BJSM is said to be paternalistic and is usually justifi ed on the grounds that others, in this case, healthcare professionals, possess better, or more knowledge about an individual’s best interests than the individual concerned, or that he/ she is incapable of making informed choices. Where the actions of others are thought to be involuntary or unwittingly taken and will lead to their harm, or when time is needed to check that this action is indeed voluntary, then intervention is permissible. This is often called ‘soft paternalism’. We object to hard paternalism, which is interference in the voluntary and informed choice of another. We hold that mandatory exclusion of at-risk athletes with the aim of preventing SCD requires the use of unjustifi able hard paternalistic restrictions. There are several possible objections to our position against the mandatory exclusion of athletes which we will present and discuss. The fi rst objection is that many people who have a positive screening test are not competent to choose whether or not to participate. Objectors might agree that competent individuals should be left to make their own decision, but some being screened are minors and therefore not legally competent, so a conservative response should be taken to prevent them from taking risks. This could be justifi ed under soft paternalism. Although we agree that some very young people will not be competent to make such a decision, the true number is likely to be low. Many young teenagers are able to make reasoned and sensible choices, including accepting or declining medical treatment, and this is not necessarily age dependent. This concept is accepted in law where we may consider a young person to be Gillickcompetent, meaning that despite their age, the young person may be judged capable of making a reasoned decision. (The Gillick principle was developed in relation to young girls being able to decide on contraception.)14 Therefore, we should not be too hasty in considering young people incapable of weighing up evidence for themselves. The next objection might be that an athlete’s decision making is not voluntary (or not voluntary enough) when we consider the pressures extant in competitive sport, particularly at the elite level. Athletes are under pressure to compete from coaches, teammates, family and others, and this may result in someone making a decision they would not necessarily wish to make. Pressure to compete can be pervasive and systemic in competitive sports and can distort risk perception.15 However, the existence of pressure does not necessarily render the decision involuntary. Pres18 Sport & Geneeskunde | juni 2012 | nummer 2 sures can and should be managed appropriately in potentially coercive environments. Care must be taken to ensure that the decision is suffi ciently voluntary, particularly where the risk element is high and the harm posed is irrevocable.13 In the case of potential SCD, the possible harm is nearly always irrevocable, and the risks may be considered relatively high so that it is important that athletes are provided with full information about the risks and options associated with participating with their condition, and given time and space to make such a decision. Here, an effective relationship with a doctor is invaluable in providing a clear healthrelated focus in the face of pressures to participate. Despite such a relationship and the existence of risk, the values that give shape to an athlete’s life may lead some to a decision that may be at odds with medical advice. Interference with such a voluntary and informed decision is a case of hard paternalism and is therefore unjustifi ed. Objectors may also argue that SCD (especially when televised) causes harm to others and therefore we can legitimately intervene in such circumstances. A legitimate restriction, using ‘harm to others’ arguments, is the suspension of an impaired airline pilot. This action is justifi ed when we consider how many lives would be lost or harmed if an impaired pilot remained in active service. It is hard to see how stopping an athlete from playing sport could prevent comparable harm to others. Nonetheless, objectors might argue that emotional harms are suffered by the millions who may witness an SCD, and the aggregate of these harms could be considered to be greater than that suffered by an individual excluded from participation. We reject the aggregation argument because to take this seriously would lead to absurd positions. Any nasty sports injury, such as broken limbs, that is witnessed by others could potentially lead to incalculable amounts of harm to a vast number of people. To avoid this, our only recourse would be to ban sport or spectators, both of which are unacceptable. Objectors may challenge the harm principle itself, suggesting that the presence of existing laws that limit selfendangering choice indicates that the harm principle is not inviolable, thereby setting a precedent for interfering in the lives of others. Objectors might point to laws that set conditions on individual actions, such as laws in many countries that force the use of cycle helmets or Seatbelts, suggesting that these are imposed in an effort to stop harm we might do to ourselves. These laws do in effect stop people from taking unnecessary risks by reducing the risks involved, but do not prevent participation in the activity. Such laws are Pagina 17
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