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The Spirit of Sport and the Medicalisation of Anti-Doping: Empirical and Normative Ethics

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There has been much discussion in academic conferences and sport policy-makers with respect to the role of anti-doping (McNamee and Møller 2011; Hanstad, Smith and Waddington 2008). Put simply, there is a potential schism between the overarching function of anti doping — is it first and foremost a sports-related issue, or is it more generally to be understood as a public health issue? (Møller et al. 2009)? It is clear that these two aspects are not mutually exclusive such that the question cannot simply be a case of which should be its focus. Sports are, after all, social practices, engaged in by hundreds of millions of people. What goes on in these practices, to the extent that it affects the health of its participants, must also be a public health issue, irrespective of its (disputed) significance. Nevertheless, one particularly problematic aspect of present anti-doping policy relates to the existence of what are often and variously referred to as “social drugs”, “recreational drugs” or “substances of abuse”, in the list of prohibited methods and substances that comprise “doping” as defined the global body responsible for anti-doping: the World Anti-Doping Agency (WADA). The focus of this article is whether and how the presence of Cannabinoids on the Prohibited List (PL) is justified or not. Many scholars, scientists, and key actors in anti-doping policy — in confidential interviews — have argued that it should not be included. They argue that the presence of Cannabinoids is present on the Prohibited List merely as an extraneous and unwelcome function of governmental intrusion on sport and not because of any coherent anti-doping policy. In effect, it is thought to be a political intrusion that is paternalistic and, in effect, a “moral policing” of high-profile athletic populations. They argue, moreover, that the criterion, which facilitates Cannabinoids’ inclusion on the PL (that it is against the “Spirit of Sport”), is conceptually vague and should be removed. They believe this will negate the presence of Cannabinoids on the PL. In short, they seem to be arguing that Cannabinoid use ought not be thought of as “doping”. In this article, I argue to the contrary — that Cannabinoids should be retained on the Prohibited List; that its use may be thought of as doping; and that the Spirit of Sport criterion, though vague, is still a defensible criterion for the demarcation of “doping”. To achieve this, I critically discuss the legitimacy of Cannabinoid inclusion in the light of contemporary literature on “enhancement”, and introduce the findings of a recent empirical investigation into anti-doping policy with a sample of international key actors in anti-doping policy. In the first section, I describe the definition of doping and the current state of policy flux in anti-doping, then I set out the extant and the proposed criteria for a method or substance to be considered doping (i.e., for inclusion on the Prohibited List). I review then one bioethical critique of the Spirit of Sport criterion (Foddy and Savulescu 2010), and a recent challenge by an internationally recognised group of scholars and scientists working in the field of anti-doping (the International Network of Humanistic Doping Research) to remove the criterion. I then included narrative data from key actors on the international scene of anti-doping such as Heads of National Anti-Doping Organisations, Heads of Medicine and Science in Anti-Doping Organisations, and senior members of the World-Anti Doping Agency (WADA), before arguing against their position and for the status quo. Following the Ben Johnson scandal at the 1988 Seoul Olympics, the subsequent Dubin enquiry and the Tour de France scandal in 1998, the IOC established a working group to formulate a robust and independent international body to regulate doping in sport. In consequence, the WADA was set up. Following a UNESCO convention, signed by nearly all nation-states in the world, the World Anti-Doping Code (WADC) came into effect in 2003. It was agreed that WADA would be funded jointly by nation...
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Asian Bioethics Review December 2012 Volume 4, Issue 4
374
The Spirit of Sport and the
Medicalisation of Anti-Doping:
Empirical and Normative Ethics1
MICHAEL J. MCNAMEE
I. Introduction
There has been much discussion in academic conferences and sport policy-
makers with respect to the role of anti-doping (McNamee and Møller 2011;
Hanstad, Smith and Waddington 2008). Put simply, there is a potential schism
between the overarching function of anti doping — is it first and foremost a
sports-related issue, or is it more generally to be understood as a public health
issue? (Møller et al. 2009)? It is clear that these two aspects are not mutually
exclusive such that the question cannot simply be a case of which should
be its focus. Sports are, after all, social practices, engaged in by hundreds
of millions of people. What goes on in these practices, to the extent that it
affects the health of its participants, must also be a public health issue, irre-
spective of its (disputed) significance.
Nevertheless, one particularly problematic aspect of present anti-doping
policy relates to the existence of what are often and variously referred to as
“social drugs”, “recreational drugs” or “substances of abuse”, in the list of pro-
hibited methods and substances that comprise “doping” as defined the global
body responsible for anti-doping: the World Anti-Doping Agency (WADA).
The focus of this article is whether and how the presence of Cannabinoids
on the Prohibited List (PL) is justified or not. Many scholars, scientists, and
key actors in anti-doping policy — in confidential interviews — have argued
that it should not be included. They argue that the presence of Cannabinoids
is present on the Prohibited List merely as an extraneous and unwelcome
function of governmental intrusion on sport and not because of any coherent
ARTICLES
374–392 © 2012 The Author. Asian Bioethics Review December 2012 Volume 4, Issue 4
375
anti-doping policy. In effect, it is thought to be a political intrusion that is
paternalistic and, in effect, a “moral policing” of high-profile athletic popula-
tions. They argue, moreover, that the criterion, which facilitates Cannabinoids
inclusion on the PL (that it is against the “Spirit of Sport”), is conceptually
vague and should be removed. They believe this will negate the presence of
Cannabinoids on the PL. In short, they seem to be arguing that Cannabinoid
use ought not be thought of as “doping”.
In this article, I argue to the contrary — that Cannabinoids should be
retained on the Prohibited List; that its use may be thought of as doping; and
that the Spirit of Sport criterion, though vague, is still a defensible criterion
for the demarcation of “doping”. To achieve this, I critically discuss the legi-
timacy of Cannabinoid inclusion in the light of contemporary literature on
“enhancement”, and introduce the findings of a recent empirical investigation
into anti-doping policy with a sample of international key actors in anti-
doping policy.
In the first section, I describe the definition of doping and the current
state of policy flux in anti-doping, then I set out the extant and the proposed
criteria for a method or substance to be considered doping (i.e., for inclusion
on the Prohibited List). I review then one bioethical critique of the Spirit
of Sport criterion (Foddy and Savulescu 2010), and a recent challenge by an
internationally recognised group of scholars and scientists working in the field
of anti-doping (the International Network of Humanistic Doping Research)
to remove the criterion. I then included narrative data from key actors on
the international scene of anti-doping such as Heads of National Anti-Doping
Organisations, Heads of Medicine and Science in Anti-Doping Organisations,
and senior members of the World-Anti Doping Agency (WADA), before
arguing against their position and for the status quo.
