f r o m b i r t h t o d e a t h a n d b e n c h t o c l i n i c THE HASTINGS CENTER Bi o e t h i c s Br i e f i n g Bo o k for Journalists, Policymakers, and Campaigns

Chapter 33 Sports Enhancement

Thomas H. Murray, “Sports Enhancement,” in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book for Journalists, Policymakers, and Campaigns, ed. Mary Crowley (Garrison, NY: The Hastings Center, 2008), 153-158.

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Framing the Issue HIGHLIGHTS Spring in America brings flowers, sweet warm breezes, and the thwack of a bat striking a baseball. But swings that would n Use of performance-enhancing substances once have resulted in a fly ball to the warning track may now, in sport is not new, but the means of with chemical assistance, deposit the ball in the bleachers. The enhancement are increasing. , an early Christmas present to baseball fans n The 2007 Mitchell Report found that sever - released in December 2007, confirmed that a number of Major al players had used League players have used performance-enhancing drugs. performance-enhancing drugs; other reports have found doping prevalent in Athletes using drugs to boost performance is hardly news. cycling, track and field, and other sports. Anabolic steroids and have plagued the Olympics for n The public reaction to sport doping is split: decades. Professional cycling—including its premier event, the some categorically condemn it as cheating Tour de France—nearly collapsed over reports that drug use was while others see benefits, such as the widespread. The 2006 victor, American Floyd Landis had his title potential to give fans more entertainment. stripped because of evidence that his testosterone levels were n There are several reasons to ban perform - abnormally high, an indication that he may have boosted them ance-enhancing drugs: respect for the rules with injections or patches. of sports, recognition that natural talents An intriguing split has emerged in the public reaction to base - and their perfection are the point of sports, ball’s drug problem. For some, there’s not much to think about: and the prospect of an “arms race” in ath - the rules forbid performance-enhancing drugs; breaking the rules letic performance. is cheating; cheating is wrong—end of story. n Emerging issues include the creation of drugs that elude drug tests and the possi - Others are not so sure. They raise a variety of objections. bility of genetic enhancement. Some claim that athletes are just giving people what they want: n More research is needed on why athletes fans enjoy home runs, athletes who take drugs such as anabolic turn to doping and effective means of stop - steroids hit more home runs, what’s all the fuss? Of course the ping it. fans in the Roman Coliseum may have loved to see lions tearing the arms off Christians or gladiators hacking each other to death.

So “what the fans desire” is not an ethically robust defense. t n

Others say that athletes should be free to do whatever they e want to their own bodies. From this point of view, each athlete is Thomas H. Murray, PhD, President, The m Hastings Center • murrayt@ e best situated to balance the risks and benefits of using perform - c

thehastingscenter.org, 845-424-4040, x201 n

ance-enhancing drugs. The principal flaw in this argument is that a Eric T. Juengst, PhD, Director, Center for it fails to understand that what one athlete chooses to do affects Genetic Research Ethics and Law, h n T everyone in the competition. The athletes I know all crave a Department of Bioethics, Case Western e C

A level playing field. If my competition is gaining an edge by using Reserve University • [email protected], s T t N a drug that tilts the field in their favor, then their choice pres - 216-368-6207 r O o

C Erik Parens, PhD, Senior Research sures me to do the same. Otherwise I may end up losing to some - p s

O Scholar, The Hastings Center •

one who is less talented or less dedicated. T [email protected], S

T 845-424-4040, x224

R 33

E , MD, Chief, Olympic Analytical Why Prohibit Performance Enhancers? P X Laboratory, University of , Los A more subtle and serious question is why we prohibit certain E Angeles • [email protected], 310-825-2635 performance aids in the first place. Sure, the rules of sport may Theodore Friedmann, MD, Director, Gene ban anabolic steroids or synthetic hormones like human growth Therapy Program, University of California, San Diego • [email protected], 858- 534-4268 Thomas H. Murray, PhD, is president of The Hastings Center.

