The Role of the Medical Profession in Boxing

CONTROVERSY 513

The not-so-sweet science defeat of Max Schmelling in 1938 J Med Ethics: first published as 10.1136/jme.2003.003541 on 5 October 2004. Downloaded from ...... united Americans of all races and stifled Hitler’s claim of Aryan super- iority. If a consequentialist position is The not-so-sweet science: the role of the adopted, based on a diachronic evalua- tion of boxing, then boxing should be medical profession in boxing permitted. It is tempting, for those unfamiliar D K Sokol with the sport, to interpret too literally the gruesome pre-fight threats of box- ...... ers. The animosity is rarely genuine; it is an essential component of the market- The medical profession’s role should be limited to advice and ing plan, as well as an exercise in information psychological intimidation. Dr Herrera’s assertion that fighters ‘‘can he medical establishment’s desire to other high risk sports, claiming that a even predict the killing before the fight, interfere with the autonomous boxer can kill his opponent without for the press’’ is irrelevant. The meta- Twishes of boxers seems at odds with breaking any rules whereas this is not phors of boxing are indeed more belli- the principle of respect for autonomy the case in other sports. This last cose than in other sports, but critics prevalent in contemporary biomedical statement is surely false. A hard hitting should interpret the metaphors as lin- practice. I argue that the role of the rugby tackle can propel a player back- guistic flourishes, not as literal expres- medical profession in boxing should be wards causing him to suffer fatal spinal sions of intent. A boxer who threatens solely an advisory and informational injuries. A cricket ball travelling at a 100 to ‘‘kill’’ his opponent in a pre-fight one. In addition, the distinctions made miles per hour and hitting a player’s conference (or ‘‘eat his children’’, as one between boxing and other high risk unprotected skull can cause death, notorious heavyweight recently said) is sports often rely on an insufficient although no rule is broken. The differ- no more intent on actually killing his knowledge of the sport. This leads to ence between boxing and those other opponent than a baseball pitcher who misdirected criticisms and excessive sports does not revolve around the legi- threatens to pierce the batter’s body emphasis on the colourful discourse of timacy of the act leading to the death with a lightning throw. He primarily boxing, as opposed to the practice of but, possibly, the intent of the agent wants a wider audience, and perhaps a boxing itself. Dr Herrera’s claim in his responsible for the death. A boxer psychological advantage over his oppo- article (see page 514) that boxing differs intends to inflict physical damage to nent. The discourse of boxing is separate from other sports in the acceptability of his opponent. A ‘‘knockout’’, referring from the activity itself, and an analysis its acts outside the realm of sport is to a boxer’s inability to stand up after a of the sport should not be confused with refuted.1 The importance of consent as a count of 10, is the ultimate goal in the an analysis of its discourse. legitimising factor is highlighted, and a sport. Yet even this is a moot point. Dr Herrera’s belief that boxing differs number of possible solutions to improve Many boxers will tell you that their aim from other sports by involving acts that safety within the sport are tentatively is to win the contest, not to reduce their would be frowned upon and, indeed,

