospital setting, potential harm is weighed against need imposed by clinical phenomena such as anaemia, ischaemia or haemorrhage. It follows therefore, that blood doping in sport solely for competitive advantage, has no clinical justification.
Corresponding author: Cindy.Towns@southerndhb.govt.nz
References
1. Savulescu J, Creaney L, Vondy A. Should athletes be allowed to use performance enhancing drugs? BMJ 2013;347. Published Online First: 22 October 2013. doi: 10.1136/bmj.f6150
2. Towns CR, Gerrard DF. A fool’s game: Blood doping in sport. Performance Enhancement & Health 2014 http://dx.doi.org/10.1016/j.peh.2014.11.001
3. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, et al. Causes, consequences, detection and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med 2009;47:143–153.
4. Stainsby D, Jones H, Asher D, Atterbury C, Boncinelli A, Brant L, et al. Serious Hazards of Transfusion: A Decade of Hemovigilance in the UK. Transfus Med Rev 2006;20:273-282.
5. Bloch E, Vermeulen M, Murphy E. Blood transfusion safety in Africa: a literature review of infectious disease and organizational challenges. Transfus Med Rev 2012;26:164-180.
6. Hassall O, Maitland K, Pole L, Mwarumba, S, Denje D, Wambua K, Lowe B, Parry C, Mandaliya K, Bates, I. Bacterial contamination of pediatric whole blood transfusions in a Kenyan hospital. Transfusion. 2009 Dec;49(12):2594-8.
7. Hamilton T, Coyle D. The Secret Race: Inside the Hidden World of the Tour de France: Doping, Cover-ups and Winning at All Costs. London, UK: Transworld Publishers 2012.
Competing interests: Dr Gerrard is currently a member of the Health, Medicine and Research Committee of the World Anti-Doping Agency (WADA) and Chair of its Therapeutic Use Exemption Committee. These are honorary positions.
“He that covereth his transgressions shall not prosper, but whoso confesseth and forsaketh them shall obtain mercy”, or not ?
I vividly remember as a college student noticing the widespread use of amphetamine-like substances among my fellow students during the examination period, this to enable them to make it through a night of studying without losing too much mental focus due to fatigue or sleepiness. I wondered “Gee, if ever someone would come up with the idea to submit university students to random testing for performance-enhancing drugs and tie the validity of their examination results to the outcome of such testing, it would be pandemonium”. However, the idea was never brought into practice and now, decades later, still is not; neither do exam regulations typically contain any stipulations that prohibit the use of performance-enhancing drugs even though the term ethics is one of the most fashionable words in the contemporary academic world.
Somehow the situation is quite different in sports, where WADA today follows a zero-tolerance policy towards performance-enhancing drugs.1 2 Sport philosophers tend to argue that such strong opposition against doping exists because the essence of the ethos of sport and fairness itself is at issue.3 In more pragmatic terms this means that the performance of one athlete only makes sense when it can be compared to the performance of others. To achieve such a valid comparison between competing athletes would therefore require that the parties involved battle with equal arms. Apart from striving to achieve this objective and demonstrate that one is better, stronger, faster or more skilled than similarly equipped athletes, there is no further substance to competitive sports, whereas there is to the results of a drugged student passing his examinations. After all, the student still proves he or she masters the topic and has obtained the knowledge, skills and abilities. If the student did not already have the knowledge, it certainly would not suddenly arrive due to taking some magic pill.
A favorite argument among doping hunters is that allowing performance-enhancing drugs violates the equality of arms principle.4 In reality it is not that simple though, and the equality of arms principle really is violated only if some athletes are allowed to use or have access to such drugs while others do not. In that respect it is, no doubt, naive to think that equality is achieved by either banning or allowing performance-enhancing drugs. In case one prohibits doping, then some athletes still will use and the challenge is to not get caught;5 6 on the other hand, if one allows doping, then equality among athletes is still prevented by the magnitude of drugs each individual chooses and is willing to take. Besides, inequality exists in many other forms in sport, in particular, financial and material. In practical terms this leads to differences in what is available to the athlete in terms of training facilities and equipment, nutrition, overall skill and commitment of the coaches. The inequality also applies to dietary supplements that are not on the list of prohibited substances, but which too might exert an effect on performance or recovery.5 So, weeding out extrinsic differences between athletes by banning performance-enhancing drugs is at best illusionary.