SpoRTS EnHancEMEnT 153 surgeons are ethi - S PORT E NHANCEMENT : P AST , P RESENT , AND F UTURE cally required to use Product Purpose the drug. anabolic steroids artificial substances related to male sex hormones So the mere fact that are used to build muscles. that some drugs Stimulants Substances such as that act on the brain enhance perform - to increase alertness. ance isn’t sufficient Human (HGH) Believed to enhance strength. to decide whether they’re good, bad, (Epo) Believed to increase endurance. or otherwise. The (THG); an once undetectable by anti-doping labs. context matters. If "the clear" it’s wrong for ath - cheetahs carbon fiber blades that replace the amputated lower legs letes to use per - of oscar pistorius, a South african sprinter. formance-enhanc - Gene therapy Genetic manipulation may one day improve athletic ability. ing drugs, there must be something about sport that hormone (HGH), believed to enhance strength, makes it so. I’ll discuss three characteristics of and erythropoietin (EPO,) which stimulates the sport that provide the context and plausible justifi - production of oxygen-carrying cells in the blood cation for banning such drugs: and thereby increases endurance. But what makes those means for improving performance bad while •The significance of rules in sport other things, from better equipment to more •Natural talents and their perfection sophisticated training methods or nutrition regi - •The prospect of an “arms race” in sport, end - mens, are perfectly okay? What makes the use of ing in the triumph of the so-called perform - performance-enhancing drugs in sport an ethical ance principle. problem? One common place to look for a response is the distinction between therapy and enhancement. The Significance of Rules in Sport Therapy is good, enhancement is suspect, right? Every sport has rules (with the possible excep - Unfortunately, it’s not so clear or simple. The tools tion of “Calvinball” from “Calvin and Hobbes,” biomedical research creates to treat disease are where the only rule is that you can’t use the same completely indifferent to the fluid and sometimes rule twice). The rules in each sport in effect deter - disputed boundary between therapy and enhance - mine which characteristics among all possible ment. A product like synthetic HGH is in certain sources of difference influence who wins and who cases like insulin for people with diabetes. For chil - loses. Team A may be wealthier than Team B, but dren who can’t make enough HGH themselves, the neither is allowed to bribe the umpire—a competi - synthetic form can help replace what is missing. tion that Team A is likely to win. On the other hand, healthy athletes can use HGH to try to build larger-than-normal muscles. The Improvements in equipment can transform a HGH molecule neither knows nor cares whether it sport. When pole-vaulters traded in their wooden is helping a child inch towards normality or mak - poles for fiberglass ones, they were able to leap ing a hugely muscled athlete even more muscular. much higher. Swimmers now have suits available Somewhere between the two, we’ve crossed the that allow them to slip through the water with a border from the friendly, familiar land of therapy minimum of resistance. Typically, sport deals with to the unmapped, vaguely ominous terrain of innovations in equipment in one of three ways. enhancement. Sometimes it embraces the new technology, as Nor is biomedical enhancement obviously bad track and field did with fiberglass poles. The criti - in all circumstances. Imagine a relatively innocu - cal factors here were continuity and equal opportu - ous drug that steadied a neurosurgeon’s hand so nity. Continuity was assured because the poles still that her patients healed more rapidly with fewer required the same skills from pole-vaulters, such as complications: the ethics of that sort of perform - speed down the runway, strength, and agility. ance enhancement would focus on whether neuro - Equal opportunity meant that all athletes had to

