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Sport and Illegal Substances

Discuss the following statement with reference to the implications on health and the current international guidelines on the use of prohibited substances in elite sport:

"Athletes and coaches should be allowed to use any type of substance and ergogenic aid as part of a training strategy as long as the substance is not detectable during or immediately after competition".

The current international guidelines on doping came to prominence in 2003 when the World Anti-doping code was agreed and published. This code brought a common interpretation of the various codes that were in force in different countries and different sports across the world. In specific relation to the question under consideration, it should be noted that the code is updated as policy and technology change. (Kamber M 1998)

It is this point that is seminal to the thrust of this essay. It is a natural sequitur to this argument that various substances are illegal if they are detected in an athlete. These substances are proscribed and the various tests to detect them are laid down in the four International Standards. It follows that if a particular substance is not proscribed and not detectable, then it is not, by definition illegal.

The four standards refer to:-

In legal terms, these four standards define and encapsulate the definitive and virtually universally accepted standards for matters relating to doping.

If one follows the exact letter of the law with regard to the international regulations, a breech of the rules occurs when an illegal proscribed substance is detected in the body (blood or urine) of an athlete. (Ashenden M 2002).

There are exceptions to this, such as a breech was presumed to have been committed, even though it could not be conclusively proved, when blood bags and transfusion sets were found in the debris after the Austrian team left Salt Lake City in 2002 (see on)

The converse (and some may say implied) argument here, is clearly that if a substance is not detected (or detectable) then technically no breech of the regulations has occurred.(Savulescu et al 2004) The counter to this argument is the implication in the UK National Anti-doping policy document, that there is an implied intention to protect an Athlete's fundamental right to participate in doping-free sport and thus promote health, fairness and equality for Athletes in the UK. This suggests that even if a drug or substance cannot be detected there is a moral obligation to promote and encourage doping free sport and a healthy environment. It is this moral argument that is the public face of sport in the UK today

In an analytical sense

One may regard these two statements as mutually exclusive although from a moral sense they are clearly intended to be mutually enhancing. In real terms most authorities would agree that the use of a substance that is proscribed and detectable is both legally and morally wrong. (Sawka MN et al. 1996)

Equally they would almost universally agree that the participation in sport with no ergogenic of pharmacological enhancement is both legally and morally correct. (Robinson S et al. 1937)

The problem changes from obvious black or white to indeterminate shades of grey when one considers the question of physiological enhancement by natural methods. (Joyner M 2003)

This raises the issue of when does the use of a naturally occurring chemical or hormone become an illegal measure. To some extent this question is answered by the arbitrary application of science. To give a specific example. Growth Hormone (GH) was in vogue several years ago as a strength and muscle bulk enhancer.(Rennie 2003)

This is a hormone which is produced naturally by the body. It can be synthesised in the laboratory and administered artificially with exactly the same detectable metabolic products as the naturally occurring substance. The doping agencies dealt with this problem by imposing a legal maximum level of urinary metabolites that was permissible. The implications being that being above that level was indicative of using extrinsic amounts of growth hormone.

The problem here is that, by definition, elite athletes are utterly exceptional people and are at one end of a broad biological spectrum. Those who are biologically (genetically) gifted may well approach one end of the normal Gaussian population distribution, by virtue of their elite status. (Ekblom B 2000)

This may put them in the bracket of being technically penalised for a biological quirk which may be normal for them. The same arguments apply to the use of erythropoetin and related haemoglobin enhancing substances and processes. (Lippi et al.2005)

The current argument rages that while it is considered (in many circles) perfectly acceptable to enhance circulating haemoglobin levels by the normal physiological processes of altitude training, it is less acceptable to take, concentrate, store and then reinfuse an athlete's own red blood cells. (Leigh-Smith 2004), and less acceptable still (illegal), to administer a naturally occurring heamopoetic agent (erythropoetin) (D'Onofrio G 2002), all of which achieve exactly the same physiological effect of booting the capacity of the blood to carry oxygen to exercising muscles.

If we examine this issue further (as being representative of a number of related doping issues) we can point to the debacle of the Salt Lake City 2002 winter games where the Austrian team of cross country skiers were suspected of blood doping techniques (two skiers being disqualified for this). The IOC later upheld the disqualifications with the comment:-

the IOC ...expressed surprise at the potential use of traditionalblood boosting by the Austrians, as it had been assumed to bevirtually obsolete since the advent of rHuEpo induced erythropoiesis. (d'Onofrio G, 2002)

rHuEpo (a form of erythropoetin) has been the focus of attention since it was thought to be undetectable and then a method of detection was introduced and caught many of the competitors in the 1998 Tour de France (Kamber M 1998)

Part of the implied subject matter of this essay is the effect on the health of the athlete concerned. This is a difficult matter to deal with for several reasons. Firstly there is the issue of manipulating the homeostasis of the body for the (arguably spurious) end of achieving better results in sport. Clearly this manipulation is considered generally acceptable if it is done with the intention of reversing or controlling a disease process. Just how ethical can it be considered if the sole purpose is to make someone run faster of jump higher? (Sugarman J & Sulmasy 2001).