Inequality among athletes is a reality. Athletes start off being unequal and by attempting to excel in their sports discipline, they try, in fact, to be as unequal as possible. Or to use the words of Savulescu et al.: “our capacity to improve ourselves using reason and judgment that may involve biological manipulation, and in this way cause that the winner in a sports event is not merely the person who was born with the best genetic potential to be the strongest, but someone who successfully has combined genetic potential with training, psychology, judgment, creativity and choice.”7
This example perfectly illustrates the nature of this debate, a debate which, yes, is interesting, but unlikely to get resolved. The reason is simple: many of the arguments of both those in favor and those against hold true, rather than one side being correct and the other side wrong.3 This is not any different with regard to the arguments provided by colleagues Savulescu, Creaney or Vodi2: neither of them is “wrong”. If one fully realizes that and accepts that, then perhaps it would make more sense to focus on what can be done to limit the major flaws of the current WADA approach and to increase its fairness. One of the major flaws is the inconsistency in mitigation, specifically with regard to the athlete who is being framed.8 While a likely excuse there certainly have been cases where scientific evidence suggests either contamination through accidental ingestion or having been framed by a third party, are more likely explanations than the athlete willingly or knowingly having committed a doping offence. Both the Contador and the current Van Snick case come to mind.9
The consequences for an athlete who finds him-/herself in such a situation are devastating in terms of participation, reputation, and potential loss of financial contracts. “He that covereth his transgressions shall not prosper: But whoso confesseth and forsaketh them shall obtain mercy”, the saying goes. Not so for WADA; WADA goes more than just one step further, with sometimes doubtful consequences for the sports community, the athlete him-/herself, and the essence of truth itself.8 Expressed in moral terms, the injustice of any such false accusation is at least as great as the unfairness caused by an athlete winning an event due to performance-enhancing drugs when none of his/her adversaries made use of doping.
1 Renström P. Arne Ljungqvist: the great fighter against doping. Br J Sports Med 2013 Sep 24. doi: 10.1136/bjsports-2013-093029.
2 Savulescu J, Creaney L, Vondi A. Should athletes be allowed to use performance enhancing drugs? BMJ 2013; 347:f6150. doi: http://dx.doi.org/10.1136/bmj.f6150
3 De Wachter F. De sportdroom bedreigd: doping als filosofische kwestie [The sporting dream under threat: doping as a philosophical issue]. Ethische perspectieven (Bel.) 2000; 10 (3): 157-62. [cited 2013 Oct 30]. Available from: http://www.ethische-perspectieven.be/viewpic.php?LAN=N&TABLE=EP&ID=165. Dutch.
4 Hoberman J. Sports physicians and the doping crisis in elite sport. Clin J Sport Med 2002; 12 (4): 203-8.
5 De Crée C. Groeihormoon [Growth hormone]. Geneeskd Sport (Hol.) 1994; 27 (5): 146. Dutch.
6 Morente-Sánchez J, Zabala M. Doping in sport: a review of elite athletes’ attitudes, beliefs, and knowledge. Sports Med 2013; 43 (6): 395-411. doi: 10.1007/s40279-013-0037-x.
7 Savulescu J, Foddy B, Clayton M. Why we should allow performance enhancing drugs in sport. Br J Sports Med 2004; 38 (6): 666-70. doi: 10.1136/bjsm.2003.005249
8 McNamee MJ, Tarasti L. Juridical and ethical peculiarities in doping policy. J Med Ethics 2010; 36 (3): 165-9. doi: 10.1136/jme.2009.030023.
9 D.P.C., V.W. Ph. Une analyse toxicologique innocente Charline Van Snick. Le Soir, 29 October 2013. Available from: http://www.lesoir.be/347762/article/sports/omnisports/2013-10-25/une-ana.... Retrieved: 29 October 2013. French
Competing interests: I was a(n unpaid) member of the Flemish Anti-doping Commission 1991-1993 and a former student (1983-1984) of the late Dr. Albert Dirix (1914-1999), at the time Secretary-General of the IOC Medical Committee.
