On the eve of the Sydney Olympic Games, sport medicine is faced with ethical dilemmas that stretch well beyond the domain of top-level competition
Advances in life sciences and biotechnology are stirring up a broad debate about ethics. Expert committees are being called upon to bring ethical codes in line with genetic research developments, assisted reproduction, prenatal screening and the prospects for human cloning.
Standards for clinical reseach on humans, spelt out in the 1947 Nuremburg Rules, are now being challenged by medical advances and research unimaginable in those days. Questions surrounding the prospects of human embryo research (and the risks of new forms of eugenics) as well as research spurred by the mapping of the human genome, are generating new laws based on consultation with national and international ethics committees, along with medical and research groups. This is the most public part of the debate, the issues that make headlines.
But medical ethics involve far more than these issues, which are all essential to imagining the kind of "humanity" that we are embarking to create. Tomorrow's society is being assembled day by day in the privacy of doctors' surgeries. For medical ethics are also being challenged by patients themselves, and by practices that have become routine.
A premium on efficiency and performance
Doctors are inevitably affected by societal changes, shifting aspirations and accepted behavioural norms. They also have to try, in their relationship with patients, to reconcile ethical considerations with the new demands arising from a liberal society that puts high value on efficiency, output and performance. This is especially true in the case of drug-taking (or doping) in sport, which can be seen as the logical outcome of a performance-based type of medical practice. Oddly enough, discussion about doping is generally reduced to a few cliches: it is branded as unethical in light of an imaginary sporting ideal. Calls are made for better drug-testing and stiffer punishment for "cheats" and their accomplices. But this skates over the real issue--the pressures of competition in sport--and hides it even further from the public, doctors and authorities.
Doping in high-pressure sports can hardly be equated with reckless or rash behaviour. On the contrary, it requires the conscious involvement of the competitor who personally controls the state of his or her own body and training. The athlete is led to take drugs daily to reduce fatigue and to increase muscle power, or to recover quickly from an injury or excessive training, for example. The scandal over the Tour de France bicycle race in 1998 showed how riders knowingly and personally take banned substances in order to endure tough training and back-to-back races throughout a whole season.
So the real ethical debate rests solely on medical practice. It means we should reflect on how doctors respond to requests from athletes at all levels, for doping is also on the rise among amateurs and children.
At the 43rd American Health Congress, held in Washington in September 1996, Thomas H. Murray, of the Center for Biomedical Ethics at Case Western Reserve University (Cleveland, Ohio), recounted how a mother asked for growth hormones for her son to improve his sporting performance. There are two factors behind this request. First, advances in medical biotechnology have made it possible to produce artificial hormones. Second, the drive to win draws the doctor into altering the body to make it perform better.
All medical codes of ethics condemn doctors acceding to such requests. The World Medical Association calls on every doctor to "oppose and refuse to administer or condone" methods that aim at "an unnatural increase or maintenance of performance during competition" or which "artificially change features appropriate to age and sex" (1981 Declaration on Principles of Health Care for Sport Medicine, amended in 1999). …