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Ethics of a relaxed antidoping rule accompanied by harm-reduction measures
  1. Bengt Kayser1,2,
  2. Jan Tolleneer2
  1. 1ISSUL, Université de Lausanne, Lausanne, Switzerland
  2. 2FABER, Katholieke Universiteit Leuven, Leuven, Belgium
  1. Correspondence to Professor Bengt Kayser, ISSUL, Université de Lausanne, Lausanne 1015, Switzerland; bengt.kayser{at}unil.ch

Abstract

Harm-reduction approaches are used to reduce the burden of risky human behaviour without necessarily aiming to stop the behaviour. We discuss what an introduction of harm reduction for doping in sports would mean in parallel with a relaxation of the antidoping rule. We analyse what is ethically at stake in the following five levels: (1) What would it mean for the athlete (the self)? (2) How would it impact other athletes (the other)? (3) How would it affect the phenomenon of sport as a game and its fair play basis (the play)? (4) What would be the consequences for the spectator and the role of sports in society (the display)? and (5) What would it mean for what some consider as essential to being human (humanity)? For each level, we present arguments for and against doping and then discuss what a harm-reduction approach, within a dynamic regime of a partially relaxed antidoping rule, could imply. We find that a harm-reduction approach is morally defensible and potentially provides a viable escape out of the impasse resulting from the impossibility of attaining the eradication of doping. The following question remains to be answered: Would a more relaxed position, when combined with harm-reduction measures, indeed have less negative consequences for society than today's all-out antidoping efforts that aim for abstinence? We provide an outline of an alternative policy, allowing a cautious step-wise change to answer this question and then discuss the ethical aspects of such a policy change.

  • Applied and Professional Ethics
  • Autonomy
  • Coercion
  • Drugs and Drug Industry
  • Enhancement

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Introduction

Doping in sports is not a recent phenomenon. In the Tour de France, doping was common for most of the race's century-long history, during the first half quite openly.1 ,2 In the 1960s, doping was more openly condemned; however, it was hardly combatted. Contemporary antidoping, labelled a ‘war on doping’,3 is a recent development. Due to the 1998 Festina affair, which is when systematic doping was discovered on the Tour de France,4 the World Anti-Doping Agency (WADA) now strives for the globalisation of antidoping across sports and the strengthening of surveillance and repression. This is ongoing and not an immediate success, as illustrated by the evidence that doping is still rife.5

Contemporary media generally present doping as intrinsically evil, but the rationale behind the antidoping rule is neither self-evident nor universally accepted. There is an ongoing academic debate about the rule, its effects and alternatives (see refs. 6–11). This debate generally opposes two discourses, in their extreme versions, as follows: ‘conservative’ refers to the stance that defends strict prohibition enforced by surveillance and punitive repression9 ,12 ,13 and ‘liberal’ refers to the stance that finds antidoping illogical and calls for the liberalisation of doping.14–16 Kayser and Broers17 find these positions defend non-realisable idealistic goals. The liberalisation of doping is deemed politically not feasible, while today's prohibition is unsuccessful since doping continues.5 The latter is problematic because the objective of antidoping, eradicating doping to guarantee ‘clean’ champions, cannot be met because of limits to testing technology and surveillance density.18 ,19 This imperative distinguishes doping from other transgressions for which such an ideal does not exist. Furthermore, antidoping has side effects. For example, the relegation of doping behaviour into clandestine behaviour, a consequence of repression, increases health risks (eg, greater risk-taking among competitive cyclists20 or increased prevalence of HIV infection among fitness clients who inject anabolic steroids).21 Thus, we can identify the following three concurrent dynamics: (1) doping poses potential harm to the user; (2) doping is insufficiently deterred by prohibitive policies and (3) the risk to the user is exacerbated by prohibitive policies.22 This is very similar to the effects of the repression of illicit recreational drugs.23 Nevertheless, under pressure from WADAi, increasingly punitive legislation is introduced, in several countries in the form of a criminal law (often also applicable to non-athletes), even though there are also arguments in favour of differentiated regulation inside and outside competitive sports (see Douglas: ref. 24). The extension of antidoping outside competitive sports (eg, in fitness centres) can result in increased harm.25 ,26 Similar to the consequences of the ‘war on drugs’, a ‘war on doping’ (anchored in international conventions obliging national governments to combat doping inside and outside of elite sports) may lead to greater societal harm than it prevents.17 This leads to the following question: How much of the present harm of doping, for the athlete and the wider society, might be related to antidoping policy rather than to the use of the performance-enhancing methods or substances per se?

