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Current anti-doping policy: a critical appraisal

Bengt Kayser*, Alexandre Mauron and Andy Miah

BMC Medical Ethics 2007, 8:2  doi:10.1186/1472-6939-8-2

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Answers to the comments by Karayi Mohan

Bengt Kayser   (2007-10-11 13:53)  University of Geneva email

[Our responses to the letter 'In defence of dope control' by Karayi Mohanare are in italics]

This writer’s arguments are a veritable catalogue of informal fallacies. But since they are so widespread in public discourse, we will discuss them in some detail. For clarity we cite the writer’s arguments preceded by excerpts of our original text, and comment on the writer’s arguments in a point-to-point fashion.

“A doctor friend of mine, who is into sports medicine and handles dope control, has been arguing for many years that “controlled doping” or “supervised doping” should be permitted and that dope control should be left to the medical community rather than sports officialdom to regulate.

Needless to say he is in complete agreement with the paper presented here and even thinks that some of the points had been borrowed from papers and lectures he had been giving around the world the past few years.

Neither he nor the learned authors of this paper has explained why doping per se is necessary in sports, though my doctor friend often argues that the world is looking for “record-breaking performances” all the time and the athletes cannot be expected to better records without the aid of some substance, whether it be supplements or drugs.

There is no evidence to show that such an argument has enough basis in major Olympic sports, but are athletes pursuing their careers to provide entertainment to the people or are they partly or fully interested in their financial stability?

I am all for “supervised doping” if it can be ensured that (a) the drugs will not bring any harm to the athlete (but don’t you think that many drugs you take in the normal course do have side effects? My answer to that will be: I take them because I have an illness, not otherwise. Healthy athletes, pursuing their normal sports activities, if they do need steroids to treat a medical condition, should be allowed to have them.); (b) all the athletes around the world will be given the same drug or a group of drugs prescribed by an independent medical panel; (mind you, we are talking about improving performances, not trying to treat an illness; thus the same drug will have to be given to all or maybe a drug from a list of drugs approved in advance) ; (c) the authorities will ensure that no designer drugs will come into the picture; (d) the quality of the drugs made available to all the athletes will be the same; (e) an international court on the lines of CAS will deal with all cases relating to harmful effects, if any, suffered by any athlete anywhere in the world, free of cost; (f) the authorities will ensure that supervised doping is not practised outside of the ‘elite’ group of athletes (g) doctors will be penalized if the dope-driven athletes fail to come up to expectations. Of course, it will have to be scientifically established that a particular drug does enhance performance and will cause only marginal harm if taken under supervision.”

A typical red herring [Red herring : a metaphor for a diversion or distraction from an original objective. Wikipedia, july 2007]. The author holds the supervised doping policy to a standard of perfection that no policy on any subject can ever attain. In fact, present day doping policies are obvious failures with respect to many criteria described here. The argument developed is a typical example of an argumentation against pragmatism and in favour of utopian idealism. In addition, the suggestion that illness is an exclusive justification for accepting health-related risks – caused by drugs or other body modifiers – is highly dubious, not least because it neglects to situate illness within its proper social context. Medicine is perpetually making people well ‘for something’, not well simply against some abstract normative standard. Even if we might talk about clear pathologies that divert significantly from typical functioning, the basis of such distinctions is malleable and we already embrace its manipulation. Objection b) here offers a libertarian approach to the distribution of goods, but it is a disputed judicial system in the context of sport. Requiring that all athletes have the same drug fails to take into account the different ways in which bodies respond to various kinds of enhancer. The emphasis should be on finding the most effective, harm-reducing enhancements to suit individual athletes, not on developing a one-size-fits-all approach. Indeed, this point is support indirectly by the author’s later discussion about the ‘level playing field’ and the role of gene-environment variation. Condition c) offers no qualifying statement to explain its concern. Condition d) is reasonable, but similarly vague so as to invite further questions. It seems to derive from a concern about equality of access to similar technologies, though science is a competitive market and an integral part of global competitiveness. While it is valuable to aspire to a standard of similar quality, it is unrealistic – and not necessarily desirable – to expect all countries to benefit from and apply in equal measure, the same kinds of knowledge.

"I do have a large number of questions and points to raise in respect of the paper that, though not path-breaking, has raised several important issues.

Here are my arguments:

1.“In this article we will argue that the moral and ethical foundations of the war on doping are doubtful at best.”

Will it be morally right for a doctor to pump steroids into an absolutely healthy, fit athlete who does not suffer from any ailment and has adequate muscle mass of his own?

