This post is a part of our Bioethics in the News series. For more information, click here.
By Karen Kelly-Blake, Ph.D.
“Football is not a contact sport, it’s a collision sport.” Vince Lombardi
This is probably football’s most famous quote coming from one of football’s most iconic figures. Football, American football, is indeed a collision sport of spectacular proportion, and there lies the rub.
The National Football League (NFL) is being sued by more than 4000 former players charging that the NFL failed to inform them of the harm of playing with concussions, and that the NFL “… Ignored, minimized, disputed, and actively suppressed broader awareness of the link between sub-concussive and concussive injuries in football and the chronic neuro-cognitive damage, illnesses, and decline suffered by former players.” (Breslow 2014)
Former players with repetitive brain trauma are now being diagnosed with a neurodegenerative disease known as “chronic traumatic encephalopathy.” (Testoni et al. 2013) The NFL admits that in-game concussions occur about 100 times a year, but teams report only half this number. (Lipsky 2008) Football is about hard hits, and the harder the more exciting, so the question is not whether there is risk of concussion in playing football, but whether the players are fully and properly advised about the risk.
Stiggelbout et al. (2012) have argued that shared decision-making (SDM) is an ethical imperative that incorporates the four principles of medical ethics: respecting autonomy, beneficence, non-maleficence, and justice. The SDM model focuses on patient and provider sharing information and making a decision together. The provider provides information about treatment alternatives, risks and benefits, and the patient provides information about his preferences, and what is important to him for living his best possible healthy life. This model is about collaboration where both parties negotiate and agree with the decision. The model makes the assumption that the clinician is able to objectively tap their clinical expertise and that the patient can effectively identify and assess their own values relevant to the respective clinical decision and understand and appreciate the evidence. (Bogdan-Lovis and Kelly-Blake 2013) Often adding to the complexity and potential confusion surrounding SDM is the disagreement over interpretation of the available evidence, presentation of the relevant information, patient rights and responsibilities, and physician rights and responsibilities, which all work to confuse the interaction. (Bogdan-Lovis and Kelly-Blake 2013)
Traditionally, SDM has focused on preference-sensitive decisions where the treatment options are relatively the same as far as risks and benefits (e.g. early stage prostate cancer treatment, colorectal cancer screening, mammography), and so the choice depends on patient preference. Concussion is not preference-sensitive, but should that rule it out as an area for collaborative decision making? No, because SDM is an opportunity to engage in meaningful communication, most typically, in the clinical encounter.
However there are areas of concern. First, the typical patient-doctor dyad does not exist in the NFL. The health care relationship in the NFL is a triad—team, team doctor, and player. Second, a typical SDM conversation would occur during a routine clinical encounter, but when would the SDM conversation occur between player and team doctor? On the sideline after the player has been hit, and the team doctor is trying to diagnose if he even has a concussion, or the next day when his head is hurting and his ears are ringing, and he is just thankful that he was able to get out of bed? Probably not, but maybe, a SDM conversation can occur prior to signing a contract because players undergo extensive physicals before signing a team contract. This could offer an opportunity to communicate that identification of concussion is not straightforward and that there are short- medium- and long-term consequences of sustaining head trauma, and if a concussion occurs, explain the treatment options. And lastly, are the doctors making determinations about concussion trained to do so, i.e. neurologists? Pellman, former head of the NFL Committee on Mild Traumatic Brain Injury was a rheumalogist! (Lipsky 2008; Pellman 2006)
I would argue that players fully apprised of the risks of concussion and how it should be treated would err on the side of caution and delay return to play until they are clinically able to do so. Of course, with the “just win, baby” mentality of the NFL, and dare I say, the fans, this position may appear grossly naïve. The conversation would need to occur using plain language, i.e. “You have a diagnosed concussion, you need to sit out for the next three weeks, and if you don’t, and sustain additional head trauma, you may not be able to tie your shoes, shave, or recognize your children in 20 years.” Both the team doctor and player would benefit from having such a “real discussion” in that the doctor can remember that even though the team is his employer that his priority has to be the best interest of the player/patient, and the player/patient has to be forthcoming in reporting symptoms.