There is, therefore, a rationale for a debate on alternative policies. Based on experience with illicit drugs, for which experimenting with alternative policies with harm-reduction strategies have come of age and proven their societal benefits,27 several scholars17 ,22 ,28 ,29 have argued in favour of relaxing the antidoping rule and accompanying it with harm-reduction strategies. The general stance is essentially a consequentialist one, but a more detailed explicit analysis of ethical aspects of a harm-reduction approach for doping in sports had not been undertaken yet. We attempt this type of analysis here.

An alternative doping policy

We have in mind the following framework: (1) the antidoping rule is relaxed within boundaries of acceptable health risks; (2) the athlete's health is monitored and (3) some urine and blood testing subsists using pragmatic evidence-based cut-off levels to control risk. For this to be possible, among the three WADA criteria for the inclusion of methods and substances on The Listii,30 the health risk argument is retained, while the spirit of sport and the performance-enhancing criteria are dropped. These conditions being met then follows that instead of today's continuous yearly inclusion of more and more methods and substances on The List, WADA can do the opposite (ie, progressively take methods and substances off The List, one by one, while monitoring the outcomes). As a test case, one could allow cannabis use. The health effects of cannabis are acknowledged; these effects are not different between the general population and athletes, causing one to question the ban for athletes.31 Another idea would be to allow erythropoietin, keeping a to be determined haematocrit no-start cut-off, while monitoring its use and the athlete's health.32 ,33 Another test case would be to allow meldonium, which was recently added to The List, since there are no documented risks with this drug. There is a precedent. Caffeine was put on The List and then removed, but it is still monitored.34 Contrary to present practice, the selection for exclusion, and also the selection for (re-)inclusion, should become a transparent procedure based on democratic principles. This would result in a dynamic that, if the overall health consequences would prove acceptable, could in theory regress to voiding The List entirely; however, it would more likely result in creating a simplified list accompanied by pragmatic cut-off values for particular parameters. This dynamic could be specific to individual sports to allow for specificities and for the time necessary for a cautious approach. Why not opt for full liberalisation? Due to the extreme stakes in elite sports, without safety margins, all athletes could (but more importantly some athletes likely would) decide to use substances in excess of reasonable health risks.22 Why would partial prohibition be better than full prohibition? In the beginning, the system would be as costly, complicated and imperfect as it is today. However, if The List was shortened, we expect improvement. We contend that given the unsurmountable negative consequences of antidoping today, it is worthwhile to experiment if our scenario results in a better overall end result.

In this analysis, we explore ethical dimensions of an antidoping rule relaxation accompanied by harm-reduction strategies. We do this in accordance with the model by Tolleneer and Schotsmans.35 They contrasted the conservative and liberal positions on five levels, according to what is ethically at stake when one decides to dope or not to dope: (1) the athlete (self), (2) the opponent (other), (3) the sport (play), (4) the spectator sport (display) and (5) being human (humanity). Our analysis responds to criticisms of harm reduction for doping, such as that the only stakeholders considered so far were the athlete and any (medical) advisors;36 however, there is certainly more at stake.12 ,35 We first draw on the literature of harm reduction elsewhere in society, specifically in the realm of (il)licit ‘recreational’ drugs; we then explore the introduction of such principles for doping according to the model by Tolleneer and Schotsmans.

Harm reduction explained

For (il)licit ‘recreational’ drug use, the fundamental assumption of harm reduction is that it is important to reduce drug-related harm, while not necessarily requiring individuals to reduce or abstain from drugs, even if reducing or abstaining might sometimes be the best choice. Harm reduction mitigates the negative consequences of drugs for the user and society. It is a pragmatic and balanced approach that deals with the fact that drugs have always been there and always will be there, no matter what. Christie et al37 discussed whether or not harm reduction for illicit drug use is ethically justified (since individuals are not required to abstain from, or at least try to abstain from, these types of drugs). They concluded that harm reduction is justified on consequential grounds since harm-reduction policies produce the greatest good for the greatest number (see ref. 27). Christie et al further suggested that the virtue of compassion allows policymakers to include harm reduction in their policymaking. Abstinence-only-based policies can be seen as too ‘hard’ and having insufficient positive effects. In addition, these policies can have significant (unintended) negative side effects that outweigh the intended effects, if any. However, the introduction of harm-reduction benefits both drug users and society without leading to increased use or overall health burdens.27 We acknowledge the differences between illicit drugs and their risk of addiction and doping methods and substances and their specific effects in competitive sports. We also acknowledge the differences between competitive and non-competitive sports, such as fitness training in which the fair play argument does not apply, at least not in the same way. (This is a notion that makes the grey zone of fitness training interesting for further ethical analysis in line with the approach of the above-mentioned Douglas24). However, we contend that harm reduction is a general, pragmatic and valid approach to limit the consequences of any potentially dangerous human behaviour, including doping in non-competitive and even competitive sports.

