A Level Playing Field
The first foundation for anti-doping concerns the concept of
fair-play. It is reasoned that athletes should compete on equal grounds
[7,8].
One purpose of the rules of sports is to define the 'level playing
field' on which athletes compete and thus to articulate the notion of
fair-play. Currently, anti-doping policies are part of these rules
since doping practices are typically seen as cheating. We do not
question the need for rules in sports nor the possibility of finding
workable 'level playing field' definitions. However, we do find the
anchoring of today's anti-doping regulations in the notion of fair-play
to be misguided.
Official thinking on these issues simply assumes the validity of the
level playing field concept without coming to terms with the reality of
widespread biological and environmental inequality. People differ in
their biological capacities, which result from interplay between genome
and environment. This also applies to athletes and their performance
capabilities. Genetic predisposition is of prime importance in this
respect even though the identification of these genetic traits is
taking time [9].
In fact, even a simple genetic mutation may confer a performance
advantage. For example, in one Finnish family, a mutation in the
erythropoietin receptor has increased the sensitivity of erythroïd
progenitor cells leading to high hematocrit. The clinical condition is
mild and life span is unaffected. The family's most famous member, Eero
Maentyranta, whose blood carries more haemoglobin and therefore more
oxygen than that of the average male, won three gold medals in
cross-country skiing at the 1964 Winter Olympics in Innsbruck [10].
This example reveals the importance of inherited characteristics for
performance. Yet, it is treated very differently by conventional sports
ethics policies when compared with for example pharmacological aids,
even though neither example is 'earned' by the athlete. Apparently,
prevailing sports ethics is unconcerned about this contradiction since
'natural' genetic variation is considered to be an acceptable (or
irrelevant) inequality, whereas artificial enhancement is not. However,
while WADA has recently signalled a concern about the use of genetic
screening for performance [11],
there are no strict prohibitions of such use. Nevertheless, it will be
interesting to follow this development as the warning from the WADA
comes just months after the commercialisation of the first genetic
tests for performance, which are now being introduced to a range of
countries [12].
In addition to genetics, several other contingent facts about the
athlete's circumstances fail to be reflected adequately in the current
ethical framework of anti-doping. For instance, depending on their
nationality and sports speciality, athletes may differ enormously with
regard to their access to care, supervision, and a high quality medical
and technological environment [5,13].
Being a top athlete from a rich country is completely different from
being an athlete from the developing world. There is certainly no
evidence of equality of conditions here and there probably never will
be. Furthermore, in a rich high-tech environment, an athlete may come
as close as possible to doping, and sometimes into doping, all the
while being medically supervised in a sophisticated technological
environment.
These inequalities are further compounded by the possibility of
undetected sophisticated doping. The recent cases surrounding the
United States Bay Area Laboratory Co-Operative (BALCO) concerning the
designer anabolic steroid, tetrahydrogestrinone (THG) [14],
clearly show that, given sufficiently high stakes, inventive people
will circumvent anti-doping strategies and may remain undiscovered, at
least temporarily. It is relevant to note that the discovery of THG
came as a result of an individual's 'good will' rather than the success
of anti-doping laboratories. In 2003, a syringe filled with the
substance was left anonymously at Dr Don Catlin's anti-doping lab at
UCLA, from which his team was able to characterise THG and develop a
test for it [15].
Presently, anti-doping relies predominantly on tests for substance
groups that are available through prescription or that are known to the
anti-doping laboratories as potential doping agents. Anti-doping cannot
possibly develop tests for all substances that have ever been
developed, especially those that never made it to full
commercialisation and about which little is known. This confers force
to the claim that anti-doping will always remain one step behind the
dopers. Moreover, these circumstances give credence to the argument
that doping tests are not effective if they lead merely to catching
those athletes who do not have the best 'rogue' scientists working for
them. The use by athletes from countries with less access to high-tech
medical supervision during the 2004 Athens Olympic Games, of 'old'
doping technology like the anabolic steroid stanozolol [16]
suggests another dimension of this economic inequality. Since testing
techniques for these older substances are well established, their users
run greater risk of discovery than those who have access to newer more
sophisticated molecules [5].
The response might be that the function of testing is as much a
deterrent as a mechanism to ensure a level playing field. Indeed, one
might claim that failure to detect all cheats is not an argument
against striving to do so, since this would mean that perhaps all forms
of regulatory systems are inadequate. However, we question this
argument, for while it is common for anti-doping advocates to analogise
their work to the criminal justice system, this analogy does not hold.