suggested. opponent’s brain to a pulp. No boxer punishable outside the sport is, to my http://jme.bmj.com/ In the United Kingdom, a competent would rejoice at the severe injury of his mind, incorrect. It is usually unaccep- adult may legally refuse medical treat- opponent. Boxers could invoke the table to run towards a person on the ment, irrespective of the severity of his doctrine of double effect, claiming that street, wrap your arms tightly around condition or the validity of his reasons. death is foreseen but certainly not his legs and push him over with your With the pre-eminence of an autonomy intended. The intention is to win the shoulders, as occurs in rugby. Similarly, based model of bioethics, respecting a fight by outboxing the opponent, which it would be equally objectionable to patient’s wishes forms an integral part is not the same as knocking him out. A punch someone in the head while of acting in his best interests. It is boxer can win on points, by the surren- queuing in the supermarket. What on September 25, 2021 by guest. Protected copyright. puzzling, then, to find that the der of his opponent or of his coach, or by would render these acts acceptable, Australian Medical Association have the referee’s stoppage during the fight. however, is consent. Society allows two called for a ban on boxing on the In other words, a knockout is not consenting people to indulge in certain grounds that the activity is excessively necessary for victory. The other justify- activities, however morally repulsive to hazardous to the health of boxers. The ing conditions of the doctrine of double others, that would be unlawful if often mentioned principle of respect for effect could also be satisfied, although performed without mutual consent. If autonomy is abandoned once the person these would no doubt be contested by boxing is to be banned, then good drops the privileged title of ‘‘patient’’. those who see boxing as a social evil. reasons need to be given to show that This suggests that being a patient As an amateur historian of boxing, I boxing differs sufficiently from other confers certain rights which would not have little doubt that the sport, at least ‘‘dangerous’’ or ‘‘immoral’’ activities exist if that same patient were healthy. in the last 100 years, has done more that even informed consent is inade- How, if at all, can this apparent incon- good than harm, by giving hope to many quate to justify it. I am so far uncon- sistency be justified by those in the young men who perhaps initially had vinced by the reasons given by medical community who wish to see none, and encouraging them into gyms. opponents of boxing. boxing banned? I largely agree with Dr Boxing contests have also served to My own view is that the medical Herrera’s position on the matter, which symbolise broader social and political profession should inform boxers and is essentially that precautionary brain struggles. The first African-American those involved in the sport (coaches, scans should be performed but that heavyweight world champion, Jack referees, and so on) of the potential boxing should not be banned. A few Johnson, who fought in the first few dangers of boxing, as well as suggesting points, however, remain unclear. decades of the 20th century, was an ways to minimise the risks. The obliga- Dr Herrera criticises the frequent inspiration to African-Americans across tion stops there. The role of the profes- comparisons made between boxing and the country. Joe Louis’s resounding sion should be no more than advisory

www.jmedethics.com 514 CONTROVERSY

and informational—the changes need to often, boxing managers pitch their J Med Ethics 2004;30:513–514. J Med Ethics: first published as 10.1136/jme.2003.003541 on 5 October 2004. Downloaded from be made within the sport itself. Perhaps boxer against evidently better or inferior doi: 10.1136/jme.2003.004952 fights can be reduced from 12 rounds to boxers to keep flawless records or to Correspondence to: D K Sokol, Medical Ethics 10 or eight rounds, just as it was acquire a significant one-off pay cheque. Unit, Department of Primary Health Care and reduced from 15 to 12 a few years ago. More than discrediting the sport gen- General Practice, Imperial College London, Intervals between the rounds can be erally, it heightens the risk of serious Reynolds Building, St Dunstan’s Road, London W6 8RP, UK; [email protected] extended to allow greater time for injury for the sacrificial lamb whose recovery. Headgear can be improved to chances of winning are next to none. Received 21 May 2003 cushion blows further. Referees can stop Boxing is indeed in need of reform, but Accepted for publication 9 February 2004 fights earlier if the contest is unevenly the medical profession’s role in this matched, or if a fighter has suffered should be limited to advice and infor- some particularly punishing blows. mation. The principle of respect for REFERENCE More generally, the world of boxing is autonomy should prevail for boxers 1 Herrera CD. Boxing is like… J Med Ethics in need of a radical change of ethic. Too and patients alike. 2004;30:XXX.

the boxers. They take the risks, but are ...... listened to least. Is this because they have the fewest initials after their names, or because some boxers seem The search for meaningful comparisons less interested in debate without fists? Either way, it is unfortunate that in boxing and medical ethics boxers, who might have something meaningful to add, are drowned out in C D Herrera the debate over their sport...... This debate finds Joyce Carol Oates Boxers and healthcare workers alike should be able to exercise cited more often than the BMA their rights In this context, sorting through the comparisons is not easy, and that is lthough there are calls elsewhere is an expression of individualism and what needs to be done. Take the to ban boxing, the Australian personal sacrifice—the next best thing inevitable comparison to sports like AMedical Association advocates a to running your own country—or it hockey, where the health risks include less restrictive rule. Professional boxers illustrates the danger in letting concern death. What those who compare this would submit to brain scans and for autonomy overstretch the social way will not concede is that a boxer can