The team is heavily invested in winning, the team doctor is invested in the success of the team by which he is employed and in the health of the player (hope reigns supreme here), and the player is invested in keeping his contract. There are a number of conflicts embroiled in this triad. Shared decision-making, touted as ethically imperative for patient-centered care may be one way to make sure players and team doctors can achieve a care relationship that ensures the best interest of the player/patient in both the short- and long-term.
Disclosure statement: I am an avid football fan. Some have argued that fans bear some of the blame for the disregard of player health related to concussions. We can consider that for future discussion.
References:
Bogdan-Lovis E, Kelly-Blake K. Autonomy’s Child: Exploring the Warp and Woof of Shared Decision Making (paper presented to the American Society for Bioethics and Humanities Annual Meeting, October 24-27, 2013, Atlanta, GA).
Breslow JM. NFL Concussions: The 2013-14 Season In Review. Frontline. Jan 30, 2014. http://www.pbs.org/wgbh/pages/frontline/sports/concussion-watch/nfl-concussions-the-2013-14-season-in-review/
Fainaru S, Barr J. New questions about NFL doctor. ESPN.com. Aug 18, 2013. http://espn.go.com/new-york/story/_/id/9561661/central-figure-nfl-concussion-crisis-appointed-years-ago-league-position-commissioner-paul-tagliabue-patient
Jenkins S, Maese R. NFL medical standards, practices are different than almost anywhere else. The Washington Post. March 16, 2013. http://wapo.st/Z6tOqs
Lipsky B. Dealing with the NFL’s Concussion Problems of Yesterday, Today, and Tomorrow. Fordham Intellectual Property, Media & Entertainment Law Journal. Mar 12 2008;18(4):959-996. http://ir.lawnet.fordham.edu/iplj/vol18/iss4/3
Pellman E, Viano D. Concussion in professional football: summary of the research conducted by the National Football League’s Committee on Mild Traumatic Brain Injury. Neurosurgical Focus. Oct 15 2006;21(4). http://www.medscape.com/viewarticle/553967
Stiggelbout AM, Weijden T Van der, De Wit MPT, Frosch D, Légaré F, Montori VM et al. Shared decision making: really putting patients at the centre of healthcare. BMJ. Jan 27 2012;344:e256 DOI: http://dx.doi.org/10.1136/bmj.e256
Testoni D, Hornik CP, Smith PB, Benjamin Jr. DK, McKinney Jr. RE. Sports Medicine and Ethics. The American Journal of Bioethics. Sep 11 2013;13(10):4-12. DOI: 10.1080/15265161.2013.828114, http://dx.doi.org/10.1080/15265161.2013.828114
Karen Kelly-Blake, Ph.D., is a Research Associate in the Center for Ethics and Humanities in the Life Sciences at Michigan State University.
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MSU Bioethics 
It seems that neurologists hired, and assigned to games, by the NFL (as is done with referees) could help address the concern about the vested interest “team doctors” may have.
Football could be “de-weaponized” by eliminating helmets or going back to leather helmets (I acknowledge it will never happen). Rugby, from which American (gridiron) football devolved, has fewer concussions and is played without helmets. Having played rugby, football with a leather helmet and football with the modern plastic helmet the latter gives one a sense of invulnerability to do things they’d never do under the other two circumstances. Furthermore players are now taught to use the helmet as a weapon.
Thoughtful article Karen!
I applaud the NFL’s efforts to improve safety in Football by incrementally penalizing forms of contact at high risk for serious harm. The industry is not doing enough to improve personal safety equipment for players. But let’s not delude ourselves regarding the nature of the sport. Football is a physically and emotionally dangerous game. As long as fame, fortune and machismo are in play, there will always be coercive forces subverting any autonomous decision-making process, shared or otherwise.
My vote is for the players’ moms making the decisions!
As for those retired players who are suing the NFL not knowing at the time that what they did could have long-term negative consequences… duh, really??
Thank you, Dr. Meerschaert. I think moms may have a conflict of interest as well. Especially those invested in their sons receiving a big pay day. Not that they aren’t interested in the health and welfare of their child, but they are also looking for a way out of, in many instances, dire economic circumstances. Not an excuse, just an observation. As for the retired players suing the NFL, I can imagine that many were not fully aware of the toll football would take on their health. They understand the physical brutality of the game, and let’s not kid ourselves, revel in it. They are charging that the NFL at some point in time had medical evidence of the danger with returning to play too soon after a head injury and failed to apprise them of that knowledge. It was to the NFL’s benefit to get players back on the field because if a player is sidelined, everyone is losing money. So, as you state in your comment, fame, fortune, and machismo all act as subversive forces to thwart decision-making, but we should make every effort to right the ship.