Harm-reduction measures are typically context-dependent and dynamic measures in order to react to changes in behaviour and their consequences. Therefore, these measures must be tailored for doping practices in sports and outside of sports. An example would be the steroid clinics in the UK, where fitness clients and body builders who use anabolic steroids can consult with healthcare professionals (eg, to prevent outbreaks of bloodborne virus infections as a consequence of needle sharing).21 Such low-threshold access to medical expertise lowers the overall burden of such behaviour. The extension of such gateways for any performance-enhancing substances and methods towards an accompaniment instead of a repression of any doping-like behaviour, together with information and prevention campaigns, would allow keeping the overall burden low. In elite sports, medical supervision is already present. Our proposal provides fertile ground for further work, detailing such a dynamic framework and also taking into account difficult problems, such as dealing with non-adult athletes. Since our proposal starts from today's unsatisfactory situation, there would be time to reflect on the consequences of simplifying The List and to propose amendments in order to progressively move away from full prohibition. We believe such a pragmatic dynamic conventionalist-intermediate stance is viable and would allow for the escape from the cornelian choice between the negative effects of prohibition and the potential spiralling towards excessive negative effects of liberalisation. Our proposal has the important advantage of being highly malleable, allowing to dynamically react on adverse outcomes. We discuss the ethical aspects of such an intermediate stance in the following sections.

Five-level approach

Tolleneer and Schotsmans35 discussed arguments for and against doping, scrutinising respect and moral responsibility on the following five levels: (1) What does doping mean for the athlete (the self)? (2) How does it impact other athletes (the other)? (3) How does it affect the phenomenon of sport and its fair play basis (the play)? (4) What are the consequences for the spectator and the role of sports in society (the display)? and (5) What does it mean for being human (humanity)? On the liberal side, sample arguments include that doping helps in fulfilling personal aspirations (self), guarantees equal opportunities (other), aligns sports with other cultural phenomena (play), reinforces the heroic character of sports (display) and fulfils the mission to push frontiers (humanity). On the conservative side, sample arguments are that doping threatens one’s health (self), reduces the opponent’s chances (other), undermines the spirit of sports (play), creates negative role models (display) and defiles human nature (humanity).35 For each level, we discuss what a more intermediate stance of a relaxed antidoping rule with a harm-reduction approach could mean.

Self

At this level, the conservative stance believes doping is dangerous. The athlete should be prevented from harm. The liberal stance believes that this is a matter of autonomy and self-realisation. Elsewhere, there is freedom to behave dangerously (eg, horseback riding, off-piste skiing, mountain biking, drinking alcohol, smoking, eating unhealthy foods and being sedentary) within some constraints (eg, wearing helmets and following age restrictions). Athletes wanting to fulfil their aspirations, and therefore their well-being, should be allowed to balance this with health risks from doping.14–16 How could an intermediate harm-reduction-based stance be articulated on this level? Harm reduction would limit the health impact of doping for the individual, while allowing the athlete to employ (within certain measurable boundaries of acceptable health risks) certain performance-enhancing techniques. These techniques could range from training methods to responsible and medically supervised methods, which currently are labelled as doping. On the conservative side, one argues this would imply admitting defeat and suggest the beginning of a spiral towards ‘universal’ doping and overall more health problems (see ref. 38). From a consequential perspective, given a relaxed antidoping rule accompanied by harm-reduction strategies, the question then concerns the net global effect, which is at present an unknown. In this context, it is useful to recall that the health risks of doping vary between forbidden substances and methods. For many, the risk is limited. Looking back at periods when doping was the unofficial norm (eg, in cycling), there is no solid epidemiological evidence base suggesting that ‘informed’ doping came with excessive risk, despite rumours and anecdotes.17 The comparison of the paternalist discussion with the liberal discussion on the extent of autonomy granted to the (adult) athlete is important in this regard. With the exception of East Germany, where adolescent athletes were coerced into a dangerous state-run doping scheme,39 the history of doping in sports would suggest that doping did not lead to excessive morbidity or mortality in comparison to the risk of participating in sports per se or other risk-taking behaviours in general.17 To stay primarily on the cautious side, it would seem prudent to place some safeguards to prevent excess use, which is exactly what we propose. Therefore, on the level of the self, relaxation of the rule accompanied by harm-reduction strategies would seem to be an alternative, allowing an individual to engage in doping within a framework of reasonable risk, potentially with a general balanced outcome that is better than the current situation. It would allow the doping athlete to behave morally, since (some) doping would be allowed, and to fully self-realise by showing additional commitment, courage and dedication to the sport enterprise.

