Miah, A. (2005) Doping & the Child: Ethics for the Most Vulnerable GroupThe Lancet [Sept 10, vol.366, 874-876.].

"On April 1, 2005, the American Academy of Pediatrics (AAP) published a policy statement on the use of performance-enhancing substances.1 The statement questions several assumptions about the so-called drug war in sports and how it might be won. It argues for a more restrictive ethical framework that takes into account the most vulnerable group it affects—namely, children. The proposal calls for greater responsibility from health-care professionals by drawing attention to the wider concerns about care in public health that surround the use of performance-enhancing substances: “A significant number of adolescents who are not involved in competitive athletics use performance-enhancing substances.”1

Framing the drug war in sport as a public-health issue has received renewed support in recent months. In the USA, the debates about the Bay Area Laboratory Co-operative and unknown designer steroids have led to further political support to tackle the problem of doping. In his 2004 State of the Union Address, President George W Bush spoke of the danger of steroids in sports and the need for sports organisers to “take the lead and send the right signal” to young people.2 Moreover, the congressional hearings on Major League Baseball have reinforced the political momentum on tackling substance abuse. The prospect of drug-testing protocols for sports programmes in US high-schools is a further indication of this momentum. However, the AAP is doubtful that such a strategy would be effective: “Drug testing and legal sanctions are intended to be deterrents but have little effect on most children and adolescents involved in sports.”1

The AAP statement reinforces the poorly defined role of health-care professionals within sports. Whilst the AAP is unequivocal about the health-care providers’ responsibility—health, not performance—the statement does not grapple with the challenges faced by professionals working with athletes, nor does it address how the integrity of a physician’s judgment might be protected within that environment. A sports physician might struggle over deciding whether the athlete/patient is entitled to reparative care, if its purpose is to return them to competition. Are the athlete’s interests best served by fixing them for competition, or by advising them to rest?

Yet this complexity might suggest a reconsideration of how a physician relates to the athlete, a special kind of patient perhaps. One might argue that greater ethical limits must be placed on the use of medicine in sport and athletes’ autonomy, because an athlete’s decisions might be influenced considerably by the pressures to perform, especially when so much is often at stake for an athlete in every major performance. This coercive environment can inhibit an athlete’s autonomous choice to reject the use of performance-enhancing substances. When treating minors, this problem is exacerbated and the AAP claims that anti-doping policy needs to reconsider its priorities, placing the potential and real harm to children at its centre

The AAP statement identifies that anti-doping policy does not distinguish between different kinds of user, which poses big challenges to the world of elite sport. Moreover, it indicates a need for greater collaboration between drug companies and anti-doping authorities, because the latter rely on the former to know what new products might be arriving on the market that athletes could obtain. Knowledge of new products is essential to ensure that new methods of detection are developed with a good lead on the cheats. However, the financial incentive for drug companies is limited, because they make money from muscle boosting of athletes. Similarly, whilst more rigorous links with scientific and medical research would be of great assistance to the world of sport, non-sport scientists do not have much of an interest in sport unless the funding relates to some greater medical insight; so their incentive is also limited

Nevertheless the statement beckons a re-definition of anti-doping strategies, which should take into account the wide range of performance-altering technologies available to athletes, beyond the lists of banned substances. For example, the latest scandal is the ethics of “blood spinning”, a form of blood manipulation, which has been proposed by Chelsea soccer club physician Dr Bryan English, as a method of promoting “rehabilitation” when injured.3 Similarly, the use of hypobaric chambers to simulate higher altitudes and allow an athlete to train harder remains legal for the moment, but it is under review by the World Anti-Doping Agency.4

The message from the AAP places a broader requirement on anti-doping strategies to be made publicly accountable and subject to greater ethical scrutiny. A significant part of this strategy aims to promote ethical debate. The AAP notes that health-care professionals cannot discourage misuse merely by scare tactics or denying known performance-enhancing effects of banned substances. Rather, education must engage young people with the morality of sport, promoting public engagement with ethics. Whilst young people might fully understand the health risks of substance abuse, cultivating a moral view on science and medicine does not arise solely from having facts about health risks. "