II. What is Doping, and What are the Criteria by Which a
Method or Substance May be Considered for the
List of Prohibited Methods and Substances?
Following the Ben Johnson scandal at the 1988 Seoul Olympics, the subse-
quent Dubin enquiry and the Tour de France scandal in 1998, the IOC esta-
blished a working group to formulate a robust and independent international
body to regulate doping in sport. In consequence, the WADA was set up.
Following a UNESCO convention, signed by nearly all nation-states in the
world, the World Anti-Doping Code (WADC) came into effect in 2003. It
was agreed that WADA would be funded jointly by nation-state signatories
and the Olympic Movement, while National Anti-Doping Organisations
The Spirit of Sport and the Medicalisation of Anti-Doping Michael J. McNamee
Asian Bioethics Review December 2012 Volume 4, Issue 4
376
(NADOs) are funded by nation-states but are typically — though not always
— independent of direct political control. This system of dual funding is
germane to later considerations of the chief functions of an anti-doping orga-
nisation (ADO).
The WADC, which is the heart of global anti-doping policy (ADP), was
amended in 2009 and this second revision is still in effect. It is currently in
the second phase of its second revision. On 1 January 2015, the third version
will come into operation. It is important to detail both since there is a signi-
ficant conceptual shift in procedure.
Since 2009, WADA defines doping in relation to a violation and then it
subsequently lays out a procedure and criteria for inclusion as follows. The
definition of doping is consistent between 2009 and the proposed 2015
Code. It is a formal definition only in terms of the types of violations that
exist. There are only minor amendments to the nature of Anti-Doping Rule
Violations (ADRV) and therefore the current revisions (2015) are cited here.
What becomes evident then is that doping is not per se defined by prohibited
substance ingestion. That is one, perhaps the most typical but not the only,
form that doping can take. Thus:
ARTICLE 1 DEFINITION OF DOPING
Doping is defined as the occurrence of one or more of the anti-doping rule
violations set forth in Article 2.1 through Article 2.10 of the Code.
WADC 2015 — Version 1.0
Additionally, the following constitute anti-doping rule violations:
ARTICLE 2 ANTI-DOPING RULE VIOLATIONS [ADRVs]
2.1 Presence of a Prohibited Substance or its Metabolites or Markers in an
Athlete’s Sample.
2.2 Use or Attempted Use by an Athlete of a Prohibited Substance or a
Prohibited Method.
2.3 Evading Sample Collection.
2.4 Filing Failures and Missed Tests.
2.5 Tampering or Attempted Tampering with any part of Doping Control.
2.6 Possession of a Prohibited Substance or a Prohibited Method.
2.7 Trafficking or Attempted Trafficking in any Prohibited Substance or
Prohibited Method.
2.8 Administration or Attempted Administration to any Athlete In-Compe-
tition of any Prohibited Method or Prohibited Substance, or Adminis-
tration or Attempted Administration to any Athlete Out-of-Competition
377
of any Prohibited Method or any Prohibited Substance that is prohi-
bited Out-of-Competition.
2.9 Complicity in an Anti-Doping Rule Violation.
2.10 Prohibited Association
The number and heterogeneity of forms that ADRVs can take are noteworthy.
Doping, thus defined and contrary to everyday understanding that it is bio-
technological cheating, is not a unified phenomenon. Instances 2.1–3 are the
object of discussion in this article. It should be noted that 2.4 is a frequent
ADRV, since athletes who think they may submit a positive sample often
simply refuse to answer the door to a doping control officer, flee the scene,
or do not locate themselves at the time and place they have promised to be
at according to the “whereabouts” data they have submitted.2
The object of most discussions in the ethics of anti-doping revolves around
which substances should comprise the PL. In the current version (prevailing
since 2009), it is held that at least two of the following must apply:
4.3.1.1 Medical or other scientific evidence, pharmacological effect or
experience that the substance or method, alone or in combination
with other substances or methods, has the potential to enhance or
enhances sport performance;
4.3.1.2 Medical or other scientific evidence, pharmacological effect or
experience that the Use of the substance or method represents an
actual or potential health risk to the Athlete;
4.3.1.3 WADAs determination that the Use of the substance or method
violates the spirit of sport described in the Introduction to the
Code.3
In addition is included a category widely referred to as masking agents:
4.3.2 A substance or method shall also be included on the Prohibited
List if WADA determines there is medical or other scientific evi-
dence, pharmacological effect or experience that the substance or
method has the potential to mask the Use of other Prohibited
Substances or Prohibited Methods.4
The criteria may thus be summarised as follows: (i) (potential) performance
enhancement; (ii) (potential) health risk; (iii) (potential) violation of the spirit
of sport. I shall ignore the masking function set out in 4.3.2. It is clear that
the use of the qualifier “potential” gives the medical and scientific sub-group
that determines the PL considerable latitude. Moreover, it is frequently noted
The Spirit of Sport and the Medicalisation of Anti-Doping Michael J. McNamee
Asian Bioethics Review December 2012 Volume 4, Issue 4
378
that the operations of this group are not transparent. WADA’s defence of this
position is based on the fact that in declaring their discussion, and the evi-
dential basis for them, they may actually assist doping efforts by individuals
and Athlete Support Personnel (ASP) such as sports physicians, scientists,
pharmacologists, and so on.5
In philosophical terms, the “at least two from three” procedure takes ad-
vantage of what philosophers call “defeasibility”. In the early days of analytical
philosophy, it was widely thought that the meaning of concepts might be
precisely understood in terms of analysis of linguistic usage that would yield
individually necessary and jointly sufficient conditions (or criteria or rules) for
the proper application of concepts. The work of Wittgenstein drew attention
to the limitations of this theory of meaning. Where such boundedness
of meaning might apply, say, in geometric concepts (e.g. a triangle is a:
(i) plane shape; (ii) internally bounded; (iii) whose internal angles sum to
180°), natural languages were mostly populated by words whose meanings
could not be understood independently of their usages, which were understood
in a context sensitive fashion. Friedrich Waissman (1965), who had colla-
borated with Wittgenstein in the middle of his career, published a theory of
the open-textured nature of certain concepts. Their meaning cannot be fixed
rigidly to a set of conditions that exist or may come to pertain. Famously,
Wittgenstein used the word “game” to illustrate the plasticity of meaning,
revealed in the myriad of comprehensible uses to which the word “game”
might be put, which seemed to have no essence but that were loosely related
to each other. All that the different uses of the word had in common were
a number of “family resemblances”. This openness, he noted, did not hinder
our use of those words or concepts.
