Doping Control on Cannabinoid Use
There are additional inconsistencies in the foundation of the
world-wide war on doping. If anti-doping were purely addressing the
unfair advantage of an ergogenic intervention, anti-doping should be
focussing on the control of the use of ergogenic substances only.
Cannabis (marihuana, hashish) and its active substance THC are not
performance enhancing; THC is probably merely deleterious for
performance for any elite sport activity [51].
At present the WADA-AMA rules do not allow for traces of THC
metabolites in urine, even though it is well known that these
metabolites are found in urine well after the psychophysiological
effects of the substance have subsided. Why then test for the
substance? We believe that the inclusion of control on THC goes beyond
the declared goal of anti-doping. Moreover, justification of their
inclusion on the claim that athletes are role models is problematic, as
this places an unreasonable burden on athletes, compared with other
public figures like musicians, politicians or actors whom are not
required to undergo such tests. Our point is that the intrusive
monitoring of athletes actually undermines their status as role model,
since it stigmatizes athletes as people who, without surveillance, will
behave improperly. Thus, the burden is unreasonable not because it is
unfair, but because it constitutes an attempt to orchestrate role model
status which we consider to be deceptive and antithetical to what role
models should be. In any case, there is no obvious reason for why
testing for THC or similar drugs should be a matter of public concern,
unless one also requests tests from other such public figures. If the
response is that testing should be applied to other such people, then
at least part of our claim would be redundant. However, we believe that
there are good reasons for why such surveillance practices would be
quite inappropriate in a liberal society. One might also raise
questions about the role model status of most athletes. After all,
while all competitive athletes are subject to anti-doping rules, only a
few have a high public profile or a high salary. The majority have no
greater public role than, say, a teacher or a parent. Yet, we do not
hear pleas to test these and other people for illicit substances on
account of their being role models.
Accepted technology
The use of recombinant erythropoietin for enhancing the oxygen
carrying capacity of the blood is prohibited in competitive sports. The
alleged reason is clear, since it is accompanied by higher oxygen
uptakes and improved endurance performance. Altitude exposure has a
similar effect and leads to a natural increase in hematocrit and an
increase in oxygen carrying capacity. Nowadays, altitude training
camps, often touted with the slogan "sleeping high and training low"
are popular [52].
Modern technology allows for the simulation of altitude with the use of
hypobaric and normobaric hypoxia. Costly adaptations of sleeping
quarters allow sleeping at virtual altitudes and several federations
now have these facilities. Even individual athletes who can afford it
have altitude sleeping rooms at home [52].
Since it is the body itself that brings about the increase in
hematocrit when exposed to hypoxia, athletes are for now allowed to use
this technology even though its objective is to gain "undeserved"
advantage, just as with erythropoietin doping, and there are no long
term data on its alleged innocuousness. Again, this is a challenge to
equity, since many athletes cannot afford nor have access to such
technology. Probably in part in response to this, WADA-AMA recently
considered whether such technology should be banned, though has
concluded that it should not. This outcome reinforces the inadequacy of
anti-doping measures, since the difference between using these
techniques and happening to live in a high-altitude locality is
ethically irrelevant.
Other permitted technologies reflect a similar hypocrisy in
anti-doping rules. For example, electrical muscle stimulation is
increasingly used, either in preparation before a competitive event, or
after. German athlete Wojtek Czyz won three gold medals (100 and 200
metres, and the long jump) at the 2006 paralympics in Athens after
having trained with a unique, commercially unavailable electrical
muscle stimulator developed for international space station use [53].
Many sports involve high tech material from swim suits and running
shoes to futuristic bicycles. There is certainly no equitable access to
these technologies for rich and poor alike [54].
The usual response to this comparison is that these forms of
performance enhancement provoke a physiological response while doping
methods a pharmacological one. Yet, this is not the justification for
distinctions made within anti-doping policy. Indeed, we suggest that it
reveals a dubious essentialism about what it means to be human that
relies on claims about what is 'normal' or 'natural' for people to
exhibit physiologically. We argue that sports have never been a test of
merely 'natural' capabilities, but that they have always been
constitutively technological, whether this involves specific artefacts
or simply the application of scientific knowledge. This interaction
between potentiality and environment is consistent with critical views
of human genetics. Moreover, the difficulty with a commitment to
essentialist views about natural capacities is made more apparent
through the application of genetic technologies to sport specifically.
Genetic Technology
Thus, one further challenge that lies ahead for the world of doping
exacerbates the need for reform in anti-doping ethics: gene transfer.
