Sports Physicians, Ethics and Antidoping Governance
Sports Physicians, Ethics and Antidoping Governance
Each of these cases highlights different aspects of the general considerations of fiduciary relationship between the athlete and sports physician. The duties of care of sports physicians that are not affected here range from negligence to lack of follow-through in treatment cessation. None of the cases can be called 'physician-assisted doping' in a strong sense, such as were witnessed in the Tour de France during the 1990s. In general, medical doctors are defined as 'athlete-support personnel' in the 2009 Code. It is said that 'athlete-support personnel' (often called the 'athlete entourage') comprises any coach, trainer, manager, agent, team staff, official, medical, paramedical personnel, parent or any other Person working with, treating or assisting an athlete participating in or preparing for sports competition.
The code also defines, in very general terms, the role and competencies of medical doctors in relation to doping in article 21.2:
Finally, the code defines punishment of medical doctors in article 10.3.2. For violations of articles 2.7 (trafficking or attempted trafficking) or 2.8 (administration or attempted administration of prohibited substance or prohibited method), the period of ineligibility imposed shall be a minimum of 4 years up to lifetime ineligibility. An ADRV involving a minor is considered especially serious because of the failure of a heightened fiduciary obligation, and, if committed by athlete-support personnel for ADRVs other than specified substances referenced in article 4.2.2, shall result in lifetime ineligibility for athlete-support personnel.
The central aim of the WADA code with respect to athlete-support personnel is that those who are involved in 'physician-assisted doping' in a strong sense, or assisting athletes in masking doping practices should be subject to sanctions that are more severe than the athletes who test positive. The athlete is always responsible for any prohibited substance in his body (article 2.1) under strict liability, but the period of ineligibility shall be reduced or even eliminated if player can establish that they bear no fault or negligence. In line with strict liability, antidoping panels typically argue that players did not ensure that no prohibited substances enter their body, and because of this, they cannot shift their responsibility under the rules to support personnel. Nevertheless, antidoping tribunals may hold that a player's negligence is not insignificant and that it is, therefore, appropriate to impose variable sanctions on them.
Case 1, that of the handball player, is an interesting and complex one. Clearly, his case passes through the hands of several physicians; some local, some international physicians, one non-sport physician, several club doctors and an event physician. The potential for confusion, lack of clarity, oversight or even neglect, is obvious. Nevertheless, the consulting physician is professionally obliged to work in the athletes' best interests. This entails, in the case of team doctors and event physicians, that they are sufficiently aware of their obligations arising from the WADC. There are a number of issues of poor governance that can be highlighted here in the form of questions. Precisely, who ought to be accountable for the neglect of the TUE certificate being gained? To what extent are the records of the athlete patient shared among treating physicians at international events? How ought data sharing be better effected? Who has the ultimate responsibility for athletes' use of proscribed substances at any given time?
In the three FIBA cases (cases 2–4) presented above, the Russian athlete (case 2) received a 1-year sanction because of anabolic steroids use, while the other two players (cases 3 and 4) were punished between 1 and 9 months, reflecting offences of lesser performance-enhancing seriousness and the apparent therapeutic context of the offence. Moreover, concerning the athlete entourage, only the Russian doctor (in case 1) was significantly punished. Despite the fact that the Russian doctor used nandrolone inappropriately, this difference demonstrates the need for an urgent policy debate concerning governance. It is far from clear that case 1 and 2 merit such substantially different treatment for the doctors concerned. Specifically, it raises questions regarding the efficacy of the WADC in relation to the responsibility of doctors in sport. The need is not new. It is not clear precisely how well-founded are fears that the revised WADC may include physicians in the group of persons who can fulfil the elements of a doping offence.
Athletes are expected to bear most of the responsibility for taking medical drugs and supplements that are potentially performance enhancing, harmful, and/or contrary to the spirit of sport, yet sport physicians are responsible to athletes for questions regarding antidoping and medical care. If athletes cannot rely on the trustworthiness of physicians, particularly in relation to their competence regarding anti-doping regulations, then it would seem that their right to proper healthcare in the contexts of elite sports medicine is jeopardised. On the other hand, one can ask whether the supply of qualified sports physicians may dry up if colleagues are repeatedly found guilty of ADRVs.
From another aspect, medical doctors are often seen to be held responsible by sport administrators, athletes and the general public. The main accusations made are, first, that some are engaged in 'physician-assisted doping', and second, that they supply athletes with doping agents, through carelessness. In the study by Laure et al up to 61% of adult amateur athletes stated that they obtained anabolic steroids and other banned drugs from a doctor. It has been shown that general practitioners' (GPs) knowledge of prohibited substances in sport is poor. Greenway and Greenway in their survey has showed that only 53% of GPs were aware of banned drugs, and that 12% believed that medical practitioners were allowed to prescribe anabolic steroids for non-medical reasons. A Dutch study of 1000 GPs was even clearer: 85% of the respondents admitted that they were not familiar with banned drugs or their side effects. If, as in this study, doctors are the most common source of information for the athletes (61%) then the situation become more problematic.
