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Sports Medicine

Ethics of prescribing drugs to enhance sporting performance

Crossing the line between good medicine and cooperating with unhealthy or illegal behaviour

Michael C Kennedy and Judith R Kennedy

MJA 1999; 171: 204-205
See also Corrigan

Introduction - What should be done for athletes - Patient autonomy - Harm minimisation - Acknowledgements - References - Authors' details Make a comment - Register to be notified of new articles by e-mail - Current contents list - More articles on Sports medicine

Introduction There are two groups of people who undertake sporting activity while taking drugs. The first are those who require medication for chronic conditions such as hypertension and hyperlipidaemia, in specific circumstances such as paraplegia or organ transplant, or for acute intermittent conditions such as inflamed joints, infections and injuries. The second group comprises healthy people who take drugs to enhance sporting performance. We include bodybuilders in this category. Doctors are always the prescribers for the first group and are often the prescribers for the second.1 In this article, we provide an overview of ethical practice when consulted by individuals in this second category.

The use of drugs for enhancing sporting performance is widespread and has been documented in Europe, North America and Australia.2-5 Some drugs seem to have enduring appeal, while others come and go in fashion. Anabolic/androgenic steroids (AAS) have been popular for over four decades; in 1990, an estimated one million people in the United States were either current or former users of AAS.6 Over the past 15 years there has also been a steady increase in the use of growth hormone,7 erythropoietin8 and insulin.9 The use of stimulants is still common, although the popularity of amphetamines has decreased since the 1960s.

The media's focus on high-profile athletes who test positive for a banned substance overshadows the pattern of use: most non-therapeutic drug use is at the non-competitive, non-elite level of sport where there is no drug testing.6 Particularly troubling is the use of AAS on and by adolescents2,3 and the known connection between some of the drugs and myocardial infarction, stroke and psychiatric episodes in apparently healthy athletes.10,11

It is therefore important that doctors carefully consider their actions before prescribing drugs to those who wish to enhance their sporting performance. The doctor's purpose should be no more than assessment of the clinical state and the management of this as best suits the patient within prevailing social and ethical constraints. There is no authority for either the patient or the doctor to widen the purview to include the creation of social rights, coaching in how to cheat, or violating regulations.12


What should be done for athletes
It is important to incorporate questions about sporting activities into clinical history-taking. Before prescribing to athletes, the following points should be routinely addressed:

  1. Banned drugs: If the athlete is competing at competition level it is essential that care be taken to avoid a drug on the banned list. Mistakes can be easily avoided by checking the drug details in publications such as MIMS or the Drugs in sport handbook2 (published by the Australian Sports Drug Agency [ASDA], or by contacting the ASDA hotline on 1800 020 506).

  2. Exposure conditions: Doctors should be aware that athletes will often expose themselves to extremes of endurance, so care is needed when using agents such as non-steroidal anti-inflammatory drugs, prochlorperazine and pseudoephedrine, which can affect heat regulation or cardiac rhythm. Patients should also be informed of the effects a drug may have on their sporting performance per se. For example, if -blockers are medically indicated, the trade-off will be a decrease in aerobic performance.

  3. Professional competence: It is the responsibility of each prescriber to know the pharmacological facts about a drug and the medical facts about the patient. For example, AAS are not only widely abused, but also are a drug group about which there is much published information. A healthy athlete has no medical condition that will require prescribing of AAS, which will worsen, not improve, tendon and muscle injuries.13 There are no studies showing that AAS enhance skilled performance. There are data showing AAS increase muscle size and strength,14 although these data need to be interpreted conservatively.15 There are also a number of predictable adverse reactions that occur with their use, such as acne and gynaecomastia.10

In the absence of a clinical reason for prescribing drugs, and in the presence of good clinical reason for not doing so, any case for prescribing a drug must then rely on over-riding, non-medical considerations. The patient-autonomy and harm-minimisation arguments are the most ethically powerful of these.


Patient autonomy
Patient autonomy is the right to self-determination. Starting with this notion, it is argued that non-medical use of drugs is simply a matter of personal liberty and individual experimentation: if athletes are aware of possible adverse reactions and are willing to accept the risks in the hope of other rewards, there should be no prohibition on doctors' prescribing. It follows that the doctor's task is merely to ensure informed consent. Clearly, society does not agree with this argument. Prescribing is restricted to those with both clinical and pharmacological knowledge for good reason -- the expectation is that there will be a causal link between specific drug use and clinical benefit. Predictable negative effects -- and, for athletes, this may be exclusion from competition -- are traded off against the required medical outcome. There is no suggestion that medical practitioners should do whatever the patient asks. We are not obliged to prescribe a drug simply because it has been asked of us.

