Ethical Considerations in Sports Medicine
Ralph G. Oriscello
Christopher E. Jonas
Ethics in general terms is the conforming to accepted standards or principles of conduct. No one achieves ethical perfection, but most sports physicians are good by nature and guided by high ethical standards. Sports themselves are considered to reflect values generally considered to be important to society: character building, health promotion, and the pursuit of competitive excellence and enjoyment (3).
Ethical considerations in the area of sports medicine are similar to those in medicine in general, including basic principles and rules (10).
Beneficence, the principle of performing acts or making recommendations only potentially beneficial to an athlete, is the overriding principle.
Nonmaleficence (“first do no harm”), the principle of prohibiting recommendations or actions detrimental to an athlete’s short-term and long-term health, is considered with every action taken in the training room or medical setting when tending to an injured athlete.
Confidentiality, shared decision making, informed consent, and truthfulness are absolutely essential for the ethical management of any sports-related medical decision.
THE SPORTS PHYSICIAN’S RESPONSIBILITIES
An athlete’s autonomy, his or her interests and desires and the third principle of medical ethics, must always be taken into consideration in any decision made by a sports physician. Such decisions should always be made in the athlete’s best interest (17).
Whether the decision involves a diagnostic test or the athlete’s eligibility, its end result is the maintenance of good health with the least risk to the athlete.
Conflict between physician and athlete should always be minimal or absent. The physician should use all reasonable means possible to resolve a dispute with an athlete-patient (4).
Although autonomy is respected, most athletes can and should rely on their sports physician to lead them in the shared decision-making process.
Sports physicians recognize that one solution rarely applies to every athlete who presents the same problem, and the same set of circumstances can also lead to a different suggested solution by the same sports physician (3,5).
Exactness and infallibility, while desirable, are not traits of even the finest sports physicians (11,13).
The sports physician’s primary duty is to make the best effort to maintain or restore health and functional ability (9). Despite the athlete’s wishes, the sports physician cannot do less than seek the best possible outcome (1). The athlete’s welfare must guide all efforts.
A good sports physician must have a genuine appreciation for the importance of athletics in an athlete’s life. Donald O’Donoghue, MD, suggests the following timeless precepts for sports physicians: accept athletics, avoid expediency, adopt the best methods, act promptly, and try to achieve perfection (14).
The injured athlete must understand the diagnosis, comprehend its implications, and participate in all therapeutic decisions.
All sports medicine physicians gain knowledge, wisdom, and better judgment with experience, soon recognizing that many recommendations or forms of therapy have risks as well as benefits.
Harm can come to the athlete-patient from unnecessary or excessive restriction as well as from failure to restrict activity when appropriate.
The sports physician does not operate in a vacuum. To make sports-oriented medical decisions, one must be well versed in current recommendations for eligibility and continued participation and not depend on his or her own limited personal experience or unscientific reasoning (4,7).
Recognizing the wide range of opinions and individual fallibility, athlete-patients can assert their right to another opinion.
Continuing education of the sports physician aids in the development of a suitable level of skill and knowledge and their maintenance (12).