Shared Decision Making and the Cardiovascular Care of Athletes: Is It Time to Get Back in the Game?

Prevention of sudden cardiac arrest/death and disease progression has traditionally been the primary basis for determining exercise recommendations for those with underlying cardiovascular disease. Potential harms of exercise restriction, including physical inactivity's impact on obesity, chronic disease, and negative psychological and emotional consequences, have been considered ancillary, if considered at all. Accumulating evidence suggests the relative safety of continued sport and exercise participation in the vast majority of those with a variety of cardiac conditions that were previously considered to be criteria for exclusion. Despite ongoing clinical uncertainty however, respect for patient autonomy and the inclusion of patient values and preferences is now required in the decision-making process. The shared decision-making construct, a cornerstone of patient-centred care, should be applied for determining exercise and participation recommendations for those with cardiovascular disease. Safe exercise principles should be employed in all cases, regardless of whether athletes chose to follow recommendations, following a harm-reduction model. This approach is recommended by the 2019 Canadian Cardiovascular Society and Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes, and other contemporary societal guidelines, for all aspects of cardiovascular care of athletes.

Exploring Predictors of Moral Disengagement in Collegiate Athletic Trainers.

CONTEXT: Considering recent high-profile reports of malpractice and negligence by National Collegiate Athletic Association (NCAA) athletic trainers (ATs), it is prudent to investigate the psychological mechanisms that may influence ATs' ability to justify unethical behaviors. When treating injured student-athletes, ATs may undergo a cognitive process known as moral disengagement, which involves convincing oneself that ethical standards do not apply in a particular context. OBJECTIVE: To explore the psychological factors and traits among ATs that may predict moral disengagement pertaining to allowing athletes to play through injuries. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: A total of 187 Division I, II, and III ATs from 100 NCAA universities. MAIN OUTCOME MEASURE(S): In addition to the primary outcome variable of moral disengagement, the survey captured the AT's demographic background, sport and athletic training histories, and measures of sport ethic, contesting orientations, commitment, and social identity. RESULTS: Cluster analysis was used to identify homogeneous subgroups of participants based on these variables. A 2-cluster solution emerged, with cluster 1 (n = 94) scoring higher in the sport-ethic and sport-contesting orientations but lower in commitment and social identity compared with cluster 2 (n = 93). An independent-samples t test revealed that moral disengagement was highest (t185 = 19.59, P < .001, d = 0.69) among ATs in cluster 1. CONCLUSIONS: These findings advance our understanding of the psychological processes that may predict moral disengagement of ATs in allowing student-athletes to play through injury. Although additional research is needed to test whether moral disengagement influences return-to-play decisions, we provide initial evidence that ATs who conform to sport norms (eg, "no pain, no gain") and who tend to view sport competition with a "war-like" orientation are more likely to morally disengage.

Medical care in unlicensed combat sports: A need for standardised regulatory frameworks.

OBJECTIVES: To explore the provision of medical care at 'unlicensed', full-contact amateur and lower-level professional combat sports competitions in England. DESIGN: Qualitative, mixed methods. METHODS: Observations totalling 200h of fieldwork shadowing medical professionals at 27 individual combat sports events, alongside formal, semi-structured interviews with 25 medical professionals, 7 referees and 9 promoters/event staff. RESULTS: Practices and standards vary widely. Event organisers and promoters often have very little understanding of how different types of medical practitioners operate. They rarely, if ever, check that the staff they are hiring are qualified, sometimes resulting in unqualified staff being used to provide medical cover at events. Venues are often poorly equipped to accommodate basic medical procedures. Patient confidentiality is very often compromised. Medical professionals often have limited autonomy within the combat sports milieu and may find themselves marginalised, with their judgements overruled by non-medical staff during competitive events. Some practitioners are cognisant of the dangers such working environments pose to their professional reputations and livelihoods, but remain working within combat sports regardless. CONCLUSIONS: Despite pockets of good practice, the lack of standardised rules for medical care provision creates substantial risks to athletes, to practitioners and the standing of the profession. The development and implementation of standardised, enforceable regulatory frameworks for full-contact combat sports in England is urgently needed.

Impossible "Choices": The Inherent Harms of Regulating Women's Testosterone in Sport.

In April 2018, the International Association of Athletics Federations (IAAF) released new regulations placing a ceiling on women athletes' natural testosterone levels to "ensure fair and meaningful competition." The regulations revise previous ones with the same intent. They require women with higher natural levels of testosterone and androgen sensitivity who compete in a set of "restricted" events to lower their testosterone levels to below a designated threshold. If they do not lower their testosterone, women may compete in the male category, in an intersex category, at the national level, or in unrestricted events. Women may also challenge the regulation, whether or not they have lowered their testosterone, or quit sport. Irrespective of IAAF's stated aims, the options forced by the new regulations are impossible choices. They violate dignity, threaten privacy, and mete out both suspicion and judgement on the sex and gender identity of the athletes regulated.

Ethics, Evidence Based Sports Medicine, and the Use of Platelet Rich Plasma in the English Premier League.

