The Ethical Issues in the Sports Medicine Research Paper

Executive Summary

For nations, sports provides some sense of national pride, and for individuals, sports provides strong financial rewards and personal recognition. Based on this fact, it is no surprise that many players will do all they can to reach high levels of success in the game. With the growing popularity of sports in the international arena, a growing sense of concern has emerged regarding the welfare of the players. This concern has led to the emergence of a new field of medicine – sports medicine. However, like other branches of medicine, sports medicine has unique ethical issues. These ethical issues have been discussed scantly in contemporary medical literatures and there has been little discussion regarding the intricacies of sports medicine in general.

This paper focuses on highlighting the ethical issues in sports medicine. The methodology of the paper is mainly focused on using secondary research sources by carrying out a meta-analysis on the same to come up with a comprehensive analogy of the research problem. The scope of the topic is wide and it encompasses many ethical problems in sports medicine with occasional comparisons with conventional medicine. Nonetheless, this paper identifies that many of the ethical problems in sports medicine are common to conventional medicine, except for the uniqueness of some ethical problems. Ethical issues such as confidentiality, patient autonomy, truthfulness and conflict of duties/interests are identified as the main ethical problems in sports medicine. These ethical issues are witnessed in conventional medicine but the competitive nature of sports and the financial muscle that the profession exercises play a big role in determining the outcome of the ethical problems that arise as a result. These are some of the most significant ethical influencers in sports medicine.

Introduction

Nature of the Problem

As is witnessed from the proliferation of literature on ethical issues, recent years have witnessed growing emphasis on ethical issues in medical practice and healthcare in general. Most of the existing literatures on ethical issues are focused on life issues such as those involving the beginning or end to life (Beauchamp, 1989). There is also a growing volume of literature discussing ethical issues relating to the adoption of new technology in healthcare. However, in recent times, focus has shifted further to policy issues in healthcare and how resources are allocated in this sector. Based on the above background, it is crucial to note that, ethical issues, which are not represented by mainstream medicine, have been considerably ignored. Usually, authors who have attempted to research on minor aspects of ethical issues in healthcare have focused their analysis on the nursing field at the expense of other minor fields of medicine.

Sports medicine is a conspicuous field of medicine that has been neglected by many healthcare experts, even though it provides a lot of insight into issues relating to contemporary medicine. This neglect has existed for long despite the fact that sports medicine is a unique field of medicine. One noticeable characteristic of sports medicine is that it is ordinarily practiced out of the hospital setting. Usually, sports medicine is practiced on the pitch, sports clubs, healthcare institutions, and by extension, the private sector (Gorowitz, 1991). Unlike patients who have specialized doctors, sports medicine does not have specialized doctors (Gravson, 1988, p. 2). The unique characteristics of sports medicine (compared to other allied areas of medicine) also go a long way to explain the unique relationship that sports medicine shares with other sectors of sports such as sports organizations and professional sports leagues.

Another aspect of sports medicine that makes it unique to other fields of medicine is the strange relation between its pathology and the fact that it can be a recreational activity or a professional pursuit (Gorowitz, 1991). For a sportsman, a small injury may have a profound impact on his psychological and financial wellbeing because some of these people depend on sports for their livelihood. This analogy also represents another noticeably unique characteristic of sportsmen, which centers on their intense awareness about sports injuries and its impact on their lives. In other words, ordinary patients have a higher likelihood of misunderstanding their health risks when compared to sportsmen (Gorowitz, 1991). This attribute can be traced to the link between sports and the personal or professional lives of the players. Sports patients are therefore highly aware of the impact or significance of sports injuries (on their wellbeing) even though they may not carefully understand the methodologies used to treat their injuries (Higgs, 1985, p. 5).

Probably, the most conspicuous aspect of sports medicine, which makes it innately different from conventional medicine, is the fact that, often, patients admitted under this criterion (sports medicine) are generally healthy. This comparison should be made on the premise that sportsmen are ordinarily healthier than the average patient (Higgs, 1985, p. 5). This understanding (coupled with the fact that most cases of injuries or admission in sports medicine are largely musculoskeletal) account for the low rates of death in sports medicine (when compared to conventional medicine).

Inherently, the above qualities of sports medicine make the analysis of ethics in sports medicine to be unique to other forms of medicine. Particularly, these unique qualities of sports medicine provide specific ethical perspectives regarding contemporary health issues in medicine. However, in understanding the ethical issues in sports medicine, it is vital to conceptualize the concept of ethics in healthcare. This analysis is important because the understanding of ethics in healthcare has been used to include a spectrum of issues. It is easy to substitute these issues with one another. For example, the numerous laws that surround the sporting practice may influence the understanding of ethical or moral principles in sports medicine. To explain further the importance of this distinction, it is crucial to highlight a new branch of medical ethics known as professional ethics that defines professional qualities in healthcare (such as courtesy and etiquette) as opposed to conventional moral or ethical issues in medicine. For instance, there are certain professional stipulations in medicine (like healthcare professionals should not disagree in front of a patient, or a health consultant should see a patient only after a referral has been done with a general practitioner), which elicit important ethical concerns in healthcare but fail to conceptualize the main issues of courtesy or inter-professional negotiations. This observation highlights the importance of understanding specific ethical issues in medicine because the above examples show instances of professional courtesy and etiquette but not necessarily instances of medical or healthcare ethics (Higgs, 1985, p. 5). The latter category should be perceived to mean issues of moral dilemma. However, this is not to mean that there is no unique health or moral issues in healthcare, which may transcend professional etiquette and moral dilemmas. The same way healthcare ethics need to be excluded from professional etiquette is the same way that sports medicine should be excluded from the numerous laws that surround it. This distinction should be made because ethical issues in sports medicine incline towards moral issues in sports medicine while sports rules refers to a set of enforceable social rules. Though it is a desirable trait for laws to be designed around the foundation of moral principles, this is not always the case because not everything that is legal is immoral (Capozzi, 2000, p. 1668). In the same breadth, it should be understood that not everything that is immoral is illegal. Therefore, as this study seeks to expose the ethical issues in sports medicine, emphasis should be given to the distinction between law and ethics because this paper focuses on “right” or “wrong” issues.

Purpose of the Study

Today, healthcare is among the most important components of our society. For example, focus and attention is now directed at healthcare issues such as insurance and coverage than ever before. To explain further the increased attention on healthcare, the US only recently passed a healthcare bill trying to establish a healthcare medical scheme to cover all Americans. However, even as healthcare issues continue to receive public attention, it is important to pay equal attention to emerging sectors of healthcare, which are also growing in importance, but receiving less attention (nonetheless). Already, we have established that sports medicine receives less attention than mainstream medicine probably because the “sport” aspect of the profession overshadows its “medical” component.

However, it is impossible to neglect the sheer importance of sports in the society and the serious ethical dynamics it brings to the field of medicine. Moreover, the sporting industry shares an explicit relationship with healthcare because healthcare perceives sports to be a form of exercise, which is vital for human health and fitness (Capozzi, 2000). Many healthcare experts therefore appreciate the importance of sports as a form of exercise and fitness venture. Due to the significance of sports in today’s society, it is also important to recognize the heavy financial muscle that sports brings to healthcare practice and the influence of money on the behaviors of healthcare experts. The sports industry is a multimillion-dollar industry that is slowly growing in prominence around the world. Major world leagues such as the English premier league, the American NBA (and similar leagues) are known to rake in millions of dollars in endorsements, franchises, sales and similar lucrative ventures; however, at the core of their operations are the players. Nonetheless, like other professions, players are subject to injuries (mainly) because they use their bodies as the main tools of trade.

To sustain the future of sports in the world, it is important to observe disciple in the game. Here, the concept of discipline not only applies to how the game is played but also how different players conduct their practices. This is the main reason different sports leagues establish unique rules to guide the conduct of all the stakeholders in the game (Capozzi, 2000). Key in the area of sports governance is how team physicians and doctors manage the health of the players. However, based on the numerous scandals surrounding the management of players’ health, there is no doubt that there needs to be a harmonization of the ethical practices of team physicians and doctors. Based on this understanding alone, the findings of this paper will go a long way towards ensuring sports medicine is perceived as a credible aspect of sports governance. Through this input, the findings of this study will be beneficial to sports leagues and players because this paper highlights important areas of ethical practice in sports medicine that will boost the performance of the profession. An assumption will hereby be made to point out that the identification of significant areas of ethical practice in sports medicine will be the first step to improving the performance of physicians and other healthcare experts in sports medicine. Comprehensively, this paper strives to improve the standards of professionalism in sports medicine.

Statement of the Problem

As noted in previous sections of this paper, sports medicine is different from conventional forms of medicine. Based on this understanding, it is vital to point out that the unique differences in sports medicine complicate the understanding of ethical issues in the profession. For instance, conventionally, healthcare ethics would only include two parties – the physician and the patient. However, in sports medicine, a third party is always included – the team (organization) (Kuhse, 1985). The inclusion of the team (alone) complicates the understanding of ethics in sports medicine because it affects the decision-making process of ethical decision-making. In conventional ethical studies of medicine, there are certain known criteria for understanding ethics in healthcare such as confidentiality, informed consent and similar attributes; however, sports medicine does not have any common criterion for assessing its ethical decisions (Bunch, 2004, p. 183). On many occasions, the ethical issues surrounding sports medicine are therefore not clear.

