For those unaware of it, Virtual Mentor is the American Medical Association’s green open-access medical ethics journal.  IMO, it is quite good, and it has an extensive library of cases with expert commentary that is extremely helpful in teaching ethics in medical and health professional education.

The July 2014 issue addresses the theme of Ethical Issues in the Physician-Patient Relationship, and includes a case entitled Evaluating the Risks and Benefits of Participation in High-School Football.  Commentary is provided by Michael J. O’Brien & William P. Meehan III.

The case involves 15-year-old Jesse, who wants to play high school football.

Jesse’s mother speaks up. “I’ve read that they’ve started placing sensors in players’ helmets, and they show that a lot of these boys are taking pretty hard hits. They say that concussions are actually more harmful than we knew about back in our day, and that over time all these head injuries could really cause damage to the brain. I’m worried, because Jesse’s already had one or two concussions in the past. Should we really let Jesse play football?”

Jesse’s father does not seem to share his wife’s concern:

Jesse’s father shakes his head and interjects: “Jesse’s brothers played high school football, and they got banged up pretty bad, but they’re fine. One of them has a scholarship to a good university, and he’s still playing football. I played the game myself when I was in school and it taught me a lot of important life skills—skills that served me as a unit leader in the Army and that I still use in running my business. I want Jesse to have the chance to play on a team and learn the value of sportsmanship. More important, I don’t want him hanging around after school with these other kids who are doing drugs and getting into trouble.”

The case and the analysis are detailed, thoughtful, and well-worth reading.  Naturally, I disagree with the reasoning and the conclusion completely, so let’s take a look.

The commentators deploy a principlist framework in their analysis:

In order to respect the family’s autonomy, Dr. Gupta must allow them to make an informed and free decision regarding the risks they are willing to accept in order to achieve the benefits of participation in football. The principle of beneficence, however, mandates that Dr. Gupta act in the best interest of Jesse’s health. This is a classic conflict that arises frequently in the field of sports medicine.

In the interests of full disclosure, I should note that I am decidedly not a fan of principlism in applied ethics in general.  There is an extensive literature critiquing the framework, so I will not belabor the point here, though I may blog about in the future.

Wherefrom does the value conflict derive?

O’Brien and Meehan argue that the patient’s right to self-determination may conflict with what is in the best interests of the patient (i.e., not subjecting his brain to the risks of American football).  The commentators do an excellent job of summarizing mTBI science, what is known and what is unknown — the latter being a much larger set than the former.

But O’Brien and Meehan argue that the principle of beneficence cuts both ways:

Jesse’s father, on the other hand, rightly notes the benefits of participation in team sports, focusing on social benefits such as sportsmanship. The health benefits of regular exercise are well known, including reduced rates of all-cause mortality, cardiovascular disease, hypertension, rheumatoid arthritis, fibromyalgia, metabolic syndrome, type 2 diabetes, breast cancer, colon cancer, chronic fatigue syndrome, and depression.

I hear this argument in context of American football all of the time, and IMO it is a non sequitur.  The very real benefits of sports and exercise are not specific to American football.  It is a false choice indeed to pose the decision as between “risk of brain injury” and “risk of insufficient exercise.”  It is obviously possible to play sports and engage in exercise that, to the best of our limited knowledge, seems to pose lower risks of traumatic brain injury than what the evidence increasingly suggests as to American football.  Consequently, it is not legitimate, IMO, to include the health benefits of participation in sports and exercise as the benefits to be weighed in the decision calculus of whether the patient here ought to play high school football.  Where sports and exercise can presumably be engaged in myriad ways other than participation in American football, the only ethical principle relevant here is the wishes of the patient and the family, not a set of benefits that remain open to the patient even if he does not play football.

This point matters because the existence of these real but highly nonspecific benefits figure centrally in the commentators ultimate decision:

The risks of participation in football, particularly the cumulative effects of concussion and chronic traumatic encephalopathy, are not fully clear. Dr. Gupta cannot reliably predict whether or not Jesse will sustain further concussions, whether those concussions will have a significant effect on his future well-being, and whether or not the subconcussive blows he is likely to sustain while participating in high school football will result in long-term consequences. Thus, it is unclear whether the decreased risk of injury associated with prohibiting Jesse from playing football outweighs the benefits to his health and well-being of allowing him to participate.

But the balancing analysis in the final sentence is ill-advised, IMO.  The balance the moral agents ought to undertake is not between the decreased risk of injury associated with a prohibition on football play and the benefits of participation in football, because the vast majority of the benefits of such participation can presumably by captured by other athletic endeavors that likely do not pose such substantial risks.

While O’Brien and Meehan correctly note the extensive uncertainty in our capacity to understand the risks posed by playing American football, such does not preclude our responsibilities as moral agents to interpret the evidence as best we can and weigh the risks relative to other choices.  In fact, as to health care providers, such is really the primary reason why people seek out the advice of health care professionals to begin with, and simply is a restatement of the basic problem of evidence-based medicine itself.  IMO, the limitations of our knowledge do not prevent us from examining the evidentiary trends and drawing plausible inferences about relative risks — i.e., that, while sports participation of any kind likely involves risks, some pose lower risks of traumatic brain injury than others, and American football without question ought to be regarded as within the category of the very highest risk, especially to children and adolescents with developing brains.

IMO, O’Brien and Meehan’s conclusion based on this evidentiary uncertainty is unpersuasive.  They argue that

Because there is no unusual risk in this case, respect for the family’s autonomy outweighs any potential net benefit, if indeed there is one, to prohibiting Jesse from playing.

The phrase “no unusual risk” is doing a lot of rhetorical work in the argument.  O’Brien and Meehan go on to explain what they mean by it:

If there were a clear history of unusual risk or vulnerability (for instance, if Jesse had a history of multiple concussions occurring with decreasing force, injuries that were taking longer and longer to recover, or incomplete recovery) then it would be the responsibility of the physician to step in and insist that Jesse be disqualified from contact sports.

But this is a skewed sense of what “unusual risk” means.  The evidence, as uncertain as it is, strongly suggests that participation in American football itself poses unusual risks of serious long-term damage to neurological health, especially for age groups with developing brains.  To be sure, patients with the kinds of history (multiple concussions, incomplete recoveries, etc.) the commentators note likely pose increased risks above what a player without that history demonstrates, but this simply begs the question regarding the proper baseline for the ethical evaluation.  That is, we ought not assume that the proper standard for comparison is “player without history of past injury playing football” vs. “player with history of past injury playing football.”  The proper baseline for comparison is instead “player participating in sports other than American football.”  We are eminently justified in concluding that playing American football poses unusual risks.  If there are additional variables that seem to increase the risks of play, that is ethically relevant, but it skews the analysis to imply that a player presenting without these additional variables is somehow experiencing “no unusual risk” by participating in American football.

Playing American football presents an unusual risk of long-term neurological injury.  By itself this fact does not mean that a physician examining the patient here ought to prohibit his patient’s play.  Indeed, as I have noted, whether children and adolescents ought to play American football is an extraordinarily complex and difficult question, and I have no interest in legislating and even less qualification to legislate an universal answer to this question.  But the process by which we go about weighing and analyzing the question is important, regardless of the answer to which we arrive.