Ethical Considerations in the Child and Adolescent Athlete

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Ethical Approaches

Ethical approaches in medicine can be classified into these areas:

• Virtuous Practice
• Deontology
• Utilitarianism
• Principles Approach

No single approach will provide the solution to every ethical concern, however, in sports medicine these approaches are useful to provide a framework to help with decision-making and ethical practice.

Virtuous Practice

Virtuous practice encompasses the following:

• Virtue ethics places importance on the medical professional's/clinician's character (or moral agent).
• Virtuous practice argues that morality arises from an individual's character and not only portraying the actions of the individual.
• The 5 virtues that applies to a medical professional are:
  • trustworthiness
  • integrity
  • discernment
  • compassion
  • conscientiousness
• Another valuable virtue is discipline.
• Good judgement comes from good character.
• In virtuous practice the motivation of the clinician is paramount.
• Ethical decision making is based on the character of the clinician.
• The virtuous sports medicine clinician's role is first and foremost the welfare of the athlete.
• Virtuous ethics allows for the adaptation of choices in specific scenarios and the people involved.
  • This flexibility encourages creative thinking and problem solving.
• "A virtuous person perceives a situation, judges what is right, and then wants to act accordingly because it is their disposition to act well."

Deontology

The Deontology approach can be summarised as follows:

• Duty-based ethics
• Do the right thing because it is the right thing to do
• When deciding what you should do in certain situations ask yourself: "Would it be acceptable if everyone took this type of action?"
• Clinical Scenario:
  • An athlete with concussion wants to continue playing
  • Ask yourself: "Would it be acceptable if every athlete with concussion is allowed to continue playing?"
  • The clear answer in this scenario is no, because athletes would be put at unacceptable risk and this is morally wrong.
• The athlete is seen as the end and not the means
• The success of the team is never more important than the welfare of the individual athlete
• The core teaching of deontology is that people have the duty to do the right thing, irrespective of good or bad consequences.
  • Thus, a decision or action cannot be justified because it had a good outcome or condemned because it had a bad outcome.
• The issue with deontology is that it yields absolutes and allows for no grey areas in decision-making

Utilitarianism

The Utilitarianism approach entails:

• The principle of utilitarianism promotes consequentialism
• The rightness or wrongness of a decision or action is judged by its consequences
• The concept of putting the team before the individual athlete is at the forefront of this approach: "There is no 'I' in team"
• The goal is to create the greatest happiness for the greatest amount of individuals (in a sports context this will imply the team)
• The action or decision can be justified if the benefits outweigh the actual or potential harm (for example sporting organisations want to do what is right for the sporting organisation)
• The issue with this approach is that it disparages the interest and welfare of the individual athlete in favour of the team's success
• This can never be the approach of a team clinician/medical professional
• Clinical scenario:
  • There are certain team environment scenarios where an utilitarian approach may be appropriate
  • Touring team scenario - an athlete on tour is injured
  • The athlete requires focus, time and resources from the team clinician for treatment and rehabilitation that are so demanding that it can potentially negatively affect the rest of the team and the medical services available for the rest of the team
  • In this scenario a decision may be made to rather send the athlete home for further treatment and rehabilitation

Principles Approach

Principles ethics involve the following:

• Most well-known and useful practical, ethical approach
• Regarded as the most appropriate approach in medical ethical situations
• Four pillars of Principles ethics are:
  • Autonomy
  • Beneficence
  • Nonmaleficence
  • Justice

