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Doping in sport: Challenges for medicine, science and ethics

Article  in  Journal of Internal Medicine · September 2008

DOI: 10.1111/j.1365-2796.2008.01994.x · Source: PubMed

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 Editorial Comment |
Doping in sport: challenges for medicine, science and
ethics
Introduction
The struggle against performance enhancing drugs in
sport is nearly half a decade old. It has encountered
many obstacles, stumbled often, but also achieved
notable successes. The anti-doping movement for the
Olympic Games in particular has become more
sophisticated than its earlier versions from the analyti-
cal laboratories conducting the testing to the processes
for evaluating and classifying doping substances and
methods, its adjudication procedures, and, not least,
its attention to the ethical foundation for anti-doping.
Anti-doping faces very significant challenges
today—and possibly greater ones in the near future
from technologies such as genetic manipulation and
from skeptics opposed to the effort to discourage
performance enhancing drugs in sport.
The excellent article by Catlin, Fitch and Ljungqvist
[1] in this issue of the Journal of Internal Medicine
provides a concise description of the history of drug
testing for the Olympic Games with fascinating details
of the evolution of laboratory equipment and analyti-
cal strategies. It also identifies failings of the overall
anti-doping system, most of them out of the laborato-
ries’ control and describes a number of challenges to
be confronted. In this article, I will analyse the ethical
foundation for prohibiting doping in sport, describe
the essential elements of a successful anti-doping pro-
gram and assess the current efforts towards that end.
Finally, I will describe a set of challenges that must
be met for anti-doping to succeed in the long run.
What’s wrong with doping in sport?
In research conducted at The Hastings Center in the
early 1980s, we evaluated the ethical arguments for and
against permitting the use of performance enhancing
doi: 10.1111/j.1365-2796.2008.01994.x
drugs in sport. We found that the arguments were pro-
ceeding at two levels. At the first level, the argument
was over what constituted a fair system for deterring
doping in sport. At the second level, the argument chal-
lenged the assumption that using performance enhanc-
ing drugs in sport was ethically problematic.
Interviews with elite athletes and others concerned
with sport made it clear that athletes felt great pres-
sure to do everything they could to hone a keen com-
petitive edge. If they suspected that their competitors
were gaining advantage by using drugs such as stimu-
lants or androgenic anabolic steroids (AAS), those
athletes faced three unpleasant alternatives: continue
to compete clean, knowing that they might lose to an
otherwise inferior competitor who doped; give up
competing at the elite level; or unwilling to lose and
reluctant to drop out, give in and use the performance
enhancing drugs they believe their competitors were
using. The anti-doping movement is an effort to cre-
ate a fourth alternative: compete clean with a reason-
able assurance that their fellow athletes are likewise
refraining from doping. This is the ‘level playing
field’ athletes seek [2].
The fundamental insight from this research was that
the very competitiveness of sport gave doping great
coercive power. Athletes did not experience the deci-
sion whether to dope or not as an unpressured free
choice; if it was not being urged on them by trainers,
coaches or hangers-on, the typical athlete in a sport in
which doping was prevalent, nevertheless faced the
unpleasant alternatives described above. But, some
skeptics argue, the problem is not doping, it is the
effort to curtail it. They ask why should drugs like
AAS, erythropoietin or human growth harmone be
treated any differently than improvements in equip-
ment, diet or training regimens [3].
ª 2008 Blackwell Publishing Ltd 95
 T. H. Murray
| Editorial Comment
A full response to this criticism, which can take many
forms, is beyond the scope of this article. But two
observations are worth making. First, every sport
must make decisions, embodied in its rules and cul-
ture, as to what differences among competitors will
be permitted. A modestly talented roller blader could
cover the course of a marathon faster than the swiftest
runner, but roller blades are banned because they dis-
tort the meaning of the marathon. Athletes could of
course organize a roller-blading marathon, but that
would be a different sport than the marathon we now
admire. It is neither unreasonable nor irrational to
draw a line between good nutrition, which is encour-
aged, and powerful pharmacological ergogenic agents,
which are banned. Those drugs and synthetic biologi-
cals have the power to distort a sport much like roller
blades in the marathon; this would be sufficient rea-
son to prohibit them. They also would pose a public
health risk if the performance principle – the quest for
maximum performance by any means at any cost –
were to triumph.
Antidoping efforts are vulnerable to the criticism that
they may be unacceptably paternalistic. Paternalism is
roughly doing something to or for another person for
their benefit but without regard for that individual’s
preferences. Telling adult athletes who compete in a
dangerous sport such as Alpine skiing that they
should not use drugs because they might hurt them-
selves may strike many people, athletes included, as
hypocritical. The risks of descending a steep slope at
speeds in excess of 100 km h)1 are more immediate
and urgent than the possibility of some long delayed
side effect from doping. But the situation of doping
in sport is not the usual sort of paternalism. For one
thing, athletes’ choices are far from free and uncon-
strained. As in an arms race among nations, the
actions of each agent push the others towards ever
riskier and more wasteful decisions. In addition, the
potential for a public health catastrophe is clear if all
barriers to doping were flattened. Athletes would be
driven to try ever larger doses of a multiplying array
of drugs and biologicals in novel combinations. No
knowledgeable physician or scientist could view this
scenario as benign. The precise potential for harm is
impossible to predict, but that many athletes – young
