WHY WE SHOULD ALLOW PERFORMANCE ENHANCEMENT IN SPORT

Executive Summary

  In this submission, we will argue that performance enhancement occurs, it is not against the spirit of sport, and that we should remove anti-doping legislation to permit safe performance enhancement. We should focus more on testing athletes' health and fitness to compete.

  1.  What is wrong with doping? The key idea is that it is against the spirit of sport. It is cheating, not merely because against the rules but because against the spirit of sport. The The World Anti Doping Agency's Code says explicitly that all "[d]oping is fundamentally contrary to the spirit of sport".

  2.  What is sport? Sport is defined variously as:

—  "recreational or competitive activities that involve a degree of physical strength or skill";

—  "sports are an invention" by homo sapiens cf play or hunting;

—  "physical contests performed for their own sake and not for some ulterior end"; and

—  "since sports are an invention, a part of culture rather than an aspect of nature, all definitions of sports are somewhat arbritrary." (Encylopaedia Brittannica).

  3.  For our purposes, sport can be defined as the pursuit of human physical excellence (skill or strength) in a rule governed activity.

  4.  The rules of sport are: (1) arbitrary; (2) define the nature of the activity to bring out the display of certain skills or strengths; (3) allow for meaningful comparison in competitive sport to determine who is better.

  5.  Human excellence has typically been biological endowment plus training to realise own innate biological potential.

  6.  There are many different good reasons to choose or amend the rules of a sport:

—  To bring out or develop a particular set of skills, strengths or physical excellences.

—  To facilitate meaningful competition.

—  To promote or protect health.

—  To provide spectator interest.

—  To increase its lucrativeness.

—  According to some cultural or historical precedent.

—  To allow historical comparison.

  7.  Performance enhancement using drugs or other doping agents is against the spirit of sport if sport is the of natural ability/talent in a rule governed activity.

  8.  There is no reason sport must remain purely a test of natural ability.

  9.  WADA's Code allows some performance enhancing drugs. Caffeine is not illegal, even though it can strongly increase performance. In endurance sports, caffeine helps to mobilize the fat stores of an athlete. [12]It can make as much as a 20% difference in the time to exhaustion among competitive athletes, depending on how the trial is performed. In the context of elite sport, that is a massive difference. Dietary supplements such as creatine are also legal on this 2-out-of-3 rule, and they also strongly influence performance. Creatine is similar to the banned drug EPO—in that it supplements an endogenous substance. Two different double-blind studies found that the time to exhaustion in anaerobic exercise could be increased by over 10% through the use of creatine.[13], [14]The reason that these performance enhancers are permitted is because they are safe. It is inconsistent not to allow other performance enhancers if they are safe enough.

  10.  Some high tech training techniques produce exactly the same effect as doping. Altitude training and hypoxic air tents both raise haematocrit by stimulating the body to produce erythropoietin (EPO). This has the same effect as blood doping (autotransfusion) or administering EPO. The former are permitted, while the latter are not. This is inconsistent.

  11.  Classical musicians are allowed to use drugs such as beta blockers to remove tremor and increase performance. This does not corrupt the spirit of their performance. Rather, it is seen as facilitating better and more desirable performance.

  12.  Humans are different to other animals and human sport is different to other sports involving animals. Humans are autonomous, capable of making evaluative judgements and capable of deciding what kind of sportsperson to be. The human spirit is to choose to be better and to modify oneself to improve one's performance. It is consistent with the human spirit to allow sportspeople to make choices about performance enhancing modifications, if these are safe enough. While animal sport may be a brute test of genetic potential, human sport could be a test of the whole person, including their capacity to make their own rational decisions about what kind of competitor to be.

  13.  Sports evolve over time. We have allowed changes to sport over the years. In tennis, large head tennis racquets changed the game. This allowed players to hit the ball harder from a wider range of places on the court. Ultimately, this, together with other changes to game, reduced the spectacle as male players were hitting, particularly serving, the ball so hard that there were no rallies. Subsequently, the pressure of the balls was reduced. The increase in the size of the racquet head was allowed because it was thought to be in the spirit of tennis at the time. However, double strung tennis racquets were never permitted. They would have allowed too much spin and would have radically changed the game.

  14.  In general, as human beings, we are biased in favour of small, gradual change and against large or dislocated changes. We are likely to accept small, gradual enhancements rather than radical and profound ones. There may be no moral reason for this but it seems important to people to keep some thread of continuity in the nature of a particular support. However, such a thread can be maintained while allowing small to modest enhancements.