MRIs—but what to do with the results fabric. And so the comparisons con- be killed even if no rules are broken. http://jme.bmj.com/ of such tests? Critics say that boxers tinue, without really convincing anyone. Fighters can even predict the killing should decide which risks they take, but Not surprisingly, reformist proposals before the fight, for the press. In hockey, boxers are not the only ones in the that could include mandatory brain soccer, or tennis, a threat to ‘‘destroy’’ debate. Healthcare workers understand- scans for boxers are viewed as intrusive the opponent is brushed aside as meta- ably want some say in which risks by some and insufficient by others. phorical. people take, because the hospital is Turf consciousness enters into the For some in the medical community, where boxers go when injuries occur debate too. Journalists snub academics this places boxing outside the threshold (assuming they live). These issues of in the field of sport philosophy. for acceptable risk. Waiving clinical on September 25, 2021 by guest. Protected copyright. ethics and obligation are not made Academics, with the exception of some evidence, the Australian Medical Asso- easier to resolve by the many disputed historians, repay the favour by ignoring ciation and others call for restrictions, comparisons in this debate. Is boxing boxing’s pop culture aspects. Social some want a ban, and they do this on like other risk taking behaviour? Are scientists gather empirical data (in comparative grounds. Boxing is por- physicians like other public employees? psychology of sport, and sociology of trayed as a public hazard—like dirty Until such questions are answered, a sport) relevant to boxing. Yet because drinking water—that the public must be compromise would have check ups others find key terms like ‘‘violence’’ protected from. made mandatory, without forcing box- unclear, or the application of the data to It is tempting to let doctors recom- ers to act on any knowledge gained. boxing arbitrary, the scientists typically mend safety equipment, thank them for There is no shortage of comparisons get little notice outside of their field. their research, and politely ask them to in the debate over boxing. Boxing, we Doctors have the straightest path to stop interfering in boxing. Boxing is like hear, is like fast food: dangerous yes, mainstream media, and clearly under- mountain climbing, the argument might but it does offer some benefits. No, the stand the health risks and the prospects go: it is risky, but adults should be opposing side contends, boxing is like a for treatment, but that does not mean allowed to climb as long as they do not pistol duel: once considered sophisti- anyone listens. This debate finds Joyce endanger others. Healthcare workers cated, it is now just a ritualistic violence. Carol Oates cited more often than the seem hesitant to accept this, possibly Perhaps boxing is like smoking: inform British Medical Association. It is also a because their profession is itself hard boxers of the risks and let them at it. debate where those who collect empiri- to compare. In most professions, the Then again, if boxing is like smoking, cal data offer judgments well beyond person who provides a service is free people who do not realise how danger- the evidence, whereas those more suited to decline, on moral and economic ous it is need protection from it. to abstract speculation offer empirical grounds. If I continue to splash through Depending on who you listen to, boxing generalisations instead. Lastly, there are wet paint, you will tell me you are no