In fact, sports are particular because their social value relies on
whom is celebrated as the winners of competitions. In turn, it is
presumed that these winners undertake their achievements by actions
that merit praise or are virtuous. Such actions might include the
discipline of training, the learning and acquisition of skills, or even
a feel for the game that is somehow special. Yet, if the system is
ineffective, then these crucial values are compromised. In contrast,
normative systems designed to police society at large do not make
high-minded assumptions about universal virtue and are, therefore, more
resilient as regards the continued existence of transgressions. In
addition, even though in elite sports repression may have led to a
reduction in doping such is not the case in amateur sports and outside
sports, where the available evidence clearly indicates continuous use
of performance enhancing substances [17-22].
One more important problem concerns the potential of false positive
tests. A recent report mentioned the potential of wrongly accusing an
athlete of EPO use with the current testing procedures for EPO [23].
Anti-doping tests are just as much limited by sensitivity, specificity,
precision and reliability as any other biomedical test and acceptable
limits for certain products have to be set rather high to prevent false
positives and therefore false negatives will continue to occur.
To summarize, we argue that the present concept of fair-play
implicit in the war against doping fails to incorporate several other
sources of inequality between athletes. Considering the continuous
discovery of doping cases and the impossibility of eradicating doping
practices, the basic inequality between undiscovered doped athletes and
'clean' athletes is likely to persist. These circumstances invite
questions about what system of addressing the inequalities associated
with performance enhancement would be most likely to optimise equality.
While we do not consider that the discussion turns merely on an
equality argument, the 'spirit of sport' criterion within the World
Anti-Doping Code is used to give special value to fairness within
sport. It is used as an argument on which anti-doping is justified: to
ensure athletes are playing the same game. We suggest that, from the
perspective of equality, supervised doping practice is likely to
provide the greater prospect of ensuring equality of competition. On
such a system, competition results would be based on some system of
merit, rather than the undeserved inequalities arising from, say,
genetic capacities. Critics might argue that scientists, rather than
athletes, earn such advantage and that this kind of achievement is not
relevant to sports. However, elite athletes are also constituted by
scientific knowledge and this is a valued aspect of contemporary sport.
As such, translating doping enhancements into earned advantages –
having the best scientists on one's team – would more closely align to
the values of competition than leaving it all to chance, unequal access
to illicit practice, and the cleverness of undetected cheating.
Protecting the Athlete's Health
The second ethical foundation for anti-doping is the protection of
the athlete's health. It is reasoned that anti-doping control is
necessary to prevent damage from doping. Even though we endorse the
principle of concern about the health of the athlete, there are reasons
to question the particular form of this principle as related to
anti-doping policy.
The Concern for Professional Integrity
When advocating the need for anti-doping in sport, a strong claim
seems to emerge from the values implied by the medical professional's
role and the proper role of medicine. There are two parts to this
claim; the first relates to a stance on the legality of medical
standards, which rejects doping methods because they are instances of
medical intervention for non-therapeutic purposes. According to a
commonly held position today, medical practice should be either
preventive or therapeutic, i.e. aimed at preventing or treating
disease, but should not use bio-medical technology for human
enhancement. Indeed, much discussion in contemporary bioethics seems
particularly concerned about the legitimacy of this conceptual
distinction, though it is reasonable at least to indicate that such
distinctions are made within medical practice, either because of the
need to ration treatment or because health care providers do not
consider enhancement to correspond with the proper role of medicine. Of
further concern is that a particular doping practice has not been
approved for use with healthy persons (such as athletes) and so has not
benefited from the extensive clinical trials normally necessary before
a therapeutic substance can be used. This is why, according to current
anti doping policy, doping might be used legitimately with a
therapeutic objective to increase the rate of repair of injury, but not
if there is no medical need as such. In this sense, the use of doping
methods to enhance performance is not sensible to many medical
professionals because little is known about their effects on people who
do not suffer from the very specific condition(s) for which the
intervention was designed and tested. However, this view is not
reflected in the wide spread use of off-label prescriptions. While the
risks associated with such practice might be acceptable in a
therapeutic context [24],
it is deemed unacceptable in the realm of enhancement for sport. This
is a salient point, since an advocate of doping cannot simply map onto
sport substances that are already in existence for therapeutic use.