The second point at issue is the potential for causing unwanted side effects. Anabolic steroids are well know to cause infertility, mood swings, cardiovascular abnormalities and hepatic cancer. (Rennie M 2003)

Erythropoetin can cause polycythaemia and coagulation disorders and strokes. One only has to look at the deaths of 18 Belgian and Dutch cyclists in the late 80s, which were widely believed to be due to hyperviscosity problems (Eichner M 1992). Just how ethical is it for a medical advisor to sanction the use of such substances for overtly non-medical ends? (Kuhse & Singer 2001)

The corollary of such arguments is that:

If, in a desperately competitive elite field it is known (or even suspected) that one competitor is using a banned method of performance enhancement, then every other athlete in that field will feel that, in order to stay competitive, they will also have to consider their use together with the potential health risks that go with it. (Eichner E 1992)

Another aspect of this argument that is often overlooked is that drugs and medications for medical use have enormously stringent checks and controls on their prescription and usage. This is usually as the result of many years of testing in physiological situations. Medications that are used outside of this envelope are often used in situations which they were not originally designed for and for which little experimental data exists.

The fact of the matter is that athletes may not actually be able to know exactly what health risks they are facing. It is quite wrong to assume that just because there is no published adverse data for a particular dosage regime that there are no adverse effects. It is just as likely that there is no published data simply because nobody has actually done the work to look at unphysiological dosage levels.

In the light of the current knowledge relating to detectable methods attention is focusing on the subject of genetic manipulation which is proving to be currently beyond the limits of delectability with our current technology.

The statement which we are asked to discuss has a clear implication that there is an acceptance that any type of intervention can be used as long as it is not detectable. The fact of the matter is that coaches and trainers from time immemorial have used performance enhancers whether, they were the horse urine of the ancient gladiators (Carrick P 2000) or the purely psychological prop of Dumbo's feather which enabled him to believe that he could fly, to either inspire their own athletes or to put doubt into the mind of their adversaries. In either eventuality, it was to give their man the edge.

Is it right to cry foul because one team has better ergonomic aids than another. (Newell & Simon. 1992)

Perhaps it is right to question the health risks that one team manager will accept on behalf of his players to give them the short term advantage over their opponents

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Conclusion

Perhaps we can conclude by considering the words of Savelescu (et al 2004) that the only realistic way of stopping doping cheats is either to raise the likelihood of being caught to totally unrealistically high levels or to reduce the payoffs for winning to unrealistically low levels.

The fact of the matter is that technology does not currently allow us to achieve the former and the competitive features of human nature will not let us achieve the latter. the corollary of that statement is that we will therefore have to learn to live with doping cheats and accept that the idea of drug-free sport is realistically little more than a pipe dream. The old fashioned concept of fair play and good sportsmanship effectively died with the first bad looser (Parker & Lawton 2003)

References

Ashenden M. 2002 A strategy to deter blood doping in sport. Haematologica 2002;87:225-34

Carrick P 2000 Medical Ethics in the Ancient World Georgetown University press 2000 ISBN: 0878408495

D'Onofrio G, Zini G. 2002 Addendum to strategies to deter blood doping in sports.Haematologica 2002;87(07):ELT31

Eichner E. 1992 Better dead than second. J Lab Clin Med 1992;120:359-60

Ekblom B. 2000 Blood boosting and sport. Best Pract Res Clin Endocrinol Metab 2000;14:89-98.

Joyner M. 2003 VO₂max, blood doping, and erythropoietin. J Sports Med 2003;37:190-1

Kamber M. 2001 Fight against doping-national and international developments after Tour de France 1998. Ther Umsch 2001;58:220-5.

Kuhse & Singer 2001 A companion to bioethics ISBN: 063123019X Pub Date 05 July 2001

Leigh-Smith S 2004 Blood boosting Br. J. Sports Med., Feb 2004; 38: 99 - 101.

Lippi G, M Franchini, and G C Guidi 2005 Cobalt chloride administration in athletes: a new perspective in blood doping? Br. J. Sports Med., Nov 2005; 39: 872 - 873.

Newell & Simon. 1992 Human Problem Solving. Prentice-Hall, Englewood Cliffs: 1992.

Parker and Lawton 2003 Psychological contribution to the understanding of adverse events in health Qual. Saf. Health Care, Dec 2003; 12: 453 - 457.

Rennie MJ 2003 Claims for the anabolic effects of growth hormone: a case of the Emperor's new clothes? Br. J. Sports Med., Apr 2003; 37: 100 - 105.

Robinson S, Edwards HT, Dill DB. 1937 New records in human power. Science 1937;85:409-10.

Savulescu J, B Foddy, and M Clayton 2004 Why we should allow performance enhancing drugs in sport Br. J. Sports Med., Dec 2004; 38: 666 - 670.

Sawka MN, Joyner MJ, Miles DS, et al. 1996 American College of Sports Medicine position stand: the use of blood doping as an ergogenic aid. Med Sci Sports Exerc 1996;28:i-viii. Sugarman J & Sulmasy 2001

Methods in Medical Ethics Georgetown Univeristy Press 2001 ISBN: 0878408738

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