Red herring again: “Pumping steroids into an athlete” rhetorically suggests an evil deed. On the contrary, our proposed change of policy insists on the principle of nonmaleficience and on refusing to inflict harm. It is not impossible that anabolic steroids might be used under medical supervision with minimal risk, but at present this is unknown since their use is forbidden and relegated into clandestinity.

2.“Official thinking on these issues simply assumes the validity of the level playing field concept without coming to terms with the reality of widespread biological and environmental inequality. People differ in their biological capacities, which result from interplay between genome and environment. This also applies to athletes and their performance capabilities. Genetic predisposition is of prime importance in this respect even though the identification of these genetic traits is taking time. In fact, even a simple genetic mutation may confer a performance advantage.”

Such genetic advantages are there in all walks of life. A brilliant child of brilliant parents might score well over others in exams. In order to create a “level playing field”, will you allow all other students to copy during exams?

Questionable analogy: a student is examined against an objective standard of achievement. Basically, students compete against themselves. Competition between students is a more or less (un)desirable side effect. Competing between athletes (or teams) is the very point of sports, unlike virtually every other human activity that entails some degree of competition. As a result, innate differences have very different implications. In education, they call for remedial measures to help those who lag behind. In sports, the implications are more complex, but at a minimum, they call for a frank acknowledgment that they exist. As such, it is important to realise that the use of pharmacological aids by students to overcome intellectual obstacles like exams, for example by using a beta-blocker to reduce stress, or by using modafinil to be able to make long study hours, does not induce similar strong reactions of disdain as the use of the same drugs in the realm of sports.

3.“Apparently, prevailing sports ethics is unconcerned about this contradiction since 'natural' genetic variation is considered to be an acceptable (or irrelevant) inequality, whereas artificial enhancement is not.”

Artificial enhancement of the type you are advocating will continue to have this inequality since you will not be able to put all the athletes of the world through the same “controlled doping”. Thus, America will have a set of athletes who have been put through a regimen of drug ‘A’ while China will have its own set of athletes who have been given a course of drug ‘B’. Both drugs happen to be unknown to the rest of the world. Unless you inject the same drug to all the athletes at the start of a particular competition/particular race the inequality will remain. “Controlled” doping then will become meaningless. But let’s say, for argument purposes, “controlled doping” will mean a set standard approved by WADA/IOC resulting in drug ‘X’ being given to all the athletes of the world before the Olympics. That will mean further testing to find out whether any one is crossing prescribed thresholds. Or anyone has taken anything other than drug ‘X’. Where will this lead to?

Red herring: Nobody argues that “controlled doping” will solve all problems of doping policies. It will solve an important one, albeit of a conceptual and ideological nature: it will destroy the superstitious belief that the line between “legitimate medical treatment and training” and “doping” drawn by the sports establishment reflects an objective, natural, difference between the two practices. “Controlled doping” forces us to face up to the uncomfortable reality that enhancement practices are inherent to modern medicine and wherever we draw the line between permitted and forbidden ergogenic practices, a measure of arbitrariness necessarily exists. The line is not completely arbitrary, though: nonmaleficience provides a principled justification for it. Moreover, enhancement technologies vary in the degree to which they affect the intended tests of competitions. Our proposition does not negate the tests of sports, rather it enriches the kind of flourishing that is celebrated.

4.“There is certainly no evidence of equality of conditions here and there probably never will be. Furthermore, in a rich high-tech environment, an athlete may come as close as possible to doping, and sometimes into doping, all the while being medically supervised in a sophisticated technological environment.” The same argument as above will hold good. The rich high-tech countries will employ more sophisticated methods to have “controlled doping” while the poorer countries will opt for outdated methods and drugs. The end result will be the same without the so-called level-playing field being obtained through “controlled doping”.

Red herring: Nowhere do we claim that “controlled doping” will make a level playing field possible. That is the claim of the anti-doping ideology and we show how it must fail. Yet, we do argue that there are differences in these different moral systems. In our case, we offer the possibility for athletes to undertake greater control of their performances, to think critically about how performance changes via various technological systems – including, coaching, nutritional advice, psychological preparation, training and knowledge of their own biochemistry. On our model, these become relevant knowledge for athletes to acquire, which, in turn, bring about a qualitative difference in the kind of equality that operates within elite sports.

5.“We raise questions about the degree of privacy violation that anti-doping organisations are entitled to request from athletes, on the basis of this sporting norm. We are doubtful about the rule that fair competition should trump fundamental liberties in the majority of cases and are concerned about the escalation of this requirement in contemporary elite sport.”

