A Comment from Dr. Matuszak on Concussions and the NFL
An Espn.com story this week highlighted an anonymous NFL Nation survey of 320 players where 85 percent said they would play in the Super Bowl with a concussion.
Both on the surface and in the undercurrents, this is a fascinating topic. Is this a selfless act, a case where someone is truly acting altruistically, like the squirrel who screeches out an alarm at the sight of a hawk, allowing others to find shelter at a personal cost of making itself a target, or like bees launching kamikaze-like attacks against attackers of the hive? Or is this the ultimate in selfishness, putting pride, jealousy, or fear of losing playing time above the team good? Is this more about ego, with the athlete believing that even at less than 100% they are still better than their backup? Or is this about self-doubt, believing their backup is better than they are? Is this about machismo or about feeling less of a man?
Clearly, there are a number of external factors involved, such as financial gain and coach, team, family and public expectations, so it is difficult to know what is driving a decision. But it is notable that at the same time NFL retirees are fighting a beleaguered battle in court suggesting they were not protected enough against the ravages of head injuries resulting in chronic traumatic encephalopathy with its twin scourges of memory loss and psychiatric illness, a new group of players, who should be quite aware of the long term implications of brain trauma, are, through their actions and words betraying the very tenants and underpinnings of the retirees lawsuit. Yet another recent survey showed that current players are much more concerned about the health of their knees than the health of their brains.
We hold certain ethical tenants in medicine that guide our actions. In some cases, the tenants are diametrically opposed, like the irresistible force and immovable object. The first is called Autonomy. The principle of autonomy has been defined as “self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice.” [1] In other words, it means the person is free to determine the chosen course of action, but needs to be able to clearly understand the risks and benefits of each choice. Even if the well-informed choice seems to be disruptive to health and well-being, the physician should respect the patient’s decision, while counseling them or trying to convince them otherwise. In a case of complete autonomy, the football player would be able to decide whether or not to participate in a game while injured after being counseled and thoroughly understanding the risks.
The second principle in medical ethics in play in this scenario is called Beneficence. Beneficence is an action that is done for the benefit of others. In medicine, our role is to prevent and remove harms to a patient and weigh and balance possible benefits against possible risks of an action or inaction. An example of beneficence is a physician recommending you stop smoking. In the case of the football player with a concussion, our role as medical professionals is to reduce the risk of further harm from continuing to play, where we hold a player out “in their best interests.” The retired players’ courtroom arguments primarily involve the idea that the league and the team physicians did not act in the players’ best interest and they have long-term complications as a result of this lack of beneficence.
Unfortunately, we cannot fully quantify the risks for a concussed individual returning to sport. We do know they have worse reaction time and this increases the risk for another injury, either to the head or to another body part, such as a knee. We also know that if a brain is still recovering and suffers another injury, the person has a much greater risk of having longer lasting symptoms or post-concussive syndrome.
Reportedly, Sidney Crosby was symptomatic for 10 months following his second injury in a matter of days. With younger individuals, there is also a risk of sudden onset brain swelling from another injury, a phenomenon known as second impact syndrome that usually results in sudden death. Although this has not been described in professional football players or adults, there are other conditions, like brain bleeds, that could be present and could result in severe and permanent neurologic impairment or death.
Several studies have shown that having a concussion impairs a person’s ability to perform basic tasks such as driving a car, walking a straight line, or even touching their finger to their nose. The effects can be quantified and show a similar effect to drinking alcohol. It is unclear whether an athlete in such a state should be permitted to make decisions that are clearly not in their best medical interest when they are impaired in this manner.
The American Medical Association’s Code of Medical Ethics subsection on Sports Medicine provides a framework for handling these types of cases by stating the physician’s role is to “protect the health and safety of the participants” and suggesting the desires of the injured athlete should not be controlling. Also, several court cases have supported the decision making power of the team physician to withhold an athlete from sports against their wishes. This is somewhat different than other aspects of medical care where we routinely allow patients to make decisions against our better judgment, decisions to not treat illness, or even in some states to assist in suicide.
As a sports medicine physician, my role is to put the athlete’s health and safety above all, this is why we have develop our Play Safe Program and offer Baseline Concussion testing for all young athletes. As a person, I sympathize with the plight of the injured player trying to fulfill their lifelong dream of playing in a Super Bowl. Who is correct? Maybe neither.
———-
[1] Med Health Care Philos. 2006 December; 9(3): 377–388.