Thus, we cannot claim that a specific form of, say, an anabolic steroid
be granted permission for use by athletes. Rather, our claim would
require approval for the development of an anabolic substance or dosage
scheme designed and adapted specifically for athletes. The implications
of this claim are quite different from advocating an uncritical
acceptance of substances that already exist.
However, the ethical force of this point arises in the second part
of the claim, which relates to the principle of non-maleficience, a
principle that applies to all health professionals. In view of this
principle, the ethics of anti-doping justifies itself on the basis that
the counter-position would require medical professionals to
use medical products in a way that might lead to greater harms for the
patient or because it might compromise the physician's personal
integrity. Thus, one might suggest that such risks are different from
those an athlete takes when choosing to, say, go horse riding, since
the latter does not require prior medical intervention before taking
part. At most, it might involve some form of approval that the
participant is in good health. In contrast, under medically supervised
doping, a physician is making possible the enhancement by intervention
and so undertakes a duty of care when treating the athlete. The
difficulty with this claim is that sports physicians already engage
in such practices when repairing athletes. Consequently, to reject
'enhancement' on this basis fails to take into account the bio-cultural
character of health: that making people well always involves making
them well for something that involves a whole range of risks. While it
might be unreasonable to claim that all physicians have an obligation
to enhance athletes, one would nevertheless recognise as legitimate a
physician's choice to facilitate such a lifestyle. Indeed, the
remaining arguments that might counter this view would involve some
concern about the scarcity of resources, though sports are unlikely to
rely on public funding for this purpose.
The Concern about Unnecessary or Irrelevant Risks
The second concern about protecting the athlete's health that is
often used to justify anti-doping is that doping risks are
qualitatively different from other sporting risks, because the former
are unnecessary and irrelevant. This view takes into account the fact
that elite sports are not innocuous [25,26];
participation may lead to serious health problems. Consequently, such
practices are not considered unambiguously health promoting. For
example, soccer comes with high risks for knee and ankle problems, well
beyond that of the general population, especially in elite players [27]. Boxing, in its present form, is well known to be dangerous for the CNS [28]. In ice hockey and American football spine injury is frequent [29].
These risks – unlike doping risks – are often characterised (and
justified) as a necessary part of the competition. However, the various
sports are not defined by their essential nature; rules can be changed
to make them safer. For example, boxing has made a number of rule
changes over the years to reduce the potential for serious injury. But
there is often a limit to reducing risk in this way, since excessive
risk reduction could undermine the value typically attached to a
particular sport. For instance, if one seeks to free climb a particular
mountain route, then the practice is possible only by accepting the
rule that no safety support is used. If this rule is not maintained,
then the claim that one has climbed freely cannot be made. Thus, if the
rules are changed, then the type of experience changes along with the
values associated with it. While medical professionals will strive to
make sports as safe as possible, there are certain risks that must be
accepted in order to have the games take place.
For many practices, the claim about logical necessity and relevance
cannot be advanced in relation to doping: one can undertake free
climbing without using some form of doping. An interesting case arises
when considering extreme performances. For instance, there are some
forms of performance that are not possible without some form of
technological enhancement. Perhaps for some climbers supplemental
oxygen for climbing Mount Everest falls into this category. In these
kinds of activities, enhancement has a contested status, though might
be seen as a constitutive element of the performance in the same way
that a tennis racquet is a constitutive technology of playing tennis.
However, doping practice might make possible the experience of certain
physical achievements that are simply not possible without the
technology. Indeed, one might suggest that the level of competition in
many sports is so high that being competitive requires a wide range of
sophisticated technological assistance to be used in training.
Therefore the notion that current elite sports competitions only test
some naturally inherent ability of athletes does not reflect reality.
However, the more salient point is that the level of risk one
accepts within the practices we enjoy cannot be prescribed by the moral
norms of the medical profession. The kinds of risks one takes in daily
life are determined through a complex, personal value system that can
often appear inexplicable – such as the motivation for jumping out of
aeroplanes or deep sea diving. It is problematic to make such value
systems accountable to the moral judgement of the medical profession.
Indeed, one conception of a health care system (which we advocate here)
would suggest that one of its functions is precisely to care for the
risks people freely take in their daily lives.