Athletes take performance enhancing drugs to gain an advantage on their competitors. One consequence of allowing performance enhancing drugs would be that everyone competing as elite level have no option but to use drugs just in order to keep up. Sport, especially cycling has suffered dreadfully from the scandals of drug use. Allowing drugs would mean that drugs and sports would be as inseparable as ecstacy and raves. Drug use remains highly stigmatised and like ravers, athletes would be seen as druggies.
Given that many elite sports would necessitate the use of 'sanctioned' drugs, none of the athletes would have a drug assisted advantage, so the use of alternate, banned substances would continue unabated in order to give the users advantages their competitors do not have. Wealthy teams and nations would extend the advantages they already have.
It might lead to alternative leagues of conscientious objectors who [say that they] do not use drugs. It would be interesting then to see which leagues attract most interest and/or commercial success.
Creaney and Vondy are right that the present situation puts a lid on the pressure cooker and holds off the dystopian future Savulescu advocates.
Competing interests: No competing interests
Re: Should athletes be allowed to use performance enhancing drugs?
The use of performance enhancing drugs is on record as early as the games of the third Olympiad, when Thomas Hicks won the marathon after receiving an injection of strychnine in the middle of the race. Most sports organizations attempt to ban the use of performance enhancing drugs, such as steroids, by athletes. Despite these regulations, there continues to be wide-spread use of drugs in sports. People are using performance enhancing drugs because they want to take unfair advantage over the competitors. It is a major problem and health hazard to many participants. Yet there is no respite of this spiralling issue. Let us understand the reason. Let us understand what we call unfair.
People do well at sport as a result of the genetic lottery that happened to deal them a winning hand. The starkest example is the Finnish skier Eero Maentyranta. In 1964, he won three gold medals. Subsequently it was found he had a genetic mutation that meant that he “naturally” had 40–50% more red blood cells than average. Was it fair that he had significant advantage given to him by chance?
We take punitive approach but and a lot of effort is spent in outsmarting the screening process. There is a possibility that many participants are and coaches not sure about the status of their opponents. So the bias is tilted towards taking the unfair advantage but a major effort is focused to evade detection.
We need to debate on an experimental new normal. Participants won't be punished if they fail drug screening test. They will be simply put to a new group. Let us see the preference of participants and difference in records. A lot of levers should be in a perfectly aligned position to give someone an unfair advantage over opponents. Performance enhancing drugs may be just one of these with very little positive impact on performance. Reliance on performance enhancing drugs may reduce the body’s natural ability to respond to demanding physical requirement.
We need understand that performance enhancement is not against the spirit of sport; it is the spirit of sport. It is our desire to choose to be better is to be human. Athletes should be the given this choice. Their welfare should be given importance. But taking drugs is not necessarily cheating. The legalisation of drugs in sport may be fairer and safer. Moreover, according to a publication, permitting drugs in sport could reduce economic discrimination.(1)
We should just accept it as an inevitable part of sports and stop trying to regulate it. We have no double blind, randomized, placebo-controlled study on this and we also understand the complexity of getting it approved by ethics committee. Let us take an alternative situation to shed some light on this situation. It is now generally understood that high frequency traders (HFTs) are dominating the equity market, generating as much as 70% of the volume. According to one study, at the current phase of markets’ development, it is theoretically possible for algorithmic trading (and especially high- frequency strategies) to exceed the returns of index strategy. However, in terms of market volatility, it was not found any evidence for a detrimental impact of either algorithmic trading or high-frequency trading. That shouldn’t be a surprise. Technological advance makes super profits, capitalists are greedy, so technological advance spreads quickly, super profits disappear and the consumer benefits.(2) Well it is not a perfect analogy but we can debate on this unconventional or out of the box idea.
1. Br J Sports Med 2004;38:666-670
2. http://www.forbes.com/sites/timworstall/2015/01/26/relax-everyone-the-hi... accessed on 04 April, 2015.
Competing interests: No competing interests