The use of platelet rich plasma (PRP) as a novel treatment is discussed in the context of a qualitative research study comprising 38 interviews with sports medicine practitioners and other stakeholders working within the English Premier League during the 2013-16 seasons. Analysis of the data produced several overarching themes: conservatism versus experimentalism in medical attitudes; therapy perspectives divergence; conflicting versions of appropriate evidence; subcultures; community beliefs/practices; and negotiation of medical decision-making. The contested evidence base for the efficacy of PRP is presented in the context of a broader professional shift towards evidence based medicine within sports medicine. Many of the participants while accepting this shift are still committed to casuistic practices where clinical judgment is flexible and does not recognize a context-free hierarchy of evidentiary standards to ethically justifiable practice. We also discuss a tendency in the data collected to consider the use of deceptive, placebo-like, practices among the clinician participants that challenge dominant understandings of informed consent in medical ethics. We conclude that the complex relation between evidence and ethics requires greater critical scrutiny for this emerging specialism within the medical community.

Medicamentos e suplementos nos exercícios e esportes: dopagem e antidopagem, orientações de uso, riscos à saúde, responsabilidade profissional / Medicines and supplements in exercise and sports: doping and anti-doping, guidelines for use, health risks, professional liability

Casos de dopagem no esporte, na sua grande maioria, ocorrem quando um atleta ou praticante de atividade física utiliza substâncias não naturais no corpo que potencializam seu desempenho, aumentando sua força, resistência e velocidade. Essa prática pode acontecer de duas formas: propositalmente, com o objetivo claro de alcançar esses resultados, ou em consequência da ingestão inadvertida de fórmulas aparentemente inofensivas, cujo efeito colateral também pode render punições aos seus usuários. Infelizmente, há vários registros de dopagem ­ nessas duas modalidades ­ durante disputas envolvendo competidores e membros de comissões técnicas. Por isso, fortalecer mecanismos que afastem essa ameaça de pistas e estádios configura um desafio e um compromisso com a ética. Como parte integrante de comissões técnicas ou simplesmente como um profissional que acolhe pacientes em seus consultórios ou numa emergência de pronto-socorro, o médico pode ser importante agente de prevenção e de combate ao emprego inadequado de medicamentos e suplementos. Por isso, é relevante mantê-lo bem informado sobre esses riscos. Para tanto, com o suporte dos integrantes da sua Câmara Técnica de Medicina do Esporte, o Conselho Federal de Medicina (CFM) elaborou este guia, cujo alvo principal são os médicos. De linguagem clara e didática, podendo ser consultado inclusive pelos próprios desportistas, este documento traz orientações adequadas sobre os riscos e limites a serem respeitados. Como defensor da ética no exercício da medicina e em todas as circunstâncias, o CFM entende ser essa uma oportunidade de contribuir com o estímulo à adoção de comportamentos exemplares dentro e fora das pistas

Tracking U.S. Professional Athletes: The Ethics of Biometric Technologies.

Professional sport in the United States has widely adopted biometric technologies, dramatically expanding the monitoring of players' biodata. These technologies have the potential to prevent injuries, improve performance, and extend athletes' careers; they also risk compromising players' privacy and autonomy, the confidentiality of their data, and their careers. The use of these technologies in professional sport and the consumer sector remains largely unregulated and unexamined. We seek to provide guidance for their adoption by examining five areas of concern: (1) validity and interpretation of data; (2) increased surveillance and threats to privacy; (3) risks to confidentiality and concerns regarding data security; (4) conflicts of interest; and (5) coercion. Our analysis uses professional sport as a case study; however, these concerns extend to other domains where their use is expanding, including the consumer sector, collegiate and high school sport, the military, and commercial sectors where monitoring employees is viewed as useful for safety or to maximize labor potential.

Fundamental Ethical Principles in Sports Medicine.

In sports medicine, the practice of ethics presents many unique challenges because of the unusual clinical environment of caring for players within the context of a team whose primary goal is to win. Ethical issues frequently arise because a doctor-patient-team triad often replaces the traditional doctor-patient relationship. Conflict may exist when the team's priority clashes with or even replaces the doctor's obligation to player well-being. Customary ethical norms that govern most forms of clinical practice, such as autonomy and confidentiality, are not easily translated to sports medicine. Ethical principles and examples of how they relate to sports medicine are discussed.

Confidentiality in Sports Medicine.

This article synthesizes existing literature to provide a summary of the ethical issues concerning patient confidentiality in sport. It outlines the medical principle of confidentiality and identifies cross-cultural ethicolegal variations that shape its implementation. Clinicians' multiple obligations, physical environments, and practice and policy contexts are discussed, and research detailing experiences of maintaining patient confidentiality in sport is reviewed. Policy recommendations for enhancing compliance with this ethical principle are summarized. It is argued that the context of sport exacerbates pressures on clinicians to break patient confidentiality, breaches occur regularly, and interventions are required to enhance ethical compliance in sports medicine.

Conflicts of Interest in Sports Medicine.

Conflict of interest is common in the practice of medicine, and likely more so in the practice of sports medicine at the highest levels of competition. Two areas where conflict of interest frequently manifest in sports medicine are confidentiality and clinical decision making. Confidentiality can be challenging by the team physician's dual responsibilities to the player-patient and the team. Clinical decision making, traditionally associated with a patient's long term health interests, can be complicated by short term interests rooted in pursuit of winning. These issues are reviewed, hopefully to increase awareness in clinicians who find themselves in these unique situations.