  15.  Performance enhancement is not necessarily against the spirit of sport.

  16.  There are four positive reasons to allow safe performance enhancers in sport. Firstly, current prohibitionist policy has failed. Only around 10-15% of athletes are tested. There are enormous pressures to win. Many modern doping agents like EPO and growth hormone mimic natural hormones and are extremely difficult to detect. As gene doping becomes more efficient, it is likely to offer great opportunities for doping in sport and is likely to be very difficult to detect. For example, Insulin-like growth factor injected into the muscles of mice increases strength. Direct injection into the muscles of athletes would be simple and very difficult to detect as DNA would be taken into muscle DNA, requiring muscle biopsy (which is dangerous and difficult) to detect it. Vascular endothelial growth factor stimulates the development of new blood vessels and could also be of use to athletes in the future. EPO genes could be directely integrated into host DNA. Since gene therapy works in animals now, there is no reason why it could not be attempted by athletes now.

  17.  The second reason is that it would be fairer. The present system of doping controls disadvantages the honest athletes who forego doping. Cheaters are rewarded. Cheating is against the spirit of competitive sport. If performance enhancers were allowed, cheating would be eliminated. Athletes do not cheat when they take legal performance enhancers like caffeine or creatine.

  18.  The third reason is that it would reduce risk to athletes. The present system creates an environment of risk to the athlete. Since nearly all doping is illegal, the pressure is to develop undetectable performance enhancers with no mind to safety. Performance enhancers are produced on the black market and administered in a clandestine, uncontrolled way with no monitoring of the athlete's health. Allowing the use of safe performance enhancers would make sport safer as there would be less pressure on athletes to take unsafe enhancers and there would be a pressure to develop new safe performance enhancers.

  19.  Allowing safe performance enhancers would not eliminate risk to athletes' health but it would reduce it. Some would still cheat, and seek an advantage through the use of unsafe, illegal enhancers. But it would narrow the gap between the cheaters and the honest athletes. By allowing some (safe) performance enhancement, honest athletes get closer to the level of the cheaters. If this were coupled with greater focus on evaluating fitness to compete and health, as suggested below, rather than drug detection, there would be an even greater improvement in athlete health.

  20.  Allowing safe performance enhancement would reduce what has been called "soft coercion" in sport. Coercion occurs when a person is compelled to accept an option that makes him or her worse off than she would otherwise have been, if the option had not been presented. "Your money or your life" is an example of coercion because the person typically prefers to have both her money and her life, but she is forced to accept something which is worse than what she had and could have. Safe performance enhancement is not a coercive offer: being able to perform better without unreasonable risk to health is a benefit not a burden. Unsafe performance enhancement can be a coercive offer, but this is precisely what is encouraged by preventing all doping as we currently do. If we are concerned to reduce coercion, we should allow safe performance enhancement. Offering safe performance enhancement is no more coercive than offering prize money.

  21.  A "Real World Anti-Doping Code" would allow safe performance enhancing interventions. It would have three major planks.

  22.  Firstly, we should develop safer performance enhancing drugs or interventions. These need to be as effective as riskier options. Ideally, they need to be no more effective when taken in harmful megadose quantities. They need to be provided at a competitive price.

  23.  Secondly, we should focus detective efforts on unreasonably risky drugs and practices.

  24.  Thirdly, we should test health of athletes and fitness to compete. It is far easier to test haematocrit (the amount of red blood cells in the blood), and set a safe level (such as 50%) and ban anyone who is above that level and at risk, than it is to detect the cause of that elevation, which could be natural, autotransfusion, use of hypoxic air tent, gene doping or exogenous EPO. We should test heart structure and function, which has been recommended even with high levels of training. We could also test immunocompetence and testosterone levels and joint structure and function. In Melbourne, boxers are excluded from competition if they have measurable brain damage on magnetic resonance imaging.

  25.  The question is: what risks should athletes be exposed to? It is not: what is the origin of that risk? Setting the acceptable risk level for performance enhancing drugs should be consistent with the magnitude of risk which athletes are allowed to entertain in elite sport.

  26.  Elite sport can be extremely harmful. Even clean elite athletes have to accept serious harms to be competitive. These risks are usually reduced or absent in amateur competition, so just like drug risks, they are risks which are extrinsic to a sport—they are not a necessary part of the sport. There is nothing special about a drug-related risk which demands that we intervene, when we permit these unnecessary non-drug risks to exist.

  27.  One group has written that there is a limit to human cardiac adaptation to sports training, placing some athletes at risk of sudden cardiac death. [15]This risk is elevated if exotic training schemes are undertaken to increase hematocrit, such as altitude training or hypoxic tent training.

  28.  Athletes who are stressed or overtrained also suffer a depletion in their immune systems.[16], [17]Normal amounts of exercise increase the effectiveness of a person's immune system. But when we begin to overtrain, the effect is reversed. In elite sports, athletes are at heightened risk of infection.

  29.  One Norwegian study found 15% of gymnasts were anorexic. [18]Christy Henrich is one example: she was an American gymnast who died of multiple organ failure when she was 22 from anorexia.