The athletes don’t think so. In a large majority of forums, the athletes commissions, whether that of individual international federations or that of the IOC have wholeheartedly backed the dope control measures of IOC/WADA/IFs etc. You might turn around and say vested interests are at work, that the athletes’ commissions are saying what the federations want them to say. But is there any scientific evidence to suggest that supervised doping is harmless? That supervised doping will not lead to a free for all situation? That supervised doping will forever remain free of vested interests? That it can be implemented better than dope control?

Selective reading of evidence: many athletes are actually unhappy about the present state of affairs, as the reaction to the UCI request that cyclists pledge to abandon one year of income if caught using doping. Sports federations turned racketeers of their own athletes: what a nice moral model for youth! Increasingly shocking human rights violations by sports federation is what eventually might put the whole system in crisis. Indeed, in the very case of cycling’s major global event, the Tour de France, one might as well argue, as many cyclists and support personnel do, that anti-doping is killing the event instead of the reverse,. One only has to look at recent commentaries and op-eds in the last few months to notice that an appeal to a united moral community is unpersuasive. For example, consider the recent editorial in Nature (2007).

6.“In elite sports there may at least be some medical supervision, possibly of good quality. This is not the case for the general population, which may result in serious health problems for a much greater number of subjects. Indeed, recent reports on the use of illicit pharmacological means to enhance performance in amateur sports are alarming with regard to the high prevalence of these practices.”

If the general population is now unaware of the consequences of doping, will it improve if doping is legalized? The opposite will be the case since, from then on, athletes will realize that since doping is permitted, any type of medicine can be taken or any type of quacks could be approached. Currently, if at all there is hesitation to go in for unknown, untested drugs or to approach quacks, it is only because of the ban on doping and its consequences. It is foolish to think that legalizing doping will mean every athlete will be guided by expert medical opinion. No police force in the world will ever say “we are unable to tackle law and order since our force is not equipped enough to handle such problems because of its small size; the easy way out then is to allow thieves, dacoits, rapists and killers to roam the streets!”

It is the very present anti-doping policy, with its attendant criminalisation of doping, that may eventually contribute to the logistic crunch so vividly described by the writer. The author’s concern here is about the efficacy of regulative practices and, as such, the response should focus on the capacity to ensure athletes are working with entrusted experts. We recognise that supervised doping could open up certain commercial enhancement practices and our focus should be on monitoring and regulating such practices, rather than shying away from their inevitable – and already visible – emergence.

7.“Now that recombinant erythropoietin is detectable, there is a shift to the use of other oxygen carrying capacity enhancing drugs, with higher potential health risks. These consequences of anti-doping practices may thus paradoxically introduce more health problems than they prevent.” This is equivalent to suggesting that if substance ‘A’ which is mildly harmful to the humans is detectable in an edible oil which is subjected to adulteration tests, then the unscrupulous traders/manufacturers might turn to substance ‘B’ which is more harmful, but undetectable. So, let’s allow adulteration with substance ‘A’. But let’s also control it by prescribing percentages of adulteration!

This begs the question as adulterating food is non-controversially criminal and therefore does not provide a viable analogy to doping.

8.“Today, the rich countries can pay the bill for the increasingly costly practice of doping control, but the developing countries cannot. There is money coming through international federations like the IOC, but increasingly, resources will accrue from governmental sources.” In many countries, the money being spent on dope control is negligible. If dope control is a costly practice then bidding for multi-discipline games is a costlier practice. Yet countries like India continue to spend huge amounts of money on such exercises while spending very little on dope control. Resources for sports promotion, especially in developing countries, will have to come from governmental sources and dope control should not be an exception.

Again, this begs the question of whether anti-doping policies have a legitimate claim on public funding. We claim that governments, especially in poorer countries have, or should have, better things to do with their taxpayer’s money than embark on the lost cause of extensive and expensive anti-doping control.

9. “The highest sanction for an athlete, whose doping practice is discovered, is a lifetime exclusion from competition, which is not enough to scare all athletes away from doping.”

Murderers/rapists get capital punishment in many countries including India. This does not deter prospective murderers nor has it helped curb crime in many countries. Yet it stays in the statutes, so does the life imprisonment clause which also does not deter people who kill for money or other reasons. Should countries abolish both forms of punishment saying that it does not scare enough?

The role of deterrence in criminal codes is a highly complex and controversial question. Nevertheless, punishments that do not deter hereby lose a substantial fraction of their legitimacy, especially if we move away from old-fashioned retributivist theories of criminal justice. This is even more apparent for practices such as doping which are not per se illegal in many countries, even if they are considered undesirable conduct.