It is usual to draw a strong link between sports medicine and contemporary medicine. In fact, some scholars explain that sports medicine is nothing more than a branch of medicine, which focuses on physical fitness as opposed to diseases and other forms of health complications (Kuhse, 1985). In addition, similar to conventional medicine, the main actors in sports medicine are healthcare professionals. The link between sports medicine and conventional medicine provide an abstract criterion for understanding the ethical issues in sports medicine but it only scratches the surface of the problem because ethical issues in conventional medicine focus on the medical aspect of the ethical issues in sports medicine alone (Gillon, 1986).

As noted in earlier sections of this paper, sports medicine is unique because it is influenced by the nature of sports. Sports medicine therefore conceptualizes the “sporting” aspect of the profession and the medical aspect of the profession. Therefore, in understanding sports medicine, the medical aspect of the profession needs to be understood within the confines of sports (as a profession). From the above assertion, it is therefore interesting to identify the ethical issues in sports medicine because of its uniqueness (when compared conventional medicine). For instance, is it correct to say that since sports medicine is considered a branch of conventional medicine, any ethical issues in conventional medicine would have the same implications in sports medicine? Based on such questions, it would be interesting to establish if crossing the line of ethics in contemporary medicine would also amount to crossing the ethical line in sports medicine.

Limitations of the Study

In undertaking this study, we need to recognize that the cross-disciplinary nature of the research problem may be a significant limitation factor. The cross-disciplinary nature of this paper emanates from the fact that this study will incorporate elements of “sports” and “medicine” in the same analysis. It is therefore probable that some of the ethical components of sports may be influenced by some ethical components of medicine. Similarly, certain ethical components of medicine may be influenced by specific ethical components of sports.

The extent to which this study’s findings can be generalized across all sectors of sports medicine is also a limiting factor because different sports organizations have different standards of operation and different healthcare experts have different ethical standards as well. The cases and examples narrated in this paper may therefore be too limited or unspecific for the generalization of different ethical components of sports medicine. For instance, this paper concentrates on the ethical components of sports medicine in major leagues across the world such as European football, the NFL, the NBA (and others) but the same findings may not be applicable to smaller leagues across the world.

Considering the fact that this paper mainly relies on secondary data as the main cause of data collection, the study’s findings are subject to the limitations of secondary data collection. For instance, secondary research is known to be limited by the self-governed nature of the researcher who undertook the primary research. Critics of secondary research point out that secondary research are likely to affect the quality of the research information. However, to uphold the validity of this study’s findings, the reliability of the study information will be reviewed before using the information. In addition, the fact that the secondary research data is known to contain incomplete information may also be a setback to the collection of conclusive information regarding the research problem. The findings of this study may also be limited by the fast-paced nature of ethical changes in sports medicine. This limitation emanates from the growing emphasis on good ethical conduct in sports medicine. Comprehensively, the above factors characterize the limitations of this study.

Significance of the Problem

Historically (since the ancient Greek period), physicians have pondered on the right medical ramifications for sports medicine; however, the process of identifying the basis for the right medical ramifications in sports medicine does not hide the fact that upholding principles of good conduct in medical practice promotes principles of justice and equality in sports (Bunch, 2004, p. 183). There is no better way to explain this phenomenon than focusing on a player’s well-being. Like other players in the healthcare sector, sports medicine is also required to uphold the welfare of the patients as the first priority of the profession. Patient welfare is at the core of sports medicine because patients have suffered significant career threatening and life threatening injuries simply by engaging in sports. Ironically, sports is known to improve one’s physical fitness.. Historically, heart-wrenching stories of sportsmen losing their lives or having their lives take a completely different turn have been reported.

Several major league players have therefore suffered (possibly) life-threatening injuries. Peyton Manning is one such player. Manning is a well-known American football quarterback who is perceived to be among the most valuable players in NFL history. In 2011, the player underwent a neck and arm surgery to treat some injuries he suffered during the 2010 playing season. These surgeries preceded a $90 million deal he signed with Colt to play for the club for the next five years (Mohamadi, 2011). Due to the intensity and urgency of Manning’s injuries, the player had to miss the 2011 season after doctors said he was to undergo a cervical infusion surgery. This surgery was the third among a series of surgeries that Manning underwent. Mohamadi (2011) explains that, “In March, 2010, Manning underwent his first surgery to relieve pain in his throwing arm that was related to pressure from a bulging (herniated) disc being applied to nerves in his cervical spine” (p. 4). The second surgery was done on the player after he started experiencing neck pains. About six to eight weeks after the surgery, Manning was back on the pitch. However, the player started experiencing pains again. He was booked for the third surgery. The third surgery was designed to correct a spinal surgery. In reference to this surgery, Mohamadi (2011) explains that “A herniated disc occurs when the contents of the cartilage that normally separate the vertebrae spill out and start pinching on the nerves that exit the spine” (p. 4). Patients who have undergone such surgery normally take about 4-6 months to recover but Manning was expected to play again after only two to three months (Mohamadi, 2011). The shortened nature of the recovery period for respected NFL players expose the unbecoming nature of team pressures on sportsmen to return to the game even before they have healed completely (this phenomenon will however be discussed in subsequent sections of this study).

The mere history of Manning’s injuries and treatments show the severe nature of sports injuries on sports men (Mohamadi, 2011). Evidently, these types of injuries are not only career threatening, they are also life threatening. Often, many players ignore the impact such injuries may have on their lives. It is only until it is too late that some players discover that such injuries may lead to their demise. Despite the recurrence of life-threatening cases of sports injuries around the world, few people seem to learn from the past.

Manning’s case is therefore not a secluded one; Kevin Everett (an American football player) also suffered a similar fate when he sustained a life-threatening spinal cord injury when he tried to tackle another player. He suffered the injury when he tried to duck his head, thereby exerting a lot pressure on his spinal cord. The player fell on the pitch and was unconscious for a while. Upon the occurrence of the accident, the team doctor said that the player could possibly not walk again because the injury may have had a significant neurological damage on the player’s health. It was reported that the player’s injury was possibly life threatening because the player was susceptible to blood clots, breathing problems and new infections because such an injury bore such risks. In reference to the treatment options, Associated Press (2007) narrated that,

“Cappuccino (the doctor) repaired a break between the third and fourth vertebrae and also alleviated the pressure on the spinal cord. In reconstructing his spine, doctors made a bone graft and inserted a plate, held in by four screws, and also inserted two small rods, held in place by another four screws” (p. 6).

Everett underwent a spinal cord surgery that saw the doctors relieve the pressure on his spinal cord. Initially, the player was not able to move his hands or legs. However, in subsequent months, he was able to wiggle his toes and later, he was able to move his hands. Here, the doctors’ main fear was the patient’s ability to breathe on his own (after the injury). This concern informed the doctor’s decision to term the player’s injury as life threatening. During the early stages of the patient’s recovery process, Everett was put under a respiratory machine. However, after the patient was able to breathe on is own, the machine was switched off. In subsequent months, Everett was able to use his limbs but doctors expressed a lot of pessimism regarding the player’s ability to recover fully (Associated Press, 2007). In 2011, Everett made an appearance at the super bowl by walking through the pitch. He later won an endurance award for being the most outstanding player to have recovered from a spinal injury. The doctors attributed his recovery to his young age, sound health and quality medical care. However, Everett’s injury marked the end of his career in sports. He is now under a pension scheme for players who suffered sever disabilities.

Mike Utley is another NFL player who suffered a career-ending injury during his third year of play. The player was an offensive lineman who played for a Detroit team. Initially, the player broke three ribs and dislocated his shoulder in previous games (before he suffered a spinal cord injury that left him paralyzed from the chest down) (Walden, 2004). The injuries were not very visible at first because many people thought the player’s injurious were not severe. These sentiments were held because the player flashed a thumb up sign as he was wheeled from the pitch (after suffering the injury). The thumb up sign has been used to refer to the player’s foundation, which seeks to find a cure for paralysis.

The player’s thumb up sign was also used to draw comparisons to other injuries suffered by other players such as Everett who was unconscious when he suffered his spinal cord injury. Many people therefore thought that when Everett suffered his spinal injury, the outcome would have been worse. In fact, Everett’s injury drew a lot of concern among his teammates because he reminded them of Utley (Walden, 2004).

Nonetheless, Utley’s injury was career ending and life threatening. The injury therefore exposed the risks associated with sports and the potential impact such injuries can have on a person’s life and career. However, to date, many players have not learned the impact of sports injuries on a player’s health. Many players still put their lives at risk by using drugs and body enhancing medications (among other practices that are dangerous to their health).

