Ethical issues in return-to-sport decisions.
Subject: Sports medicine (Laws, regulations and rules)
Sports medicine (Social aspects)
Sports teams (Management)
Sports teams (Ethical aspects)
Author: Burgess, Theresa L.
Pub Date: 12/01/2011
Publication: Name: South African Journal of Sports Medicine Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 South African Medical Association ISSN: 1015-5163
Issue: Date: Dec, 2011 Source Volume: 23 Source Issue: 4
Topic: Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime; 290 Public affairs; 200 Management dynamics Advertising Code: 94 Legal/Government Regulation; 91 Ethics Computer Subject: Government regulation; Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 280557373
Full Text: The complexities of return-to-sport decisions are not unfamiliar to healthcare professionals working with elite and recreational athletes. Medical advances and effective rehabilitation protocols have increased the potential for returning athletes to competition more quickly. However, these advances cannot keep up with the increasing expectations for athletes to perform at continually higher levels. These expectations are compounded by both the large financial rewards apportioned to most professional athletes; and increasing media attention, which creates additional social pressure. (1) It is therefore acknowledged that both physical and psychological aspects of injury need to be addressed to ensure holistic injury recovery. (2) The ethical issues in making return to sport decisions might not seem that prominent in many cases. However, one of the main ethical issues that have been identified by healthcare professionals working with athletes and sports teams is the tension between the long-term welfare of an athlete and premature demands to return an athlete to sport. (3)

Perhaps one of the most publicised cases related to return-to-sport decisions and long-term welfare of athletes is that of National Football League (NFL) player Andre Waters. Waters was a former Pro Bowl safety for the Philadelphia Eagles. In 1994 he told a local newspaper that he 'had lost count of the number of concussions he suffered at 15'. Following his retirement from the game, he suffered from severe clinical depression. He died at 44 years of age, from a self-inflicted gunshot wound to the head. The forensic pathologist who performed the postmortem examination stated that 'Water's brain resembled that of an octogenarian Alzheimer's patient' and attributed the marked brain damage to Water's repeated injuries as an NFL player. (4) In addition, Guskiewicz et al. (5) determined that retired NFL players with a history of three or more concussions were three times more likely to be diagnosed with depression, compared with retired players with no history of concussion.

This case demonstrates the impact of short-term return-to-sport decisions on the long-term welfare and future societal participation of an athlete. It also highlights the need to consider ethical issues when making return-to-sport decisions. The first challenge for healthcare professionals working with teams is to recognise potential conflicts of interest that may influence return-to-sport decisions. Healthcare professionals are responsible for the welfare of the team as a whole, but must also protect the health of individual athletes. Strong emotional involvement in a team's success may lead to a loss of objectivity when making decisions regarding individual athletes. (6)

There may also be conflicting duties between the care of an athlete and contractual obligations to team management or sports governing bodies. Such conflicts of interest may increase the risk of harm to individual athletes, and may also threaten the integrity of healthcare professionals. As return-to-sport decisions are needed on a regular basis, healthcare professionals should show increased self-awareness to recognise how conflicting interests may influence decision-making, and should disclose potential conflicts of interest to athletes when providing care and advice. If the healthcare professional is unable to make an objective decision, an impartial external professional should be consulted.

Return-to-sport decisions should also promote an athlete's autonomy. Autonomy allows for self-determination and the individual governance of actions. Autonomy is linked to informed consent, and allows an athlete to actively participate in return-to-sport decisions. However, maintaining full and thorough informed consent in return-to-sport decisions may be problematic, particularly due to the numerous external pressures associated with team sports. It may be difficult to preserve individual athlete autonomy with external pressures such as financial gain and coach, team, family and public expectations. Return-to-sport decisions may also be strongly influenced in competition or match situations by desires to compete, to win, and to avoid disappointing team members. The FIMS code of ethics regarding return-to-sport decisions states: 'It is the responsibility of the sports medicine physician to determine whether the injured athletes should continue training or participate in competition. The outcome of the competition or the coaches should not influence the decision, but solely the possible risks and consequences to the health of the athlete.' (7) In return-to-sport decisions, the primary obligation of healthcare professionals is to the individual athlete. Sufficient and appropriate information should be given to an athlete to facilitate informed decision-making. (6,8,9) The healthcare professional should therefore confirm that an athlete understands the risks and benefits associated with return-to-sport decisions, and must also appreciate the extent of external pressures on an athlete that may influence decision-making. In addition, athletes must be educated regarding the importance of reporting injuries, to ensure effective management and to facilitate an efficient and safe return to sport.

The core ethical principle of beneficence must also be considered in return-to-sport decisions. Promoting beneficence is complex, particularly due to the inherent risks associated with participating and competing in most sports. (9) There are also difficulties associated with identifying and quantifying the often apparent short-term benefits, compared with the potentially uncertain long-terms harms of return to sport. External pressures and associated short-term benefits such as fame and financial reward may compel an athlete to return to sport too soon. (1,6) Unfortunately, the potential long-terms harms may often be uncertain because of a lack of scientific evidence. When making return-to-sport decisions, the relative benefits should outweigh the potential harms. (9) In addition, an athlete should be informed of the existence of clinical uncertainty to promote autonomous decision making when performing a risk/benefit analysis. (4)

Healthcare professionals working with sports teams have a fundamental responsibility to promote the health and well-being of athletes. (6,8,9) However, return-to-sport decisions may often challenge the clinical decision-making processes of healthcare professionals and judgements regarding the best interests of an individual athlete. It is necessary to appreciate the various influences and pressures that exist in recreational and professional sporting environments. Return-to-sport decisions should be guided by the central ethical principles of autonomy, beneficence and non-maleficence. Increased self-awareness and reflection regarding ethical issues are required to make return-to-sport decisions that promote the current and future welfare of athletes.


(1.) Bauman J. Returning to play. The mind does matter. Clin J Sport Med 2005;15:432-435.

(2.) Podlog L, Dimmock J, Miller J. A review of return to sport concerns following injury rehabilitation: practitioner strategies for enhancing recovery outcomes. Phys Ther Sport 2011;12(1):36-42.

(3.) Anderson L, Gerrard D. Ethical issues concerning New Zealand sports doctors. J Med Ethics 2005;31:88-92.

(4.) Goldberg D. Concussions, professional sports, and conflicts of interest: why the National Football League's current policies are bad for its (players') health. HEC Forum 2008;20(4):337-355.

(5.) Guskiewicz K, Marshall S, Bailes J, McCrea M, Harding H, Matthews A et al. Recurrent concussion and risk of depression in retired professional football players. Med Sci Sports Exerc 2007;39(6):903-909.

(6.) Johnson R. The unique ethics of sports medicine. Clin J Sport Med 2004;23:175-182.

(7.) International Federation of Sports Medicine: Code of Ethics. September, 1997. (accessed 22 November 2011).

(8.) Dunn W, George M, Churchill L, Spindler K. Ethics in Sports Medicine. Am J Sports Med 2007;35(5):840-844.

(9.) Devitt B, McCarthy C. 'I am in blood Stepp'd in so far ...': ethical dilemmas and the sports team doctor. Br J Sports Med 2010;44(3):175-178.

Theresa L Burgess (BSc (Physiotherapy), PhD (Exercise Science))

Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Groote Schuur Hospital, Cape Town

Correspondence to: Theresa Burgess (
Gale Copyright: Copyright 2011 Gale, Cengage Learning. All rights reserved.