BJSM Sudden cardiac death Mandatory exclusion of athletes at risk is a step too far Lynley Anderson, Dan Exeter, Lynne Bowyer Br J Sports Med 2012;46:331–334. doi:10.1136/bjsports-2011-090260 Abstract Sudden cardiac death (SCD) in young athletes is a distressing event and it is not surprising that some physicians working with sports people are proposing that preventive action should be taken. There is a push for a system similar to that established in some countries, which involves screening and mandatory exclusion of those at risk. We argue that while screening can provide useful information to at-risk athletes making decisions about their future athletic careers, mandatory exclusion of athletes is paternalistic and such decisions are not rightfully within the domain of medicine. Introduction Sudden cardiac death (SCD) in a young athlete is a distressing event that is often witnessed by a large Audience. What makes SCD so distressing is that it strikes people in their prime and challenges our beliefs about the association between sport and good health. It is traumatic for the athlete’s family and community, and concerns have been raised that it may have the effect of discouraging observers and the general public from participating in sport and exercise. Consequently, it is not surprising that many people want to take action to prevent SCD. SCD can occur without any warning symptoms, so preventive intervention requires instigating a broad cardiac screening programme in an effort to identify those at risk. In some countries, national screening programmes are now in place.1,2 When initial screening suggests an abnormality, that athlete undergoes further investigations to confi rm a diagnosis. If an athlete is diagnosed with an SCD-linked condition, he/she is excluded from competition. Physicians in other countries are advocating for similar programmes. The broad principle for initiating a screening programme is to prevent harm to the individual who may be at risk of SCD. 16 Sport & Geneeskunde | juni 2012 | nummer 2 Maron et al have voiced this by stating, “there is general consensus that in a benevolent society, a responsibility exists on the part of physicians to initiate prudent efforts to identify life-threatening conditions in athletes for the purpose of minimizing the risk associated with the intersection of sports and cardiovascular disease.”3 (page 1645) . A benevolent society is concerned about the well-being of its citizens and where methods to identify life-threatening conditions exist, we should arguably make use of them. Doctors have a duty to identify and respond to the health needs of their community, and therefore we broadly agree that if a screening programme can identify health risks, it would be benefi cial to adopt it. There are, however, constraints on intrusive benefi cence. Maron et al go on to say that “The devastating impact of even relatively infrequent sudden death events justifi es restriction of young athletes from competition to reduce their risk related to silent and unsuspected cardiac disease.”3 (page 1652) (The term ‘young athletes’ refers to those younger than 35 years. Most screening programmes are aimed at athletes aged between 13 and 35 years). It is this statement and the basis for mandatory exclusion it expresses that is objectionable. There are two grounds on which we object to mandatory exclusion. The fi rst relates to our ability to accurately predict the risk of death during vigorous exercise for those individuals diagnosed with a condition that can lead to SCD. But more importantly, even if we could accurately predict the risk of death, mandatory exclusion is unacceptable medical paternalism. Decisions that limit the choices of an individual in this situation are not rightfully within the domain of medicine. Pagina 15
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