154 THE HaSTInGS cEnTER BIoETHIcS BRIEfInG Book have access to fiberglass poles. One controversy rules. But why? On what grounds does Nordic ski - over the new slippery swimsuits is whether all ing ban EPO? What gives baseball the right to pro - competitors will be able to use them. Otherwise, an hibit anabolic steroids? inferior swimmer wearing the suit might beat out If the point of an endurance sport like cross- the most talented one. Technology would trump country skiing is to see how rapidly you can cover ability. long distances without collapsing, then anything Sometimes a sport accepts technological innova - that allows you to go harder and longer would tion as a part of the competition. Skiers use special improve your performance, including EPO. Why combinations of waxes, bobsled teams compete to doesn’t Nordic skiing welcome EPO the same way come up with the fastest sled. Even then, sports it welcomes synthetic fiber garments and faster make and enforce rules. Athletes can compete on skis? To some critics, Nordic skiing is being incon - technology only up to a certain point: no jet sistent. If the point of the sport is to go faster, then engines allowed on bobsleds, for instance. EPO should be treated just like better ski waxes, Many innovations that would surely improve the critic may argue. performance are banned outright. An athlete who But most aficionados of sport persist in seeing a showed up for the Boston Marathon wearing difference between using drugs to enhance per - Rollerblades would be wheeled right off the start formance and employing other means to the same line. The marathon is for runners, not skaters. (Of end. Intensive training, smart tactics, dedication, course, one could try to organize a sport where studying your competitors—all these can improve Rollerbladers competed to cover the same course as one’s performance and all of them are regarded as the Boston Marathon; but that would be a different admirable ways of perfecting your natural talents. sport.) The Tour de France insists on a minimum Those natural talents are, of course, allotted in weight for all bikes. As every road cyclist knows, vastly uneven measure among us all. Some com - the lighter the bike, the less energy required to mentators see this as a form of injustice and per - climb the mountains that help make the Tour so formance-enhancing drugs as a remedy for nature’s famous and so difficult. This rule accomplishes two cruel inequalities. Why should the race go to the things. It neutralizes one advantage that the wealth - swift? What if I’m a clumsy, slow-footed slogger? iest or best-supported cyclists would gain by using Shouldn’t I have an equal opportunity to get to the fabulously expensive, custom-made parts of exotic finish line first? If anabolic steroids or stimulants metals or synthetics. It also protects cyclists against can balance out the uneven shares of talent given the temptation to shave every last gram off of criti - by birth, shouldn’t I be allowed to use them? Then cal components, increasing the risk of catastrophic victory will belong to the one who trains the hard - failures when the bike is screaming down a switch - est perhaps, talent be damned—or neutralized, at back mountain road at 100 kilometers an hour. least. t n

Rules are changed at times to preserve a sport. When performance-enhancing drugs have the e

Basketball banned goaltending—swatting the ball power to overcome differences in natural talents m away just as it was about to go into the hoop— e and the willingness to sacrifice and persevere in c when players became so tall and athletic that they the quest to perfect those talents, we cannot avoid n could stand by the basket and prevent most shots a confronting the question, What do we value in h from having a chance to go in. Later, basketball cre - n

sport? Emerging technologies—from hypoxic cham - e ated the three-second lane to keep offensive play - bers and carbon fiber prostheses to genetic manipu - s t ers from camping under the basket, and then the lation—will force us consider what, after all, is the r three-point line to reward good shooting and force o

point of sport? p defenders to venture out to the perimeter. These s changes opened the game up for rapid cuts, screens, and sharp passes once again. Sport, the “Arms Race,” and the 33 Triumph of the Performance Principle The Point of Sport: Natural Talents and When Hastings Center researchers spoke with Their Perfection? athletes in the early 1980s about performance- enhancing drugs in sport, they described an In most sports—including all Olympic events— intensely competitive world in which tiny differ - using performance-enhancing drugs is against the