Other

The individual doping behaviour of an athlete has meaning for the athlete's opponent. The conservative stance rejects doping because it diminishes the winning chances for the non-doping opponent. The doping athlete further exerts pressure on the other athlete to engage in similar behaviour. This pressure on the other athlete to give in is labelled as coercion. It does indeed deprive the other athlete of the possibility to compete among ‘clean’ opponents, but the other athlete can still freely pull out of the game, so there is no actual coercion (such as being forced at gunpoint), at least according to Lev in his article on coercion, competition and inducement.40 The concept of ‘undue inducement’ and its relation with coercion might need further scrutiny in this specific context. Nevertheless, the liberal stance further argues that pressure to engage in extreme behaviour exists anyway. This also comes with health risks, such as those associated with strenuous training routines and diets. What would a relaxation of the antidoping rule with harm-reduction strategies imply for the non-doping athlete? Harm-reduction proponents argue that it would put the non-doping athlete on par with the doping athlete because the non-doping athlete would be allowed to and enabled to engage in similar behaviour, while being protected from excessive risks because of a similar harm-reduction setting. The conservative side still prefers no doping because no risk is better than use under medical surveillance. However, since it is likely that doping continues and comes with risk despite today's repression,20 ,21 ,26 the question again rises regarding whether or not the overall increase in health risks from a relaxation would be offset by the reduction in risks by a simultaneous harm-reduction approach within a medically supervised setting. Thus, on the level of the other, the principle of greatest good is not necessarily met. A relaxation of the antidoping rule accompanied by harm-reduction measures needs to be tested to see if it would decrease the overall negative impact of doping in sports and society at large. If the antidoping rule were relaxed, the non-doping athlete would be able to engage in allowed doping since the athlete would not be acting immorally. An athlete might not want to participate in doping because of a personal moral belief that doping is wrong, but the athlete would be free to choose not to dope, similar to refusing to engage in any other extreme behaviour necessary for elite athletic careers.

Play

The conservative position says that violating the antidoping rule is cheating and, therefore, immoral. Not playing with the official lusory means equates to not playing the game. Doping is called non-lusory, and it is against the equal opportunities principle. The liberal side argues that the distinction with other inequalities, like talent and access to technology, is blurred at best and that the argument fails when abrogating the rule. The introduction of a more relaxed stance would imply a change in the antidoping rule. The play would continue but under a different rule set. For some sports (eg, cycling, baseball and athletics), this would be a de facto return to their former states (when doping was common and tacitly accepted by a majority as the norm) before today's antidoping efforts. Doping as such, independent of its rule breaking (formal fair play), is also labelled as immoral because it goes against the spirit of sportiii (informal fair play) (see also ref. 41 in defence of the spirit of sport criterion). However, dropping the spirit of sport criterion would obviate this point. The objection that this would profoundly change the nature of the play is weak to the extent that such changes are not uncommon; strict amateurism in the Olympics was only abandoned approximately 40 years ago because it was unworkable. The amateur rule was undermined by state-sponsored amateurs. It is time to change the antidoping rule for the same reason. The result would likely be viable and functional play, similar to that played for most of the time in the past, but cheating would still remain possible for the substances and methods that would remain on The List. Therefore, surveillance and repression cannot be done away with fully. The dynamic resulting from what we propose would not necessarily imply a weakening normative force; it would provide a basis for what Morgan called ‘a balancing of the moral books [..] necessary if we are going to find some way out of the impasse created by the current struggle between dopers and regulators’.42