HLA Hart’s account of legal concepts developed the notion of defeasibility.
He recognised that there were clear and less clear concepts in law just as there
were clear cases of application and hard ones. In the latter, considerable inter-
pretive work was necessary. In certain concepts, he argued, the criteria are
“underdetermined”. We employ defeasible interpretation when only some but
not all of the required criteria apply. This allows us to recognise cases or
instances that an action falls under while not fully satisfying what are thought
to be exhaustive criteria. While Hart’s easy/hard conceptualisation rests on
accepting the more radical account of language and concept acquisition that
Wittgenstein advocated, the idea of defeasiblity is helpful in understanding
the concept of doping generally, and the Spirit of Sport specifically.
Foddy and Savulescu (2010) attack WADA’s claim that “Doping is funda-
mentally contrary to the spirit of sport”.6 They argue that it appears to be
379
setting out a condition: if x is not fundamentally contrary to the spirit of
sport, it is not doping. And this is how Foddy and Savulescu (2010) interpret
the statement. They, however, misquote WADA. They write:
However, the Code goes on to say explicitly that all ‘[d]oping is funda-
mentally contrary to the spirit of sport’. In other words, if a drug is banned
because it is both harmful and performance enhancing, it is necessarily
considered to violate the spirit of sport as well. This statement contradicts
the 2-out-of-3 rule because it adds this spirit-violating property to every
banned group. Perhaps this is a mistake, but if it is not, then WADA and
its supporters are not seriously worried about health risks. Neither are they
seriously worried about performance enhancement. (2010: 512)
As I have said, this is an illustration of how a concept’s openness or under-
determination allows for misreadings. The point of defeasible criteria is
to allow for the application of criteria that are not jointly sufficient. The
meanings of words can mutate and shift in relation to the contexts of their
use. The WADC does not say “all doping”, which is what Foddy and Savulescu
(2010) accuse it of. The simple addition of one word leads them astray in
their critique. Nevertheless, they have pointed to a lack of clarity that might
easily have been avoided. It can seem in tension with their two-from-three,
defeasible approach. Simply removing the statement would help avoid this
charge. Moreover, because of the lack of transparency of the PL group, we
do not know in practice whether it is the Spirit of Sport criterion or the risk
to health criterion that dominates the thinking of the committee. Since it is
populated by physicians, medical scientist and researchers, but not philosophers
or social scientists, there is every reason to suspect it is the former, not the
latter, which predominates. If this assumption is true, then what is happening
appears to be an unjustifiable form of medicalising of doping. If it is not,
then we might reasonably ask on what basis the judgements are being made
as to the Spirit of Sport in the absence of those with any expertise in the
ethics of sports and human enhancement more generally.
Two points of application arise from this very brief account of meaning
and its application. First, the heterogeneity of ADRVs does not detract from
our comprehension of the phenomena but merely illustrates how a prescrip-
tive definition can serve clear policy purposes for actions that range broadly.
Definitions serve many functions. It could be argued that in offering ten
separable ways of committing an ADRV (and by defining doping exclusively
in terms of defeasible criteria), they are allowing for a conceptual inflation
that renders the “doping” more problematic. Yet no one has made this
The Spirit of Sport and the Medicalisation of Anti-Doping Michael J. McNamee
Asian Bioethics Review December 2012 Volume 4, Issue 4
380
complaint. Scholars and scientists, and anti-doping personnel themselves, have
made precisely this complaint against the Spirit of Sport criterion, though.
My point here, then, is that if the complaint of defeasibility is to be taken
seriously, it should apply to the definition of doping itself and not merely
to the Spirit of Sport criterion. But I do not think it should in either case.
Insights into the philosophy of language already solve the problem of essen-
tialism, there is no need to resurrect it: doping is a heterogeneous pheno-
menon; and the “spirit of sport” is an open concept.
Second, and more promising for critics of extant ADP, it is still a moot
point whether there might be some necessary condition but no set of jointly
sufficient conditions. In the following, I shall show how both these points
apply. In the case of the former, the phenomena of doping are so varied that
defeasibility is a proper manoeuvre and that the other criteria are open to the
same objection, so simply ridding ADP of the Spirit of Sport will not solve
the problem.
III. Critics of the Spirit of Sport Criterion: Vagueness,
Scope, Application
This is what WADA says about the Spirit of Sport:
The spirit of sport is the celebration of the human spirit, body and mind,
and is characterised by the following values:
Ethics, fair play and honesty
• Health
Excellence in performance
Character and education
Fun and joy
• Teamwork
Dedication and commitment
Respect for rules and laws
Respect for self and other Participants
• Courage
Community and solidarity
WADAs list of values falls far short of a definition of the “Spirit of Sport”.
Note that it does not claim to be one. It merely says that the aforementioned
are features that “characterise” the Spirit of Sport. Nevertheless, Foddy and
Savulescu (2010) argue vigorously that the Spirit of Sport criterion is inade-
quate. They assert that this is WADA’s attempt to “define” the spirit of sport
381
(2010: 511) but that is not a fair criticism, as we have seen above. WADA
does not offer a definition. Moreover, they write that “This may be a good
list of features that embody the aspirational ‘spirit of sport’. But as a way to
choose which drugs to ban, it is terrible”.
WADA’s list of values is inadequate as a description of how sport is practised
universally, and this is often how critics understand it. Foddy and Savulescu
are closer to a better understanding of the function of the list when they call
it “aspirational”. Though WADA does not say this, I think it better to under-
stand the Spirit of Sport as an ideal. Under this conception, the argument
would run as follows: this is what sports look like ideally, and this is the
standard we shall use partly to determine what may be considered on the
Prohibited List, not, pace Foddy and Savulescu, what will count as doping. I
shall elaborate on this point below.
For now, I merely summarise Foddy and Savulescu’s complaint that the list
of values is ineffective in distinguishing licit from illicit means of performance
enhancement. There is some substance to this view. Nevertheless, what can
be said in a spirit of charity is this: WADA’s list of values is an incomplete,
unsystematic and unstructured account of key values that are in association
with ethical sport. It is incomplete since, if one were setting out an ideal,
it would need to offer a fuller account of the range of personal and social
virtues that would sustain an ethical conception of sport. Present in this list
are both “respect” and “courage” and though these are important, no one
would pretend they were exhaustive. The list is unsystematic. We are not
offered a framework that is hierarchical or ordered in some way that might
distinguish what is elemental from what is peripheral. The list is unstructured.