Autonomy

• A fundamental ethical principle is respect for an individual's autonomy
• Autonomy is the capacity of a competent individual to make an informed, uncoerced decision
• Knowledge is an imperative part of autonomy and is central to informed consent
• In sports medicine, an athlete with an injury who needs to make a decision on treatment choices, needs to understand the injury, comprehend the risks and benefits of all treatment options as well as be aware of the future prognosis
• Even though the decision will not only influence the athlete, but perhaps the team as well, the team clinician's primary obligation remains with the individual athlete!
• Other factors that can influence decision-making are:
  • Pressure from other parties
  • Goals of athlete
  • Financial implications
• Clinical Scenario
  • Athlete with an in-season meniscal injury
  • The meniscal tear is repairable but the athlete has two options
    • Option A: Arthroscopic meniscectomy and a fast return to play
    • Option B: Meniscal repair and potentially out for the rest of the season
    • Both options have short and long-term consequences
      • Short term consequences: With option A a quicker return to play, whereas with option B a lengthier rehabilitation period and potentially misses out on the entire season.
      • Long-term consequences: With option A there is an increased risk of developing degeneration in the knee later on, whereas with option B there is a reduced risk of long-term risks and degeneration to the knee.
    • In the principle of autonomy the athlete needs to be aware of all these options in their entirety, understand the injury, the risks and benefits of all treatment options and the future prognosis. This is the only way an athlete will be able to make an informed, uncoerced decision.
    • Read more: Informed Consent

Beneficence

• This principle governs that a medical professional/clinician should "do good" and promote the interest of the patient
• Sports medicine professionals can "do good" for the athlete by treating any injuries and prevent further harm.
• Beneficence goes hand in hand with Non-maleficence

Non-maleficence

• First, do no harm
• In sport, athletes are aware that injury and harm is a risk, but it remains the sports medical professional's role to minimise further harm and try to limit risk as much as possible
• Clinical Scenario:
  • Athlete requesting an injection of local anaesthetic from the team doctor to allow the athlete to continue playing or to compete again
    • Option A: Doctor provides the injection and athlete can continue (short-term gain) but potentially risking further injury and/or long-term risk and damage
    • Option B: Doctor does not provide the injection and the athlete can not continue play, but this allows for a more thorough assessment of the injury. The athlete will however lose out on possible sporting success and the team may also be impacted.
    • World Rugby has an anaesthetics guideline clarifying that "a player may not receive local anaesthetics on match day unless it is for the suturing of bleeding wounds or for dental treatment administered by an appropriately qualified medical or dental practitioner."

Beneficence vs Non-maleficence

Athletes may sometimes show risky behaviour towards their own career and welfare and this may cause difficult situations. As already stated, athletes are aware of the risk and the sports clinician's role is to minimise further harm and try and limit risk. The athlete is not obliged to follow the advice or recommended plan suggested by the clinician, but athletes should be aware of the risk and consequences of the decisions that they make. The sports clinician should also respect an athlete's decision even if it is not aligned with the clinician's opinion. Sporting organisations can help with this in providing guidelines on controversial treatment.

Justice

The fourth pillar of Principles ethics is justice and includes the following:

• Justice = to act fairly when the interest of different individuals are in competition with each other
• Three categories of obligations of justice:
  • Distributive justice - fair distribution of scant resources
    • Scarce resources should be distributed equally based on need and not on the basis of star players getting preferential treatment
  • Rights-based justice - respect for people's rights
    • Clinicians should respect each athlete's right to treatment and may not fail to treat because of bias or contrary beliefs
  • Legal justice - respect for morally acceptable laws
    • Clinicians should wilfully do no harm to any athlete in their care
      

Code of Ethics

The International Federation of Sports Medicine (FIMS) has a Code of Ethics that can be read here.

The International Federation of Sports Physical Therapists (IFSPT) also has Code of Ethics based on the International Federation of Sports Medicine (FIMS) Code of Ethics and the WCPTs ethical principles. You can read the IFSPT Code of Ethics here.

Uniqueness of Sports Medicine

Some of the unique challenges clinicians face when managing athletes include:

• Pressure from coaching staff, team management and athletes themselves to return to sport as early as physically possible
• Athletes experience pressure to earn their team mates' respect as well as financial implications if injured
• Inaccurate reporting of an injury and the severity thereof by athletes out of fear of missing training or match time
• Maintaining confidentiality of information as the clinician-patient relationship is often a clinician-patient-coach triad with third parties involved such as a coach or team manager
• Athletes are forever striving to improve their performance. Certain tools that athletes will use to achieve this may include:
  • dietary supplements
  • medication such as mismanagement or overuse of analgesics
  • doping with prohibited substances and performance-enhancing drugs
    • find the Word Anti-Doping Code International Standard Prohibited List 2022 here
  • excessive training by athletes that increases risk
• Read more: Ethical concerns in sport: when the will to win exceed the spirit of sport