Sports medicine was introduced to help mitigate some of the above health risks. Clearly, from the above examples, sports injuries have a profound impact on a person’s life. However, even as new measures to mitigate health risks are introduced, the field of sports medicine is still faced with ethical and moral dilemmas. These dilemmas undermine the integrity of the game and the main aim of practicing sports medicine in the first place. Considering the sheer impact of sports injuries on the players and the sporting fraternity, it is important develop the proper framework for understanding the underpinnings of the profession. Identifying the right framework for doing so cannot be overemphasized. In support of this assertion, Bunch (2004) explains that,

“There are many situations in healthcare that have legal and social implications for both the medical practitioner and the patient. For example, the confidentiality of a patient’s health records is the ethical responsibility of the physician handling the case. Another issue is the relevance of euthanasia or mercy killing. The question of ‘freeing’ a person from suffering is as much an issue of morality as it is of medicine. In these contexts, ethical judgment and a guiding framework to deal with the issues become very important” (p. 184).

Through the same analysis, it is important to uphold principles of high ethical integrity in sports medicine because they have the same impact as conventional medicine. However, the importance of ethics in sports medicine carries many variations depending on the individual in question. For instance, sometimes, ethics may interfere with a person’s rights, thereby complicating the initiative to act ethical because ironically, it makes it unethical to infringe on a person’s rights (Bunch, 2004, p. 183). The importance of upholding good ethical conduct in sports medicine is as much a community issue as it is for the players and the leagues that they play in. From this understanding, it is important to see that there is a set of principles, which outline healthy living, through the upheaval of good ethical standards.

Comprehensively, from the above understanding (of the importance of upholding good ethical conduct in sports), the fact that justice, fairness and equity oil the wheels of sports should not be ignored. If no relevant stakeholders observe the ethical codes of conduct outlined by the relevant bodies, the medical fraternity may lose its credibility and fall into disrepute. Here, players may resort to unorthodox ways of solving their healthcare problems. In addition, the lack of ethical discipline may breed a lot of public discontent regarding the way physicians manage health issues in sports. Furthermore, it should not be forgotten that physicians in the sports industry are trained professionals and they are required to observe their ethical responsibilities as they discharge their duties. Ethical responsibility is therefore an important part of the medical profession. This fact is supported by an assertion made by Lynn (2005), which states that, “a profession’s most valuable asset is its collective reputation and the confidence which that inspires” (p. 88). Sports medicine should especially have the confidence of the spectators, players, communities and the organizations that run it because these stakeholders ensure the sustainability of the game. However, the biggest challenge of sports medicine is to resolve the historic paradoxes that face its operations. This initiative should be designed to make sports medicine more effective and accessible to all the players. In this regard, sports medicine should be viewed to be motivated by the need “to preserve and where necessary, to defend the best of the old rules requiring honesty, fidelity loyalty, diligence, competence and dispassion in the service of clients, above mere self-interest and specifically above commercial self-advantage” (Lynn, 2005, p. 45).

Definition of the Terms

• NBA – National Basketball Association
• NFL – National football league,
• NATA – National Athletics Trainers’ Association
• AMA – American Medical Association

Review of the Literature

Good ethical conduct is considered an important component to the success of not only the medical profession but other professionals as well. This observation is true because most professions are faced with situations that call for the application of right ethical principles (Bernstein, 2000, p. 50). Some researchers substitute this dilemma with the application of the right moral principles. There has been no shortfall of ethical theories that define the way ethics should be applied in different professions. Usually, most of these theories apply to different professions because they are universal in nature (Bok, 1978). The sports medicine profession is therefore subject to these ethical theories but most importantly, by subjecting sports medicine to these ethical theories, authors draw the similarity or distinction between sports medicine and other ethical components of medicine. For instance, the concept of “consequence”, which is narrated by the consequentialism theory, maintains that all medical actions taken in the event of a moral dilemma depend on the non-moral consequences of the same action (Bernstein, 2000, p. 50). The consequentialism theory therefore emphasizes the importance of striking a balance between the “good” and the “bad” of a medical action (Daniels, 1985). However, through this explanation, the consequentialism approach maintains that the definition of “good” and “bad” is not objective because it depends on the individual or circumstance of the moment. For instance, if a person bumps into another vehicle in the parking lot and causes a minor damage that the owner can fix with a few hundred dollars, he may decide to drive away if there are no witnesses and the owner is not around. This action may be prompted by the fact that the victim has insurance and he can contact his company to repair the damages, thereby avoiding the hassle of contacting the person who bumped into his vehicle and undertaking time-consuming negotiations with the insurance company. However, the mere action that another person bumped into his vehicle and drove off seems wrong but if the person is tracked, he may end up paying higher premiums.

This situation is further compounded by the ethical egoism, personal egoism and impersonal egoism concepts because the ethical egoism concept notes that one should act in a way that their actions safeguard their personal and long-term interests (Bok, 1978). The personal egoism concept also states the same but it does not stipulate how other people should act in similar circumstances. The impersonal egoism concept also stipulates that an individual should act in a way that safeguards their long-term interests. These are just a few theories that were developed to highlight the characteristics of ethics in sports medicine. The main message in this analogy is the fact that sports medicine is subject to unique ethical principles, which have also been highlighted by other authors. For example, Vergeer (1999) states that,

“Medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of the profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals and to self” (p. 43).

The above statement is part of the preamble for ethical conduct that was developed by the American Medical Association (AMA) (American Medical Association, 2007, p. 1). The National Athletics Trainers Association (NATA) also shares this preamble because they expect all physicians to provide quality medical care and uphold high standards of professionalism (National Athletic Trainers Association, 2011, p. 1). More so, both organizations (AMA and NATA) stipulate that the duty of responsibility usually rest with the physician. However, AMA is more specific to its requirements because it expects all physicians to provide utmost care to their patients in the field even if the demands of spectators, event organizers and other parties in the athletic field desire otherwise (American Medical Association, 2007, p. 1). NATA stipulates that ethical codes of conduct should be upheld at all levels of athletic training because this is the base level of ethical implementation. By extension, the association aims to uphold a high level of professionalism for all its members. Though the guidelines for ethical behavior are outlined by NATA, they do not cover comprehensively all the situations which are encountered by the athletic trainers. However, they establish the spirit that healthcare providers in the athletic circuit need to base their decisions (National Athletic Trainers Association, 2011, p. 1). As conventional ethical guidelines stipulate, NATA also upholds principles of confidentiality and privileged information to the patients while upholding the rights of every stakeholder at the same time. For instance, concerning issues of patient confidentiality, NATA observes that patient information should only be given to third parties when consent has been received from the patient (National Athletic Trainers Association, 2011, p. 1). Furthermore, NATA also outlines that healthcare providers in sports medicine should only receive compensation for relevant services and for the educational or mentorship services, they accord younger professionals in sports medicine.

In addition, it is a strong conviction among NATA that no member should engage in health practices that are perceived to compromise their professional conduct; similarly, members should not take part in any activities that may be considered a conflict of interest on their part (National Athletic Trainers Association, 2011, p. 1). In explicit terms, it is correct to explain that NATA forbids the placement of financial rewards at the expense of patient welfare.

Considering the strict ethical requirements placed on healthcare providers, there have been many questions asked regarding how the ethical policies should be applied in the real world. This question is often common because historically, sports and medicine have been known to have conflicting goals. For instance, sport is known to focus on the goal of victory and accomplishments while medicine is concerned with the long-term wellbeing of an individual. In other words, it can be said that sports is considered a short-term venture while medicine is a long-term venture. For instance, sportsmen are known to have extremely short careers (compared to other professions) and younger players take their place as soon as the “older” players retire. Soon after retirement, these players are not subject to sports medicine.

The financial rewards associated with sports also complicate the understanding of sports medicine because heavy financial rewards always seem to compromise the ethical conduct of healthcare providers in the sports fraternity. This situation is realized despite the fact that healthcare professionals should see that the long-term wellbeing of the players is taken care of (regardless of the short-term nature of the sporting profession). Through this understanding, the fame, fortune, financial opportunities and the interests of affiliated players or institutions should be disregarded. For instance, in 2000, it was reported that New York’s Nets and Yankees announced the evaluation of their physician but in the same year, the teams advertised existing vacancies for the teams’ healthcare provider and an associated health institution (National Athletic Trainers Association, 2011, p. 1). In this example, obviously, being the physician for a prestigious team such as the Yankess comes with immense publicity, but in the same understanding, this situation comes with immense conflicts of interest. Therefore, from the same understanding, it can be said that team interests may influence the patient-physician relationship, which needs to be the main point of focus. In fact, there are cases (mostly in national and regional teams) where the health of an athlete is contravened because of team championships or contests. Usually, the situation is uglier when the team doctor is part of the organization that funds the team or is part of an advertising contract that binds his actions.