10.“Hence, its consequences have to be seen from a public health perspective. We believe that current anti-doping does not adequately prevent damage from doping in sports, that it creates health problems of its own, and diverts health-care resources from more worthwhile pursuits.”

If current anti-doping is creating health problems of its own, will controlled doping solve such health problems in a general sense? Will you then say, “Controlled doping” is applicable only to the top 100 athletes in a discipline in a country; the others will be bound by normal anti-doping rules. Won’t that be discrimination? If on the other hand, dope control is abolished, will the whole of sports talent across the length and breadth of a country like India or China pursue only “controlled doping”? If they don’t, will it not lead to more harm than good?

Red herring: we do not advocate a free-for-all reserved for a small elite, nor do we recommend an abolition of doping controls across the board. “Controlled doping” should be first and foremost an education program about ergogenic interventions, geared to the specific needs of elite athletes, and of amateur and leisure sports respectively.

Bengt Kayser, Alexandre Mauron and Andy Miah

Competing interests

No competing interests.

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In defence of dope control

Karayi Mohan   (2007-06-18 13:30)  Hindu email

A doctor friend of mine, who is into sports medicine and handles dope control, has been arguing for many years that “controlled doping” or “supervised doping” should be permitted and that dope control should be left to the medical community rather than sports officialdom to regulate.

Needless to say he is in complete agreement with the paper presented here and even thinks that some of the points had been borrowed from papers and lectures he had been giving around the world the past few years.

Neither he nor the learned authors of this paper has explained why doping per se is necessary in sports, though my doctor friend often argues that the world is looking for “record-breaking performances” all the time and the athletes cannot be expected to better records without the aid of some substance, whether it be supplements or drugs.

There is no evidence to show that such an argument has enough basis in major Olympic sports, but are athletes pursuing their careers to provide entertainment to the people or are they partly or fully interested in their financial stability?

I am all for “supervised doping” if it can be ensured that (a) the drugs will not bring any harm to the athlete (but don’t you think that many drugs you take in the normal course do have side effects? My answer to that will be: I take them because I have an illness, not otherwise. Healthy athletes, pursuing their normal sports activities, if they do need steroids to treat a medical condition, should be allowed to have them.); (b) all the athletes around the world will be given the same drug or a group of drugs prescribed by an independent medical panel; (mind you, we are talking about improving performances, not trying to treat an illness; thus the same drug will have to be given to all or maybe a drug from a list of drugs approved in advance) ; (c) the authorities will ensure that no designer drugs will come into the picture; (d) the quality of the drugs made available to all the athletes will be the same; (e) an international court on the lines of CAS will deal with all cases relating to harmful effects, if any, suffered by any athlete anywhere in the world, free of cost; (f) the authorities will ensure that supervised doping is not practised outside of the ‘elite’ group of athletes (g) doctors will be penalized if the dope-driven athletes fail to come up to expectations. Of course, it will have to be scientifically established that a particular drug does enhance performance and will cause only marginal harm if taken under supervision.

I do have a large number of questions and points to raise in respect of the paper that, though not path-breaking, has raised several important issues.

Here are my arguments:

1.“In this article we will argue that the moral and ethical foundations of the war on doping are doubtful at best.”

Will it be morally right for a doctor to pump steroids into an absolutely healthy, fit athlete who does not suffer from any ailment and has adequate muscle mass of his own?

2.“Official thinking on these issues simply assumes the validity of the level playing field concept without coming to terms with the reality of widespread biological and environmental inequality. People differ in their biological capacities, which result from interplay between genome and environment. This also applies to athletes and their performance capabilities. Genetic predisposition is of prime importance in this respect even though the identification of these genetic traits is taking time. In fact, even a simple genetic mutation may confer a performance advantage.”

Such genetic advantages are there in all walks of life. A brilliant child of brilliant parents might score well over others in exams. In order to create a “level playing field”, will you allow all other students to copy during exams?

3.“Apparently, prevailing sports ethics is unconcerned about this contradiction since 'natural' genetic variation is considered to be an acceptable (or irrelevant) inequality, whereas artificial enhancement is not.”

Artificial enhancement of the type you are advocating will continue to have this inequality since you will not be able to put all the athletes of the world through the same “controlled doping”. Thus, America will have a set of athletes who have been put through a regimen of drug ‘A’ while China will have its own set of athletes who have been given a course of drug ‘B’. Both drugs happen to be unknown to the rest of the world. Unless you inject the same drug to all the athletes at the start of a particular competition/particular race the inequality will remain. “Controlled” doping then will become meaningless. But let’s say, for argument purposes, “controlled doping” will mean a set standard approved by WADA/IOC resulting in drug ‘X’ being given to all the athletes of the world before the Olympics. That will mean further testing to find out whether any one is crossing prescribed thresholds. Or anyone has taken anything other than drug ‘X’. Where will this lead to?