Thank you for your comments. I absolutely agree with you that physicians hired by the NFL would address the conflict of interest we see with “team doctors”. You are right that leather helmets will never see a comeback, but some people have suggested that the single bar face mask helmet (still used by some kickers) could be an effective way to reduce head injuries. It would not completely “de-weaponize” the game, but perhaps it would make players think twice about how to tackle and take down their opponent.
Thank you for this thoughtful piece, Dr. Kelly-Blake. It seems all the more timely after the now-notorious recent World Cup incident in which a player knocked out cold for two minutes was asked if he wished to return to the game, and said yes. (FIFA, soccer’s international governing body, received appropriate world-wide criticism for this scenario played out before millions.) American football has no corner on the sports market for concussions.
While I appreciate your commitment to shared decision-making and your articulation of the question “what would that mean in this circumstance?”, I disagree with your answers in three ways. (1) I disagree that informedness of risk is missing, and improving that will solve the problem. I think there is plenty of information out there now about the risks. The problem for the injured player is trading off short versus long-term risk in an environment of cultural coercion. There can indeed be career risks involved in taking the health-recommended break– and that is what should be changed by policy. (2) I disagree that “informedness” is the key element of respecting autonomy in such cases, more generally. The brain bruise itself can impair risk/benefit analysis even amidst a flood of correct information–indeed can make it harder to sort through a flood of information. In all illness and injury, a paradoxical key to respecting patient autonomy is to be mindful of the specific ways that impairment affects aspects of full human autonomy. Telling a concussed patient the plain truth in plain terms, that the medical world widely agrees continued play is too risky, would respect autonomy. It would help give the patient necessary ammunition to combat the cultural and commercial pressures instrumentalizing his body–those pressures are the real threat to autonomy. (3) Ultimately, I disagree with the framing of the challenge as one of creating conditions for shared decision-making in this situation– in which conflicts of interest abound, and cultural pressure to ignore injury are extreme. Alternatively, I see the challenge as recognizing real limits to shared decision-making.
“Paternalism” has gotten a bad name in bioethics. Certainly professional athletes are not children. But they do have special vulnerabilities. The lost language of “justified paternalism” should be revived here, rather than extending the language of shared decision-making to a realm where it loses coherence. Ethically justified paternalism requires a strict league-wide concussion policy that requires time off from play and practice, with evaluative criteria to be assessed by non-team doctors dictating when play can be resumed. This policy should become a worldwide norm for all professional sports.
And certainly “paternalism” is justified on real children. Just among my own personal circle of kids in sports, one adolescent boy was recently called female anatomical parts by his football coach when– on doctor’s advice following continuing side effects from concussion–his parents required he wait until the following season to resume play. A young girl was mocked by her soccer coach for requesting to abide by the supposed international standard of “no intentional heading before 16.” (Since there is more space between children’s growing brain and skull than adults, heading the ball poses relatively greater danger to younger players.)
I heartily concur with Dr. Kelly-Blake that shared decision-making protocols are generally important to ethical medicine. But they cannot enact the wholesale cultural change required for the world of sport to address head injury. Justified paternalism is needed, embodied in coercive policies that bench head-injured players,and result in disciplinary action against coaches or teams when violated.
In the world off the field, bioethics should stop assuming “paternalism” is always a bad word. Recognizing patients’ real vulnerabilities is even more basic to medicine’s mission than contemporary norms of shared decision-making.
Thank you Dr. Mongoven for your comprehensive response to the blog post. Shared decision-making is not the panacea for correcting what ails the NFL and its response to player concussion. I merely suggest that a meaningful conversation can possibly occur, not at the time of a concussion, but at the time of the intensive physical evaluations that occur for players prior to signing an NFL contract. Sure, information about risk is now available, but the player lawsuit is arguing that full information was not provided by the NFL. A conversation, within the context of the physical evaluations, about risk and about the short-,mid-, and long-term outcomes of brain injury could help players better evaluate how they play the game.