www.jmedethics.com CONTROVERSY 515

longer interested in shining my shoes, like hunting than football or track and align boxing with changing social J Med Ethics: first published as 10.1136/jme.2003.003541 on 5 October 2004. Downloaded from no matter what I pay. Society does not field events. It involves behaviour that is standards. When given a fair hearing give healthcare workers this option; punished wherever it is identified out- by all concerned, including the ath- society expects healthcare workers to side the ring. The elimination of the letes, these proposals deserve considera- treat even those who repeatedly dis- opponent in boxing also sets it apart tion. Boxers might receive advisories regard their warnings. It would be an from most other sports, insofar as the about health risks, purchase mandatory interesting show of frustration and elimination can, within the rules, be health insurance, know that medical solidarity if doctors were to decline any final. This contrasts with, for example, care might be selective (the way that association with boxing, even refusing baseball—the ‘‘elimination’’ that the pregnant women know that some hos- to go near the ring (but do not expect batter suffers when his or her shot is pitals will not provide abortion), sign this to happen). caught is only for the duration of that waivers to release anyone from lawsuits, Given this social expectation, doctors inning. and so on. Why not envision a boxer’s naturally want a say in which risks Society is probably not ready for roof- union, with required membership and people take. Are they being reasonable? top Sumo, but boxing is already here. As officials who look after the wealth I am wary of healthcare workers who people can avoid being affected by and health of boxers? At the same time, make pronouncements about the social boxing, why not let boxers consent to relieve the medical community of its merits of boxing or any other pursuit. this special risk taking, and make sure social obligation towards athletes who However, their remarks are not always that they fight within varying restric- play Russian roulette with their health far fetched. Boxing does differ from tions? Defenders like to note that box- and there should be less need for skydiving or American football, for ing has a legacy that few activities can intervention. We do not prevent some- example, sports that defenders routinely match. They are right, and that may be one with a heart condition from enter- ing the local marathon. Force boxers to compare it to. Boxing involves acts that where the key to resolution lies. Despite undergo brain scans and other tests as a are frowned upon outside the sport. claims about history being on the side of condition of employment, but leave Parents do not tell their children not to boxing, this sport has withstood many them free to fight, until we are willing jump out of airplanes or tackle each changes over the centuries. In ancient to radically alter our thinking about risk other—they don’t have to. They tell kids times, fights with no weight limits and personal liberty. For now, it seems not to hit each other, and many a parent lasted until a boxer could no longer best to engage in straight talk about (rightly) suffers guilt at having hit a stand (this sometimes meant hours of boxing, to understand how it compares child. pummelling, culminating in death). with other high risk activities, and Does consent matter? Maybe, but Today we have weight categories, time create conditions where boxers as well consent does not end the debate. keepers, and restrictions on which areas as healthcare workers can exercise their Imagine a game where two opponents of the body are acceptable targets. Box- autonomy. try to push each other off a rooftop. The ing has changed along with most things risks would include serious injury and in society. If society concludes that there J Med Ethics 2004;30:514–515. death, but would not affect non- should be additional restraints on what doi: 10.1136/jme.2003.003533 athletes. Would it be extreme to force two people can consent to, it could Correspondence to: Dr C D Herrera, Philosophy those athletes to undergo mandatory indicate a change in attitudes about Department, Montclair State University, 1 brain scans? Perhaps it would be con- punching, not a move towards author- Normal Avenue, Upper Montclair, NJ, USA; [email protected] sidered irrelevant whether they con- itarianism and paternalism. http://jme.bmj.com/ sented to the risks. Whatever else Proposed rule modifications and med- Received 25 February 2003 might be said about it, boxing is more ical testing could be viewed as moves to Accepted 9 February 2004

that indicate a predisposition to brain ...... damage. Nathan Croucher, a 24 year old on September 25, 2021 by guest. Protected copyright. construction worker and champion Compulsory brain scans and genetic amateur boxer has been banned from professional boxing after a compulsory tests for boxers—or should boxing be brain scan showed an abnormality which makes him susceptible to brain banned? injury. About the ban, he said ‘‘I am very disappointed but I’m just focussing M Spriggs on my family and my work now’’.1 Croucher is the third boxer in the last ...... 12 months found to have a brain Compulsory genetic tests which reveal a predisposition to brain abnormality and to be banned from professional fighting.1–4 The other two damage could be of more use in preventing harm than brain boxers were already fighting profession- scans which show that damage has already occurred ally. One is reported to be upset by the ban, while the other ‘‘understood the mid calls for a ban on boxing the measure. Others think the law is of potential dangers and did not object to 5 Victorian government in Australia limited value because the damage has his licence being revoked’’. Aintroduced compulsory brain already occurred by the time something The State Government introduced scans for professional boxers in June shows up on a brain scan. The Victorian compulsory brain scans after the death 2001. Some people think the introduc- government is also considering the of boxer Ahmad Popal in April 2001. tion of this new law is a ‘‘tough’’ introduction of compulsory genetic tests Popal was the third boxer since 1974

