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Dazed and Confused: Sports Medicine, Conflicts of Interest, and Concussion Management

Abstract

Professional sports with high rates of concussion have become increasingly concerned about the long-term effects of multiple head injuries. In this context, return-to-play decisions about concussion generate considerable ethical tensions for sports physicians. Team doctors clearly have an obligation to the welfare of their patient (the injured athlete) but they also have an obligation to their employer (the team), whose primary interest is typically success through winning. At times, a team’s interest in winning may not accord with the welfare of an injured player, particularly when it comes to decisions about returning to play after injury. Australia’s two most popular professional football codes—rugby league and Australian Rules football—have adopted guidelines that prohibit concussed players from continuing to play on the same day. I suggest that conflicts of interest between doctors, patients, and teams may present a substantial obstacle to the proper adherence of concussion guidelines. Concussion management guidelines implemented by a sport’s governing body do not necessarily remove or resolve conflicts of interest in the doctor–patient–team triad. The instigation of a concussion exclusion rule appears to add a fourth party to this triad (the National Rugby League or the Australian Football League). In some instances, when conflicts of interest among stakeholders are ignored or insufficiently managed, they may facilitate attempts at circumventing concussion management guidelines to the detriment of player welfare.

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References

  1. Australian Football League (AFL). 2011. The management of concussion in Australian football. Melbourne: AFL Research Board and AFL Medical Officers’ Association. http://www.aflcommunityclub.com.au/fileadmin/user_upload/Manage_Your_Club/3._Club_Management_Program/9._Football_Operations/Trainers/Injury_Management/Management_of_Concussion/Concussion_Man_v7.pdf.

  2. Australian Football League (AFL). 2013 The management of concussion in Australian football: With specific provision for children 5–17 years. Melbourne: AFL Research Board and AFL Medical Officers’ Association. http://www.aflcommunityclub.com.au/fileadmin/user_upload/Coach_AFL/Injury_Management/1211_AFL_Concussion_Management_2013_LowRes_1_.pdf.

  3. Anderson, L.C., and D.F. Gerrard. 2005. Ethical issues concerning New Zealand sports doctors. Journal of Medical Ethics 31(2): 88–92. doi:10.1136/jme.2002.000836.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  4. Anderson, L., and S. Jackson. 2013. Competing loyalties in sports medicine: Threats to medical professionalism in elite, commercial sport. International Review for the Sociology of Sport 48(2): 238–256. doi:10.1177/1012690211435031.

    Article  Google Scholar 

  5. Aubry, M., R. Cantu, J. Dvorak, et al. 2002. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001: Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. British Journal of Sports Medicine 36(1): 6–10. doi:10.1136/bjsm.36.1.6.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  6. Badel, P. 2012. Concussed players must now be kept from field. The Daily Telegraph, February 8. http://www.dailytelegraph.com.au/sport/nrl/concussed-players-must-now-be-kept-from-field/story-e6frexnr-1226266185805.

  7. Choudhry, N.K., H. Stelfox, and A.S. Detsky. 2002. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. The Journal of the American Medical Association 287(5): 612–617. doi:10.1001/jama.287.5.612.

    Article  Google Scholar 

  8. Davis, M. 1982. Conflict of interest. Business & Professional Ethics Journal 1(4): 17–27.

    CAS  Article  Google Scholar 

  9. Davis, M., and A. Stark, eds. 2001. Conflict of interest in the professions. New York: Oxford University Press.

    Google Scholar 

  10. Devitt, B.M., and C. McCarthy. 2010. “I am in blood Stepp’d in so far…”: Ethical dilemmas and the sports team doctor. British Journal of Sports Medicine 44(3): 175–178. doi:10.1136/bjsm.2009.068056.

    PubMed  Article  Google Scholar 

  11. Dillon, R. 2011. Head count. Newcastle Herald, March 29, Sport section, 56. http://newsstore.fairfax.com.au/apps/viewDocument.ac?page=1&sy=nstore&kw=newcastle+and+knights+and+concussion&pb=nch&dt=selectRange&dr=2years&so=relevance&sf=text&sf=headline&rc=200&rm=200&sp=nrm&clsPage=1&docID=NCH110329OU4P57I6K27.

  12. Dunn, W.R., M.S. George, L. Churchill, and K.P. Spindler. 2007. Ethics in sports medicine. American Journal of Sports Medicine 35(5): 840–844. doi:10.1177/0363546506295177. Dunn, W.R., M.S. George, L. Churchill, and K.P. Spindler. 2007. Ethics in sports medicine. American Journal of Sports Medicine 35(5): 840–844. doi:10.1177/0363546506295177.

    PubMed  Article  Google Scholar 

  13. Finch, C.F., P. McCrory, M.T. Ewing, and S.J. Sullivan. 2013. Concussion guidelines need to move from only expert content to also include implementation and dissemination strategies. British Journal of Sports Medicine 47(1): 12–14. doi:10.1136/bjsports-2012-091796.

    PubMed  Article  Google Scholar 

  14. Gardner A. (2013) The complex clinical issues involved in an athlete's decision to retire from collision sport due to multiple concussions: A case study of a professional athlete. Frontiers in Neurology 4. September 1–6. doi:10.3389/fneur.2013.00141.

  15. Gilbert, F., and B.J. Partridge. 2012. The need to tackle concussion in Australian football codes. Medical Journal of Australia 196(9): 561–563.