WADA has argued for the necessity to systematically work with doctors about (1) use of performance-enhancing drugs (including pain killers, doping agents etc), recreational drugs and other products (extra proteins, vitamins), and legal substances such as tobacco or alcohol; (2) health risks (physical and psychological) as effect of doping agents and a way to identify them during a clinical and/or biological examination. The same issues are noted by Striegel and Geoffrey elsewhere. It is problematic (not least for athletes) that medical doctors do not regularly improve their knowledge and attitudes to doping issues. This seriously brings into question the quality of training of medical doctors involved in sport on the subject of doping. Moreover, the issue raises the familiar problem of the specialism itself and the differing international standards for who may legitimately be called a sports physician and the level of training required for such. It is clear that holding GPs and specialist sports physicians, accountable to the same degree, would offend natural justice. Nevertheless, it seems that from the cases discussed above, that are not atypical, medical doctors are not familiar with the PL and/or that they do not use it in practice. As a result, doctors are not always aware of what it is that they are being asked, or they simply do not realise that certain prescribed medications can be misused for doping purposes. This situation is likely to be compounded in situations where there is an event physician covering a variety of athletes and teams of whom the physician is unlikely to have a full medical history. Whether employing organisations should take some responsibility for checking up-to-date knowledge of antidoping protocols of the sports physicians whom they engage is a point worthy of serious consideration.
What is also clear is that WADA are somewhat impotent in the process of disciplining members of the athletic entourage. National and International Sports Federations can apply sanctions (though, as we have noted above, this is fair from standardised) to prevent doctors, physiotherapists and other healthcare professionals from working with individuals or teams. What is more likely to be effective is interagency collaboration between WADA, Institute of National Anti-Doping Organisations (or international antidoping organisations such as Europe's CAHAMA group) in order to bring pressure to set international antidoping education guidelines. They ought also, however, to bear on individual healthcare professionals via their licensing associations. For the most egregious of infractions, the temporary revoking of licenses might be considered. This would not be without precedent. Indeed, the physician involved in that case, back in 1989 in Canada in the wake of the Ben Johnson incident, was held not to be fit to practice and had his licence revoked.
Discussion
Each of these cases highlights different aspects of the general considerations of fiduciary relationship between the athlete and sports physician. The duties of care of sports physicians that are not affected here range from negligence to lack of follow-through in treatment cessation. None of the cases can be called 'physician-assisted doping' in a strong sense, such as were witnessed in the Tour de France during the 1990s. In general, medical doctors are defined as 'athlete-support personnel' in the 2009 Code. It is said that 'athlete-support personnel' (often called the 'athlete entourage') comprises any coach, trainer, manager, agent, team staff, official, medical, paramedical personnel, parent or any other Person working with, treating or assisting an athlete participating in or preparing for sports competition.
The code also defines, in very general terms, the role and competencies of medical doctors in relation to doping in article 21.2:
To be knowledgeable of and comply with all antidoping policies and rules adopted pursuant to the code and which are applicable to them or the athletes whom they support (article 21.2.1).
To cooperate with the Athlete Testing programme. (article 21.2.2).
To use their influence on athlete values and behaviour to foster antidoping attitudes. (article 21.2.3).
Finally, the code defines punishment of medical doctors in article 10.3.2. For violations of articles 2.7 (trafficking or attempted trafficking) or 2.8 (administration or attempted administration of prohibited substance or prohibited method), the period of ineligibility imposed shall be a minimum of 4 years up to lifetime ineligibility. An ADRV involving a minor is considered especially serious because of the failure of a heightened fiduciary obligation, and, if committed by athlete-support personnel for ADRVs other than specified substances referenced in article 4.2.2, shall result in lifetime ineligibility for athlete-support personnel.
The central aim of the WADA code with respect to athlete-support personnel is that those who are involved in 'physician-assisted doping' in a strong sense, or assisting athletes in masking doping practices should be subject to sanctions that are more severe than the athletes who test positive. The athlete is always responsible for any prohibited substance in his body (article 2.1) under strict liability, but the period of ineligibility shall be reduced or even eliminated if player can establish that they bear no fault or negligence. In line with strict liability, antidoping panels typically argue that players did not ensure that no prohibited substances enter their body, and because of this, they cannot shift their responsibility under the rules to support personnel. Nevertheless, antidoping tribunals may hold that a player's negligence is not insignificant and that it is, therefore, appropriate to impose variable sanctions on them.