Display

The conservative view says doping devalues the image of a sport for spectators and society. The athlete is expected to be an exemplary role model. Doping is bad, and a doping athlete is immoral.13 The liberal view says athletes participating in modern sports are all about personal sacrifice aimed at superior performance. If doping improves performance, it increases spectator experience, which is a reason that turns the role model argument around. What would be the consequence of introducing a more relaxed stance with harm reduction? Doping as a concept is recent, and its public perception is dynamic.43 If a growing fraction opposes doping today,44 echoing the lay press discourse, there is also a sizeable, more liberal fraction.45 Given the increasing role of technology in sports, an extension of the methods and substances that are forbidden today would seem viable. The argument that this would transform the display into something similar to Formula-1 car racing fails, exactly because elite sports are already a technological enterprise. Athletes are surrounded by support personnel and sports scientists who programme performance enhancement by any admitted means imaginable. If one would also allow (some) doping, this could be considered ethically laudable because striving for what philosophers call the good. It would mean, in this particular setting, aiming at a good display; aiming in a balanced way for the preservation or even improvement of the spectacle of sport. One could further defend that allowing doping to an extent would strengthen the positive heroic image of athletes, adding to the value of display. Finally, since doping is a staple of sports media consumption, selling it to the public would be a matter of rebranding the sporting product along these lines.

Humanity

As recognised by Tolleneer and Schotsmans,35 the doping debate reaches beyond sports because it concerns the general human enhancement debate.46 The conservative standpoint says doping is short changing humanity and defiling human nature. The liberal stance says that improving human performance with technology exemplifies the natural human tendency for seeking out and moving boundaries. The transhumanist movement strongly argues in favour of exploiting technology for the betterment of humanity in general through human enhancement. Surely, prudence would seem required, but ‘just say no’ evidently is not a viable option. Inescapably, human invention impacts the future of humanity in one way or another. Perhaps, sports is a good place to experiment? Are elite athletes modern heroes at the front of human enhancement? The debate on doping ties in with the wider debate on transhumanism and posthumanism. In his analysis ‘The price of perfection’,46 Mehlman highlights the links between the ‘war on doping’ and the ‘war on drugs’ and questions whether or not today's antidoping policy in sports is the correct approach for controlling the use of biomedical enhancements outside of sports. He finds prohibition to be ill-informed and says we need better ways to minimise potential harmful effects of biomedical enhancements. Instead of pragmatic dealings with the potential of biomedical invention, today's antidoping is a slippery slope towards the generalisation of surveillance and repression in a society with dystopian characteristics. This is illustrated by the extension of antidoping laws in Denmark and Belgium to include the repression of anabolic substance use by fitness clients, the inclusion of anabolic steroids on lists together with illicit drugs in the UK and the USA and the increased use of drug testing in schools in the USA.

Conclusions and perspectives

Our analysis suggests that a partial relaxation of the antidoping rule accompanied by harm-reduction measures on all five levels of the model by Tolleneer and Schotsmans seems ethically defensible. The analysis is incomplete because it does not fully take into account the inevitable, complicated, messy environment of real life and needs to be spelled out. For example, the adult athlete's capacity to autonomously make well-informed decisions is obviously not given. Furthermore, athletes' careers often start before adulthood, and different clear-cut (and enforced) rules are necessary for non-adults. Given how we deal with other ‘adult only’ activities in life, this seems feasible even if accompanied by some inescapable muddied interface between age groups. The strength of our idea is that it allows progressive experimenting, monitoring and adapting, similar to how experiments are happening that deal with illicit drugs in ways other than repression only. The main question to be answered is as follows: Do today's abstinence-based antidoping policies indeed have greater negative consequences for society than a more relaxed position combined with harm reduction? We believe our analysis provides a fertile basis for further reflexion on what might be called a pragmatic athlete-centred drug use perspective. We believe that the proposed alternative framework potentially provides an escape from the present, which is spiralling towards a criminalisation of doping and doping-like behaviour in society. It is time to start discussing the practical details of such a policy change and to start experimenting.

Acknowledgments

We thank several colleagues at Metaforum, KULeuven, who provided constructive criticism on the manuscript.

References

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Footnotes

  • Contributors BK and JT did the preparatory work together. BK wrote the first version of the manuscript. BK and JT wrote the final version.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • i https://www.wada-ama.org/en/media/news/2015-10/wada-statement-on-the-criminalization-of-doping-in-sport

  • ii WADA maintains a yearly updated list of forbidden substances and methods called The List.

  • iii The spirit of sport is described in the World Anti-Doping Code by WADA. ‘The spirit of sport is the celebration of the human spirit, body and mind, and is characterised by the following values: ethics, fair play and honesty, health, excellence in performance, character and education, fun and joy, teamwork, dedication and commitment, respect for rules and laws, respect for self and other participants, courage, comunity and solidarity’.30

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