not solely there to minimise risk taking, but also to lessen the costs to a publically funded health system should a cyclist be knocked from the bike or a driver hit the windscreen at speed. This is not comparable with SCD where there are no on-going costs to society resulting from disability. The use of Seatbelts and cycle helmets are an attempt to mitigate the risks posed by particular activities. When we consider mitigating the risks posed by sports we focus on the use of safety procedures and protocols. For example, in motor sport, fire-resistant clothing, helmets and rollbars are standardly imposed on all drivers; in mountaineering, most mountaineers will adopt modern safety methods in an effort to mitigate risks involved with the terrain, the weather and the experience of the climber. Despite these attempts, we know that capable and experienced people will die. In contrast to sports where risk can be mitigated, the risks associated with cardiovascular abnormalities are not capable of being reduced in a similar way (there is no Seatbelt equivalent). Objectors may claim that because these risks cannot be mitigated, those with identified cardiovascular abnormalities should therefore be mandatorily excluded from competitive sport. Although we should take steps to reduce risk wherever possible, this does not lead to the conclusion that where this is not possible, the activity, or the at-risk athlete, should be banned. Life contains risk and we all differ in the levels of risks we are personally willing to accept and the activities we are willing to engage in. Challenging ourselves and pushing ourselves to the edges of our physical limits are valued in our society, and being free to do so is an important part of selfexpression and identity for some. The doctor’s role While we reject forcing or compelling someone into a course of action that another considers is ‘good’ for him, we also reject the other extreme of leaving the athlete unsupported in such decisions. A good relationship between a doctor and an athlete is centrally important in providing the information required by the athlete to make a decision. But, while the doctor can be the source of support and information, the ultimate decision is the athlete’s. The International Olympic Committee (IOC) supports this approach. Where physicians are carrying out periodic health evaluations (PHEs) of athletes, two important considerations are expressed: • If PHE evidences that an athlete is at serious medical risk, the physician must strongly discourage the athlete from continuing training or competing until the necessary medical measures have been taken. • Based on such advice, it is the responsibility of the athlete to decide whether to continue training or competing.16 (page 632) This position is reiterated by Dr Douglas in the 26th Bethesda Conference panel discussion. Her comments resonate with the IOC’s position when she states that ‘doctors are advisors, not decision makers’.17 Dr Levine also involved in the Bethesda discussion agrees, stating: I do not think that it is really the role or authority of the physician to literally “permit” an athlete to compete or alternatively to “exclude” an athlete from competition. It may be well meaning and benevolent, but I would regard this view as extending beyond the limits of the usual doctor–patient relationship because it removes from the patient the ultimate right of self-determination.17 (page 859) The IOC PHE Consensus Group acknowledges the ethical, medical and legal diffi culties associated with screening and subsequent disqualification, especially the unnecessary exclusion of ‘competitive athletes with non-lethal diseases’.16 (page 9) Objectors may suggest that it would be ethically problematic for a doctor to know about a risk of death and not have prevented it by excluding the athlete. The relationship, support and information that skilled medical practitioners provide help inform individuals in making life choices. By informing and educating the athlete of the risks involved with continued participation the doctor has acted ethically, and should not be held responsible for how someone chooses to live his/her life. This fits with the harm principle whereby we can educate or reason with people to encourage them not to engage in activities that might cause them harm, but the final decision rests with them. Conclusions A benevolent society is concerned with the interests of its citizens and in achieving this there are many aspects that such a society needs to consider. These include: • Caring about the health and well-being of its citizens. Therefore, doctors have a duty of care to consider the health needs of the population they serve. • Enabling citizens to be free to live the kind of life he/she chooses, as long as those choices are freely made by competent people, and their decisions do not directly harm others. In balancing these two aspects, a benevolent society is required to keep compelled interventions into the lives of others to a minimum. Medical practitioners have a role in screening for SCD. A robust SCD screening programme will nummer 2 | juni 2012 | Sport & Geneeskunde 19 Pagina 18
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