www.jmedethics.com 516 CONTROVERSY

‘‘to die from blows sustained in the E (ApoE) 4 that makes people more J Med Ethics 2004;30:515–516. J Med Ethics: first published as 10.1136/jme.2003.003541 on 5 October 2004. Downloaded from ring’’.5 Since June 2001, Victoria’s susceptible to brain damage from head doi: 10.1136/jme.2003.003541 professional boxers must undergo a injuries or ‘‘punch-drunk syndrome’’. A Correspondence to: Dr M Spriggs, Ethics Unit, magnetic resonance imaging (MRI) doctor on the panel advising the Murdoch Children’s Research Institute, Royal brain scan when they register as profes- Victorian government’s boxing regulator Children’s Hospital, Flemington Road, Parkville, sional, every three years when then said: ‘‘There is no policy at the moment Victoria, 3052, Australia; merle.spriggs@mcri. edu.au renew their registration, and at the of whether [people with the gene] discretion of the Professional Boxing would or would not be allowed to box. Received 4 March 2003 and Martial Arts Board during the I’d support the board if it wanted to In revised form 6 March 2003 three year period.6 The scans detect prevent them boxing’’.9 Accepted for publication 9 February 2004 existing brain damage—particularly Since Croucher’s ban from boxing ‘‘structural weaknesses in the brain’’ was reported, Pedro Alcazar, a Pana- REFERENCES that ‘‘might be worsened during a manian boxer, collapsed and died in professional fight’’.7 his Las Vegas hotel room 36 hours after 1 Giles T. Boxer floored by brain tests. Herald Sun, 2002 June 25;news section, 3. Many in the boxing industry support taking part in a world title fight. A 2 Hewitt S. Brain scan KOs top boxer. Sunday the compulsory scans. According to the boxing doctor said ‘‘Alcazar had shown Herald Sun, 2002 June 16;news section, 27. director of the Australian Academy of no symptoms of being hurt until he 3 Editorial. Out for the count. Herald Sun, 2002 June 25, 8. 10 Boxing: ‘‘[B]oxers, under pressure from fell’’. 4 Brain test KOs boxer. The Australian, 2002 June promoters, trainers and their own ambi- There were more calls for a ban on 25;news section, 6. tion needed to be protected.’’7 boxing in the lead up to a bout between 5 Giles T. Boxing brain bans. Herald Sun, 2002 February 12;news section, 3. Both the national and the state Anthony Mundine and Lester Ellis in 6 Cauhci S, Foley B. Boxer brain scans insufficient, branch of the Australian Medical Melbourne. The fight was described as says AMA. The Age, 2001 May 28;news section, Association (AMA) have called for box- ‘‘one of the most farcical mis-matches in 4. 5–7 7 Bachelard M, Kerin J. Compulsory brain scans for ing to be banned altogether. The Australian boxing history’’. The AMA boxers. The Australian, 2001 May 28;news Victorian state president of the AMA claimed Ellis, who is 10 years older and section, 3. claims that brain scans may be useful had not fought since being ‘‘brutally 8 Murdoch S. Vic: Another Victorian boxer barred after brain scan. AAP Newsfeed, 2002 June 24.. but they are limited because the damage knocked out’’ in a fight six years ago, 9 Robotham J. Pro boxers face going down for the detected has already occurred.5 was ‘‘a soft target who shouldn’t be gene count. Sydney Morning Herald, 2001 June The Victorian government is consider- allowed to risk being badly hurt’’.11 1;news section, 1. 10 Boxer dies in hotel room hours after title fight. ing the introduction of compulsory According to Ellis however: ‘‘All this The Australian, 2002 June 26;news section, 15. genetic testing for boxers.589There is a talk that I could get hurt or killed is 11 Reed R. Mundine ready to prove himself. Herald genetic test which indicates a predis- rubbish. Hardly anyone gets hurt ser- Sun, 2002 July 12;sport section, 118. 12 Weidler D. Mundine to Phelps: don’t worry, position to brain damage. It screens for iously in boxing, crossing the road is darling. Sunday Age, 2002 July 14;sport section, a genetic variation called apolipoprotein more dangerous’’.12 4. http://jme.bmj.com/ on September 25, 2021 by guest. Protected copyright.