Case 1, that of the handball player, is an interesting and complex one. Clearly, his case passes through the hands of several physicians; some local, some international physicians, one non-sport physician, several club doctors and an event physician. The potential for confusion, lack of clarity, oversight or even neglect, is obvious. Nevertheless, the consulting physician is professionally obliged to work in the athletes' best interests. This entails, in the case of team doctors and event physicians, that they are sufficiently aware of their obligations arising from the WADC. There are a number of issues of poor governance that can be highlighted here in the form of questions. Precisely, who ought to be accountable for the neglect of the TUE certificate being gained? To what extent are the records of the athlete patient shared among treating physicians at international events? How ought data sharing be better effected? Who has the ultimate responsibility for athletes' use of proscribed substances at any given time?
In the three FIBA cases (cases 2–4) presented above, the Russian athlete (case 2) received a 1-year sanction because of anabolic steroids use, while the other two players (cases 3 and 4) were punished between 1 and 9 months, reflecting offences of lesser performance-enhancing seriousness and the apparent therapeutic context of the offence. Moreover, concerning the athlete entourage, only the Russian doctor (in case 1) was significantly punished. Despite the fact that the Russian doctor used nandrolone inappropriately, this difference demonstrates the need for an urgent policy debate concerning governance. It is far from clear that case 1 and 2 merit such substantially different treatment for the doctors concerned. Specifically, it raises questions regarding the efficacy of the WADC in relation to the responsibility of doctors in sport. The need is not new. It is not clear precisely how well-founded are fears that the revised WADC may include physicians in the group of persons who can fulfil the elements of a doping offence.
Athletes are expected to bear most of the responsibility for taking medical drugs and supplements that are potentially performance enhancing, harmful, and/or contrary to the spirit of sport, yet sport physicians are responsible to athletes for questions regarding antidoping and medical care. If athletes cannot rely on the trustworthiness of physicians, particularly in relation to their competence regarding anti-doping regulations, then it would seem that their right to proper healthcare in the contexts of elite sports medicine is jeopardised. On the other hand, one can ask whether the supply of qualified sports physicians may dry up if colleagues are repeatedly found guilty of ADRVs.
From another aspect, medical doctors are often seen to be held responsible by sport administrators, athletes and the general public. The main accusations made are, first, that some are engaged in 'physician-assisted doping', and second, that they supply athletes with doping agents, through carelessness. In the study by Laure et al up to 61% of adult amateur athletes stated that they obtained anabolic steroids and other banned drugs from a doctor. It has been shown that general practitioners' (GPs) knowledge of prohibited substances in sport is poor. Greenway and Greenway in their survey has showed that only 53% of GPs were aware of banned drugs, and that 12% believed that medical practitioners were allowed to prescribe anabolic steroids for non-medical reasons. A Dutch study of 1000 GPs was even clearer: 85% of the respondents admitted that they were not familiar with banned drugs or their side effects. If, as in this study, doctors are the most common source of information for the athletes (61%) then the situation become more problematic.
WADA has argued for the necessity to systematically work with doctors about (1) use of performance-enhancing drugs (including pain killers, doping agents etc), recreational drugs and other products (extra proteins, vitamins), and legal substances such as tobacco or alcohol; (2) health risks (physical and psychological) as effect of doping agents and a way to identify them during a clinical and/or biological examination. The same issues are noted by Striegel and Geoffrey elsewhere. It is problematic (not least for athletes) that medical doctors do not regularly improve their knowledge and attitudes to doping issues. This seriously brings into question the quality of training of medical doctors involved in sport on the subject of doping. Moreover, the issue raises the familiar problem of the specialism itself and the differing international standards for who may legitimately be called a sports physician and the level of training required for such. It is clear that holding GPs and specialist sports physicians, accountable to the same degree, would offend natural justice. Nevertheless, it seems that from the cases discussed above, that are not atypical, medical doctors are not familiar with the PL and/or that they do not use it in practice. As a result, doctors are not always aware of what it is that they are being asked, or they simply do not realise that certain prescribed medications can be misused for doping purposes. This situation is likely to be compounded in situations where there is an event physician covering a variety of athletes and teams of whom the physician is unlikely to have a full medical history. Whether employing organisations should take some responsibility for checking up-to-date knowledge of antidoping protocols of the sports physicians whom they engage is a point worthy of serious consideration.
What is also clear is that WADA are somewhat impotent in the process of disciplining members of the athletic entourage. National and International Sports Federations can apply sanctions (though, as we have noted above, this is fair from standardised) to prevent doctors, physiotherapists and other healthcare professionals from working with individuals or teams. What is more likely to be effective is interagency collaboration between WADA, Institute of National Anti-Doping Organisations (or international antidoping organisations such as Europe's CAHAMA group) in order to bring pressure to set international antidoping education guidelines. They ought also, however, to bear on individual healthcare professionals via their licensing associations. For the most egregious of infractions, the temporary revoking of licenses might be considered. This would not be without precedent. Indeed, the physician involved in that case, back in 1989 in Canada in the wake of the Ben Johnson incident, was held not to be fit to practice and had his licence revoked.
Source...