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Physicians have struggled with the medical ramifications
of athletic competition since ancient Greece, where
rational medicine and organized athletics originated.
17
Historically, the relationship between sport and medicine
was somewhat adversarial due to rival objectives. The goal
of sport is triumph, whereas the goal of medicine is well-
being and the pursuit of victory can threaten health. Two
physicians commonly referred to as fathers of sports
medicine—Galen, who started clinical practice as a physi-
cian for gladiators, and Hippocrates—were both critical of
the lifestyle of professional athletes.
17
Rational medicine
was deeply rooted in the notion of moderation; hence, the
immoderate lifestyle of athletes, which involved intense
training, excessive diets, and obsession with victory, was
viewed as unhealthy and potentially dangerous behavior.
In accordance with this disapproval, sports medicine
served more of an observational role and, perhaps reluc-
tantly, a restorative role in the “premodern” period,
17
which
continued throughout the 19th century.
The evolution of sports medicine in the 20th century
brought about significant change; modern sports medicine
emerged with the goal of improving athletic performance,
accompanied by newfound physician endorsement. Sports
medicine physicians are now an integral part of athletic cul-
ture, with the distinction of “team physician,” and often serve
in a variety of roles. Many of these roles are purely voluntary,
especially at the high school or recreational level; at the
collegiate or professional level, however, team physicians may
serve as either consultants or employees of the team, which
can be associated with significant prestige and market power.
The 21st century transformation of the sports medicine doc-
tor into the team physician creates some unique ethical chal-
lenges. The most basic of these challenges is to beneficence,
the physicians’ traditional obligation to seek the well-being
of their patients above other goals, even at some cost or incon-
venience to themselves.
7
In other words, the ethics of the clas-
sic doctor-patient dyad, in which the physician has a primary
obligation to the patient’s well-being, is challenged by
the emergence of the doctor-patient-team triad, in which the
team’s priorities can conflict with or even replace those of the
patient-athlete.
12
This means that the customary ethical
norms for most forms of clinical practice, such as confiden-
tiality and patient autonomy, cannot be translated easily into
sports medicine. Furthermore, this more complex triadic rela-
tionship creates unique ethical dilemmas in areas such as
advertising and third-party influence. Unfortunately, there is
no widely accepted code of ethics for sports medicine that ade-
quately addresses these questions. The reader is referred to
Mathias, to whom we are intellectually indebted, for a more
detailed description of the history of ethics in sports medicine
and the irony of sport and health.
17
Ethics in Sports Medicine
Warren R. Dunn,*
†‡
MD, MPH, Michael S. George,
§
MD, Larry Churchill,
ll
PhD,
and Kurt P. Spindler,
†
MD
From the
†
Vanderbilt Sports Medicine Center, Nashville, Tennessee,
‡
Center for Health
Services Research, Vanderbilt University Medical Center, Nashville,
§
KSF Orthopaedic Center,
Houston, Texas, and
ll
The Center for Biomedical Ethics and Society, Vanderbilt University
Medical Center, Nashville.
Physicians have struggled with the medical ramifications of athletic competition since ancient Greece, where rational medicine
and organized athletics originated. Historically, the relationship between sport and medicine was adversarial because of conflicts
between health and sport. However, modern sports medicine has emerged with the goal of improving performance and pre-
venting injury, and the concept of the “team physician” has become an integral part of athletic culture. With this distinction come
unique ethical challenges because the customary ethical norms for most forms of clinical practice, such as confidentiality and
patient autonomy, cannot be translated easily into sports medicine. The particular areas of medical ethics that present unique
challenges in sports medicine are informed consent, third parties, advertising, confidentiality, drug use, and innovative technol-
ogy. Unfortunately, there is no widely accepted code of sports medicine ethics that adequately addresses these issues.
Keywords: ethics; team physician; informed consent; confidentiality
1
*Address correspondence to Warren R. Dunn, MD, MPH, Center for
Health Services Research, 1215 21st Ave. South, 6007 MCE, Nashville,
TN 37232-8300 (e-mail: warren.dunn@vanderbilt.edu).