SpoRTS EnHancEMEnT 155 ences—fractions of a second in the hundred meter glove more suited for baseball in the 1950s and 60s. sprint, inches in the discus or shot put—separated The new glove certainly enhanced my perform - the victor from the vanquished. Where a drug ance as an infielder—though not by much, at least could give even a small edge, some athletes would not until my late teens when my scrawny body be tempted to use it. And, just as significant, every acquired a little muscle and coordination. other athlete in that event would feel enormous Modern baseball gloves—supple, long-fingered, pressure to join in. The dynamics of drugs in sport webbed—allow fielders to snatch line drives and bear more than a superficial resemblance to an scoop up hard grounders with relative ease. They arms race: each party drives the other further, lest improve performance, no doubt. But infielders still either be left behind. have to get to the ball, catch it, and throw accurate - Critics of doping control sometimes argue that ly to the base. They need quickness, agility, sport would be better off if athletes were just strength, and extraordinarily swift reaction times, allowed to take whatever drugs they wanted. Fans qualities that great infielders have always pos - would get more dramatic performances. The play - sessed. This is one technology that has enriched ing field would be leveled (because every athlete rather than detracted from sport. could use the same drugs). We could do away with Sport as we know it faces emerging challenges the cat and mouse game between drug users and on many fronts. To mention just a few: testers, saving money and aggravation. n Will the underworld of clandestine drug devel - These purported advantages would come at opers, promoters, and enablers overwhelm the some cost. Sports that revere records and historical drug control apparatus? The synthetic anabolic comparisons (think of baseball and home runs) steroid tetrahydrogestrinone (THG)—now infa - would become unmoored by drug-aided athletes mous as “the clear” peddled by the Balco lab— obliterating old standards. Athletes, caught in the was created by an independent chemist. Its sport arms race, would be pressed to take more and selling point was that the processes by which more drugs, in ever wilder combinations and at samples were prepared for testing by the anti- increasingly higher doses. While the scientific evi - doping labs made the drug undetectable. The dence that the drugs athletes use are harmful is lab got its hands on a sample of THG, deci - often less conclusive than opponents of drugs in phered its chemistry, and adapted their proce - sport portray, that’s little reason for comfort. dures to detect it. Balco was exposed and the Athletes often take drugs at multiples of the chemist went to prison. Is this evidence that dosages that have been studied for their benefits doping control can work effectively? Or does it and risks, and they take drugs in bizarre combina - show that ultimately the effort will be futile tions. It’s unlikely that any research ethics commit - because other chemists, other labs, and more tee would permit a scientifically controlled study willing athletes will inevitably pop up? that administered such large amounts and odd mix - n Hypoxic chambers permit athletes to mimic tures of drugs. So, yes, we should be concerned what very few would otherwise be able to find: about risks to athletes, and we should perform a geography that would enable them to train at whatever epidemiological and observational studies low altitude (and therefore train at maximum are possible under the circumstances. The drug intensity) but “live” at high altitude, as simulat - race in sport has the potential to create a slow- ed by the hypoxic chamber (and thereby gain motion public health catastrophe. Finally, we may the increased endurance that some athletes lose whatever is most graceful, beautiful, and develop from spending most of their time in admirable about sport, which brings us back to the an oxygen-depleted environment). Oscar quintessential American game, baseball. Pistorius, a South African sprinter, saw both of his lower legs amputated. Yet he can achieve remarkable times in the 400 meters thanks to Emerging Challenges his talent, his perseverance—and a pair of car - When I was a kid my father, born in 1917, gave bon fiber blades known as Cheetahs. Scientists me the baseball glove he’d used as a young man. It disagree over whether Cheetahs are more effi - was indeed a glove: leather, rather stiff, with short cient than our flimsy biological equipment. fingers and no webbing. I might has well have Pistorius wants to run in the Olympics, not the worn an oven mitt. Eventually I acquired a fielder’s Special Olympics. Technologies like hypoxic

