An all-out effort: coached by Russian gymnasts, the young South African Victor Mzimango
gets ready to launch himself onto the parallel bars.
The New York City marathon: a yearly event prized by executive types, among others.
The scandal over
the Tour de France bicycle race in 1998 showed how riders knowingly and personally
take banned substances in order to endure tough training and back-to-back races throughout
a whole season.
|
Ethics:
the tablets of stone
The Hippocratic Oath
“I swear by Apollo the Physician, and Aesculapius, and health, and all-heal,
and all the Gods and Goddesses, that, according to my ability and judgment, I will
keep this oath and stipulation:
(...) I will follow that method of treatment which, according to my ability and judgment,
I consider for the benefit of my patients, and abstain from whatever is deleterious
and mischievous. I will give no deadly medicine to any one if asked, nor suggest
any such counsel. (...) Into whatever houses I enter, I will go into them for the
benefit of the sick and will abstain from every voluntary act of mischief and corruption.
(...) While I continue to keep this oath unviolated, may it be granted to me to enjoy
life and the practice of the art, respected by all men at all times, but should I
trespass and violate this oath may the reverse be my lot.”
The Olympic Charter, inspired by Pierre de Coubertin, responsible for reviving
the Olympic Games in 1896
“Olympism is a philosophy of life which glorifies the qualities of the body, the
will and the mind by unifying them into a perfectly balanced entity. Uniting sport,
culture and education, Olympism wishes to create a way of life based on contentment
born of effort, on the educational value of setting the example and on the respect
of universal ethical principles.”
The Olympic Charter against Doping in Sport
The International Olympic Committee in February 1999 defined doping as “the administration
or use of prohibited classes of drugs and of banned methods.”
|
Sport medicine is a forerunner of the medicine of the future - a medicine at the
behest of institutions in the business of boosting efficiency. |
On the eve of the Sydney
Olympic Games, sport medicine is faced with ethical dilemmas that stretch well beyond
the domain of top-level competition
 Advances in life sciences and biotechnology
are stirring up a broad debate about ethics. Expert committees are being called upon
to bring ethical codes in line with genetic research developments, assisted reproduction,
prenatal screening and the prospects for human cloning.
Standards for clinical reseach on humans, spelt out in the 1947 Nuremburg Rules,
are now being challenged by medical advances and research unimaginable in those days.
Questions surrounding the prospects of human embryo research (and the risks of new
forms of eugenics) as well as research spurred by the mapping of the human genome,
are generating new laws based on consultation with national and international ethics
committees, along with medical and research groups. This is the most public part
of the debate, the issues that make headlines.
But medical ethics involve far more than these issues, which are all essential to
imagining the kind of “humanity” that we are embarking to create. Tomorrow’s society
is being assembled day by day in the privacy of doctors’ surgeries. For medical ethics
are also being challenged by patients themselves, and by practices that have become
routine.
A premium
on efficiency and performance
Doctors are inevitably
affected by societal changes, shifting aspirations and accepted behavioural norms.They
also have to try, in their relationship with patients, to reconcile ethical considerations
with the new demands arising from a liberal society that puts high value on efficiency,
output and performance. This is especially true in the case of drug-taking (or doping)
in sport, which can be seen as the logical outcome of a performance-based type of
medical practice. Oddly enough, discussion about doping is generally reduced to a
few clichés: it is branded as unethical in light of an imaginary sporting
ideal. Calls are made for better drug-testing and stiffer punishment for “cheats”
and their accomplices. But this skates over the real issue—the pressures of competition
in sport—and hides it even further from the public, doctors and authorities.
Doping in high-pressure sports can hardly be equated with reckless or rash behaviour.
On the contrary, it requires the conscious involvement of the competitor who personally
controls the state of his or her own body and training. The athlete is led to take
drugs daily to reduce fatigue and to increase muscle power, or to recover quickly
from an injury or excessive training, for example. The scandal over the Tour de France
bicycle race in 1998 showed how riders knowingly and personally take banned substances
in order to endure tough training and back-to-back races throughout a whole season.
So the real ethical debate rests solely on medical practice. It means we should reflect
on how doctors respond to requests from athletes at all levels, for doping is also
on the rise among amateurs and children.
At the 43rd American Health Congress, held in Washington in September 1996, Thomas
H. Murray, of the Center for Biomedical Ethics at Case Western Reserve University
(Cleveland, Ohio), recounted how a mother asked for growth hormones for her son to
improve his sporting performance. There are two factors behind this request. First,
advances in medical biotechnology have made it possible to produce artificial hormones.
Second, the drive to win draws the doctor into altering the body to make it perform
better.
All medical codes of ethics condemn doctors acceding to such requests. The World
Medical Association calls on every doctor to “oppose and refuse to administer or
condone” methods that aim at “an unnatural increase or maintenance of performance
during competition” or which “artificially change features appropriate to age and
sex” (1981 Declaration on Principles of Health Care for Sport Medicine, amended in
1999).
