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Sport-Related Neurotrauma and Neuroprotection: Are Return-to-Play Protocols Justified by Paternalism?


Sport-related neurotrauma annually affects millions of athletes worldwide. The return-to-play protocol (RTP) is the dominant strategy adopted by sports leagues and organizations to manage one type of sport-related neurotrauma: concussions. RTPs establish guidelines for when athletes with concussions are to be removed from competition or practice, and when they can return. RTPs are intended to be neuroprotective, and to protect athletes from some of the harms of sport-related concussions, but there is athlete resistance to and noncompliance with RTPs. This prompts consideration of whether RTPs, as employed in adult, professional sports, are paternalistic, and if they are, whether they are objectionably so. If RTPs are uniquely effective at protecting current or future athlete autonomy, they might be justified by paternalism. I conclude that RTPs are paternalistic in their effects, but are not adequately justified, and thus they are objectionable.

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  1. The term “sport-related neurotrauma” will be used to refer to any mild traumatic brain injury related to sports, such as concussions and sub-concussive trauma. The risk of severe traumatic brain injury certainly exists in sports, but will not be addressed in this paper, as RTP protocols are not relevant to management of severe traumatic brain injuries.

  2. “Football” in this paper refers to American-style tackle football.

  3. The ostensible function of RTP protocols is to enforce or allow the period of rest for symptomatic athletes. As there is little evidence supporting the effectiveness of rest, it is questionable whether RTP protocols are effective for managing concussions.

  4. See footnote 3

  5. I have elsewhere considered appropriate strategies for preventing and managing sport-related concussion in youth sports [25, 59].

  6. Following two incidents in the 2013–14 season, in which players allegedly returned to play against medical advice, the NFL proposed enacting fines for players (but not teams) who violate the league’s “Madden Rule.” This proposal indicates that for the NFL, the onus is on players, and not teams or team medical personnel, to enforce “no go” judgments. [60]

  7. At other levels of football, for example, more diligent reporting and better diagnosis has resulted in a pronounced uptick in reported concussions. Rosenthal et al. found that concussion rates doubled among high school football players in a comparison between the 2005–2006 and 2011–2012 seasons, a period during which concussion education and awareness became more prevalent [61].

  8. Muratore concludes that the culture is such that “We have to protect players from themselves” [38].

  9. A recent lawsuit filed on behalf of retired NFL players charges that teams illegally distributed addictive painkillers to players to conceal injuries and mask pain [40]. A significant number of players report having been coerced to play—with the assistance of illegally provided drugs—while injured [41].

  10. Thanks to an anonymous referee for pointing me to this interesting debate.


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Correspondence to L. Syd M Johnson.

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Johnson, L.S.M. Sport-Related Neurotrauma and Neuroprotection: Are Return-to-Play Protocols Justified by Paternalism?. Neuroethics 8, 15–26 (2015).

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  • Return-to-play
  • Sports
  • Concussion
  • Neurotrauma
  • Paternalism
  • Autonomy
  • Consent
  • Football
  • CTE