4.“There is certainly no evidence of equality of conditions here and there probably never will be. Furthermore, in a rich high-tech environment, an athlete may come as close as possible to doping, and sometimes into doping, all the while being medically supervised in a sophisticated technological environment.”

The same argument as above will hold good. The rich high-tech countries will employ more sophisticated methods to have “controlled doping” while the poorer countries will opt for outdated methods and drugs. The end result will be the same without the so-called level-playing field being obtained through “controlled doping”.

5.“We raise questions about the degree of privacy violation that anti-doping organisations are entitled to request from athletes, on the basis of this sporting norm. We are doubtful about the rule that fair competition should trump fundamental liberties in the majority of cases and are concerned about the escalation of this requirement in contemporary elite sport.”

The athletes don’t think so. In a large majority of forums, the athletes commissions, whether that of individual international federations or that of the IOC have wholeheartedly backed the dope control measures of IOC/WADA/IFs etc. You might turn around and say vested interests are at work, that the athletes’ commissions are saying what the federations want them to say. But is there any scientific evidence to suggest that supervised doping is harmless? That supervised doping will not lead to a free for all situation? That supervised doping will forever remain free of vested interests? That it can be implemented better than dope control?

6.“In elite sports there may at least be some medical supervision, possibly of good quality. This is not the case for the general population, which may result in serious health problems for a much greater number of subjects. Indeed, recent reports on the use of illicit pharmacological means to enhance performance in amateur sports are alarming with regard to the high prevalence of these practices.”

If the general population is now unaware of the consequences of doping, will it improve if doping is legalized? The opposite will be the case since, from then on, athletes will realize that since doping is permitted, any type of medicine can be taken or any type of quacks could be approached. Currently, if at all there is hesitation to go in for unknown, untested drugs or to approach quacks, it is only because of the ban on doping and its consequences. It is foolish to think that legalizing doping will mean every athlete will be guided by expert medical opinion. No police force in the world will ever say “we are unable to tackle law and order since our force is not equipped enough to handle such problems because of its small size; the easy way out then is to allow thieves, dacoits, rapists and killers to roam the streets!”

7.“Now that recombinant erythropoietin is detectable, there is a shift to the use of other oxygen carrying capacity enhancing drugs, with higher potential health risks. These consequences of anti-doping practices may thus paradoxically introduce more health problems than they prevent.”

This is equivalent to suggesting that if substance ‘A’ which is mildly harmful to the humans is detectable in an edible oil which is subjected to adulteration tests, then the unscrupulous traders/manufacturers might turn to substance ‘B’ which is more harmful, but undetectable. So, let’s allow adulteration with substance ‘A’. But let’s also control it by prescribing percentages of adulteration!

8.“Today, the rich countries can pay the bill for the increasingly costly practice of doping control, but the developing countries cannot. There is money coming through international federations like the IOC, but increasingly, resources will accrue from governmental sources.”

In many countries, the money being spent on dope control is negligible. If dope control is a costly practice then bidding for multi-discipline games is a costlier practice. Yet countries like India continue to spend huge amounts of money on such exercises while spending very little on dope control. Resources for sports promotion, especially in developing countries, will have to come from governmental sources and dope control should not be an exception.

9.“The highest sanction for an athlete, whose doping practice is discovered, is a lifetime exclusion from competition, which is not enough to scare all athletes away from doping.”

Murderers/rapists get capital punishment in many countries including India. This does not deter prospective murderers nor has it helped curb crime in many countries. Yet it stays in the statutes, so does the life imprisonment clause which also does not deter people who kill for money or other reasons. Should countries abolish both forms of punishment saying that it does not scare enough?

10.“Hence, its consequences have to be seen from a public health perspective. We believe that current anti-doping does not adequately prevent damage from doping in sports, that it creates health problems of its own, and diverts health-care resources from more worthwhile pursuits.”

If current anti-doping is creating health problems of its own, will controlled doping solve such health problems in a general sense? Will you then say, “Controlled doping” is applicable only to the top 100 athletes in a discipline in a country; the others will be bound by normal anti-doping rules. Won’t that be discrimination? If on the other hand, dope control is abolished, will the whole of sports talent across the length and breadth of a country like India or China pursue only “controlled doping”? If they don’t, will it not lead to more harm than good?

Competing interests

None declared

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