Another important issue needs to be considered in relation to autonomy: athletes are in an environment where competition is fierce and selection is never assured. Therefore, they may be in no position to object to proposed medical interventions and sports-health supervision by doctors who are not their usual practitioner. An extreme example of the type of abuse possible under these circumstances occurred in the former German Democratic Republic.16 One lesson from this is that it may be difficult for an athlete to refuse even seemingly innocuous procedures such as vitamin injections or the taking of supplements to "boost the immune system" when suggested by those in official positions. Respect for the athlete's autonomy requires that administration of substances occurs only when the athlete is fully informed and truly free to refuse.


Harm minimisation
The harm-minimisation argument is that some athletes will take drugs irrespective of whether supervised or not, and that giving drugs under medical supervision potentially results in less harm as there is control over the quality of the drugs supplied and early detection and treatment of adverse reactions. The controlled use of heroin in registered addicts is one example of the application of the harm-minimisation argument in medicine.17 However, this model is not applicable to drugs in sport. Both types of drug-taking may involve unfortunate victims and major criminal and financial enterprises,18 but there the similarity ends. In contrast to heroin, little is known of the pharmacokinetics and pharmacodynamics of high doses of AAS taken as single agents. There is even less knowledge of their pharmacokinetics and pharmacodynamics when taken in various multiple doses ("stacking") or in increasing doses ("pyramiding"). In addition, experience has shown that when a doctor prescribes low doses of AAS, this may lead to the prescriber's being used as one of a number of sources of supply.19 Under these circumstances, the doctor faces a new dilemma when an adverse reaction follows: to cease prescribing the offending agent or to prescribe yet another drug (for example, tamoxifen when oestrogenic side effects occur). The absurdity of this argument becomes evident when extended to justify prescribing insulin, erythropoietin or amphetamines.

Respect for the general principle of autonomy and individual freedom means an acceptance that individuals -- both doctors and patients -- "own" their actions and are responsible for what they do. Athletes can request what they like, but doctors need not comply. Non-maleficence means that medical actions must cause as little harm as possible, not that medical skills should be used to fine-tune enterprises of harm.

If approached about prescribing drugs to enhance sporting performance, the proper medical response is to provide accurate information and advice in a non-judgemental manner. If the patient has been or is exposed to a known health risk it is reasonable to diagnose and treat any ill-effects. This applies to drug use as much as it does to smoking, and does not require crossing the line between good medicine and cooperating with behaviour that is unhealthy, illegal or just plain wrong.

If requested to prescribe drugs to enhance sporting performance the proper response is to refuse. Saying "no" to unreasonable requests is not always easy, but to do otherwise is to miss the point of what practising medicine is all about.


Acknowledgements
Ms Dianne James, Librarian, Manly Hospital, Manly, NSW.

References
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  9. Willey J. Insulin as an anabolic aid? The Physician and Sports Medicine 1997; 25: 103-104.
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  13. Laseter JT, Russell JA. Anabolic steroid-induced tendon pathology: a review of the literature. Med Sci Sports Exerc 1991; 23: 1-3.
  14. Bhasin S, Storer TW, Berman N, et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med 1996; 335: 1-7.
  15. Kennedy MC, O'Sullivan AJ. Do anabolic-androgenic steroids enhance sporting performance? [editorial]. Med J Aust 1997; 166: 60-61.
  16. Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government. Clin Chem 1997; 43: 1262-1279.
  17. Farrell M, Hall W. The Swiss heroin trials: testing alternative approaches [editorial]. BMJ 1998; 316: 639.
  18. Fleming C. Abuse and trafficking in anabolic steroids -- United States and Canada. A report to the Sir Winston Churchill Memorial Trust. Australia 1997.
  19. Duda M. Do anabolic steroids pose an ethical dilemma for US physicians? Phys Sports Med 1986; 14: 173-175.

Authors' details St Vincent's Hospital, Sydney, NSW.
Michael C Kennedy, MD(UNSW), FRACP, Research Associate, Department of Clinical Pharmacology and Toxicology, and Consultant Physician, Manly.

Manly, NSW.
Judith R Kennedy, MA(ACU), MAPS, Psychologist.

Reprints: Dr M C Kennedy, Manly Non-Invasive Cardiac Laboratory, Level 4, 22 Darley Road, Manly, NSW 2095.
Email: drmkennATozemail.com.au

©MJA 1999
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