  30.  Gymnastics is not the only sport with unbreakable body-shape requirements—even horse-riding and motor sport have weight restrictions. Some elite sports require an unhealthily large body shape. Sumo wrestlers and some American footballers suffer dramatically increased mortality from weight-related causes. Emmanuel Yarborough is a sumo wrestler who weighs 390 kg—this weight is not healthy.

  31.  Dysfunctional eating also seems to create a high incidence of menstrual dysfunction and stress fractures in female athletes. The rates are shockingly high—Beals studied a group of female college athletes and found that 37% had suffered some form of menstrual dysfunction, and 37% had suffered a stress fracture. [19]

  32.  A number of sports have a high risk of Mild Traumatic Brain Injuries—boxing and football are predictable examples, but also skiing, snowboarding, cycling, and horse-riding. [20]One group found that the brains of athletes with these injuries couldn't be differentiated from the brains of people who were abusing recreational drugs. [21]

  33.  Depending on the sport, at elite levels athletes are always at high risk of some sort of accidental injury. In American football there is nearly one "significant" injury per game—meaning it caused them to miss at least one game. [22]

  34.  In the Australian Football League from 1997 to 2000, teams of 40 players had around 40 new injuries per season. [23]Playing these sports at an elite level commits you to about one injury every year. If a drug had this kind of risk factor, it would bring about a major witch-hunt. But these baseline risks are imposed on every athlete who accepts a place in one of these teams. Some sports have chronic health conditions in almost every elite participant—for example, top-tier trampolinists have an 80% incidence of stress urinary incontinence. [24]

  35.  Injuries are not limited to ankle sprains or concussion either. From 1990 to 1999, 14 people died playing Australian Rules football, mostly from brain injury following collisions between players. [25]None of the deaths were drug-related. Australian Rules is a comparatively dangerous sport, but it comprises only a tiny fraction of the total number of sportspeople worldwide who play high-impact, contact sports. It is difficult to ascertain the number of deaths caused by anabolic steroids every year worldwide, but to be comparable to the baseline risk of injury in elite contact sports, there would have to be hundreds or even thousands of such deaths every year. It doesn't seem like there are anything like that many.

  36.  Playing sport at an elite level is not suicide, but neither is the use of growth hormone. To be sure, elite athletes are probably more healthy on the whole than any morbidly obese person. But elite athletes in some sports can expect to have a serious medical problem every year or two. This is not true of EPO, taken at sensible dosage.

  37.  Elite sport without performance enhancing drugs is not safe. It will continue to get less safe as athlete wages go up, and they push the performance limits harder and harder. It is not made significantly less safe through the use of existing performance enhancing drugs, even if everyone uses them. It is inconsistent to crack down on drugs for health reasons when we don't mind if athletes consent to be injured all the time.

  38.  If we are concerned about health, we should evaluate health. It is far easier to test haematocrit, or the red blood cell level in the blood, than it is to try to detect EPO or whether someone has been using a transfusion machine. We can set a safe limit, say 50% as is the case in cycling, and allow anyone to compete who is below that and ban everyone who is above that, for whatever cause, because it is unsafe to compete. We can evaluate heart size and function, heart rhythm and other cardiac parameters and disqualify athletes who are at risk, whether the cause is natural variation, training or use of steroids or growth hormone. And we could consider the limits on damage which will have later effects—we could evaluate joint structure and function and disqualify athletes if they were likely to get arthritis in the future, if we thought that health was very important.

  39.  It is sometimes objected that allowing performance enhancement is unfair and we want "a level playing field." However, sport is a test of genetic inequality. The starkest example itws the Finnish skier Eero Maentyranta. In 1964, he won three gold medals. Subsequently it was found he had a genetic mutation that meant that he "naturally" had 40-50% more red blood cells than average. [26]There is no good reason to privilege genetic inequality.

  40.  Allowing performance enhancement need not discriminate against poorer countries. The cost of a hypoxic air machine and tent is around US$7,000. Epogen (EPO) costs the athlete about US$122 per month. Drugs may be cheaper than expensive training facilities that achieve the same effect.

  41.  In sum, performance enhancement is not against the spirit of sport; it is the spirit of sport. To choose to be better is to be human. Concern for athletic welfare should be paramount. But taking drugs is not necessarily cheating. The legalization of drugs in sport may be fairer and safer. There is nothing wrong with an enhanced competition.

  42.  The limits to the use of drugs and other performance enhancers in sport should be on safety grounds, based on a consistent comparison with other risks taken in elite sport, and their use should not corrupt the nature of that activity (eg creating webbed feet or using flippers in swimming).

  43.  We should redirect scarce resources to protect athletes' health and be less concerned with whether some biological substance or intervention improves performance, per se.

May 2006

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