The above conflict is often realized because the financial attachment associated with sports not only affects the wellbeing of the patient but also affects the wellbeing of the organization. Pipe (1993) explains that, “The pressure on the physician or medical personnel responsible for return to play decisions when these factors, along with the prestige and market potential provided via the advertisement contract, certainly could cloud the decision-making process” (p. 888). Since sports medicine involves more parties in the process of ethical consideration, the health practitioner is required to observe discretion and often, they are required to maintain a careful balance between team benefits and patient well-being. In a past study done on 45 physicians practicing in sports medicine, it was revealed that about half of them often experienced the pressure of returning a team member to the field before full recovery (Flint, 1992, p. 84). The complexity experienced by these physicians was seen to come from different quarters but pressures from the coach, fans, press and the players were observed to be the most common. In the same study, it was revealed that players also had a difficult time trying to strike a balance between observing their long-term wellbeing and losing on long-term contracts that were going to give them a lot of money. In a study undertaken by Davis (2011) on 384 US college players who joined the NFL, it was established that 223 of the players underwent some form of surgery but still went on playing. This statistic shows that, the players played despite their injuries – an indication of the rampant practice to allow players to play at the expense of their physical wellbeing. In the same study, it was noted that some of these players intentionally decided to play despite being advised against it. Going back to the ethical requirements stipulated by the AMA and NATA, there are many questions to be asked regarding when physicians should step in to prevent players from playing when they have a medical problem. Different parties hold different views regarding this dilemma but some physicians are on record to term ??? the practice as shifting the responsibility to the players so that they can make informed decisions about their health (Davis, 2011). However, other observers note that physicians and the players should make an informed choice together. Nonetheless, despite these perspectives, it is correct to say that the players should be given all the right information regarding the extent of their injuries and what options are available to treat their injuries (Davis, 2011). Interestingly, a common ethical principle of patient autonomy surfaces in this argument.

Law and medical ethics stipulate that a patient’s autonomy should be respected always, thereby merging a common ethical principle in conventional medicine and sports medicine. However, as mentioned in earlier sections of this study, a patient should be given the right information regarding their injuries and the available treatment options. Important information about the medical diagnosis, purpose for treatment and the nature of the available treatment methods should also be availed to the patient; at least so that there is no possibility of incurring any legal suits arising from a failure to disclose such information (Davis, 2011). Several professional sports leagues have experienced legal suits of this nature. The NFL and the NBA are a few of such examples because players from these leagues have successfully sued their physicians for insufficiently providing them with information regarding their diagnosis, prognosis and treatment (Flint, 1992, p. 84). These suits were based on the long-term injuries experienced by the players when they continued playing with significant injuries. Flint (1992, p. 84) explains that, in such a situation, informed consent and the assumption to waiver risks should be included in an argument to establish the ethical and legal implications of a player continuing to play with injuries. These are some of the intrigues shared by Fu (1994) as he tried to explain the similarity between the ethical differences and similarities between sports medicine and conventional medicine.

Confidentiality and privacy are also other ethical principles, which have been discussed by many scholars to explain the ethical implications in sports medicine. Ordinarily, the Health Insurance Portability Accountability law governs all issues relating to security and confidentiality issues in sports medicine (Flint, 1992, p. 84). The same law has been used to outline security and privacy issues in conventional medical practice but the focus in sports medicine has mainly be centered in the issue of privacy. Privacy is an important issue in sports medicine because of the nature of the profession. For instance, with the fame and publicity accorded to different sportsmen, the media and fans are likely to seek information regarding a player’s health (despite the fact that such an action may infringe on the ethical practices of the profession). For example, coaches are known to seek information regarding a player’s fitness while sports organizations often want to know a player’s health status to assess its effects on players’ contracts (Flint, 1992, p. 84). When a player’s health information is leaked to the media, there exists a big question regarding how the media is able to pick information regarding a player’s health while such information is normally deemed to be confidential. Confidentiality is a sacred concept in this analysis because patients are accorded this right through a signed agreement with their physicians. Information regarding their health status should therefore only be disclosed with the players’ permission. However, sports medicine is considered unique to this requirement because players and sports organizations have a valid contract, which contravenes conventional ethical principles in medicine (Flint, 1992, p. 84).

The contracts signed between the players and sports organizations normally require the sports organizations to be supplied with sufficient information regarding a player’s health so that they can make informed decisions regarding the affected players. Team physicians are therefore required to accord their allegiance to the players (medically) and the team organizations (contractually).

From the above understanding, the real question to be asked is how much information about a player’s health can be released to the public and the sports organizations while maintaining patient confidentiality. Through the same understanding, Flint (1992) explains that ethics in sports medicine will always remain a grey area because its guidelines are normally shrouded in the circumstances of the time and the philosophies of the person involved.

There are numerous real-life examples that have been shared by many scholars regarding the nature of ethics in sports medicine. For instance, many people perceived the move by LA Galaxy to sign Beckham to the American soccer league as a boost to American soccer and LA Galaxy (Blum, 2007, p. 2). Beckham’s move to America was widely publicized but true to the nature of most sport transitions, the move was rough. In a related event, Beckham suffered an ankle injury during one of a widely publicized match prompting him to miss the game, thereby causing a lot of uproar among the fans (who expected to see him play in the game) (Gordos, 2011, p. 1). Since LA Galaxy was languishing in the lower end of the league, the coach and management of the team forced Beckham to play with his ankle injury (Blum, 2007, p. 2). True to prediction, Beckham suffered a knee injury that saw him out of the game for close to one and a half months. The player admitted that his knee injury was caused by ignoring his ankle injury (Blum, 2007, p. 2).

The Beckham example exposes the intrigues of sports medicine and how it is clouded in different aspects of the game’s politics. For instance, Beckham’s contract was worth $250 million and he was regarded as the “team savior” (Gordos, 2011, p. 1). Moreover, the player wanted to please his fans due to the big transition to American soccer. For instance, due to Beckham’s attendance in the match, the stadium almost filled to capacity after it registered an attendance of more than 66,000 fans while ordinarily, the stadium reports an attendance of 11,000 people (Fox Sports, 2007). Beckham’s club, LA Galaxy, also enjoyed improved T-shirt sales and lucrative sponsorship deals from major US companies. These factors piled a lot of pressure on Beckham to ignore his ankle injury and play. The biggest question however remains to be why the team physician allowed Beckham to play while he knew the player were in no position to do so.

It is no secret that the decision to allow the players to continue playing (or not) is not an easy one. Waddington (2002) exposes this complexity by narrating that whenever a player suffers an injury, the focus almost shifts from the player’s wellbeing to how long the player will be sidelined (and if the player will be able to play in an important match). From this assertion, Waddington (2002) recommends that the paradigms driving sports medicine should steadily shift from team focus to the players’ wellbeing.

Sanderson (1981) suggested a framework to be used by team physicians and sports associations to determine when a player should be allowed to play (after he has suffered an injury). The framework is designed to document different components of the player’s fitness level before the injury and only after the player has been able to satisfy his initial fitness standards should he be allowed to play. It is also no secret that a player’s decision to play (in the event of an injury) may be clouded by fears of losing a spot in the team or losing an important game in a league. Therefore, obviously, players do not make a decision in their best interests but in the interests of the teams. In light of these concerns, Speed (2001) recommends that coaches should be educated about medical ethics and how they should be applied in sports medicine. Studies done by Roberts (2000, p. 93) exposed the fact that coaches normally depend on different variable such as the age of a player, the likelihood that the player will suffer injuries and the importance of the competition to ascertain if a player should play in a game (with or without injury). In line with such intrigues, Midwestern State University (2011) suggest that coaches’ conduct should be aligned with the ethical conduct of AMA and NATA to reduce any instances of players suffering more health risks because of playing with injuries. The Medical Letter Inc. (2001) also notes that, the sports fraternity should not shy away from educating their players regarding the implications of their injuries or courses of treatment (though NATA and AMA guidelines do not have the necessary muscle to enforce such ethical principles). Sperryn (1980) shifts the responsibility to the players and their physicians by noting that they should make informed choices about the decision to play. Their mottos should therefore be to do no harm.

Focusing on real-life examples to demonstrate the extent of ethical dilemmas in the sports field, there have been many debates regarding the use of painkillers to suppress players’ pains (when they have an injury). Often, many anesthetics and specific drugs (such as cortisone) have been used to minimize player’s pain thereby enabling them to play while they still have an injury. In a recent study done on NFL players, it was established that about 45% of the players used some form of anesthetic drugs to numb their pain (from injuries) during plays (Orchard, 2001, p. 212). The outcomes of using such drugs have been known to result in suboptimal outcomes because it interferes with the natural healing process.

In fact, there are drugs such as cortisone injections, which are known to further worsen player’s injuries if they are used to facilitate play (Orchard, 2004, p. 209). The use of cortisone injections is ordinarily supposed to be followed by a two-to-six week’s rest, which is not observed by most players. In addition, most players also overlook the fact that such injections should be widely spaced to about four-to-six weeks because they use more than the recommended dosage in one sitting (Orchard, 2001, p. 212). The subsequent use of such drugs should be accompanied by an assertion that its use is effective for the players; however, Wright (1987) notes that a false sense of relief by players when using such injections lead to its abuse. Furthermore, after narrowing down the effects of using cortisone injections for a long time, it is established that players may suffer numerous side effects such as:

“Osteoporosis, weight gain, fluid retention, cataracts, glaucoma, acceleration of atherosclerosis, avascular necrosis, poor wound healing, gastric ulcers and GI bleeding, hyperglycemia, hypertension, adrenal suppression and increased risk of infection” (Orchard, 2001, p. 212).