Hormone
boosts
But many doctors must still
deal with the consequences of sporting activity. Physiologically, sport depletes
a person’s natural reserves, especially hormones. Intensive training for example,
uses up the male hormone testosterone faster than the body replaces it. A doctor
can put an athlete on supplements to make up for that loss, just as iron or vitamins
are prescribed for people lacking them. So a deficiency in the body is made up for
without any regard for what might have caused it in the first place—such as malnutrition,
overwork or disease.
We do not yet have a separate branch of medicine dealing with performance. So far,
it is just a few doctors straying from the original purposes of medicine. In the
richest countries and among the elites in poor nations, such medicine is in demand
as a medical prop to cope with the new emphasis placed on performance in all spheres
of life. This is also very similar in principle to anti-ageing treatments, where
health care is being adjusted to the fact that people are living longer. Hormone
replacement therapy in elderly people is aimed at “improving the quality of life
to match the extra number of years gained,” according to Dr. Bruno Delignières,
head of the endocrinology service at the Necker Hospital in Paris. Here too, hormonal
adjustment is being prescribed because of progress in life sciences and patients’
requests for drugs to alleviate the effects of ageing. The doctor is responding to
a person’s natural desire to improve their physical condition. Just like cosmetic
surgery and treatments for impotence, which have been boosted by the invention of
the drug Viagra, medicine is turning towards satisfying desires, spurred by images
of well-being and youth. The pressure to get, maintain or preserve an “efficient”
body and a “slim” figure is steadily increasing. The same goes for reducing pain
during childbirth, old age and of course in everyday life, which includes sporting
activity.
So one might think there is nothing wrong with prescribing drugs which improve the
quality of an athlete’s life, marked by intense physical activity. Fighting against
stress, recovering from long-term fatigue, using anti-inflammatory drugs to reduce
pain caused by intense exertion become normal given social expectations of chemically-assisted
well-being.
But testosterone and related products, such as nandrolone, are classified as anabolic
steroids and are the substances most frequently detected during drug testing. When
taken in big doses, together with sufficient food and training, testosterone increases
body mass, strength and muscle power as well as aggressivity and resistance to fatigue
and pain. Corticoid drugs also reduce pain and help a person to tire less easily.
So these substances are very suitable for easing the physical effects and psychological
pressures of competitive sport.
The crucial issue lies in deciding where medical efforts to restore equilibrium end
and efforts to improve performance begin. An artificial dividing line has been drawn.
A scale has been devised to measure the quantity of “supplements.” Medical tests
can now detect if a person has taken “unreasonable” amounts of substances that are
no longer banned, but tolerated up to a certain point.
The good
health riddle
Medical ethics do not require
a doctor to ask whether someone is “cheating” under the rules of sport. A doctor
does not have to take a stand on demands made in fields other than his own. The problem
is how to define the state of health that the doctor aims for, not the level of doping.
The World Medical Association’s Geneva Declaration (adopted in 1948 and amended in
1983) is clear: “The health of my patient will be my first consideration,” a doctor
is supposed to pledge. So it naturally condemns “procedures to mask pain or other
protective symptoms if used to enable the athlete to take part in an event when lesions
or signs are present which make his participation inadvisable.”
Doctors (in sport or otherwise) who engage in these practices are not performing
their duty towards patients (which involves prescribing a halt to painful activity)
but are complying with the demands of sport. From an ethical standpoint, a desired
performance must not be taken into account in the course of diagnosis or treatment.
Medical ethics condemn any action dictated by interests or pressures not related
to the goal of good health.
This is where the debate gets really tricky, because in modern parlance and in the
language of doping in sport, good health is understood to mean the absence of illness
or lasting after-effects. However, since 1940, the World Health Organization has
defined good health as a combined state of physical, emotional and social well-being.
The Centre for Health Promotion at the University of Toronto, points out that good
health is not an end in itself but a means to a balanced life.
This makes good health a quest for well-being based on individual aspirations in
a particular social and cultural context. Put this way, it becomes something extremely
subjective and changeable according to the time and place as well as the sex, age
and social class of the person involved. Each individual decides on the basis of
his or her own life and cultural environment a relationship to well-being, pain and
illness.
Sport presents doctors with a paradox. Most of them believe physical activity makes
for a balanced life. But they are also well aware that competition upsets this balance,
and that chemical-based treatments can be prescribed to supplement deficiencies.
If they respond to such demands, they are only reinforcing the alienating emphasis
put on performance at all costs, of which sport is just the most striking example.
Science
at the altar of performance?
But doctors can still,
without any qualms of conscience, refuse to play the game and deplore the effects
of a hectic life-style imposed by the obligation to perform. Acting in the interest
of patients’ welfare involves teaching them how to pursue a balanced life. A doctor’s
duty is to tell patients why they are ill. If this can be done without problem where
obesity and the dangers of smoking or drinking are concerned, the same goes where
the dangerous effects of sport are involved.
Sport medicine is a forerunner of the medicine of the future—a medicine at the behest
of institutions in the business of boosting efficiency. It runs the risk of ushering
in a common norm dictating people’s appearance (through cosmetic surgery), character
(through prenatal diagnosis) and social behaviour, namely through the demand for
performance in all fields, be it professional, sexual or sporting.
|
