AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. July 2004, Volume 6, Number 7.

From the Editor

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Medicine in Sports and Fitness

The assistant journal editor introduces a theme issue on the role of medicine in sports and fitness.

If there were such a thing as perfect health, exercise would be a big part of it. Many physicians have preached that gospel successfully to their patients, and many Americans have embraced sports as a way of life. It's clear that other nations have done so too, in this current summer Olympiad.

The Olympic contenders themselves testify to what dedicated athletes, coaches, trainers, and sports physicians can do together to achieve a goal of perfect health, or as close as humans can possibly get. In a sphere of life that looms so large as sports, however, it's not surprising that ethical issues arise and medical ethics problems too. For example, ergogenic aids are causing controversy from the Olympic level all the way down to high schools and even middle schools.

The AMA Code of Medical Ethics encourages competition in sports, even contact sports, with appropriate precautions. "Informed decisions" by athletes together with their physicians is the goal.

This issue is not strictly about professional sports medicine. It is as much about family medicine. The American Academy of Pediatrics encourages children to develop good lifelong habits of physical activity and has monitored the problems and possibilities that go along with youth sports. An AAP physician as well as an orthopedist of the American Academy of Orthopaedic Surgeons helped us develop our cases. The AAP's work on youth sports and the American Academy of Family Physicians' study of sports-related ethics problems were helpful resources in formulating the questions we posed to our authors.

Thanks to a number of studies in the field and to advances in sports medicine that have been applied to pediatrics and family practice, some of our health habits must be seen in a new light. We can see the outlines of some societal problems, and, in fact, researchers, in their alarm, have borrowed the language of infectious disease. An "epidemic" of obesity has reached the top of almost everyone's list of health problems. Fitness offers one solution. Physicians face a choice: allow the problem to continue unabated and treat obesity when it occurs, or try to prevent it. If the prevention path is the chosen one, as urged by Centers for Disease Control and others, then physicians will be called on to act more effectively as health educators about fitness.

An unintended consequence of the growth of organized sports is, again, an "epidemic" of injuries. Not just the several million visits to the ER for sports and recreation-related injuries, as documented by a CDC study published in JAMA in October, 2002, but, according to the Institute for for Preventative Sports Medicine, a hidden epidemic totaling 12 million injuries a year. Injuries from overuse affect a vulnerable public—youth participants in organized sports. What is the obligation of physicians to educate or warn about overuse injuries, or to prevent them, now that these injuries have reached epidemic proportions? Some of our authors say it is the physician's role to make sure that active patients avoid overuse injuries.

Do physicians have a duty or obligation to be better educators of their patient about fitness and health? One of our case commentators warns that, today, physicians rank at or near the bottom of the list of people who athletes will consult about the efficacy or safety of ergogenic aids, nutritional supplements, or drugs.

Sports medicine itself is a relatively new specialty. For example, The American Orthopaedic Society for Sports Medicine was founded in 1972 and its journal started publication in 1974. American College of Sports Medicine is a bit more mature, celebrating its 50th anniversary this year. In that amount of time, a great deal of new information from the sports medicine field has become common knowledge that is now helping not only elite athletes, but school physical education programs as well as family practitioners.

Specialized codes of ethics are evolving. One of our authors calls for a worldwide code of ethics in sport medicine. The American College of Sports Medicine's code includes a statement that is more far-reaching than most medical codes, because its members—trainers, physicians, and researchers—not only pledge to help return patients to good health, but to improve well-being, through exercise and fitness:

"The ideals of the College imply that the responsibilities of each Fellow or member extend not only to the individual, but also to society with the purpose of improving both the health and well-being of the individual and the community."

The spectacle of those striving for perfection through sports—some dutifully following all the rules, others trying many ergogenic aids and drugs of unknown safety or efficacy—provides an ironic commentary on human nature. And then we see those who would benefit from just a few minutes a day of any kind of aerobic exercise but can't find the time or will to do so.

The field of sports and fitness yields examples of situations that are at once prevalent and important in many patient-physician relationships. The clinical and ethical lessons debated at the elite levels of performance form a foundation for decision-making by primary care physicians. If those ideals expressed in the sports medicine ethics code filter down to treatment of patient-athletes at all levels, the relationships will have been mutually beneficial.

The learning objectives for this issue are:

Understand the ethical problems unique to sports medicine, such as the physician's duties to the patient-athlete.

Learn about ethical situations where the immediate performance goals of the athlete may affect his or her health over a long term or permanently.

Understand the physician's role in advocating and promoting physical activity for health, especially when lifestyles require adding exercise to a patient's routine.

Understand the problem of performance-enhancing drugs and related ethical dilemmas.

Learn about possible conflicts of interest between the physician's duty to the patient's health and contractual interests as a team physician.

Understand the role of physician-advocate in reducing sports-related injuries.



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