This work was supported by Grant Number 1K23 AR05392-01A1 from
the National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS) and the Pfizer Scholars Grant in Clinical Epidemiology.
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. X, No. X
DOI: 10.1177/0363546506295177
© 2007 American Orthopaedic Society for Sports Medicine
Team Physician’s Corner
AJSM PreView, published on January 11, 2007 as doi:10.1177/0363546506295177
Copyright 2007 by the American Orthopaedic Society for Sports Medicine.
2 Dunn et al The American Journal of Sports Medicine
INFORMED CONSENT AND
THIRD-PARTY INFLUENCES
Informed consent attempts to harness an otherwise complex
and abstract issue of honoring the free will of others into a
practical process that allows patients to choose their treat-
ment with a full understanding of all the options.
3
The pur-
pose of consent is to respect patient autonomy, and to enable
them to make decisions that reflect their values. At least one
study suggests that this is one of the more difficult aspects
of medical ethics for orthopaedic surgeons to grasp.
22
The
physician must work as both a patient advocate and an edu-
cator to ensure that the patient really understands the risks
and benefits of all possible treatment options. All reasonable
operative and nonoperative treatment options must be pre-
sented to the patient to obtain truly informed consent.
Consider, for example, the matter of graft choice for a patient
who has decided to have anterior cruciate ligament recon-
struction using autograft. While this may seem rather
straightforward, obtaining informed consent in this situation
can be quite complex. For the patient to make an informed
decision, he or she requires an unbiased summary of avail-
able evidence regarding the options. Although numerous
autograft options have been described in the literature, a
discussion of at least the more common choices, such as cen-
tral third patellar tendon and hamstring tendon, should be
considered. Often patients will naively subvert this process
and afford the surgeon an easy way out by asking which is
the best choice; in such instances, it can be very tempting to
advise the patients based on the surgeon’s bias. Surgeon
bias is often not evidence-based and can stem from many
things, including training or clinical experience. Because
there is level 1 evidence that outcomes are similar with
either graft,
19
this should be conveyed to the patient as part
of the informed consent. In the end, physicians may not
agree with the decision of the patient; however, they must
preserve the patient’s right to autonomy.
15
In sports medicine, this consent is threatened further by
the fact that different parties in the triad of relationships
may have different values and priorities, and therefore might
choose different options. The following classic example
addresses the issues of balancing medical risk with nonmed-
ical benefit and balancing patient preferences with team pri-
orities. An athlete sustains a potentially repairable meniscus
tear that occurs a few weeks before the playoffs. An excision
of the tear would permit participation, whereas meniscal
repair would preclude participation. If the physician believes
that meniscectomy increases the long-term risk of arthritis
and that a successful meniscal repair may decrease this risk,
then the physician’s and the athlete’s goals may diverge. The
player’s present desire to participate in the playoffs may out-
weigh future consequences to the knee. The physician’s belief
that excision may lead to arthritis in the future may out-
weigh the short-term benefit of the playoffs.
More subtle layers of complexity that can complicate med-
ical decision-making can arise because physicians, as mor-
tals, are affected (at least to some degree) by their personal
history and can be influenced (consciously or unconsciously)
by the psychosocial allure of prestige, gratitude, and admi-
ration. A team physician in this situation may face implicit
or explicit pressure from multiple sources, such as manage-
ment, coaches, trainers, and agents, to improve performance
now rather than preserve the long-term health of the athlete.
Indeed, it could be argued that in the role of team physician,
the physician owes both information and loyalty to team
owners and coaches. Should the informed consent process be
aimed at the team authority, such as the coach or owner, as
well as the patient-athlete? In what ways can the sports
medicine physician recognize that the team has a legitimate
stake in the outcome and yet remain loyal to the patient?
Should the physician ever seek a consensus about treatment
among all the parties involved, or only treat this as an issue
between physician and patient? We argue that the primary
loyalty is still to the patient-athlete, but we recognize the
extraordinary pressures to involve others and the special
pressure on the athlete to choose in ways that balance team
benefit in the short run with personal health in the long run.