Some values refer to individual virtues, e.g. respect, courage), others refer to
social virtues (e.g. solidarity), and some others bridge technical and ethical
aspects (excellence). The relation between health and sport is ambiguous. Elite
sport has little to do with biostatistical understandings of health (e.g. Boorse
1977), but then elite sportspersons are not “normal” in a biostatistical sense.
Teamwork neither promotes nor mitigates doping. It is not a truism that
excellent performance is to be understood only in the absence of doping. And
so on. The critique of the list could be extended considerably. What can be
said in agreement with Foddy and Savulescu (2010) is at least this: what the
Spirit of Sport criterion is taken to mean and how it is to be used is unclear.
Given that the WADC is currently in the middle of a two-year review, we
can ask whether the 2015 proposed version (at the time of writing) has made
good on any of argumentative, philosophical or procedural deficiencies.
The Spirit of Sport and the Medicalisation of Anti-Doping Michael J. McNamee
Asian Bioethics Review December 2012 Volume 4, Issue 4
382
IV. WADAʼs Redefinition of the Criteria for Inclusion
on the Prohibited List (PL)
“Mission creep” is a political term of art that has gained currency lately. Is
this true of WADA? Part of the criticism of WADA is that its extension into
matters of public health extends its scope into matters concerning civil society
that are beyond its remit. The issue that most clearly begs the description
“mission creep” in anti-doping is the inclusion of Cannabinoids on the PL.
How they merit inclusion on the list is thought to be a function of the vague-
ness of the concept of the Spirit of Sport, the failure of WADA to remain true
to its core activities and sport -focus, and the politicisation of sport’s ADP.
A group of international scholars and scientists, partly in response to the
medicalisation and scientisation of doping and anti-doping, recently formed
to establish the International Network of Humanistic Doping Research.7 In
a recent publication, members of the network led by Prof. Ivan Waddington,
a medical and sports sociologist, appealed to WADA to remove the Spirit of
Sport criterion, and retain the focus on cheating in sport qua doping.
They wrote:
We hold that it is nonsensical that an athlete can be banned under WADA
rules for consuming a drug which has no performance-enhancing effects,
for it is precisely the performance-enhancing nature of a substance which is
the central defining characteristic of doping; in effect, this regulation means
that athletes can be punished under the anti-doping code for a form of
behaviour — the use of recreational drugs which are not performance-
enhancing — which is not cheating and which does not constitute ‘doping’
in any meaningful sense of the term.8
There is of course an element of rhetoric in this claim. Contrary to the asser-
tion, it is perfectly “meaningful” that if one prescriptively defines a concept
(doping) in relation to three defeasible criteria, which includes the spirit of
sport (which itself is partly characterised by “health”), then recreational drug
use may be thought of as doping. But there is a point, however insufficiently
precise it has been made in the above quotation. I shall return to this point.
Second, they offer no strategy to support their essentialist claim that perfor-
mance enhancement is the “defining characteristic of doping”. And I have
indicated above how a defeasible approach is to be preferred. Indeed, it is
too minimalistic a conception of doping. One might wish to add criteria like
“deception”, “unfairness”, to the list of potential criteria such as one might
wish to argue that certain modes of enhanced recovery were to be thought of
383
as doping too. To reiterate: doping is itself a heterogeneous phenomenon that
underscores a defeasibilist approach.
Nevertheless, WADA (whether in response to the call or not) has modified
their stance with respect to the criteria in line with the call above. In the
current proposed version of the Code review (the second of three phases), they
have amended the WADC to as follows:
4.3.1 WADA shall consider a substance or method for inclusion on the
Prohibited List if it determines in its sole discretion that the sub-
stance or method alone or in combination with other substances
or methods has the potential to enhance or enhances sport perfor-
mance and the substance or method meets, in addition, one of the
following two criteria:
4.3.1.1 Medical or other scientific evidence, pharmacological effect or
experience that the Use of the substance or method represents an
actual or potential health risk to the Athlete;
4.3.1.2 WADA’s determination that the Use of the substance or method
violates the spirit of sport described in the Introduction to the
Code.9 (bold, emphasis added)
What this reformulation entails, in philosophical terms, is a twofold strategy.
First, it establishes performance enhancement (PE) as a necessary condition
or inclusion criteria for the PL: it leaves defeasible the health and Spirit of
Sport criteria. The critics from the INHDR might now cheer since it seems
foreseeable that recreational drugs may readily fall under 4.3.1.1 and 4.3.1.2,
but not under 4.3.1 (the PE condition), and therefore be ineligible as doping.
It would appear that this objection, to expanding doping into public health
and private morality, has been altered by WADA.
The academic signatories to the call have further ethical and political ob-
jections that merit careful consideration in support of their cause. They write:
It is clear that WADA’s third criterion for inclusion — that the use of drugs
is against the vague concept of the ‘spirit of sport’ — performs a ‘catchall
function’; it provides an argument for the banning of recreational drugs
whose use cannot be banned on sporting grounds, that is on grounds of
performance-enhancement. It is important that we, and WADA, are clear
about the implications of this rule: since WADA may suspend an athlete
for the use of recreational drugs which are not performance-enhancing
WADA is, in effect, using anti-doping regulations in order to police personal
lifestyles and social activities which are unrelated to sporting activities.
In terms of their argument, what is claimed is that the idea of the Spirit of
Sport criterion cannot be used to impose a(n) (apparent) public morality on
The Spirit of Sport and the Medicalisation of Anti-Doping Michael J. McNamee
Asian Bioethics Review December 2012 Volume 4, Issue 4
384
athletes who may or may not choose to use canabinoids in their non-sport
time. They are not alone in this view.
Consider a perspective from an Athlete Trade Union in Europe offered to
the author in interview for a European empirical ethics study:
Regarding cannabis, our position is that it is not a performance enhancing
substance and should not be included on the list. Athletes using marijuana
hurt their teammates more than their competitors. Marijuana use is not
cheating or sport fraud. WADA has enough to handle with real doping. It
is important to note that collectively bargained anti-doping systems in the
U.S. distinguish between substances of abuse and performance enhancing
substances. A rehabilitative approach would make more sense rather than
a punitive one. Politics and punishment, unfortunately, go together on
this one. (Code: AT1)
Here there is recognition of (potential) harm to participants but it is held
that doping ought to be conceptually restricted to performance enhancements
that create sporting injustices. Moreover, it suggests a public health approach
to substances of abuse, and a punitive approach to (its restricted conception
of) doping. The move has much to recommend it in terms of apportioning
different policy responses to differently motivated acts.