156 THE HaSTInGS cEnTER BIoETHIcS BRIEfInG Book chambers and carbon fiber limbs are harbin - gers of what sport will confront in the future. RESOURCES They will compel us to ask again and again, what is the meaning of this sport? What counts Web sites as “fair” competition? What, in the end, should • www.wada-ama.org – The World anti-Doping agency. mark the difference between excellent per - Includes the complete World anti-Doping code, resources, formance and lesser performances—or some - and news. thing else entirely, like the Rollerblading • www.usantidoping.org – The U.S. anti-Doping agency. marathoner? Includes tools for athletes, resources, and a press kit. n A huge volume of hot air is being created Recent news around the prospect that athletes will be • Joshua Robinson and alan Schwarz, “olympic Dream genetically enhanced. The same techniques Stays alive, on Synthetic Legs,” New York Times , May 17, being perfected for gene therapy may be used 2008. to give athletes a genetically programmed • Duff Wilson and Michael S. Schmidt, “Report Ties Star boost. Progress in gene therapy is in a relative - players to Baseball’s ‘Steroids Era,’” New York Times , ly early stage of development, but the doping December 14, 2007. control agencies have realized that they need • Michael Hiltzik, “She Did It, But all Will pay,” Los Angeles to engage the interest and creativity of top sci - Times , october 6, 2007. entists, who are now working on a variety of • Randal c. picker, “competitive Disadvantage: as contests promising strategies to detect . Move from playing field to Laboratory, athletes, Sports Would Be Hurt,” Chicago Tribune , august 22, 2007. • Joel Garreau, “Is it Time for a flex plan?: Techno-athletes Challenges for Policymakers and change the Definition of natural,” Washington Post , Journalists august 1, 2007. For policymakers, two major categories of chal - Further reading lenges emerge. The first set of challenges have to • Thomas H. Murray, “Enhancement,” in The Oxford do with research. For decades the competition Handbook of Bioethics , ed. Bonnie Steinbock, oxford between drug-using athletes and their enablers on University press, 2007. the one hand and antidoping workers on the other • Sarah Glazer, Enhancement, The Hastings center, 2006. was uneven. The labs, for example, had to scramble primer available at to support their research into new substances and www.thehastingscenter.org/uploadedfiles/publications/enh new analytic methods. Dopers could make plenty ancement%20primer.pdf. of money supplying athletes seeking a competitive • Thomas H. Murray, “Gene Doping and olympic Sport,” Play True , Spring 2005. advantage. Finally, with the advent of new agencies t such as the World Anti-Doping Agency (WADA) and • Don H. catlin and Thomas H. Murray, “performance- n e the Anti-Doping Agency (USADA), a Enhancing Drugs, fair competition, and olympic Sport.” m small but reliable stream of funds for research Journal of the American Medical Association , July 1996. e c

became available. With better funding, much more • norman fost, “Banning Drugs in Sports: a Skeptical View,” n could be done. Hastings Center Report July-august 1986. a h

It could be very helpful to learn more about the n e

culture of sports doping—why athletes dope, who and may also prove useful in monitoring the s t influences their decisions, and the like. It would be cyclists’ health. Other strategies should be encour - r equally interesting to do research to develop alter - o aged and studied. p native strategies to encourage clean sport and dis - s I pointed out earlier the difficulty of studying courage doping. Some promising ideas are being the risks when athletes use drugs in high dosages pursued, like the commitment of Team Slipstream 33 and novel combinations. We may not be able to (now Team Garmin-Chipotle) and Team High Road construct an ethical clinical trial, but scientists can (now Team Columbia), professional cycling teams, gather helpful data with other methodologies. Such to test each of their riders regularly. In addition to research should be encouraged and funded. catching possible drug users, the routine tests establish physiological baselines; sharp departures The second major challenge is nontherapeutic from them could signal pharmacological tampering drug use among adolescents. Various reports dis -

SpoRTS EnHancEMEnT 157 agree about the percentages of teens using drugs meaning of sport. Should ’ home run such as anabolic steroids, but study after study totals be marked with an asterisk because they may 32 shows alarming high levels of use. The research also have been drug-assisted? Should he be elected to the reveals that young people may be more eager for Baseball Hall of Fame in Cooperstown? What’s fair? the cosmetic effect—looking “buff” on steroids or What after all is valued most in baseball? What HGH—than for any impact on performance. How to makes it fascinating, regularly frustrating, and occa - make such drugs less available and less attractive to sionally transcendently beautiful? A steady tattoo of adolescents is a significant policy challenge. monstrous home runs? Or, like the greatest wines, a Finally, a word of appreciation for journalists, diverse mix of elements, somehow blending into a especially sports columnists: My admittedly unsci - harmonious whole? entific impression is that the items in the daily There are wide and vigorous disagreements on newspaper most likely to be devoted to philosophy just about every matter I’ve touched. Let the dia - are the columns in the sports section. There, grand logue flourish, and let the games begin. debates unfold over matters of justice and over the

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