Managing sports-related concussion
Ethical and Legal Matters
Umpire Aleem Dar is helped to his feet by medical staff after New Zealand’s Mitchell Santner (right, rear) ran into him during play in their test against Australia in Perth, Australia, yesterday. Incidents like these are often not taken seriously but could lead to concussion-like symptoms later on. PICTURE AP
Management of athletes with sports-related concussion poses several ethical and legal challenges, beginning with who makes the decision regarding removal from the field or return to play. The Concussion in Sport Group encourages a multidisciplinary, collaborative approach.
However, it places the final decision in the hands of the team clinician or an appropriately licensed healthcare professional. This poses a challenge, since a team physician is employed by the sporting organisation to look after the team and not just individual athletes. At a sporting event, the team doctor is faced with tremendous pressure from multiple sources. The decision to remove a player can have a negative impact on team psyche and adversely affect tournament outcome, resulting in harm for the entire team. This may result in the team doctor facing threats from the athletes, the organisations, family members and the public. It is not an uncommon practice therefore to see injured players return to the field because the risk/benefit analysis falls in favour of ‘return to play and deal with the injury later’.
With concussion injuries, however, the risks may be death and severe/permanent disability. For sports like American football and boxing, these concerns have resulted in decisions to have independent, match day doctors make the decision regarding concussion.
The downside here is that a bad call can be made due to the physician’s lack of familiarity with the player’s baseline normal behaviour.
By placing the decision in the hands of the physician, we have moved into the realm of disregard for autonomy. One may feel it is a backward step to the days of paternalistic medicine where the doctors made decisions for patients.
Respect for an adult of sound mind to decide what happens to them or what is done to them is a fundamental human right. In the case of sports, however, one must consider whether an athlete in competition can make autonomous decisions.
An autonomous decision requires the athlete to be of sound mind and free from external pressures. When thousands of fans are screaming for the athlete to return to the field and they are facing the risk of losing endorsements and are under the pressure of failing their teammates, can they make an autonomous decision? Add to that the altered mental state of a concussed individual.
In standard medical care, when someone is mentally compromised, decisions are made by a proxy. The proxy is someone who knows the person well enough that the likelihood of them making the same decision the person would make for themselves is high. Do our athletes name a proxy before the tournament season? Is this something we may want to consider instead of leaving decisions to the team physician? Autonomous decision making requires having adequate knowledge to weigh the risks and benefits of a decision. Sporting organisations and their associated health care team have an ethical obligation to ensure that athletes and coaches are sufficiently educated about concussions and the associated risks before the start of a tournament. Only then can autonomous decisions be made.
Distributive justice must also be taken into consideration. Concussed athletes may require specialised care which can be unaffordable and inaccessible. This is particularly so for persons from lower socio-economic brackets and rural communities.
At a governmental level, there must be plans for educational campaigns that can reach these individuals.
Special, national health insurance coverage for athletes should be discussed at this level since many athletes may originate from homes where health insurance is not affordable. Long waits for access to ‘free healthcare’ through the public sector does not bode well for athlete’s outcomes and some of the specialised services may not be available in the public sector.
Privacy and confidentiality laws pose a significant challenge in concussion management. Athlete safety requires coaches and managers to be informed about the extent of injury, progress, precautions and outcomes, yet the player can demand that the information not be shared.
This leaves a risk for players who are not fully cleared for returning to play. Without adequate information being shared with coaches and managers, team decisions may also be adversely affected resulting in compromised team performance. One solution is for athletes to complete waivers, before the start of the season, giving permission to the team doctor to discuss medical information with their coaches and managers.
Verbal consent is inadequate.
Without signed, legally binding documents, sports medicine practitioners and sporting organisations leave themselves vulnerable to lawsuits.
Sporting bodies, as well as schools, must be proactive and develop institutional concussion policies that will protect both the athlete and the organisation. In doing so, the differential roles of a team doctor versus a personal doctor must be considered and decisions made regarding the use of matchday doctors in our region. All stakeholders must be involved in the shaping of policies and guidance documents.