A principle can be established from both quotations: recreational substance
(ab)use does not threaten the Spirit of Sport. That their use is a health risk
has been disputed for many decades though some recent research is fairly
clear on the relationship (see Meier et al. 2012; Gonzalez and Swanson 2012).
Under the 2009 tri-partite defeasible system, Cannabinoid use if detected
would constitute an ADRV. Since ADOs do not actually catch so many doping
cheats this is not unimportant. Moreover, according to WADA’s 2011 figures,
there were 445 positive tests for Cannabinoid use10 including famously the
multi-Gold-medal-winning figure Michael Phelps. This datum represents the
third highest category of doping (prohibited substance) for which athletes were
tested for. Might its exclusion lead to a dimunition of WADAs legitimation?
After all, there appears to be some relationship between the credibility of a
system which places a burden on athletes and the positive effects of those
burdens. If athletes come to believe that so few doping competitors are caught
doping, then the whole system will come under pressure. On the other hand,
it might be argued that their legitimacy was enhanced by a focus only on
illicit performance enhancement.
Who wants Cannabinoid use on the PL then? One can assume that since
most nation-states making sale and trafficking of Cannabinoids (though not
possession) illegal, then they would have a vested interest in its being made
illicit to sportspersons. Hitherto NADOs are all but certain to come under
385
pressure by state parties to symbolically outlaw recreational substance abuse.
Therefore, one might suspect a fair-play/cheating narrative from IFs and Trades
Unions, and a public health perspective from NADOs.
V. On Whether Cannabinoids Should be Retained
on the Prohibited List: The Voices of Key Actors
in Anti-Doping Policy
I turn now to a study in empirical ethics of physical enhancement from the
European (EPOCH) project noted above. In that study, only a minority of
12 European NADO heads were strongly in favour of retaining Cannabinoids
on the PL. One stated:
I have huge problems with WADA’s definition of doping. It isnt a defi-
nition as far as I’m concerned. […] if I’m trying to apply it and I’m trying
to write my strategy based on what we’re trying to achieve, I dont know
what we’re trying to achieve. I have a real problem, I don’t know what
we’re trying to achieve and I dont know what this … I think that their
definition is so broad that it could cover anything and everything and I
don’t think it’s appropriate. I actually have a real problem with the defi-
nition. (Code NADO 5)
They continued:
And even now in response to that, the EU thing that came through a week,
a few weeks ago there about the gyms and that side of it, you know and
they referred to doping substances. But what does doping mean? You look
up try and find the definitions and doping is linked to people taking sports
people and then you look up the definition of sportsperson. And you know
they don’t include these guys and doping is a definition that’s taken within
the context of competitive sport.
And so therefore the word doping doesnt mean anything in those con-
texts. It’s not, I mean I think you used a different term for it which I think
is right but this EU thing was referring to it as doping and I dont think
it is. And strictly speaking if you’re using the definitions we have in place
at the moment but I think the WADA definition is so broad. (NADO5)
What we have here are powerful voices in ADP who all privately agree that
catching recreational doping athletes is not at the core of anti-doping. Their
conclusions chime with the critics from the INHDR. On the face of it, it
would appear that the WADA are listening to stakeholders. This view is
certainly underwritten by many NADO heads in Europe who formed part
The Spirit of Sport and the Medicalisation of Anti-Doping Michael J. McNamee
Asian Bioethics Review December 2012 Volume 4, Issue 4
386
of the sample. One NADO head understood the desire of a politicisation of
ADP but, were they given the choice, would not burden ADP with it:
What they’ve proposed at the moment and bearing in mind this is first
red line draft and it’s probably going look vastly different come November
next year. Is I think a good compromise and certainly something we sug-
gested which is: give performance enhancement a greater weighting in your
determination of whether you’re going to consider it on the list or not.
So, basically it has to tick performance enhancing. Now, if you can then
wed it to Spirit of Sport as well, that’s fine with me. Because I think one
of the things that is often forgot particularly by those not working within
government is government’s ambition is that, government’s objective is that
this is contributing to the Public Health Agenda. (Code: NADO 1)
Here it seems the NADO participant has realigned the Spirit of Sport argu-
ment with the health argument. But the relationship is a tenuous one. Govern-
ments have both an interest in sports being vehicles for positive social and
ethical values and for the health of their population. Yet the relation between
health and sport is at best unclear. While on the one hand there is certainly
a symbolic value (people who take physical exercise might appear to be less
unhealthy than those who do not), it is unclear whether competitive sports
— and especially elite competitive sport which is WADA’s primary concern
— has anything much to do with health at all. Just as there are competing
conceptions of health, so there are multiple ways to realise it — and it is not
a given that sport is chief among them.
A final complication must be noted. Even if WADA goes on to ratify the
bipartite system, there is a further mechanism by which Cannabinoids might
be outlawed. As a preface to the PL, which the bipartite mechanism is used to
construct that list, they write the following:
S0. NON-APPROVED SUBSTANCES
Any pharmacological substance which is not addressed by any of the subse-
quent sections of the List and with no current approval by any govern-
mental regulatory health authority for human therapeutic use (e.g. drugs
under pre-clinical or clinical development or discontinued, designer drugs,
veterinary medicines) is prohibited at all times.11
While it might be possible then to remove Cannabinoids with this catch all,
what seems clear to me, is that it is not the Spirit of Sport that is the prob-
lematic “catch all” rule. It does seem, however, that no guidance is set out
for the employment of this rule. But then there appears to be a lack of trans-
parency about how any mechanism is employed in the construction the PL.
387
It is most likely that the Olympic Movement, and IFs too, have a consi-
derable interest in associating sports with health. In terms of sponsorship
and marketing, being positively associated with health is a(n) (economically)
good thing. So each of the parties, with the exception of ATU and a minority
of athletes, has reason to align the Spirit of Sport with health for sporting,
public health, and economic reasons.
VI. Anti-Doping between Medicalisation, Conceptual
Vagueness and Political Interference
What would be the conceptual gain of rendering doping under two necessary
and now sufficient conditions? Doping is performance enhancement that is
(potentially) harmful to health. Well, on the one hand, there will be greater
specifiability since the constituents of the list are reduced in number. On the
other hand, there is a medicalisation of doping since after the performance-
enhancing credential are satisfied, it is seemingly a medical matter whether
the methods or substances are harmful or potentially harmful to health. I call
this a medicalisation in a pejorative way. As Parens (2010) notes, the term
originally noted by sociologists is merely descriptive of a process (see Conrad
et al. 2010). And there seems to be a minor, but contested, view that it is
health in individual terms that counts most, not a public health perspective.
