On January 2, NFL player Damar Hamlin collapsed after being hit in the chest while playing football. He was fortunate to be rapidly surrounded by those able to provide effective CPR. He was efficiently transported to a hospital where state of the art medical care continued. According to recent reports, he is on a path to what appears to be good neurologic recovery and is now also breathing on his own without mechanical ventilator support. While this is cause for celebration, it also presents an opportunity to think more carefully about the role of medicine in sustaining Americans’ enthusiasm for football.
Though death in NFL play is rare, injury is not. Common are a range of musculoskeletal injuries as well as debilitating head injuries like chronic traumatic encephalopathy (CTE), a degenerative brain injury caused by repeated head trauma. Researchers at Boston University found evidence of CTE in 99% of former NFL players studied. Sports medicine helps people recover from acute injuries, and in the case of the professional athlete where millions of dollars are at stake, the pressure to return an injured athlete to the game can be significant. When the physician is employed by the team, the line is blurred between a physician’s duty to heal and simply being a party to permissive injury, and even death, for the sake of entertainment.
For the physician, the relationship between patient choice and health can sometimes be obvious. For some patients, deficiencies in the social determinants of health can lead to illness and death, and the doctor can do very little. Sometimes patients make poor health choices like smoking, drinking, poor diet, and no exercise. We recognize these choices as expressions of autonomy and when we encounter patients now hospitalized because of these choices, we don’t scold them; we treat them. Still, we may council these patients to modify known risk factors, and most physicians will repeat this advice on an ongoing basis.
Physicians are ethically bound to first do no harm, yet the demands and complexities of our society place the physician in a variety of situations beyond simply healing the sick. In a host of situations, medicine has been transformed from healing to enabling. Professional athletes knowingly engage in activities adverse to health. Physicians know this but may be employed to keep the players in the game. Performance-enhancing substances are widespread and raise serious concerns in sports. Performance enhancement refers to the use or manipulation of substances, either synthetic or autologous, for the purpose of improving sports performance. Substances used commonly among athletes include anabolic-androgen steroids, human growth hormone, creatine, erythropoietin, blood doping, amphetamines and stimulants, and beta-hydroxy-beta-methylbutyrate. In the NFL, amphetamines and stimulants have historically been abused.
The control of pain is a particular concern. Physicians provide pain control through a variety of interventions, obscuring the significance of pain as the body’s signal to the injured person that what they really need for an injury is to rest it, not work it harder. For the player, the culture has long been to play the game, no matter what. Ketorolac, given as an injection or orally, might be given on game day as just part of normal preparation. Long-term use of the non-steroidal anti-inflammatory drugs like ketorolac have known serious adverse effects including renal injury and increase risk of thrombotic events leading to myocardial infarction and stroke. Ketorolac is recommended for a short duration, up to 5 days, for moderate to severe pain. Some players have been taking ketorolac for years.
The ethical physician knows the imperative against standing idly by. Indeed, public health law defines the state’s legal powers and duties to assure the necessary conditions for people to be healthy. Within this broad legal mandate is the dictate in support of the prevention of illness and injury — but physicians have used this power inconsistently. A recent campaign by the American Medical Association against gun violence garnered varied public reactions. The National Rifle Association replied, “Someone should tell self-important anti-gun doctors to stay in their lane.” When physicians pick and choose which health risks to speak out against and when to stand idly by, the public might accuse physicians justifiably of pandering to certain politically expedient concerns over others. Yet, such critiques should not bring into question the fundamental obligation of physicians to point out dangers to public health.
The on-field resuscitation of Hamlin is an example of what the medical profession is supposed to do: provide the best care available given the situation that is presented. Yet, this kind of medical care does not represent the full responsibility of doctors to act in the interest of players’ health. Using the tools of medicine to help an athlete stay in the game is antithetical to the mandate that requires risk reductions. When treating an alcoholic, a physician may treat liver disease while also counseling the patient to stop drinking. The holistic job of a doctor in the context of football, similarly, should be both to treat injuries where they arise and to draw individual and public attention to the dangers that make the game antithetical to health in the first place, even as we may sympathize with Americans’ passion for it. In situations from the football field to staying quiet on gun control, physicians must consider if they’re betraying their Hippocratic Oath when they accommodate people’s pursuit of activities that predictably lead to injury, violence, and death.
Joel Zivot, MD, is an associate professor of anesthesiology and surgery at Emory University School of Medicine in Atlanta.