The media further complicate matters. Media coverage
introduces another distinctive aspect of decision-making
in sports medicine because the physician’s care comes under
an added level of scrutiny that can have either positive or
negative influence on the physician’s practice and, conse-
quently, his or her career. Unfortunately, public perception of
the athlete’s outcome may influence the public’s perception
of the physician’s competence. Clearly, partial meniscectomy
exposes the physician to less risk; it is an easier procedure
to perform and the athlete would likely return to sport
quickly, reflecting positively on the surgeon. Meniscal repair
is technically more difficult, has a much longer convales-
cence, and the tear may not heal, which could lead to reop-
eration. Despite the fact that the success of the procedure
depends on many factors other than the integrity of the sur-
gical repair, which are beyond the control of the surgeon,
meniscal repair would be season-ending and could lead to a
second operation to address the “failure” of the first proce-
dure. Reports of “successful” surgery returning athletes to
sport quickly with a backdrop of marveling advances in sur-
gical technology are common. It would be unusual to hear an
account of a retired athlete without arthritis told in such
heroic fashion. Nonetheless, it is normal for the physician to
think about the public perception of the care he or she pro-
vides; however, this should in no way factor into the treat-
ment options that are discussed with the athlete.
Patient autonomy is one of the basic tenets of medical
ethics and always supplants the physician’s partiality. In
many respects, this unburdens the physician because it is
the athlete’s right to determine what is in his or her best
interest. However, an athlete faces some unique challenges
when making informed decisions regarding medical treat-
ment. Athletes must tackle external pressure from coaches,
teammates, and agents as well as internal drives and goals
that may influence their treatment decisions.
3
The American
Medical Association (AMA) Code of Medical Ethics has a sub-
section on sports medicine that states “Physicians should
assist athletes to make informed decisions about their par-
ticipation in amateur and professional contact sports which
entail risks of bodily injury.”
1
The International Federation of
Sports Medicine (FIMS) offers position statements as guide-
lines in areas where clarity is lacking or controversy exists,
and their code of ethics states, “Never impose your authority
Vol. X, No. X, 2007 Ethics in Sports Medicine 3
in a way that impinges on the individual right of the ath-
lete to make his/her own decisions” and “A basic ethical
principle in health care is that of respect for autonomy. An
essential component of autonomy is knowledge. Failure
to obtain informed consent is to undermine the athlete’s
autonomy.”
11
At first glance, the process of informed consent can seem
rather straightforward; however, depending on how much
emphasis is placed on the athlete’s comprehension and
knowledge of the issue, a first-glance understanding may be
far too simplistic. It can be a struggle at times to preserve
autonomy when considering the external pressures on the
athlete such as financial gain, coaching, and teammate expec-
tations, and particularly in game situations, when the
player’s desire to return may overwhelm common sense. It
has been argued that in these situations, education of the
athlete and informed consent are meaningless.
18
Despite the
convolution of game situations, return to sport decisions are
somewhat simplified when constrained by the physician’s
assessment of the risk of reinjury, or the risk placed on other
athletes (for example, blood-borne infections). The subsec-
tion on sports medicine from the AMA Code of Medical
Ethics states, “The professional responsibility of the physi-
cian who serves in a medical capacity at an athletic contest
or sporting event is to protect the health and safety of the
contestants. The desire of spectators, promoters of the event
or even the injured athlete that he or she should not be
removed from the contest should not be controlling. The
physician’s judgment should be governed only by medical
considerations.”
1
The FIMS code of ethics regarding return
to play states, “It is the responsibility of the sports medicine
physician to determine whether the injured athletes should
continue training or participate in competition. The outcome
of the competition or the coaches should not influence the
decision, but solely the possible risks and consequences to
the health of the athlete.”
11
Sports medicine physicians may feel pressured by coaches,
agents, teammates, and other third parties regarding certain
treatment recommendations. The orthopaedic surgeon
should not allow outside pressure to obviate meeting the
moral and ethical obligations of the medical profession.