While this may make it easier for those with a desire to maintain exception-
alism or isolationism in sport policy, it may not be obvious to philosophers of
health that this is desirable.
Under a biomedical or biostatical theory of health as normal functioning
(e.g. Boorse 1977), we might be able to ban the kinds of methods and
substances currently thought harmful, such as blood-boosting, endongenous
testosterone ingestion, recombinant human growth hormone use, synthetic
erythropoietin supplementation, anabolic steroid use, and so on. Here doping
policy is a kind of paternalistic protection; health promotion with teeth, so
to speak. But as philosophers of health are keen to remind us, there are more
conceptions of health than the biomedical or biostatical account.
In contrast, though, on a social account of health where the securing of
one’s vital goals is definitive of health (Nordenfeldt 1995), the doping athlete
might be seen to be using methods and substances that do not harm him.12
To the contrary, he might be seen to be flourishing.13 Note that this is not
a matter of conceptual vagueness; the competing of conceptions of health
might be thought to be equally precise or imprecise. It does not matter for
the argument. The key premise is this: all concepts in a natural language may
be rendered contestable by the contexts in which they are used. “Health” is
The Spirit of Sport and the Medicalisation of Anti-Doping Michael J. McNamee
Asian Bioethics Review December 2012 Volume 4, Issue 4
388
as open to contestation as is “Sport” and the “Spirit of Sport”. The perceived
precision of the former is likely to be a function of the paradigm (or perhaps
biomedical theory-ladenness) of the preconceptions of the sports medical and
scientific communities and ADP agencies.
Moreover, a significant complication in this shift would be the loss of
an ethical discourse in anti-doping policy. The source of ethical unease now
shifts from cheating — loosely understood as deceptive unfair play — to
imprudence. The doping athlete is to be understood as deceiving others by
utilising imprudent health-risking substances or methods that are licit under
the new rule. This is not to my mind a conceptual gain. Moreover, given that
much of the discourse surrounding cheating is moralised (perhaps too highly
moralised), the intuition that doping is an ethical failure will come to be seen
as misplaced. The moral discourse of anti-doping predicated is on the idea
that sports are ethical enterprises. And this is rarely seriously accounted for
outside sports philosophy. Nevertheless, the idea that doping athletes display
deficiencies of character (McNamee 2008) and violate the fair opportunity
principle (Loland 2009) may be thought to underpin an ethical vision of
sports. And if this criterion is removed, we are left with little ethical substance
to criticise doping athletes. Under the bipartite scheme, ADP makers merely
act in a strong paternalistic way to prevent athletes from particular harms
(while ignoring others that may even be inherent in the activity, e.g. boxing,
horse racing, Formula 1 car racing, and so on). It is far from clear to me
why this is an ethical or a policy gain. Nor is it obviously a conceptual one.
Regarding the Spirit of Sport criterion, it is worth rehearsing a point made
by Wittgenstein that how we use language is crucial to meaning:
‘But is a blurred concept a concept at all?’ — Is an indistinct photograph
a picture of a person at all? Is it even always an advantage to replace an
indistinct picture by a sharp one? Isnt the indistinct one often exactly what
we need? (§ 71)
It strikes me that the Spirit of Sport criterion is exactly what ADP needs.
From a purely philosophical point of view, I have shown that the objection
against the spirit of sport qua vagueness is largely an impotent one. The world
of natural languages is not really split into two categories: the neat and the
vague. Granted, some concepts are clearer than others. It is true that WADA’s
list is neither a definition nor an analysis. I noted above that they do not
claim that it is. It is simply a list of values widely referred to in relation to
an ideal of sports and participation therein. But we handle conceptual vague-
ness every day without remarking upon it. When does yellow shade into
ochre, or orange; or when does pink become cerise? Even colour predicate is
389
conceptually vague, but we do not hear of the abandonment of colour-words.
How could we?
Likewise, if we want to argue that there are some ways of preparing for
and competing in sports that threaten the (contested) ideals that it stands
for, we must have some mechanism by which this is done. A spirit of sport
criterion is thus essential to the task of determining which substances and
methods are thought of as acceptable or not. This is not a case of line-drawing
as Murray (2007) suggests. He is clear on the problem of hard cases, but it
is not helpful to see these as arbitrary lines that may or may not be justified.
All sports rules are arbitrary, as he notes. But none are, or at least none ought
to be, random.14 There is no good reason why we could not extend a soccer
pitch by one metre, nor add to the pressure of a rugby ball by a further
0.5oz per square centimetre, or play hockey for 93.5 minutes, and so on.
The rules preserve the challenge in an arbitrary way. If ADP makers advance
the case that the symbolic relations between health and the spirit of sport are
such that we do not wish to have excessive technological augmentation, they
should erect an argument to that effect. If they wish to make licit recreational
drug use because it is dangerous to health and inimical to sports, so be it.
What is needed then, is not an objection on the grounds of vagueness, or
line-drawing, but a proper account of the goods and virtues that sports ideally
instantiate and then an account of why some will fall under the heading
“doping” while others will not. Match-fixing and corruption are a larger threat
to the spirit of sport; they are clearly not doping.
It is important to register the confluence of two problems here for ADP. It
is first a political problem. Critics of current policy from within and without
point to the idea of the mission creep into public health. The unstated but
reasonable inference is that nation-states pay for half of all anti-doping opera-
tions by NADOs and WADA, and they wish to register their opprobrium
towards users of Cannabinoids. The extent to which this political fiat will
depend on the arguments supplied and contested. The second objection is
that the criteria for inclusion on the PL incorporate a criterion, the Spirit of
Sport, which is conceptually vague in such a way that it paves the way for
politicisation of anti-doping into public health.
VII. Conclusion
I have argued that certain bioethical and social scientific criticisms about the
Spirit or Sport are mostly untenable under a conception of meaning that is
very widely shared in the philosophy of language. I have not rejected their
claims outright. It is clear that issues concerning the operationalisation of that
The Spirit of Sport and the Medicalisation of Anti-Doping Michael J. McNamee
Asian Bioethics Review December 2012 Volume 4, Issue 4
390
concept remain. The critics’ suggestion, along with that of other key voices
in ADP, that the criterion is removed from ADP is mistaken if the thought is
that the employment of the health/harm criterion is somehow precise, is open
to the selfsame criticism of vagueness, or at least theory-contestedness. More-
over, the move away from a three-part defeasible conception to a bipartite
definition of doping merely medicalises it and undermines the widespread view
that doping is an unethical act or practice, corruptive of the integrity of sports.