Dr Shermella Roopchand-Martin is attached to the Faculty of Sport and has a Doctorate in Physical Therapy, Masters in Rehabilitation Science and MSc Bioethics
However, it places the final decision in the hands of the team clinician or an appropriately licensed healthcare professional. This poses a challenge, since a team physician is employed by the sporting organisation to look after the team and not just individual athletes. At a sporting event, the team doctor is faced with tremendous pressure from multiple sources. The decision to remove a player can have a negative impact on team psyche and adversely affect tournament outcome, resulting in harm for the entire team. This may result in the team doctor facing threats from the athletes, the organisations, family members and the public. It is not an uncommon practice therefore to see injured players return to the field because the risk/benefit analysis falls in favour of ‘return to play and deal with the injury later’.
With concussion injuries, however, the risks may be death and severe/permanent disability. For sports like American football and boxing, these concerns have resulted in decisions to have independent, match day doctors make the decision regarding concussion.
The downside here is that a bad call can be made due to the physician’s lack of familiarity with the player’s baseline normal behaviour.
By placing the decision in the hands of the physician, we have moved into the realm of disregard for autonomy. One may feel it is a backward step to the days of paternalistic medicine where the doctors made decisions for patients.
Respect for an adult of sound mind to decide what happens to them or what is done to them is a fundamental human right. In the case of sports, however, one must consider whether an athlete in competition can make autonomous decisions.
An autonomous decision requires the athlete to be of sound mind and free from external pressures. When thousands of fans are screaming for the athlete to return to the field and they are facing the risk of losing endorsements and are under the pressure of failing their teammates, can they make an autonomous decision? Add to that the altered mental state of a concussed individual.
In standard medical care, when someone is mentally compromised, decisions are made by a proxy. The proxy is someone who knows the person well enough that the likelihood of them making the same decision the person would make for themselves is high. Do our athletes name a proxy before the tournament season? Is this something we may want to consider instead of leaving decisions to the team physician? Autonomous decision making requires having adequate knowledge to weigh the risks and benefits of a decision. Sporting organisations and their associated health care team have an ethical obligation to ensure that athletes and coaches are sufficiently educated about concussions and the associated risks before the start of a tournament. Only then can autonomous decisions be made.
Distributive justice must also be taken into consideration. Concussed athletes may require specialised care which can be unaffordable and inaccessible. This is particularly so for persons from lower socio-economic brackets and rural communities.
At a governmental level, there must be plans for educational campaigns that can reach these individuals.
Special, national health insurance coverage for athletes should be discussed at this level since many athletes may originate from homes where health insurance is not affordable. Long waits for access to ‘free healthcare’ through the public sector does not bode well for athlete’s outcomes and some of the specialised services may not be available in the public sector.
Privacy and confidentiality laws pose a significant challenge in concussion management. Athlete safety requires coaches and managers to be informed about the extent of injury, progress, precautions and outcomes, yet the player can demand that the information not be shared.
This leaves a risk for players who are not fully cleared for returning to play. Without adequate information being shared with coaches and managers, team decisions may also be adversely affected resulting in compromised team performance. One solution is for athletes to complete waivers, before the start of the season, giving permission to the team doctor to discuss medical information with their coaches and managers.
Verbal consent is inadequate.
Without signed, legally binding documents, sports medicine practitioners and sporting organisations leave themselves vulnerable to lawsuits.
Sporting bodies, as well as schools, must be proactive and develop institutional concussion policies that will protect both the athlete and the organisation. In doing so, the differential roles of a team doctor versus a personal doctor must be considered and decisions made regarding the use of matchday doctors in our region. All stakeholders must be involved in the shaping of policies and guidance documents.
Dr Shermella Roopchand-Martin is attached to the Faculty of Sport and has a Doctorate in Physical Therapy, Masters in Rehabilitation Science and MSc Bioethics