    PubMed  Article  Google Scholar 

  16. Kaye, A.H., and P. McCrory. 2012. Does football cause brain damage? Medical Journal of Australia 196(9): 547–549.

    PubMed  Google Scholar 

  17. Lane, S. 2011. Football’s medical fraternity split on stricter concussion guidelines. Sydney Morning Herald, March 23. http://www.smh.com.au/afl/afl-news/footballs-medical-fraternity-split-on-stricter-concussion-guidelines-20110322-1c57y.html.

  18. McCrory, P., K. Johnston, W. Meeuwisse, et al. 2005. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. British Journal of Sports Medicine 39(4): 196–204. doi:10.1136/bjsm.2005.018614.

    CAS  PubMed Central  PubMed  Google Scholar 

  19. McCrory, P., W. Meeuwisse, K. Johnston, et al. 2009. Consensus statement on concussion in sport: The 3rd International Conference on Concussion in Sport held in Zurich, November 2008. British Journal of Sports Medicine 43(Suppl 1): i76–i84. doi:10.1136/bjsm.2009.058248.

    PubMed  Article  Google Scholar 

  20. McCrory, P., W.H. Meeuwisse, M. Aubry, et al. 2013. Consensus statement on concussion in sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine 47(5): 250–258. doi:10.1136/bjsports-2013-092313.

    PubMed  Article  Google Scholar 

  21. McDermott, Q., and C. Hichens. 2012. Hard knocks. ABC, May 14. http://www.abc.net.au/4corners/stories/2012/05/10/3499950.htm.

  22. McKee, A.C., R.C. Cantu, C.J. Nowinski, et al. 2009. Chronic traumatic encephalopathy in athletes: Progressive tauopathy after repetitive head injury. Journal of Neuropathology and Experimental Neurology 68(7): 709–735. doi:10.1097/NEN.0b013e3181a9d503.

    PubMed Central  PubMed  Article  Google Scholar 

  23. McKee, A.C., T.D. Stein, C.J. Nowinski, et al. 2012. The spectrum of disease in chronic traumatic encephalopathy. Brain. doi:10.1093/brain/aws307.

    PubMed Central  PubMed  Google Scholar 

  24. Mellifont, D., J. Peetz, and M. Sayers. 2012. Concussion-driven dilemmas in sports medicine. Journal of Bioethical Inquiry 9(3): 369–370. doi:10.1007/s11673-012-9386-7.

    PubMed  Article  Google Scholar 

  25. Murray, T.H. 1986. Divided loyalties for physicians: Social context and moral problems. Social Science & Medicine 23(8): 827–832. doi:10.1016/0277-9536(86)90281-9.

    CAS  Article  Google Scholar 

  26. National Rugby League (NRL). 2012. The management of concussion in rugby league. http://www.nrl.com/About/ReferenceCentre/ManagementofConcussioninRugbyLeague/tabid/10798/Default.aspx.

  27. Omalu, B.I., R.L. Hamilton, M. Kamboh, S.T. DeKosky, and J. Bailes. 2010. Chronic traumatic encephalopathy (CTE) in a National Football League Player: Case report and emerging medicolegal practice questions. Journal of Forensic Nursing 6(1): 40–46. doi:10.1111/j.1939-3938.2009.01064.x.

    PubMed  Article  Google Scholar 

  28. Orchard, J. 2012. Concussion: How do we reconcile risk-averse policies with risk-taking sports? BJSM Blog, March 15. http://blogs.bmj.com/bjsm/2012/03/15/concussion-how-do-we-reconcile-risk-averse-policies-with-risk-taking-sports/.

  29. Partridge, B. 2011. Hit and miss: Ethical issues in the implementation of a “concussion rule” in Australian football. AJOB Neuroscience 2(4): 62–63. doi:10.1080/21507740.2011.620066.

    Article  Google Scholar 

  30. Polsky, S. 1998. Winning medicine: Professional sports team doctors’ conflicts of interest. Journal of Contemporary Health Law and Policy 14(2): 503–529.

    CAS  PubMed  Google Scholar 

  31. Price, J., P. Malliaras, and Z. Hudson. 2012. Current practices in determining return to play following head injury in professional football in the UK. British Journal of Sports Medicine 46(14): 1000–1003. doi:10.1136/bjsports-2011-090687.

    PubMed  Article  Google Scholar 

  32. Prichard, G. 2012. League and American football not concussion cousins, says medic. Sydney Morning Herald, May 17. http://www.smh.com.au/rugby-league/league-news/league-and-american-football-not-concussion-cousins-says-medic-20120516-1yrbp.html.

  33. Thompson, M. 2013. Don’t exploit new concussion process: Demetriou. AFL Media, March 23. http://www.afl.com.au/news/2013-03-23/dont-exploit-new-rule.

  34. Webster, A. 2012. Origin a test of new concussion laws. The Courier-Mail, May 18. http://www.couriermail.com.au/sport/nrl/origin-a-test-of-new-concussion-laws/story-e6frepbx-1226359326727.

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Acknowledgments

Thanks to Wayne Hall and Mal Parker for their comments on an earlier draft of this paper.

Funding and Disclosure of Interests

Brad Partridge receives funding from the Australia’s National Health and Medical Research Council (NHMRC) and the Australian Research Council (ARC).

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Correspondence to Brad Partridge.

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Partridge, B. Dazed and Confused: Sports Medicine, Conflicts of Interest, and Concussion Management. Bioethical Inquiry 11, 65–74 (2014). https://doi.org/10.1007/s11673-013-9491-2

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Keywords

  • Conflict of interest
  • Sports medicine
  • Concussion
  • Sport
  • Ethics
  • Rugby league
  • Australian Rules football