Role of the Clinician in Sports

• The health and safety of the individual athlete is paramount
• Athletes must have the right to make their own informed decision
  • Keep in mind that in a highly charged game environment informed consent is trickier
• The responsibility lies with the clinician to determine if continued training or participation by the athlete is appropriate
• Maintain a degree of professional distance from the management team
• Clinician first - team clinician second
• Never abdicate your responsibility to the individual player

Approaching Ethical Dilemmas

• Ethical approaches and principles are a framework, used as a reference for decision making
• Clinical decision-making is centred around the clinician's professional judgement
• Professional judgment always seeks balance - balance between ethical principles such as patient autonomy, avoiding doing harm, generating wellbeing and assessing risks and benefits - while at the same time trying to satisfy the needs and interests of other parties such as coaches, the team management and the team

The Principles Approach in the Child and Adolescent Athlete

Applying the principles approach to a child is dependent on competence. Competence forms part of autonomy.

• Autonomy
  • The three concepts that drive the application of autonomy in the child and adolescent athlete are:
    • Competence
      • the ability to understand the information needed to make a decision
      • dependent on the legal system of a country
    • Confidentiality
      • a competent person's right to restrict divulging of information without their consent
    • Informed Consent
      • a competent person's right to make decisions based on information
      • three components necessary for informed consent:
        • decision-making capacity, thus competent
        • full discussion about risks, benefits, outcomes and prognosis of all treatment options
        • sufficient understanding - consider language used, amount of information and maturity of athlete
  • The assessment and development of Autonomy in the child and adolescent athlete is dependent on a few factors. These include:
    • legal age
    • cognitive and affective developmental stage of child or adolescent
    • ability to understand and decide
    • Sufficient maturity and intelligence
    • Responsibility in activities of daily living (ADL)
  • Deciding where the threshold is that separates the incompetent child from the competent adult is difficult. One should accept a competent person's decision even if other believe that the choice is wrong. Children need time to develop these abilities. Responsibility and decision-making should be encouraged in the child and adolescent and as clinicians it is crucial that we encourage the development of autonomy in children, protect this developing autonomy and also respect the child's future autonomy.
• Beneficence and non-maleficence considerations
  • competent adults make decisions on what they think will make their lives go well. but incompetent children cannot make such decisions
  • what is the best interest for the child or adolescent and who decides what the standards are to which decisions should be made?
  • if the best interest standard is too demanding, should the focus then rather be on not acting against the child or adolescent's interest?
  • Consider the child or adolescent's overall needs and not just medical best interests
• Parental Authority
  • Parental authority should be in the interest of the child
  • It should not extend to causing the child long-lasting harm
  • Parent's autonomy should also be respected, but there are limits to parental authority
  • The focus should always be on the protection of the whole child and their overall interests

Clinical Case Study

"Eleven year old Martin is a promising football academy player with an acute ACL tear. There are no other knee structures involved, nor does he have any dynamic instability. Generally, Martin is well. He can run, change direction, kick and jump with no problem."

Two Scenarios in the management of Martin's injury:

A clinical case study presented by Ardern et al

Scenario 1

Scenario 2

Medical team advice ACL reconstruction, parents do not consent to surgery Medical team rationale: high knee-demand sport high level athlete Possible conflict of interest: Medical team works closely with the club Pressure from club administrators Parent's reasons for not wanting surgery: Martin is too young Previous experience of complications from surgery with another sibling

Medical team advocating for conservative management (advice against ACL reconstruction), parents keen for surgery to go ahead and want the club to pay for the surgery Medical team rationale: isolated ACL tear with no dynamic instability wants to try rehabilitation first Parents want surgery and may be invested in Martin's future financial potential Unknown if a club will offer a professional contract to someone who has sustained a serious injury, whether conservatively or surgically managed

• Scenario 1:
  • Medical team advice ACL reconstruction, parents do not consent to surgery
  • Medical team rationale:
    • high knee-demand sport, high level athlete
  • Possible conflict of interest:
    • Medical team works closely with the club and pressure from club administrators
  • Parent's reasons for not wanting surgery:
    • Martin is too young
    • Previous experience of complications from surgery with another sibling

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