The key question is whether any rule or enhancement is 'sufficiently safe', rather than absolutely safe. We believe that doping cannot be
sufficiently safe as long as it is prohibited and that this fact has a
direct bearing on the integrity of medicine and the physician's
commitment to maintain this integrity. Yet, under appropriate
supervision, this risk could be more easily justified. Thus, a
physician cannot simply assume that doping is, per se, more dangerous
than the risks of engaging in elite sports. The risks of every doping
technology must be assessed. In turn, this is especially difficult for
an illegal practice whose risks are not well described, since they are
largely hidden. For instance, the risk of well-controlled use of
erythropoietin in elite sports is not well known, since only anecdotal
information is available [30]. The use of dexamphetamine is likely to be dangerous, but scientifically sound data are scarce [30]. More data exist on anabolic steroids [30,31],
but again secrecy prevents an evidence based assessment. Furthermore,
in a context of prohibition and penalties for use that discourage
scientific assessment of the risks, declaring that doping is dangerous
becomes, to some extent, a self-fulfilling prophecy, since doping often
happens without proper medical supervision or evidence from sound
clinical trials. In elite sports there may at least be some medical
supervision, possibly of good quality. This is not the case for the
general population, which may result in serious health problems for a
much greater number of subjects. Indeed, recent reports on the use of
illicit pharmacological means to enhance performance in amateur sports
are alarming with regard to the high prevalence of these practices [19,20,30,32-35].
Response to the Protection of Health Arguments for Anti-doping
We propose that allowing medically supervised doping within the
framework of classical medical ethical standards, particularly with
regard to the principle of non-maleficience, would potentially have a
number of positive consequences.
Firstly, it might lead to a clearer view of what is dangerous and
what is not. At present doping is largely hidden and its epidemiology
unknown. Additionally, the war on doping may have adverse effects of
its own. Doping control leads to shifts in behaviour that entail an
increased health risk. The detection of oil-based esters of nandrolone,
belonging to a class of anabolic steroids with little side effects and
low risk for hepatic disease has led to the use of oral analogues with
more side effects, but more rapidly eliminated from the body and thus
less easy to detect [36].
Now that recombinant erythropoietin is detectable, there is a shift to
the use of other oxygen carrying capacity enhancing drugs, with higher
potential health risks [37]. These consequences of anti-doping practices may thus paradoxically introduce more health problems than they prevent.
Secondly, elite sports activity often results in health problems
that need specific attention. Sometimes, managing these health problems
involves pharmacological interventions that are normally considered
doping. The boundary between therapeutic and ergogenic (i.e.
performance improving) use of pharmacological means is quite blurred
and poses important problems to the controlling bodies of anti-doping
practice and athletes' sports physicians [38].
Several substances can be used for medical reasons but are proscribed
when the athlete is healthy or in competition. These rules for therapeutic use exemption (TUE) lead to complicated and costly administrative and medical follow-up [39].
They may even lead to athletes being denied medical care corresponding
to a best practice standard. Cyclists with documented asthma could not
be treated optimally because of the strictness of the rules [40].
Medically supervised doping would erase this dual identity of molecules
– legitimate therapeutic agents vs. illicit doping – and thus eliminate
these additional burdens. This would have to be put into the broader
context of non-therapeutic use of substances or practices for reasons
of human enhancement in general. Although such practices generate much
uneasiness today, they need to be addressed frankly as the diversity
and scope of human enhancement is bound to increase.
An example of accepted athlete's enhancement is a surgical procedure
originally invented to repair injury of the ulnar collateral ligament
of the elbow in baseball pitchers. Anecdotal evidence suggests that
this procedure often allows pitchers to perform even better than before
they were injured. In this case, the repair of athletes – along with
the process of recovery through exercise – works to provide a 'better
than well' performance outcome, without giving rise to any moral
concern about unfair advantages. While this procedure now has a
considerably greater success rate, its development in the 1970s was
considerably more experimental and hence dangerous [41].
Thirdly, the concern about doping is largely disingenuous, if it is
supposed to reflect a genuine moral concern for health. There is no
lack of moral entrepreneurs, poised to preach the war on doping: sports
authorities, politicians, opinion leaders, ethicists, and the media.
They claim the moral high ground by waging what has become, in effect,
what social scientists call a "symbolic crusade" [42].
Yet, while high-level sports is touted as embodying the positive values
of health, meritorious effort, harmonious development of body and mind,
this downplays the very real health risks of elite sports as well as
accepted levels of foul play with considerable health damage in certain
sports such as soccer or ice-hockey. Today's medical reality of
high-level athletics little resembles the quaint image of an ideal
harmony between beauty, strength and health dreamed up by the early
Olympic movement. Elite sports have become thoroughly alien to the sort
of physical exercise that is a legitimate general public health
concern. In addition, high-level athletes are singled out for attention
and their health-related behaviours subjected to an invasive scrutiny
that would be impractical – and unethical – if it were applied to the
general public.