96 ª 2008 Blackwell Publishing Ltd Journal of Internal Medicine 264; 95–98
and healthy for the most part – would do significant
damage to their long-term health, is a nearly inevita-
ble outcome. Antidoping is a public health measure,
not a case of indefensible paternalism.
Essential elements of a successful antidoping
program
Implicit in Catlin and Ljungqvist [1] study are five
elements necessary for a successful antidoping pro-
gram: adequate analytical capacity; a smart sampling
strategy; a trustworthy adjudication process; research;
and a solid foundation of clear principles and trans-
parent process.
Adequate analytic capacity
From gas chromatography (GC) through immunoas-
says to the linkage of GC and then liquid chromatog-
raphy with mass spectrometry to the measurement of
carbon isotope ratios, laboratories have made signifi-
cant progress in their ability to detect the use of drugs
and biologicals. No less important are the improve-
ments in laboratory practices and the sharp upward
trend towards standardization and certification.
Smart sampling strategy
It does little good to test at the time of competition
for a drug used during the training process and long
since metabolized and excreted. Unannounced out-of-
competition testing coupled with information as to
athletes’ location is an essential component of testing
if doping is to be discouraged. Access to blood sam-
ples and to forward looking profiles such as biological
‘passports’ whether required or voluntary provide new
avenues for understanding and detecting manipula-
tions and for protecting clean athletes.
Trustworthy adjudication process
Athletes who compete clean deserve an adjudication
system that reliably acquits the innocent and sanctions
cheaters. Catlin and Ljungqvist [1] detail a mixed his-
tory that includes several less reassuring episodes: five
of sixteen positive tests for AAS lost to ‘accidental’
 T. H. Murray
| Editorial Comment
shredding of codes in the 1984 Los Angeles Games;
samples with traces of AAS not pursued by adminis-
trators in the 1996 Atlanta Olympics; and an athlete
in the 2004 Athens Games for whom flow cytometry
found evidence of blood transfusion, but who escaped
sanction because of a ‘sampling handling mishap’.
With the increased role of WADA and the Court of
Arbitration for Sport, the future of adjudication looks
promising, but trustworthiness is arduous to build up
and easy to destroy. Athletes deserve an adjudication
system that is fair, open and reliable.
Research
For decades, antidoping researchers had few if any
reliable sources of funding. WADA now devotes over
a quarter of its budget to research giving investigators
opportunities to improve current analytical strategies
and anticipate new challenges such as gene doping or
the novel methods for enhancing the oxygen-carrying
capacity of blood described by Catlin and Ljungqvist
[1].
Solid foundation of clear principles and transparent
process
Where confusion and cynicism reign, those who want
to do the right thing are left feeling alone and unsup-
ported. It is vital that the antidoping movement be
clear about why doping is wrong and have an open,
accountable and principled process for deciding what
is prohibited and what is permitted. The WADA List
Committee process is a significant positive develop-
ment towards this goal.
Challenges
New scientific developments such as the discovery of
an allele affecting testosterone metabolism pathways
[4] or the future prospect of genetic manipulation of
athletes [5], demand an antidoping system that is sci-
entifically sophisticated, robust and capable of swift
response. The elements of such a system are now in
place. In addition to these scientific and technical
challenges, three other strategies will be vitally
important.
ª 2008 Blackwell Publishing Ltd Journal of Internal Medicine 264; 95–98 97
First, it is imperative that sport build upon its recent
movement towards focusing on the doping infrastruc-
ture that enables and encourages athletes to dope. The
Hastings Center’s research showed the importance of
this strategy 25 years ago. Athletes should be held
responsible if they cheat, but we must also hold
accountable the distributors such as BALCO, the
chemists who devise new compounds to evade detec-
tion such as tetrahydrogestrinone and coaches or train-
ers who make drugs a part of their athletes’ regimens.
Sport must find ways to identify and sanction such
enablers.
Second, athletes have the most to lose when their
competitors are cheating. We must continue to engage
athletes as active partners and leaders in the fight
against doping. There are hopeful signs. Cycling, a
sport suspected of rampant doping, now has organiza-
tions such as Team Slipstream ⁄ Chipotle that are com-
mitted to training and racing without doping, and
subject their athletes to regular blood tests to establish
physiological baselines against which the perturba-
tions caused by manipulations could be detected.
Finally, the discourse about the spirit of sport and the
ethics of competition and doping needs to be kept
fresh and vigorous. New challenges to ethics con-
tinue, with arguments that question whether antidop-
ing is justifiable or feasible. Those arguments deserve
to be heard respectfully and responded to forcefully.
Conflict of interest statement
No conflict of interest was declared.
T. H. Murray
President and CEO, The Hastings Center, Garrison, NY,
USA
References
1 Catlin DH, Fitch KD, Ljungqvist A. Medicine and science in
the fight against doping in sport. J Intern Med 2008; 264: 99–
114.
 T. H. Murray
| Editorial Comment

2 Murray TH. The Coercive Power of Drugs in Sports. Hastings
Cent Rep 1983; 13: 24–30.
3 Fost N. Banning drugs in sports: a skeptical view Hastings Cent
Rep 1968; 16: 5–10.
4 Schultze JJ, Lundmark J, Garle M et al. Doping test results
dependent on genotype of UGT2B17, the major enzyme for tes-
tosterone glucuronidation. J Clin Endocrinol Metab 2008 [Epub
ahead of print].
5 Miah A. Genetics, bioethics and sport Sport, Ethics and Philoso-
phy 2007; 1: 146–158.
Correspondence: T. H. Murray, President and CEO, The Hastings
Center, 21 Malcolm Gordon Road, Garrison, NY 10524, USA.
(fax: +1-845-424-4545; e-mail: murrayt@thehastingscenter.org,
http://www.thehastingscenter.org).

98 ª 2008 Blackwell Publishing Ltd Journal of Internal Medicine 264; 95–98

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