The medical establishment’s desire to interfere with the autonomous wishes of boxers seems at odds with the principle of respect for autonomy prevalent in contemporary biomedical practice. I argue that the role of the medical profession in boxing should be solely an advisory and informational one. In addition, the distinctions made between boxing and other high risk sports often rely on an insufficient knowledge of the sport. This leads to misdirected criticisms and excessive emphasis on the colourful discourse of boxing, as opposed to the practice of boxing itself. Dr Herrera’s claim in his article (see page 514) that boxing differs from other sports in the acceptability of its acts outside the realm of sport is refuted.¹ The importance of consent as a legitimising factor is highlighted, and a number of possible solutions to improve safety within the sport are tentatively suggested.

In the United Kingdom, a competent adult may legally refuse medical treatment, irrespective of the severity of his condition or the validity of his reasons. With the pre-eminence of an autonomy based model of bioethics, respecting a patient’s wishes forms an integral part of acting in his best interests. It is puzzling, then, to find that the Australian Medical Association have called for a ban on boxing on the grounds that the activity is excessively hazardous to the health of boxers. The often mentioned principle of respect for autonomy is abandoned once the person drops the privileged title of “patient”. This suggests that being a patient confers certain rights which would not exist if that same patient were healthy. How, if at all, can this apparent inconsistency be justified by those in the medical community who wish to see boxing banned? I largely agree with Dr Herrera’s position on the matter, which is essentially that precautionary brain scans should be performed but that boxing should not be banned. A few points, however, remain unclear.

Dr Herrera criticises the frequent comparisons made between boxing and other high risk sports, claiming that a boxer can kill his opponent without breaking any rules whereas this is not the case in other sports. This last statement is surely false. A hard hitting rugby tackle can propel a player backwards causing him to suffer fatal spinal injuries. A cricket ball travelling at a 100 miles per hour and hitting a player’s unprotected skull can cause death, although no rule is broken. The difference between boxing and those other sports does not revolve around the legitimacy of the act leading to the death but, possibly, the intent of the agent responsible for the death. A boxer intends to inflict physical damage to his opponent. A “knockout”, referring to a boxer’s inability to stand up after a count of 10, is the ultimate goal in the sport. Yet even this is a moot point. Many boxers will tell you that their aim is to win the contest, not to reduce their opponent’s brain to a pulp. No boxer would rejoice at the severe injury of his opponent. Boxers could invoke the doctrine of double effect, claiming that death is foreseen but certainly not intended. The intention is to win the fight by outboxing the opponent, which is not the same as knocking him out. A boxer can win on points, by the surrender of his opponent or of his coach, or by the referee’s stoppage during the fight. In other words, a knockout is not necessary for victory. The other justifying conditions of the doctrine of double effect could also be satisfied, although these would no doubt be contested by those who see boxing as a social evil.

As an amateur historian of boxing, I have little doubt that the sport, at least in the last 100 years, has done more good than harm, by giving hope to many young men who perhaps initially had none, and encouraging them into gyms. Boxing contests have also served to symbolise broader social and political struggles. The first African-American heavyweight world champion, Jack Johnson, who fought in the first few decades of the 20th century, was an inspiration to African-Americans across the country. Joe Louis’s resounding defeat of Max Schmelling in 1938 united Americans of all races and stifled Hitler’s claim of Aryan superiority. If a consequentialist position is adopted, based on a diachronic evaluation of boxing, then boxing should be permitted.

It is tempting, for those unfamiliar with the sport, to interpret too literally the gruesome pre-fight threats of boxers. The animosity is rarely genuine; it is an essential component of the marketing plan, as well as an exercise in psychological intimidation. Dr Herrera’s assertion that fighters “can even predict the killing before the fight, for the press” is irrelevant. The metaphors of boxing are indeed more bellicose than in other sports, but critics should interpret the metaphors as linguistic flourishes, not as literal expressions of intent. A boxer who threatens to “kill” his opponent in a pre-fight conference (or “eat his children”, as one notorious heavyweight recently said) is no more intent on actually killing his opponent than a baseball pitcher who threatens to pierce the batter’s body with a lightning throw. He primarily wants a wider audience, and perhaps a psychological advantage over his opponent. The discourse of boxing is separate from the activity itself, and an analysis of the sport should not be confused with an analysis of its discourse.

Dr Herrera’s belief that boxing differs from other sports by involving acts that would be frowned upon and, indeed, punishable outside the sport is, to my mind, incorrect. It is usually unacceptable to run towards a person on the street, wrap your arms tightly around his legs and push him over with your shoulders, as occurs in rugby. Similarly, it would be equally objectionable to punch someone in the head while queuing in the supermarket. What would render these acts acceptable, however, is consent. Society allows two consenting people to indulge in certain activities, however morally repulsive to others, that would be unlawful if performed without mutual consent. If boxing is to be banned, then good reasons need to be given to show that boxing differs sufficiently from other “dangerous” or “immoral” activities that even informed consent is inadequate to justify it. I am so far unconvinced by the reasons given by opponents of boxing.

My own view is that the medical profession should inform boxers and those involved in the sport (coaches, referees, and so on) of the potential dangers of boxing, as well as suggesting ways to minimise the risks. The obligation stops there. The role of the profession should be no more than advisory and informational—the changes need to be made within the sport itself. Perhaps fights can be reduced from 12 rounds to 10 or eight rounds, just as it was reduced from 15 to 12 a few years ago. Intervals between the rounds can be extended to allow greater time for recovery. Headgear can be improved to cushion blows further. Referees can stop fights earlier if the contest is unevenly matched, or if a fighter has suffered some particularly punishing blows. More generally, the world of boxing is in need of a radical change of ethic. Too often, boxing managers pitch their boxer against evidently better or inferior boxers to keep flawless records or to acquire a significant one-off pay cheque. More than discrediting the sport generally, it heightens the risk of serious injury for the sacrificial lamb whose chances of winning are next to none. Boxing is indeed in need of reform, but the medical profession’s role in this should be limited to advice and information. The principle of respect for autonomy should prevail for boxers and patients alike.