13
The
physician has an obligation to protect the athlete from poten-
tial dangers and to ensure the patient’s autonomy.
3
According
to the Committee on Ethics of the American Academy of
Orthopaedic Surgeons (AAOS), such conflicts of interest
must be resolved in the best interest of the patient (athlete);
otherwise, the orthopaedic surgeon must withdraw from the
care of the patient.
9
We concur with this priority.
ADVERTISING
Medical advertising, including sports team affiliations, raises
particularly difficult ethical questions in sports medicine.
Given the tremendous popularity, prestige, and revenue
associated with college and professional sports, serving as
team physician at this level has marketing advantages.
12
Medical advertising was considered unprofessional and ille-
gal in the United States until about 25 years ago when these
regulations were lifted. Capozzi and Rhodes
5
raise important
questions of whether there are ethical reasons for physicians
to avoid advertising and whether there are certain moral
boundaries that should not be crossed. Of particular concern
in sports medicine are ethical concerns surrounding relation-
ships between team physicians and professional sports
teams that are contingent upon ongoing corporate spon-
sorship.
2
For instance, the reported annual cost for being
Major League Baseball team physicians for New York’s
Yankees and Mets was $1.5 million per team.
21
As many as
7 teams in the National Football League and 12 teams in
the National Basketball Association have a marketing
agreement with their current team physician that, on occa-
sion, has supplanted a previous physician who was unwilling
to engage in a bidding war.
12
Teams in the National Football
League have placed the team physician position up for bid
4
;
however, this practice does not appear to be widely accepted.
The Committee on Ethics of the AAOS has recommended
that the orthopaedic surgeon not use publicity in an untruth-
ful, misleading, or deceptive manner.
9
Medical advertising
based on a professional team affiliation is not inappropriate
when it does not mislead the public. However, the physician
should not buy an unmerited mark of quality by purchasing
an association with a team.
3
When people are led to believe
that the selection and title of team physician is based on
merit when in fact it is based on the highest bid, they are
being misled.
5
The team physician has an obligation to make
sure that patients are choosing the doctor based on merit
rather than misguided assumptions of quality or skill.
Hence, Bernstein et al
3
suggest that if medical advertising
regarding team affiliation leads to patient self-referral and
the patient expresses this to the physician, the physician is
duty-bound to confirm that the patient has chosen sensibly,
and might address the issue by saying something on the
order of “Yes, I am the team doctor, but that’s only glitter. You
should choose me as your doctor because I have done hun-
dreds of these surgeries—not because I hang out in the
locker room.” It is not recommended that physicians pay for
the right to be team physicians. However, the current reality
is that exclusive marketing contracts are linked directly to
the choice of medical providers, especially at the professional
level. Perhaps just as orthopaedic surgeons are obligated to
disclose to their patients/consumers ownership in MRI or
outpatient surgery centers, team physicians should disclose
to both athletes and private patients any financial arrange-
ment associated with being the team physician.
CONFIDENTIALITY
The relationships between the sports medicine physician,
the athlete, and the team create special ethical issues
regarding patient confidentiality. The Committee on Ethics
of the AAOS states that the orthopaedic surgeon must
respect the rights of patients and safeguard patient confi-
dences within the constraints of the law.
9
Bernstein et al
3
differentiate between the obligations of a physician who is
hired by the team and one who is the athlete’s personal doc-
tor. In their opinion, the physician who is hired by the team
is an agent of the team, and thus one of his or her goals is
to ensure that all the athletes are fit to compete.
3
In this
4 Dunn et al The American Journal of Sports Medicine
situation, the physician is obligated to explain to the patient
up front that the physician is required to share the patient’s
medical information with team officials. Even if the athlete
specifically asks the physician to keep something confiden-
tial, the physician must remind the athlete of this responsi-
bility to the team.