The war on doping diverts scarce resources towards a program of
intense and intrusive health surveillance for the few, which makes no
sense in terms of public health, if only because the fraction of the
population that engages in elite sport is very small. The problem is
all the more obvious when compared to the frequent doping practices in
amateur sport [18,43]. Indeed, the recent statement on performance-enhancing drug use by the American Academy of Pediatrics [44]
emphasises the broader public-health rationale that should govern
anti-doping strategies. It argues that the use of such substances is
far broader than elite sport and focusing specifically on this area
neglects the many other ways in which substances are used in ways that
are dangerous. Doping is not just a sports issue, and therefore does
not justify a sports-only approach [45].
In this era of anti-doping, a black market in substances such as
anabolic steroids has developed, often of dubious quality. Dangerous
practices have emerged, such as sharing syringes, leading to risk of
HIV or hepatitis virus infection [17,21,22,46,47].
We should be concerned about the health of this much larger fraction of
the population, instead of investing so much effort and money in
surveillance of small numbers of often medically well supervised elite
athletes. On this view, a drug testing programme is not the most
effective way to curtail the use of performance enhancing (or lifestyle
improving) substances. Rather, resources should be invested into
understanding the shift in cultural values associated with biological
modification and the culture in which doping practices emerge. Merely
testing athletes attends only to the consequences of such a culture.
The Cost of Anti-doping : Who Pays ?
We acknowledge the need for rules in sports. The principle of the
adherence to a set of rules, including the prohibition of doping is, in
itself, not problematic when considering the practice of sports.
Houlihan [48]
for example articulates the 'keep the rules' argument as part of an
agreement that has social weight. However, one problem arises when the
application of these rules is beset with diminishing returns:
escalating costs and questionable effectiveness. As argued above we
believe that the ethical foundation of the prohibition of the use of
ergogenic substances in sports is weak at best. Therefore, we find that
the increasing cost for the practice of anti-doping raises an ethical
dilemma of greater importance and relevance than the ethical arguments
advanced as the foundation for anti-doping practices.
Elite athletes only represent a small fraction of the global
population but the resources of anti-doping almost exclusively go into
testing of these athletes. The WADA-AMA budget amounted to 21 million
dollars in 2004 [1].
According to its statutes, as of January 1st 2002, WADA-AMA's funding
is sourced equally from the Olympic Movement and the governments of the
world at least until 2007 [1].
The budget of the Swiss Anti-Doping Commission for 2004 was about SFr.
1.5 million whereof SFr. 800,000 came from the government [49]. The budget of the USA anti-doping agency in 2003 was 10 million dollars [2]. The UCI (Union Cycliste Internationale) spent 1.4 million Swiss francs directly on doping controls and testing in 2003 [50].
The overall world wide cost of anti-doping is difficult to estimate but
is likely to be high in the light of the number of athletes concerned.
It will probably increase further as the complexity of the analysis
increases and the coverage of the world's elite athlete population
improves. Today, the rich countries can pay the bill for the
increasingly costly practice of doping control, but the developing
countries cannot. There is money coming through international
federations like the IOC, but increasingly, resources will accrue from
governmental sources. Even though today the contribution asked from
developing countries is small, especially in those countries the
priorities should lie elsewhere from a public health perspective.
Furthermore, we have seen that in the competition between increasingly
sophisticated doping and anti-doping technology, there will never be a
clear winner. Consequently, such a futile but expensive strategy is
difficult to defend, especially since the much larger fraction of the
population that engages in behaviour like use of anabolic steroids and
needle sharing is a real health issue [21] and does not get the resources necessary for prevention and harm reduction.
Doping shares several characteristics with general substance abuse.
Even in a repressive environment substance abuse persists, with
potential harm because of the need to hide the abuse. The highest
sanction for an athlete, whose doping practice is discovered, is a
lifetime exclusion from competition, which is not enough to scare all
athletes away from doping. The political and economic incentive, along
with the personal quest for money, fame or the thrill of winning is so
high that risk taking is likely to continue. As long as the rewards of
competition remain high and the consequences of being caught are merely
exclusion from competition, the likelihood of athletes using doping
will remain high [5].
In addition, truly deterrent penalties would have to be as severe as
sanctions for major crimes, which is indefensible in terms of social
ethics.
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