Wright (1987) further adds that, “Even short-term corticosteroid use in low doses can cause bone loss” (p. 57).

Usually, the above side effects are not communicated to the players during the administration of these drugs, thereby contradicting an important philosophy requiring players to be equipped with the right information regarding their diagnosis and options for treatment (and the impact on their health). A case was registered between an NFL team player, Krueger, and the club’s physician regarding an anterior cruciate ligament, which he suffered from repeated injections to his knee. He successfully sued the team physician for not disclosing the status of his knee injury and the side effects of the drugs administered to him (Orchard, 2001, p. 212). More lawsuits have seen doctors and teams pay huge amounts of money in damages for failing to inform their players regarding the status of their health or the side effects of the drugs administered to them.

Truthfully, it is known that some of the drugs administered to these players do not cure their injuries but only mask their symptoms. Given such conditions, players usually run a high risk of worsening their injuries. The real question however lies with a situation where the player is informed of the impeding health risks associated with continued play or using a given drug and he ignores such advice.

Unfortunately, many sports leagues do not have active policies regarding the use of pain drugs, thereby leaving a bulk of the decision-making process to the team physicians who are supposed to be governed by medical codes of conduct and ethics (Orchard, 2001, p. 212). Considering the ensuing intricacies of sports medicine, it is clear that ethics in sports medicine is unique to different issues, which are not normally realized in conventional medical ethics. In support of this assertion, Orchard (2001) elaborates that the use of drugs among players tops the main ethical issues in sport medicine, which make it unique to other forms of ethical misconduct in healthcare. The real ethical question is therefore realized when a team doctors realizes that a player uses illegal substances to enhance his performance but he does a good job in the pitch. In such a situation, it is difficult for the doctor to know what to do because he cannot condone such a practice for professional and ethical reasons but at the same time, exposing the use of illegal drugs by one of his players may amount to heavy penalties on the player or team.

Wright (1987) identifies another ethical dilemma and he purports that the use of advanced treatment methodologies on players is another area of ethical dilemma because some players demand the use of advanced technology to treat themselves while there may not have enough information to support the use of such technology. Most of the advanced medical treatments demanded by these athletes are only in the experimental stage but because some of these players know these technologies (and are willing to pay for them) makes them demand it. In cases where such ethical dilemmas are experienced, Dyson (1990) proposes that physicians and players should sit and evaluate the benefits and risks of such treatment methods so that they can establish the right course of action to take. Physicians are therefore advised to refrain from using such advanced technology to better the health of their patients while putting the lives of their patients at risk (Wright, 1987).

The concept of truthfulness has also been identified as an important ethical concept in sports medicine. However, its importance has not only been highlighted in sports medicine but also general healthcare practice because the question of determining whether it is right to disclose grave diagnoses to the patients is an age-old moral dilemma for healthcare specialists.

The concepts of truthfulness and disclosure also stand out as important concepts in the understanding of ethics in sports medicine. Like other ethical dilemmas, the concept of truthfulness and full disclosure are shrouded by the influence of competitive ambitions in sports. Upholding the principles of full disclosure and truthfulness therefore stand in the way of achieving desirable sports outcomes because if some players are told the truth about their health, it may disappoint the wishes of their coaches to play in forthcoming games. Already, we have seen that some doctors find themselves in a tight fix where professionally, they have to be truthful to the patients but they are still bound by the coaches’ wishes to see the team succeed. The concept of truthfulness is especially important in sports medicine because sports medicine has a competitive element that interferes with the medical roles of the team doctors.

An example is given by Rachels (1986) who narrates the predicament of Dr. B who operates a weekly sports clinic that specializes on injuries of sports participants. One day, she received a 15-year old patient who was brought by her parents after suffering severe backaches. Upon examination, she realized that her patient’s lumbar hypermobility was excessive for a gymnast. Upon further examination, she realized that there were signs of excessive degenerative changes in the patient’s spinal apophyseal joints, which could be further worsened by continued participation in gymnastic activities. The doctor knew the implications of her diagnosis on the patient’s professional life, but at the same time, she acknowledged the devastation that such news would have on her patient’s parents, considering they were looking forward to their daughter having a bright future in gymnastic.

Considering the nature of the above dilemma, the importance of being truthful occurs as a crucial component of understanding the ethical dilemmas in sports medicine. It is not enough to evaluate if to tell patients the grave outcomes of their diagnosis because it is also important to ascertain the correct facts regarding the same. However, professionally, it is normally agreed that all patients have a right to know the truth. The only variation is normally witnessed when no factors in play are equal (Rachels, 1986, p. 56).

Nonetheless, the extent that the patient can be told the right information about their health largely depends on the accuracy of the information. For example, in the case of the gymnast, it is purely a matter of probability for the doctor to ascertain that the patient may suffer significant health difficulties or disabilities in future. In such a scenario, the mere nature of the truth should not be perceived as the main factor in contention because the main issue is what the practitioner perceives to be truthful. Again, in the case of the gymnast, what the physician perceives to be the truth prevails (though there is a possibility that future events may contradict her position). Concerning this assertion, Schrock (1980) says that, “The whole truth is out of reach. But this fact has very little to do with our choices about whether to lie or speak honestly, about what to say and what to hold back” (p. 81).

However, it should not be misunderstood that a patient’s right to know information amounts to the responsibility of the doctor communicating such information (Rachels, 1986, p. 56). Through this understanding, it should be understood that since there is a right to know, there exists a right for the patient to not know because the ultimate outcome of such an ethical dilemma depends on the desire of the player to know (or not know). However, determining if the patient wants to know such information (or not) is not an easy one because Bruckner (1987) maintains that, “The logical difficulty here is that the very nature of disclosed information may determine the patient’s desire to be acquainted with it, by which time of course it is too late” (p. 383). Again, in the case of the gymnastic patient, it is difficult to establish if she wants to know the future pain or the risks, she suffers from continued participation in gymnastics. It may also be fruitless to ask her parents about what needs to be done because parents are always known to have a significant stake in their children’s sporting activities. Their decision may therefore be partial. In addition, it is also known that some parents do not have the interests of their children at heart and therefore it is equally difficult to get the right information regarding if the patient wants to know the true medical diagnosis, or not. Since it is difficult to point out a benchmark for knowing the patient’s wishes, Last (2001) proposes that the bulk of the dilemma should be analyzed from the right to disclosure. Here, a suitable reason should be identified to prevent the medical worker from disclosing the medical information to the patient (otherwise, the patient should not be kept in the dark).

Furthermore, instances where disclosing true medical diagnosis may cause more harm than failing to disclose such information, doctors are advised to uphold utmost discretion (Rachels, 1986, p. 56). However, if the advantages of disclosing such information outweigh the disadvantages, there is more reason for full disclosure of information. Here, Matheson (2001) revisits the concept of autonomy and explains that doctors should only reveal enough information for the patients to make an informed autonomous decision about their health. Patients should also be given the necessary support that facilitates the outcome of an autonomous decision and if the process is deemed painful, it should be perceived to be a price for autonomy.

Conflict of duties is cited by Sim (1985) as being a strong ethical concern in sports medicine (the same way autonomy, and other aspects of medical ethics are). It is no secret that team physicians have unique duties and roles in sports medicine. However, the success of their duties depends on their working environments and the networks they build from the same. There are other times when the obligations of the healthcare professionals and the obligations of other players in the sports environment may clash because doctors have a contractual obligation to their clubs and at the same time, they have a professional obligation to their patients. Often, these roles clash because the contractual obligation with the club is mainly aimed at ensuring the team succeeds while the contractual obligation with the patients is aimed at ensuring the players have a good long-term health. The contractual obligations with the club are mainly defined by the employer-employee relationship, while the contractual obligation with the patients is defined by the doctor-patient relationship.

Usually, this clash of conflict amounts to an ethical dilemma that has to be resolved by the team physician. For example, Fuller (2006, p. 151) gives a scenario where a team doctor is required by the coach to give his scrumhalf player (link between the forward and the back players) a pain killing injection to numb his pain; however, after close examination, the team doctor realizes that giving the player this injection may lead to further injury. In detail, the team doctor was supposed to give the injection for a sprain on the lateral ligament of the ankle but he realized that the injection would impair the player’s natural healing processes considering the team lacked a replacement scrumhalf.

The ethical dilemma in this scenario is not different from other cases highlighted in this study because the team doctor had the option of refusing to give the injection to the player because it would affect his long-term health. This action is characterized by the principle of non-manifelence because it stipulates that the doctor had a duty to protect his patients from harm because upon his personal evaluation, he realized that the long-term effects of the injection was detrimental if compared to the option of administering the drugs without much caution. However, the team doctor also owes a duty of care to the club that employs him (to implement the wishes of the club – which was to inject the player with painkillers so that their scrumhalf would participate in the game). Here, there is a clear conflict of duties because the doctor owes a duty of care to the patients and the club. Nonetheless, many precedents show it is of greater importance for the team doctor to uphold the duty of care to his patients as opposed to upholding the duty of care to the club. For example, Magee (2011) proposes that the doctor could argue that the duty of care he holds to the club encompasses the duty to take care of the patient’s well-being. Therefore, ensuring the long-term health of the players is intact with upholding the duty of care to the club. The steps to be taken to achieve this goal are usually not outlined in the contractual agreement between the team doctor and the club. Therefore, the team doctor has the discretion to outline what steps need to be taken to meet the contractual obligations with the club. Focusing on the scrumhalf incident, the team doctor could argue that withdrawing the scrumhalf from the initial play would also be in the long-term interest of the club because it would allow him to play in subsequent matches. It would therefore be of no importance for the scrumhalf to play in the initial match and sit out the rest of the matches.