21
By contrast, when the physician is the
athlete’s personal doctor, the physician’s loyalty is strictly to
the athlete. If the athlete requests confidentiality, then the
physician is obligated to respect the patient’s wishes. The
personal doctor’s duty to the team is to provide truthful
information while maintaining patient confidentiality.
3
In all
cases, the physician has an obligation to be honest to the ath-
lete as well as to the team; all parties must work together to
protect the athlete’s safety.
6
However, the team physician is
also obligated to prevent harm to other members of the team
as well as other participants on the playing field. For exam-
ple, with regard to the transmission of infectious diseases,
such as impetigo, some governing bodies have explicit rules
prohibiting play.
14
Sports medicine physicians have a special
obligation, as advocates for safety, to inform team authori-
ties on all conditions that might jeopardize the safety of any
of the participants. Another example involves the revelation
of alcohol abuse. If the alcohol abuse affects safe participa-
tion for both the athlete in question and the other athletes
involved, the team physician should keep the player in ques-
tion from participating. Thus, the team physician has a
broader obligation to withhold an athlete from competition
to protect others but not to disclose the nature of the risk to
other players. If, on the other hand, the alcohol abuse does
not affect safe participation, the physician would not need to
share the information with the team.
21
Magee et al
16
detailed their interpretation of the effects of
the Health Insurance Portability and Accountability Act of
1996 (HIPAA) on the team physician. Team physicians who
care for professional teams may share an athlete’s health
information with coaches and team owners because the infor-
mation may be considered part of their employment record
and therefore would not fall under HIPAA regulations.
However, if an independent physician cares for a professional
athlete in his or her private office, then HIPAA rules would
apply. The Federal Educational Rights and Privacy Act
(FERPA) permits team physicians employed by a college or
university student health clinic to release health information
without the patient’s consent or authorization to other school
officials who have an educational interest in the information.
FERPA, however, does not allow disclosure of health informa-
tion to the media or to other outside parties without the ath-
lete’s signed authorization. Team physicians whose primary
practice is not within a student health clinic are governed by
HIPAA, not by FERPA. Therefore, the team physician in
this circumstance must obtain the athlete’s authorization
to share health information with trainers and coaches.
Medical information may be shared with another health
care provider without the athlete’s signed authorization.
The designation of the athletic trainer as a health care
provider is currently left open to interpretation. On-field
treatment evaluations may not fall under HIPAA regula-
tions if they are felt to be emergencies. In addition, play or
no-play decisions can be discussed with coaches and train-
ers because this is considered part of the emergency eval-
uation and treatment.
16
DRUGS IN SPORTS
Athletes may rely on sports medicine physicians for guid-
ance on performance-enhancing substances. The involve-
ment of sports physicians with the “doping” of athletes dates
back more than 100 years.
10
Despite the fact that it is uneth-
ical to encourage the use of banned substances,
12
there have
been well-documented cases of physician involvement with
the doping of athletes. Two prominent examples are the Ben
Johnson steroid scandal at the 1988 Olympic Games in
Seoul and the 1998 Tour de France scandal during which
many riders were found guilty of doping with erythropoietin
(EPO) and other drugs.
10
Concerning illegal or banned sub-
stances, physicians and athletes are bound by the decisions
of legislature and sports governing bodies.
3
Many governing
bodies, including the National Collegiate Athletic
Association, the AMA, and the American College of Sports
Medicine (ACSM), condemn nontherapeutic drug use by stu-
dent-athletes.
14
In addition, the National Football League
has a banned substances policy. According to the FIMS, the
use of banned substances is unethical and strictly forbidden
because they may provide unfair advantages to the athlete
and may cause harmful side effects.
20
When counseling an
athlete on illegal substances, the physician must respect the
law and uphold the dignity and honor of the medical profes-
sion
9
; hence, such information should be kept confidential
but the physician should denounce usage.
The use of legal, approved performance-enhancing sub-
stances is not necessarily unethical, but physicians must
still proceed with caution. Physicians may counsel athletes
about legal performance-enhancing substances provided
they are not dangerous, but again this is a gray area. Are
analgesics that enable athletes to continue participating
while injured considered perform-enhancing substances?
