The debate on hypoxic air devices is of interest to me as a doctor, a researcher, and an active participant in a number of committees and bodies which are concerned with ethics and doping. I write this commentary as a personal contributor though, and not as a representative of any particular organisation or authority.

The issues here appear to revolve around the concept of cheating in order to gain an unfair advantage in a sporting contest. The use of artificial means to enhance performance immediately raises eyebrows because of an unease about using other than “natural” (dare I say “God given”?) talents to compete (and win) at sport. There is a perception that cheating implies anything that appears to enhance performance by non-natural physical or chemical means. This seems fine at first pass but on a second look the issue is not so clear.

Modern sport at the elite level is all about the limits of physiology. Athletes now spend their daily lives doing nothing but enhancing their performances. Over the years athletes have moved on from simply repeating their particular sport techniques in training and now incorporate cross training, strength and conditioning work, nutrition, recovery practices, and psychological techniques to maximise performance in competition.

With advanced understanding of the chemistry and physics of the body, and of the effects of training under different climatic and environmental conditions, newer techniques such as altitude training have been devised and put into practice. Altitude was thought to provide the natural stimulus to enhanced oxygen carrying capacity and as a result of this, altitude houses and hypoxic breathing devices were born. As it happens, it may not be oxygen carrying capacity that works here, but better biological buffering systems which facilitate tolerance of hard efforts.

So where does the cheating come in? The definition of cheating (and we could say doping in this context) for me is centred around a couple of principles which I think provide useful direction for decision making.

The first of these is the notion of abusing our own physiology and anatomy to maximise performance. In other words, deliberately manipulating the body by some non-natural intervention is wrong. Surgery to improve flexibility beyond a normal range, or injection of some substance which abnormally accelerates a physiological process or exceeds a physiological normal is intuitively wrong. The idea of becoming “supernormal” is the key here.

The risk to health is also important. It would be wrong to accept the risk of impairing health to gain an advantage in sport, which is what happens when anabolic steroids are abused. Large doses to improve power and speed cost the user in terms of permanent changes to many systems within the body, and many of these changes are definitely detrimental to health.

Conversely, the use of physical or chemical means to maximise performance through normal physiological adaptation is not cheating. The argument that “if it does not occur in nature it must be wrong” does not stand up to scrutiny. As stated in the article, to throw out any such means would be illogical because this would mean the prohibition of heat chambers (for acclimatisation to hot and possibly humid conditions), weight training rooms, bicycles, treadmills, rowing machines, and swimming pools with chlorinated heated water in air conditioned facilities. Training with such facilities does not provide any performance advantage over what might be gained by any athlete who runs outside, swims in a lake and lifts heavy rocks—but these facilities make such training adaptations more easily available. This is not wrong.

Similarly, the use of hypoxic devices, altitude tents, and altitude chambers all mimic environmental conditions which promote adaptations and (may) enhance performance. They do not take the athlete into the supernormal range, and as long as the practices are safe, they pose no ethical problem.