However, Dunn (2007, p. 840) proposes that the strongest argument the team doctor could propose was the fact that the duty of care to his patients was of more importance than any other contractual obligation he had because by the nature of his profession, this was his primary duty of care. Any other contractual obligation that came later was therefore secondary. The focus on employer-to-employee relationship would therefore not have the same weight as the patient-doctor relationship because he was a team doctor. Therefore, in a situation that focuses on a careful balance between the patient and the employer, the team doctor is supposed to pay more attention to the patient, unless the contractual obligations to the patients is minor and of less significance when compared to employer obligations (Rachels, 1986, p. 56).

Focusing on the scrumhalf example, the right action would be to refrain from administering the injection because this action contravenes the principal ethical duty of the team doctor, which is to maintain the good health of his patient. Indeed, the contractual obligation that the team doctor has with the club can be perceived to be nothing more than a prudential issue. This observation is true because the contractual obligation has traces of career and financial interests written all over it. The ethical dilemma in this case would only be further complicated if the player asks for full information regarding the medical situation and insists that he be given the injection. If the player is given all the information regarding his medical condition and he still insists that he wants the injection, the team doctor would have to respect the concept of patient autonomy and administer the injection to the player (Rachels, 1986, p. 56). This development would be an interesting ethical dilemma because the principle of non-malefiecence outlines that the team doctor should not administer the injection to the patient but the concept of patient autonomy outlines that the team doctor should give the injection to the player. In this complex ethical dilemma, Matheson (2002) proposes that the doctor should decide which principle he is going to respect.

Comprehensively, Waddington (2000) states that conflicts of duties in sports medicine do not have a common framework to solve. The existent ethical considerations that prevail at the time should be taken into consideration because one ethical dilemma may not have the same outcome as another. If the outcome of one situation is considered true (or false) is a matter of perception because one’s initial perception of an ethical dilemma may be overtaken by other events. Therefore, no matter the extent of care, a doctor may accord a given ethical dilemma, the outcome of his decision may still be perceived to be erroneous in the future. Nonetheless, Melia (1989) explains that whatever outcome may be arrived at in an ethical dilemma should demonstrate the principles of honesty and conscientiousness.

Research Questions and Hypotheses

Research Questions

• Do the principles of conventional healthcare practice in medicine apply to sports medicine?
• What extent do ethical issues in sports medicine differ from the ethical issues in conventional medicine?
• What extent does the nature of competition in sports affect the ethical dilemmas in sports medicine?
• Does the financial component of sports affect the ethical behaviors of physicians and healthcare professionals in sports medicine?
• When does crossing the line of ethics in contemporary medicine amount to crossing the ethical line in sports medicine?
• Do ethical issues in conventional medicine have the same implications in sports medicine?

Hypotheses

• The principles of conventional healthcare practice in medicine apply to sports medicine.
• Ethical issues in sports medicine do not differ much from the ethical issues in conventional medicine.
• Largely, the nature of competition in sports affects the ethical dilemmas in sports medicine.
• The financial component of sports affects the ethical behaviors of physicians and healthcare professionals in sports medicine.
• Crossing the line of ethics in contemporary medicine does not amount to crossing the ethical line in sports medicine.
• Ethical issues in conventional medicine do not have the same implications in sports medicine.

Methodology

Research Design

The methodology for this study is mainly based on the qualitative research design. The qualitative research design will be used as a precursor to quantitative research design, which may form the basis for future studies on ethical issues in sports medicine. The usefulness of the qualitative research design will therefore be limited to getting a comprehensive conceptualization of the nature of ethical issues in sports medicine (based on the backdrop of ethical issues in conventional medicine). The use of the qualitative research design is also supported by the fact that this research methodology is flexible and supports the inclusion of case study research information. As evidenced in this paper, information from case studies are highly relied on to develop a framework for the development of the study’ findings. The inclusion of such data is supported by the qualitative research design. The nature of the research topic is also too complex to be answered by a “yes” or “no” response and therefore the use of the qualitative research design will be able to expose the underlying dynamics of the research topic. The simplicity of undertaking the qualitative research design is also a huge attraction for this research because it minimizes the cost of undertaking the research. Therefore, research costs associated with travelling, seeking appointments, developing questionnaires (and the likes) are minimized in this regard. This advantage is not only mirrored as a cost advantage but also as a functional advantage. For example, the use of secondary research gives the researchers more time to focus on the important parts of the research as opposed to spending a lot of time sourcing for the research information. Instances of burnout and exhaustion are also minimized in this regard. Furthermore, considering this paper focuses on the use of secondary research information as the main form of data collection, the dependence on population sample will not be as important as it is for quantitative research. Therefore, meaningful research can still be obtained with a small case study or a collection of relevant cases.

Data Collection

As mentioned in earlier sections of this paper, this study will use secondary research sources as the main data collection tool. In addition, as mentioned in earlier sections of this paper, the field of sports medicine has not been properly investigated but more so, the ethical aspect of sports medicine has not been thoroughly researched. Based on this understanding, this study uses the secondary research data as a tool for gaining initial insight into the research topic. Furthermore, since the ethical issues in sports medicine are rarely addressed, the use of secondary research data provides a broader understanding of the research problem. Though secondary research is mainly classified into internal and external sources, this study will mainly rely on external sources of data because there is no specific organization that this research seeks to address.

The main types of secondary research data to be used in this paper will be medical journals and publications. These research sources will be relied on because of their relevance to the research topic and their high credibility and validity (Rachels, 1986, p. 56). Furthermore, the reliance of medical journals and related studies will strive to ensure the findings of the study remain within the confines of the medical field because the research problem is equally medical. This principle methodology will ensure that the research study is relevant to the research problem. The outcomes of the study are therefore expected to highlight the ethical issues in sports medicine, based on an empirical understanding of the research problem. Furthermore, the outcomes of the study are expected to be peer-reviewed because the sources obtained will be peer-reviewed too. Therefore, the credibility and validity of the researcher’s outcomes is expected to be high. As mentioned in earlier sections of this paper, there is a great need to provide holistic information regarding the research problem by highlighting the sports and medical aspects of sports medicine. These two aspects will be comprehensively analyzed to provide a holistic understanding of the research problem. The study’s outcomes will therefore be fair to the understanding of ethical issues in sports medicine because it will encompass the ethical influences of medicine on sports and the ethical influences of sports on medicine. Through this understanding, the research objectives will be objective and direct to answering the research questions. Therefore, there will be no hidden motives or malicious practices in the formulation of the research’s findings. These attributes show one aspect of quality control that will be applied in the formulation of the research’s findings. Nonetheless, the accuracy of the findings will be guaranteed by the credibility of the information sources because this paper mainly relies on credible sources of information.

Books will also be relied as reliable sources of research information because they contain published texts. Their level of reliability and validity are also assumed to match to journals and medical publications. Finally, this paper will source information from online sources of research as the last type of secondary research data. The main advantage associated with this data collection tool is its easy availability. However, emphasis will be made to sources of data from reliable online sources such as medical sites.

The above research sources will provide the groundwork for a meta-analysis, which will combine the findings from the three sources of secondary data to form the framework for the research findings. Therefore, the true “effect size” of the data collected from the secondary research sources will be estimated by the meta-analysis. Comprehensively, we will be able to come up with a systematic review of the research problem by eliminating the less-precise effects size of the research information collected from the secondary research sources.

There are several advantages to be realized from the above meta-analysis. For instance, it would be easy to establish the diversity of the researches obtained from the different types of information sources highlighted in the secondary research information. This diversity is likely to be realized from the inclusion of diverse population groups in the secondary research studies. Through the meta-analysis, it is equally easy to derive the statistical testing for all the factors involved in the progress of the secondary researches highlighted in the secondary research sources. Though the concept of generalizing findings is highlighted as a limitation for this study, the meta-analysis helps to generalize the findings of this research to different but related contexts.

Data Analysis

The data analysis section will use four tools. These tools will mainly be used because of the reliance on secondary data as the main form of data collection tool. The interpretive technique is the first type of data analysis tool used in this study. The interpretive technique will be adopted within the framework of observer impression because the secondary data collected will be analyzed from an analytical and professional view to come up with a structured impression of the study’s findings. By extension, this data analysis tool will include the input of experts and professionals in analyzing the data collected. An analytical eye will also be included to sort pertinent issues regarding the research problem and eliminate any information that may not be of use when answering the research problem or meeting the objectives of the study.