This leaves two questions. Is it unreasonable that states parties who have an
interest in the order of civil society, its health, and its values, seek to influence
attitudes and behaviour to modes of enhancement? Can the concept of the Spirit
of Sport be made more precise, and can its use by the PL subgroup make more
transparent their use of it as a criterion? Both questions will require the kind
of ethical expertise that is currently underemployed, and often unemployed, in
AD discourses beyond the academy.
Acknowledgements
I am grateful for advice on Cannabinoids and the PL in WADC to Andy
Parkinson and Nenad Dikic, and to Ivan Waddington, despite our differences,
for his general comments and criticism.
Notes
1. The writing of this article was supported by the European Commission FP7 Science
in Society funded project, Ethics in Public Policy Making: The Case of Human Enhance-
ment (EPOCH), grant number SIS-CT-2010-266660, http://epochproject.com.
2. The whereabouts policy is itself hotly contested. Essentially, all athletes in a Registered
Testing Pool, which itself is a narrowly defined population of elite athletes must submit
whereabouts information for one hour per day between the hours of 7am and 10pm
when they will be available for unannounced testing controls. The intrusive nature of
such policy is widely discussed (Møller 2011, 2012) as is the fact that there are no
international standards for the inclusion criteria of the registered testing pool (Dikic
et al. 2011).
3. http://www.wada-ama.org/rtecontent/document/code_v2009_en.pdf.
4. Ibid.
5. See McNamee, M.J. (2012) Epoch Final Report: Work Package 7 (Physical Enhancement),
unpublished technical report.
6. http://www.wada-ama.org/Documents/World_Anti-Doping_Program/WADP-The-Code/
WADA_Anti-Doping_CODE_2009_EN.pdf p.14 [accessed 25 October 2012].
7. http://ph.au.dk/en/om-instituttet/sektioner/sektion-for-idraet/forskning/forskningsenhedens-
sport-og-kropskultur/international-network-of-humanistic-doping-research/ [accessed
25 October 2012]. On a point of intellectual honesty, I happily declare that I am a
391
Member of this network. I could not add my signature to the call for reasons that
will become apparent.
8. http://ph.au.dk/en/om-instituttet/sektioner/sektion-for-idraet/forskning/forskningsenhedens-
sport-og-kropskultur/international-network-of-humanistic-doping-research/newsletters/
june-2012/call-for-wada/ [accessed 25 October 2012].
9. http://www.wada-ama.org/Documents/World_Anti-Doping_Program/WADP-The-Code/
Code_Review/Code%20Review%202015/Code-Draft-1.0/WADA-Code-2015-Draft-
1.0-redlined-to%202009-Code-EN.pdf [accessed 25 October 2012]. Note that the
version on WADAs website shows what has been removed and altered by coloured
fonts and strikethrough fonts. These have been deleted in the quotation above, which
reads as if the proposed changes will come into force.
10. See WADA’s own data at http://www.wada-ama.org/Documents/Resources/Testing-
Figures/WADA-2011-Laboratory-Testing-Figures.pdf [accessed 23 October 2012].
11. http://list.wada-ama.org/prohibited-in-competition/prohibited-substances/ [accessed 27
October 2012].
12. I use the male gender advisedly: doping is a predominantly male phenomenon.
13. The contemporary case of Lance Armstrong comes readily to mind.
14. I am not suggesting that Murray does not agree with this. I am sure he does.
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... None of the listed items can be used to argue non-ambiguously against the use of some doping technology and from a legal perspective this is highly problematic. Even though there are also voices in defence of the 'spirit of sport' criterion (Loland & Mc-Namee, 2019;McNamee, 2012) the point remains that this criterion is not essential for what arguably is the core mandate of WADA, preventing dangerous use of performance enhancing substances and methods in competitive sport (Waddington & Møller, 2019). ...
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The placebo effect is a biological response to psychosocial environmental cues surrounding the use of inert or active substances or methods. Placebo effects can be exploited for performance enhancement purposes and their use is not forbidden in sport. WADA's Code stipulates that at least two out of three criteria must be met to put something on the Prohibited List of substances and methods forbidden in sport. These criteria are: Medical or other scientific evidence, pharmacological effect or experience that the substance or method, alone or in combination with other substances or methods, has the potential to enhance or enhances sport performance; Medical or other scientific evidence, pharmacological effect or experience that the use of the substance or method represents an actual or potential health risk to the athlete; and WADA’s determination that the use of the substance or method violates the ‘spirit of sport’ described in the introduction to the Code. By looking at what is on the Prohibited List and by interpreting the discourse surrounding the ‘spirit of sport’ criterion I postulate that substances and methods with documented placebo effects on performance fully meet the inclusion criteria and should therefore be included on the Prohibited List. Such reductio ad absurdum further illustrates the limits of WADA's three criteria framework for inclusion of methods and substances on the Prohibited List and reinforces the calls for a change in the way the Prohibited List is established and maintained.
Article
Introduction: There have been several reports showing that the rate of anabolic-androgenic steroid abuse has increased in athlete and non-athlete adolescents. Therefore, this study aimed to assess the prevalence of anabolic steroid misuse, as well as the awareness level and attitude toward its negative effects on male bodybuilder athletes in Kermanshah, Iran. Material & Methods: This descriptive cross-sectional study was conducted in 2019. The statistical population included all male bodybuilder athletes in Kermanshah, Iran. The data were collected using a 25- item self-reported anabolic-androgenic steroids questionnaire (demographic characteristics: n=7, awareness level: n=9, attitudes: n=5, and the prevalence of abuse: n=5) which was distributed using the multi-stage clustering method among 250 male bodybuilder athletes in Kermanshah, Iran. The obtained data were analyzed in SPSS software (version 22) through descriptive statistics (frequency, percentage, mean±SD) and inferential statistics (Pearson correlation coefficient). A p-value less than 0.05 was considered statistically significant. Findings: The results indicated that anabolic-androgenic steroid use was prevalent in 65.2% of the subjects. The most common cause was to increase muscle mass and strength. According to the results of this study, the prevalence of androgenic-androgenic steroid use showed a significant inverse relationship with attitude (r=-0.78; P=0.021), awareness (r=-0.73; P=0.032), an education level (r=-0.79; P=0.022). Moreover, sports background correlated significantly with the prevalence of androgenic-androgenic steroid use (r=0.68; P=0.035), attitude (r=0.84; P=0.013), and awareness (r=0.85; P=0.012). Discussion & Conclusion: The findings of this study indicated the high dose of anabolic-androgenic steroid use; moreover, the awareness level of the athletes was low in this regard. The low level of awareness, false attitude, and access to these steroids can lead to an increase in the use of them among athletes and different populations. Accordingly, health care professionals and sports specialists should consider these issues in the development of prevention plans and programs.