Some may say yes. Regardless of whether they are consid-
ered performance-enhancing or not, are they dangerous? In
the short term, they are probably not, but long-term risks
such as the potential acceleration of degenerative joint dis-
ease that may occur if the athlete returns to play while still
injured are more difficult to quantify.
21
However, physicians
are ethically bound to discourage substances that are
unfairly available to a limited population, which thereby vio-
lates the spirit of the rules of competition.
3
The team physi-
cian’s first obligation is protect the player from potential
harm, whether short term or long term, associated with per-
formance-enhancing substances, whether illegal or legal.
The physician should not terminate the relationship just
because an athlete does not heed this warning. The physi-
cian should follow the health of the athletes and continue to
inform them of the risks based on available scientific evi-
dence, reminding them that it undermines the sport and is
potentially unfair to opposing athletes.The physician should
not sacrifice his or her own credibility by exaggerating the
evidence to dissuade an athlete from using a drug; this
would violate the basic tenant of the relationship—trust.
EMERGING TECHNOLOGY
Sports medicine is a field of particularly rapid technological
advancement. Innovations in operative techniques, medica-
tions, and rehabilitation regimens create an environment in
Vol. X, No. X, 2007 Ethics in Sports Medicine 5
which evidence-based medicine lags behind the most recent
developments. Additionally, there is a limited population of
elite athletes, which makes it difficult to carry out quality
research to guide decision making. Professional athletes are
fully aware that their careers are relatively short lived and
their inability to participate because of an injury or chronic
condition may not only threaten their job security but may
also put them at economic risk.
21
In such an environment,
athletes may call for the most advanced treatments available,
despite the lack of data to support them. Likewise, physicians
acting in various capacities with industry can drive this phe-
nomenon. For example, it is not uncommon for physicians to
serve as consultants to biomedical implant companies and
to receive financial compensation for using that company’s
implants and providing feedback to them for development
purposes. Physician inventors will often partner with indus-
try and share patents on technology, which can result in sub-
sequent profit sharing. This paradox of progress—new
treatments are not used unless there is evidence that they are
useful, yet to obtain evidence, the treatment must be used—
can lead to moral tensions about just when to suggest new
technologies and how to present them.
3
At the very least,
clearly if a physician has a financial interest in a new tech-
nology, this relationship should always be disclosed.
The physician must honestly evaluate the basic science
and clinical evidence (which is often limited to recreational
and amateur athletes) available for the proposed treatment
to make treatment recommendations to the patient and
obtain informed consent. If a treatment has not been inves-
tigated, this should be disclosed, and the athlete must be ade-
quately informed about the experimental nature of the
treatment; if the treatment is under investigation, all aspects
of the study should also be discussed.
8
To make an informed
decision, the physician and the athlete must work together
when considering the proposed treatments, and discuss rele-
vant evidence as well as risks and benefits associated with
these treatments. Perhaps, in cases of experimental or
unproven treatments, advice from an objective third party
should be sought, much like an investigator in the academic
setting can turn to an institutional review board. Although
no such formal process currently exists, the collegial nature
of many team physicians along with national sports medi-
cine organizations like the American Orthopedic Society for
Sports Medicine and the ACSM provide an informal mecha-
nism of appraisal among team physicians. Enthusiasm for
new and promising, yet unproven, interventions is great in
sports medicine as it is in all areas of medicine; however, we
must curb this enthusiasm while evidence accumulates.
CONCLUSION
Many ethical issues are unique to sports medicine because
of the unusual clinical environment of caring for athletes
within the context of a team whose primary goal is to win.
The tension that can arise when trying to balance medical
means with nonmedical ends can be challenging. In fact,
the medical treatment of athletes may fall under special
legal and ethical guidelines. The sports medicine physician
must carefully examine these continually changing ethical
standards and direct the care of the athlete accordingly.
Ongoing awareness of national organization recommenda-
tions and legal changes and the policies and debates of
sports medicine governing bodies is important to provide
the best, most ethical care for the athlete.
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