Intended for healthcare professionals

Rapid response to:

Head To Head

Should athletes be allowed to use performance enhancing drugs?

BMJ 2013; 347 doi: (Published 22 October 2013) Cite this as: BMJ 2013;347:f6150

Rapid Response:

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:


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
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.

06 December 2014
Cindy R Towns
Medical registrar and Adjunct Senior Lecturer in Bioethics
David F Gerrard
Dunedin Hospital and University of Otago
Dunedin Hospital, Great King St, Dunedin, New Zealand