The second data analysis tool to be used will be the coding technique. The coding technique shares many similarities with the other data analysis tools used in this study because it is mainly interpretive (Rachels, 1986). Mainly, the coding technique will be used to organize the huge volumes of research data collected. The data will be analyzed and segmented into different groups, which are identified by unique codes. These codes are usually words that show the link between the information obtained and the research objectives. The different research contents represented by the unique codes will thereafter be compared to one another to expose their similarities and differences. Advanced coding techniques use integrated computer software such as the Computer Assisted Qualitative Data Analysis Software which does little to supplement the interpretative nature of the exercise but improves the efficiency of the process altogether. The increased efficiency of the integrated computer software also allows for work sharing, peer-review, and easy examination of the information obtained (Rachels, 1986).

To establish the validity of the research information obtained, the member check technique will be adopted. This technique will not only be used to check the validity of the research information obtained because it will also evaluate the accuracy, credibility and transferability of the research information obtained. The member check technique works by submitting the research findings to the sources or sample sources. In this study, the research information will be compared to the existing pool of research sources and any distinctions checked to report on the accuracy or validity of the findings. Highly accurate and valid research information should reflect the views, feelings and experiences of the authors who developed the previous research (which is relied on in the study). However, this is not to mean that the findings of this paper will reproduce information from other studies because it will go beyond that to conceptualize the research problem (from a holistic perspective) and provide a framework for future studies.

Findings

Weighing the findings of this study, we can establish a few general ethical principles, which cut across the field of sports medicine. The principle of autonomy surfaces as a common ethical issue in sports medicine, although its presence can manifest in many ways. Autonomy refers to the ability of a patient to make independent decisions regarding his or her health and there is no better place that this principle elicits more controversy than in sports medicine. For instance, throughout the studies examined, the issue of performance-enhancing drugs such as steroids stands out as a major problem in sports medicine. A player’s decision to take these drugs may have a lasting impact on their health but due to the short-term rewards of sports (like winning a championship); such players are not subjected to intense criticism.

Mark McGuire is an example of a professional player who admitted to using steroids but still, many fans wanted his name to be written on the professional players’ hall of fame (Thornton, 2011). McGuire admitted to using steroids during injury as opposed to enhancing his performance. Even though he used the drugs to aid his recovery, some observers critic his assertions by claiming that he used the drugs to enhance his performance. Principally, players who are found guilty of using performance-enhancing drugs should be banned from playing and any awards (that may be accrued as a result) nullified. However, some of these players have a profound influence on teams, sports leagues and fans (alike) such that they get to walk away with such crimes. For example, sports is mainly a fan-based venture which thrives on endorsements and fan revenue. Therefore, the wishes of the fans are normally at the top of the list for sports leagues. However, these leagues are still required to maintain their integrity by upholding sports rules. McGuire’s situation is one incident that exposes the loopholes that exist in upholding ethical principles in sports medicine because it shows the existing pressures that may lead to a failure to observe ethical rules in sports medicine. Fans reduce the pressures mounted on players by supporting them even when they are on the wrong. McGuire was clearly contravening the rules of sports medicine (and sports leagues in general) but fans still demanded that he should be recognized for the outstanding contributions he made to the league (even while under the influence of steroids and other drugs). Therefore, unlike other professions, the cult-like following that some players enjoy among their fans greatly contravene ethical and moral principles in sports medicine.

Regardless of his admission to use performance-enhancing drugs, McGuire was touted as one of the best players in professional baseball history after featuring on several sports leagues awards such as the 100 best baseball players’ awards and the major league baseball all-league awards. In St. Louis, McGuire was honored by having a highway named after him (Thornton, 2011).

McGuire’s predicament is however not an isolated one because other players such as Barry Bonds have also been accused of using performance enhancing drugs in the professional careers. Barry Bonds was a professional American football league player who was convicted by an American grand jury of using growth hormones and steroids during his professional career (Thornton, 2011). Despite the conviction for using steroids, Bonds received several baseball league awards and was ranked among the 100 baseball players of all times. Bond’s steroid use was partly blamed on the prescription medications given to him by his personal strength trainer. The personal strength trainer is perceived to be a member of the medical field and his role in the Bond saga was one of questionable integrity and ethics.

The McGuire and Bonds stories are only a few examples of how professional sportsmen risk their health and careers for the benefit of winning short-term sports championships. As observed in previous sections of this paper, the risk taken by such sportsmen is no surprise because having a competitive edge in sports comes with several lucrative financial rewards (Linnaeus, 2010). The fact that a player chooses to take the drugs out of his own volition is a clear exercise of the right to autonomy but it contravenes the entire aim of ethical conduct, which is to do no harm to the patient’s health (Boudreau, 1991, p. 88).

Weighing the findings of the researches done on ethical issues in sports medicine, the principle of paternalism also surfaces as a major theme of analysis, which is also closely related with the theme of autonomy. Paternalism surfaces when healthcare professionals perceive their players’ decisions not to reflect the long-term benefits of their health. For instance, when players make personal decisions that interfere with their long-term wellbeing, the physicians or healthcare professionals feel the need to intervene and persuade the players to think otherwise. Here, the physicians may take the decision-making responsibility away from the player, thereby denying the patient the will to make healthcare decisions on their own. The competence of the players is therefore treated as invalid because their autonomous decision is limited.

Ordinarily, the paternalism concept is deemed unacceptable because it is treated as an infringement on the players’ right to make autonomous decisions about their health. However, the concept of paternalism surfaces as a useful finding when evaluating ethics in sports medicine, considering the multifaceted nature of the profession. This concept plays a vital component in the formulation of ethical solutions to moral dilemmas in sports medicine because paternalism stands as the only way the long-term welfare of the patients can be safeguarded. Proponents of the paternalism concept explain that the concept does not necessarily infringe on the rights of the patients but it substitutes their right to autonomy (Boudreau, 1991, p. 88). The justification for the use of the paternalism concept in solving ethical dilemmas in sports medicine would however largely depend on the ascertainment of the fact that the player’s right to make autonomous decisions is impaired. Often, this right is impaired by the desire to win championship and enormous expectations by the fans and the coaches. The main question that should therefore be asked in this context is if allowing players to make autonomous decisions carry a lighter ethical implication than applying the concept of paternalism to safeguard their long-term health.

In tackling the ethical dilemmas of sports medicine, it is apparently clear that team doctors should understand their ethical environments and make informed decisions based on such frameworks. Most importantly, the team doctors should pay careful attention to the networks and relationships that exist in sports medicine because these dynamics define the competitive nature of sports. By extension, we can also establish that most of the ethical dilemmas present in sports medicine are influenced by the competitive nature of sports. Essentially, the desire to win and the multifaceted goals shared by all stakeholders in the game produce the ethical dilemmas seen in sports medicine today. By extension, the “sports” element in sports medicine seems to infringe on the professional expectations of team doctors. Ethical dilemmas such as the conflict of duty, full disclosure, truthfulness and autonomy all stem from the infringement of sports elements on the medical profession. Most of the researchers however advocate for a strong strike between the contractual obligations between the doctors and the patients, and the doctor and the employer. The team doctor should therefore evaluate the prevailing circumstances and establish a balance between the interests of the patients and the sports organizations.

In addition, we can establish that the welfare of the patients is at the center-stage of all ethical dilemmas in sports medicine (as it is in conventional medicine). This observation is especially important in the ascertainment of the duty of care between the patients and the sports organizations. This paper establishes that it is more important for the team doctors to uphold the duty of care to their patients first, and then they can observe other duties of care to other parties.

Summary, Findings and Implications

According to the ethical issues identified in this paper, we can establish that sports medicine shares the same ethical problems with conventional medicine. The ethical principles and problems in both professions are the same because this paper identifies autonomy, confidentiality, truthfulness and conflict of duties as the main ethical problems in sports medicine. These ethical principles are also the main concepts of medical ethics. Based on this finding alone, we can establish that the ethical principles in conventional medicine are similar to the ethical principles in sports medicine.

Furthermore, when we analyze the nature of the ethical dilemmas in sports medicine, we do not see any significant difference with the ethical dilemmas in conventional medicine except for the motivations behind ethical actions in sports medicine. For instance, as explained in earlier sections of this study, there are common ethical concepts in sports medicine, which resonate with the ethical considerations in conventional medicine. Such ethical considerations include the principles of autonomy, patient confidentiality, truthfulness, full disclosure, conflict of duty and similar ethical concerns. There are therefore no significant differences between the nature of ethical problems in sports medicine and conventional medicine but the nature of the sports profession outline the differences that exist between the two professions. The competitive nature of sports and the conflict of duty that team doctors experience with their teams and their patients affect the outcome of ethical dilemmas in sports medicine. The same observation is true for the financial pressures that clubs and players experience when participating in daily sports activities. Often, these pressures affect their ethical decisions. More so, pressure from fans and spectators is largely seen to affect players’ right to autonomy. This situation has been properly explained by the Beckham example where he had to play for LA Galaxy despite suffering an injury that caused a long-term damage to his physical fitness.