Article
Events surrounding the 2016 Summer Olympic Games in Rio de Janeiro brought increased scrutiny on the World Anti-Doping Agency's (WADA) Therapeutic Use Exemption (TUE) policy. Some critics even called for abolishing the TUE policy as a potential reform to improve anti-doping. This article describes the TUE policy outlined in the 2015 International Standards for Therapeutic Use Exemptions and then provides a moral argument for having TUEs based on medical rights. Next, the article discusses two types of criticisms of the TUE policy. The first, labeled “in practice” criticisms, proves to have no merit. The second, categorized as “in principle” criticisms, mostly fails to undermine the TUE policy. However, one branch of the “in principle” criticism, asserted by Dimeo and Møller, does raise doubts about the TUE policy's use of the treatment-enhancement distinction. Ultimately, the article argues that the criteria for approving a TUE should drop objections to enhancement when faced with legitimate medical conditions that offer no alternative accepted therapies. The article suggests that the medical community's ability to determine medical necessity and best practice guidelines provides sufficient criteria to prevent fraudulent TUE applications and thus should not rely on the treatment-enhancement distinction to deny TUE requests that conform to accepted medical practices. With such reforms, the article concludes that not only are critics wrong to call for an end to WADA's TUE policy, but that such a TUE policy helps sports in the Olympic Movement achieve their highest ideals.
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This study explores a controversial aspect of the new World Anti Doping Agency Code, which requires athletes in registered testing pools to submit accurate data concerning their whereabouts for one hour every day, three months in advance, to allow effective year round testing. In particular, the policy is designed to heighten the effectiveness of out-of-competition testing and close the loophole on athletes who have sought to use remote locations to avoid doping control officers. If an athlete misses three tests or records three filing failures they are deemed to have committed a doping offence, leading to a ban of up to two years. We present data from 20 National Anti Doping Organizations and 1 International Federation (cycling) regarding similar data. They reveal substantial variations in filing failures across organizations. We argue that the fairness of the system, however, is potentially vulnerable to variable interpretations of compliance, and to inaccurate and non-transparent administration regarding filing failures and missed tests. We conclude that there is a need for greater communication between anti-doping organizations and harmonization of interpretation and compliance of the rules.
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This article examines the circumstances surrounding the establishment of the World Anti-Doping Agency (WADA), which was established following the World Conference on Doping in Sport convened by the International Olympic Committee (IOC) and held in Lausanne in 1999. More specifically, the article draws upon Elias's game models to analyse: i) the way in which the IOC sought to manage this process of change in such a way that its longstanding position as the world's leading anti-doping organization would be reinforced; and ii) the IOC's inability to control this process, with the result that the IOC failed to achieve any of its objectives, its position as the world's anti-doping organization was actually undermined, and world leadership passed to a new organization which had a significant measure of independence from the IOC.
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Marijuana use has increased over the past 20 y in the United States, and current trends suggest it may continue to rise. Recent polls in the United States suggest that population acceptance is at an all-time high: 56% support the legalization for recreational use and 70% for medical use (http://healthland.time.com/2012/06/14). A survey of secondary school students in the United States (Monitoring the Future: http://monitoringthefuture.org) suggests a resurgence of marijuana use (Fig. 1): after a decade or more of decline to 22% in 1992, the annual prevalence of use in high school senior students climbed to nearly 40% in 2011, with a parallel decrease in perceived risk of regular use from almost 80% to approximately 45% (1). Although short-term trends reveal some temporary decreases (2), the recent trends of increasing use and acceptance of marijuana over the past 5 y (1) heighten the importance of a scientific basis for understanding effects of marijuana (cannabis).
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The ongoing ‘enhancement’ debate pits critics of new self-shaping technologies against enthusiasts. One important thread of that debate concerns medicalization, the process whereby ‘non-medical’ problems become framed as ‘medical’ problems. In this paper I consider the charge of medicalization, which critics often level at new forms of technological self-shaping, and explain how that charge can illuminate – and obfuscate. Then, more briefly, I examine the charge of pharmacological Calvinism, which enthusiasts, in their support of technological self-shaping, often level at critics. And I suggest how that charge, too, can illuminate and obfuscate. Exploring the broad charge of medicalization and the narrower counter charge of pharmacological Calvinism leads me to conclude that, as satisfying as it can be to level one of those charges at our intellectual opponents, and as tempting as it is to lie down and rest with our favorite insight, we need to gather the energy to have a conversation about the difference between good and bad forms of medicalization. Specifically, I suggest that if we consider the ‘medicalization of love,’ we can see why critics of and enthusiasts about technological self-shaping should want (and in some cases have already begun) to distinguish between good and bad forms of such medicalization.
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Medicalization is the process by which non-medical problems become defined and treated as medical problems, usually as illnesses or disorders. There has been growing concern with the possibility that medicalization is driving increased health care costs. In this paper we estimate the medical spending in the U.S. of identified medicalized conditions at approximately $77 billion in 2005, 3.9% of total domestic expenditures on health care. This estimate is based on the direct costs associated with twelve medicalized conditions. Although due to data limitations this estimate does not include all medicalized conditions, it can inform future debates about health care spending and medicalization.
wada-ama.org/Documents/Resources/Testing-Figures/WADA-2011-Laboratory-Testing-Figures.pdf [accessed 23
  • See
  • Wada
See WADA's own data at http://www.wada-ama.org/Documents/Resources/Testing-Figures/WADA-2011-Laboratory-Testing-Figures.pdf [accessed 23 October 2012].
I am sure he does Ethics of Performance Enhancement in Sport: Drugs and Gene Doping, Principles of Heath Care Ethics
  • R E Ashcroft
  • A Dawson
  • H Draper
I am not suggesting that Murray does not agree with this. I am sure he does. References Ashcroft, R.E., A. Dawson, H. Draper et al., B. Foddy, and J. Savulescu (2010) Ethics of Performance Enhancement in Sport: Drugs and Gene Doping, Principles of Heath Care Ethics, 3rd edn., ed. R.E. Ashcroft, A. Dawson, and H. Draper et al., John Wiley and Sons, Ltd., London. Boorse, C. (1977) Health as a Theoretical Concept, Philosophy of Science, 44, 542–73.
Commission of Inquiry into the Use of Drugs and Banned Practices Intended to Enhance Athletic Performance
  • C Dubin
Dubin, C. (1990) Commission of Inquiry into the Use of Drugs and Banned Practices Intended to Enhance Athletic Performance, Canadian Government Publishers, Ottawa.