Also known as 'gene doping', this new form of potential performance
enhancement has received considerable attention in recent years. While
there is much scientific dispute about the science and current
feasibility of gene doping [55,56],
its prospect does alert us to the inadequacy of current strategies on
doping control. Since some gene doping techniques might be undetectable
in urine or blood in principle, one may wonder whether current
approaches to doping are at all practical in an era where there can be
no realistic expectation of catching all cheats. This might also move
the war on doping to a stage of technical sophistication that might
make it financially difficult to sustain. In addition, the broader
social interest at stake with respect to gene transfer technology would
give a new perspective to the question of what kinds of performances
are legitimate in sport and how this ties in to concepts of equity,
fair-play and deserved merit.
What are the Risks of Leaving Doping Choices to the Athlete?
Even though it is presently unrealistic to abolish anti-doping in
sport, let us briefly discuss what the hypothetical consequences would
be if the use of doping were allowed. Would there be an important
increase in death rate among athletes? Would there be many (more)
athletes willing to take deadly risks? Would there be more chronic
illness and shorter life span after cessation of an athletic career? If
doping were allowed under the conditions we discuss, including an
ethical framework based on the principle of non-maleficience, we would
probably see an increase in the use of ergogenic drugs, but this need
not to lead to an increase in morbidity and mortality. The example of
the widespread use of doping in the former East-German republic [57,58]
reflects the secret and coercive nature of state mandated doping, a
framework widely different from the one we propose. Our proposal for
monitored performance enhancement would ensure that athletes are better
informed about the risks they take and transparency of these practices
would limit the possibilities for a given nation from taking advantage
of their athletes. Furthermore, taking doping out of hiding may have
positive effects beyond the restricted world of elite sports. Indeed,
the practices in the amateur sports world might become less hazardous
and thus overall incidence of health problems from doping use might
actually decrease. Unfortunately, it seems impossible to test this
hypothesis in the current political climate, since there is hardly any
interest in re-evaluating the ethical foundation of doping. Moreover,
as Houlihan demonstrates [48],
there has been no sustained open discussion of the ethical foundations
of anti-doping since it began in the 1960s. If one were to compare this
with other policy debates in science, medicine and technology, the
situation is radically inadequate.
What should the Physician's Role in Elite Sports be?
Suggestions about anti-doping reform have specific implications for
medical professionals working with athletes. Yet, even within the
present framework of anti-doping, problems arise that invite critical
scrutiny of the established model. The current ethical framework of
competitive sports is not without problems for the sports physician. As
early as 1983, Thomas H. Murray, president of The Hastings Center (a
leading institute for ethics), former United States Olympic Committee
adviser, and present Chair of WADA-AMA's Ethical Issues Review Panel,
argued that the conditions surrounding the physician's involvement with
elite sport place undue pressure on their decision making capacities [59].
Often, the coach's or sponsor's interests take precedence over the
physician's professional judgement about what is best for the athlete.
On this basis, Murray argues that standards of best practice are often
unclear or non-existent.
We believe that, in agreement with prevailing ethics of the medical
profession, the role of the physician involved in the athlete's health
supervision should be one of preserving the athlete's autonomy, which
entails a balance between ensuring that treatment leads to the highest
degree of present and future health, while acknowledging the athlete's
interest to maintain a chosen style of life. Inevitably, there will be
situations in which performance optimisation will conflict with the
preservation of health just as it is already present today when
therapeutic measures are applied to keep an athlete in the game despite
an existing injury. Ethical reasoning should be based on
proportionality, assessing the benefits and risks as objectively as
possible. Admittedly, this is not an easy task, since it requires a
process of negotiation to face the difficult question about what kinds
of health risks are acceptable for an athlete to take. While further
elaboration on this is beyond the scope of this paper, we would suggest
that the solution lies partly in the structures of sport that permit
such risk taking. Nevertheless, we believe that by carefully helping an
athlete enhance her performance (by utilising currently banned
methods), in keeping with the principle of autonomy, using any safe
technology available, the physician should again become the direct
partner of the athlete in pursuit of ever increasing performance. As a
result, a physician in the role of caring performance enhancer should
be accountable for ill effects from the use of any medical technology.
This would be analogous to the usual role of physicians. They are free
in their choice of intervention, pharmacologic or other, as long as
these are in agreement with current medical knowledge and without
disproportionate iatrogenic ill effects. Rather than speculate on
anti-doping test procedures, resources should be invested into
protecting the integrity of physicians who make such judgements.
Without clear regulation, it is possible that coaches could appoint
'performance inclined' physicians to ensure maximum competitiveness in
their athletes. Waddington [60]
recognises that much more thought is needed to establish principles of
good practice concerning the role of sports physicians. Perhaps
independent physicians whose status is comparable to other sports
officials, is the most suitable strategy through which to develop this
more ethically rigorous requirement.
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