Nonetheless, this paper also establishes that the nature of the ethical problems in sports medicine is unique to conventional ethical problems in medicine. This observation is entrenched on the fact that the competitive nature of sports and the financial muscle that supports the profession influence sports medicine. Finances are closely intertwined with the competitive nature of sports because it is the goal of sports organizations to raise as much funds as possible. Furthermore, sports provide huge monetary rewards to the players thereby compromising their decision-making process. These financial rewards associated with the profession are a source of pressure for players, team doctors and the sports clubs. It is easy to make money in sports as can be witnessed from the lucrative contractual deals made by top-notch players around the world. Many players therefore go out of their way to benefit from these financial opportunities. Unfortunately, many players do so at the expense of their health. Similarly, sports organizations exceed their mandate due to these financial incentives and strive to make as much money as possible, regardless of the health of their players. Based on this understanding, sports organizations often strive to ensure that their players rake as much money as possible for their clubs. This push is often motivated by the success of their players but the success of the players largely depends on their health. This long relationship explains the reason financial ambitions may trample the goal of ensuring players have a fruitful and positive long-term health. Examples have been given in this study about the financial deals that players have signed with different clubs and similarly, an explanation has been given to show how such financial deals affects players’ long-term health. Therefore, the huge financial incentive that exists in sports prompts some players to overlook their long-term health well-being. Therefore, it is correct to say that finances play a big role in influencing the ethical decisions in sports medicine.

Sports medicine is therefore subject to a lot of pressure from different quarters and sometimes, the players are not in a position to make proper ethical judgments about their health. Perhaps it is appropriate to single out spectators’ expectations as the strongest pressure that players have to manage. It is correct to say that, spectators are at the center-stage of sporting activities and by extension, they are the main source of funds for clubs and similar sports organizations. Therefore, all stakeholders in the sports arena strive to ensure their fans are fully satisfied with the game. Though some players know that they have injuries, they still succumb to “spectator pressure” with the aim of pleasing fans. Nonetheless, such players cannot be fully blamed for succumbing to such pressures because the sustainability of the game depends on the satisfaction of the players. Therefore, it can be said that if players are not happy (like when they want to see a specific player play and the player does not show up); there is no point of participating in sports because it will die a slow death (due to spectator dissatisfaction). However, the importance of exercising caution with a player’s injuries cannot be overemphasized because players need to ensure their long-term health is safeguarded. The players are therefore as important as the game itself. It can therefore not be assumed that one aspect of the sports profession (like players or spectators) is more important than the other.

Confidentiality and privacy constitute among the mostly discussed ethical issues in sports medicine (considering there is a lot of pressure in sports medicine for team doctors to release information about a player’s health). This pressure especially comes from coaches and managements but by extension, the media also contributes to this push (especially in high-end sports). This problem is further exacerbated by the fame and popularity of some key players in different sports leagues around the world. Due to increased fame, a player (or a team) is likely to draw a lot of public attention regarding not only their health but also regarding any issue about them. More so, some players have developed a cult-like following in the media and among their fans such that the media and fans closely follow any issue regarding the player’s life. Considering mainstream media focus on anything regarding a player’s personal life, the focus on a player’s health would be categorized as highly sought information. The popularity and fame that a player commands probably determine the agility that a player’s health information may be sought. This observation is especially true for high-end players and it is even more intense for players who are considered the “stars” of their teams. The public pressure that may come from the media and fans may sometimes overwhelm the team doctors and some may decide to divulge certain aspects of the player’s health information to curb public speculation. This action may fully contravene the principles of confidentiality.

Apart from this issue, privacy is seen as a common problem in sports medicine especially when team doctors strive to provide their patients with medical care in private facilities. Most of these facilities do not live up to the true nature of their being (private) because they are commonly shared with other team members. Sometimes, coaches or some sports agents easily find access to such facilities, thereby affecting the privacy of the doctor’s operations. It is therefore difficult for team doctors to conduct their medical practice in such easily accessible facilities. In conventional medical facilities, doctors usually have a lot of privacy in their areas of practice. In addition, only medical personnel (such as nurses) have access to such facilities. It is therefore easy to uphold the principle of privacy in conventional medical circles than in sports medicine.

Almost half of the literature sampled in this paper points out that the pressure to return physically unfit players to the pitch is a growing area of ethical malpractice in sports medicine (Boudreau, 1991, p. 88). This ethical malpractice mirrors the balance between short-term gains in sports and the long-term benefits on the player’s health. The latter advantage is normally realized when doctors hold the view that returning a player to the field (without properly recuperating) may pose many long-term health complications (Podlog, 2005, p. 20). The short-term advantages in sports (which are realized when players are forced back to the field before they heal completely) is normally realized when coaches and management do not want to lose their championships because of an absentee player(s). The conflict between short-term and long-term gains is the same point of departure for medical professionals and sports management. Usually, this clash is represented by conflicts of interest between medical professionals and sports management organizations. All the parties however bear shared interests, which are defined by owing a duty of care to the patients and the sporting organizations that oversee their activities. The conflict of interest between the team doctors, players and the sports organizations therefore need to be governed within a professional framework. Boudreau (1991) refers to this conflict of interest as owing a duty of care to another party apart from the patient. Many team doctors have identified the conflict of interest in sports medicine as an important area of ethical concern for the profession but 89% of such doctors agree that when they are faced with such ethical dilemmas, they would put the interests of the patients first. Considering all the conflicts of interest identified in sports medicine, it is agreeable that the interests of the patients would be the first priority of the profession. Largely, doctors and other medical practitioners understand this fact but the main problem observed in this analysis is the inhibitions by players and sports organizations. It is almost like team doctors pull on one direction and some players and sports organizations pull in another direction. This is an ironic state of affairs especially when players insist to take unnecessary health risks because team doctors look out for the players’ best health interests but the players ignore their advice. Sports organizations and clubs may ignore medical advice because they are mainly motivated by financial gains. They therefore perceive players to be expendable. If one player suffers a long-term injury or is physically unfit to participate in future games, the organizations would simply replace them. Unfortunately, many players fail to realize this situation and take unwarranted health risks while they are going to live with the consequences of such actions in the long-term. It is therefore prudent for players to keep their health well-being close to their hearts and refrain from risking their health for the sake of their teams.

Nonetheless, it is also important to acknowledge that a sense of responsibility and balance between the needs of the patients and the needs of the sports organizations need to be balanced. This ethical dilemma is known to be experienced by sports doctors alone. The uniqueness of this ethical problem (to sports medicine) is realized because the same problem has a very high frequency in the profession, thereby prompting many people to ask the question regarding what point in the sports structure do team doctors stand?

From the same understanding, it can therefore be said that doctor-patient relationship in sports medicine is very different from the same relationship in conventional medicine. In sports medicine, the association with different levels of hierarchy in sports governance influences the doctor-patient relationship. Excessive team demands are also likely to influence the doctor-patient relationship in the same manner. However, it is impossible to ignore the closely-knit nature of the relationship among sports organizations, team doctors and players. More so, the relationship between patients and their doctors is unique in sports medicine. Team doctors and patients forge a very close relationship in sports medicine. Unlike conventional medicine where doctors treat a multitude of patients, team doctors in sports medicine treat only a handful of people. Sometimes, some players have personal doctors whom they share a very close relationship. Similarly, it is usual for team doctors to develop a close relationship with a handful of players. The close relationship may impair the judgment of the team doctors especially when giving advice that may have far-reaching implications on the health of the players. For instance, if a doctor wants to see a player succeed in a specific championship, he may decide to give the player pain-numbing medications to allow the player to take part in a championship despite the fact that he may be physically unfit to do so. In addition, if a team doctor is highly dependent t on one player for his livelihood, he may take unethical actions to ensure the players keep playing so that he makes a living as a result.

The findings of this paper have far-reaching implications to the understanding of sports medicine because they highlight areas of weaknesses in the profession. The understanding of ethical issues in sports medicine facilitates the understanding of the nature of sports governance. Similarly, it is easy to understand the unique ethical dilemmas that plague team doctors and other health specialists in sports medicine. By understanding the background and nature of ethical problems in sports medicine, it is easier to develop a better ethical framework to govern sports medicine.

Comprehensively, weighing the findings of this paper, there are several questions to be asked regarding the nature of ethical problems in sports medicine. Firstly, considering the fact that most ethical problems in sports medicine are caused by the position of the team doctor in the hierarchy of the sports governance structure, it therefore begs the question of ascertaining which position the team doctor should be placed in the sports governance structure to avoid ethical conflicts. In addition, considering the fact that some of the ethical problems identified in sports medicine emanate from the contractual obligations between the team doctors and the organizations, it is important to establish the extent that these contractual obligations influence the doctor-patient relationship. This question is important because it is still not clear how a contractual obligation can influence the traditional concepts of medical ethics such as confidentiality, patient autonomy, privacy and similar factors. In the same contexts, we can also try to investigate the moral compass used by most team doctors when handling ethical issues in sports medicine. For instance, is it correct to conclude that the moral or ethical compass used in the medical profession is adequate to solve the ethical dilemmas facing team doctors in sports medicine? These questions should be used to form the background for future research studies.

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