Sport-related concussion (SCR) prevention and the nature of sport: possibilities and limitations

ABSTRACT

Concussions are traumatic brain injuries that can result from a blow to the head or a jolt to the body. Athletes in many sports are exposed to concussion risks. There is a growing concern in sport and society about sport-related concussions (SRC) and an increasing awareness of the importance of proper diagnosis, treatment, and prevention. A traditional, reactive approach emphasizes sound protocols in cases of suspected SRC. A proactive approach involves identifying various causes of SRC and implementing preventive measures. For example, to reduce SRC prevalence in Canadian youth ice hockey, a ban on body checking has been introduced. When a preventive SRC measure implies a change in the main rules of a sport, it impacts its nature and alters how it is played. This can lead to tensions between SRC prevention and sporting concerns. By employing an extended consequentialist framework that includes normative analyses of the values of sport, I will examine the possibilities and limitations of preventive SRC measures in terms of constitutive rule changes. More specifically, I will propose a consequentialist framework to determine the conditions under which athlete exposure to SRC risks in a given sport can be considered unacceptable, acceptable, and even valuable.

KEYWORDS:

• Concussions
• sport
• risks
• constitutive rules
• reform

Concussions are traumatic brain injuries that can result from a blow to the head or a jolt to the body. Most sports involve extensive physical activity. A certain level of concussion risk is unavoidable. Some sports expose athletes to heightened concussion risks. Examples include combat sports like boxing involving blows to the head, collision sports such as American football, rugby, and ice hockey, and sports involving athletes moving at high speeds such as alpine skiing or motocross.

There is a growing concern in sports and society at large about sport-related concussions (SRCs) and an increasing awareness of the importance of proper diagnosis, treatment, and prevention (McNamee et al. 2023; Patricios et al. 2023). A primary approach to SRCs comes from sport medicine. Its emphasis is on sound protocols in cases of a suspected SRC. Typically, these are reactive strategies to minimize harm when a concussion has occurred and say little or nothing about potential causes integrated into the practice of the sport in question, such as blows to the head in boxing and body checking in ice hockey.

Another part of the SRC campaign implies identifying such causes and exploring their elimination or reduction in terms of preventive measures. For instance, in American football, rules have been modified to protect players, such as targeted penalties and stricter enforcement of SRC protocols in helmet-to-helmet hits (Sailors 2015). In soccer, acknowledging the potential dangers of heading the ball for young players, there have been discussions about age-appropriate heading rules (Malcolm 2018). In Canadian youth ice hockey, a ban on body checking has been introduced (Emery et al. 2020).

When a preventive SRC measure implies a change in the core rules of a sport, it impacts the sport’s nature, affecting how it is played. This can lead to tensions between SRC prevention and sporting concerns. By employing normative analyses of the values of sport, I examine the possibilities and limitations of preventive SRC rule changes.¹ More specifically, I propose a systematic consequentialist argument to determine the conditions under which athlete exposure to SRC risks can be considered unacceptable, acceptable, and even valuable.²

Sport-related concussion prevalence and the need for preventive measures

The definition of an SRC as a problem that requires intervention is based on quantitative estimates of SRC prevalence. In principle, any occurrence of SRC is problematic. However, moving in a physical world implies physical contact and sometimes uncontrollable impact—e.g. falls and collisions—sometimes leading to concussions. Setting an acceptable risk threshold is not just a factual move but depends upon overall judgments, including insights into the nature of the activity under consideration. Policy development involves weighing the efficiency of preventive concussion measures against their costs. Costs can be financial in kind but also include restrictions on individual freedom and autonomy as well as on the aspects of the practice that many find valuable and meaningful.

For example, traffic involves the risk of collision and serious harm. Preventive measures include defining clear rules, among them rules on speed limits. At the same time, traffic rules are designed to facilitate efficient transportation. If speed limits are lowered to the extent that collision risks are negligible, the cost is less efficient and more time-consuming traffic. Typically, a consequentialist framework with a systematic calculus of costs and benefits provides a basis for policy and rule-making.

A similar approach can be followed in the development of SRC policies. Reliable prevalence measures provide a factual basis. There is then the need to define a threshold for determining when preventive measures are required. One comparative measure can be whether the SRC risk is higher in sport than concussion risk in other everyday activities. If so, the question is whether there is a reason for additional SRC preventive measures

The answer, however, is more complicated than in the case of traffic. Traffic serves an instrumental purpose—to move from A to B as efficiently and safely as possible. Sports are social practices that have emerged, developed, and exist primarily due to intrinsic values such as the experiential qualities of joy and challenge, excitement, a sense of community, a sense of rivalry, etcetera. Sports are non-instrumental practices in that core sporting rules serve no purpose other than defining and enabling the realization of sporting activities. Moreover, and different from traffic with the universal goal of efficient and safe transportation, sports are diverse. Due to the differences in rules and goals, downhill skiing and American football necessarily imply a higher SRC risk than swimming. Setting a uniform SRC risk level seems unreasonable.

In other words, cost-benefit analyses of SRC measures are challenging as they include non-quantifiable values, among them experiential qualities in sporting practice. I concentrate the discussion on the most controversial interventions from a sporting perspective: those that affect the core rules of a sport. What criteria can be used to evaluate SRC-preventive rule changes? There is a need here for an extended analytic framework that includes the intrinsic values of sport.

Rules and the nature of sports

When it comes to normative theories of sport, the scholarly literature offers a variety of interpretations and positions.³ A detailed overview is beyond the scope of this essay. My focus is on the costs and benefits of SRC-preventive rule changes. Let me, therefore, start with the nature and functions of sporting rules.

Sporting rules are of several kinds. Roughly speaking, rules can be categorized as either constitutive or regulative (Searle 1969). Constitutive rules create an activity that is logically dependent on the rules. Examples can be the rule against using hands on the ball in soccer or the rule prescribing skiers to pass through all the gates of a slalom course. These rules make sense only within the practice they define.

Regulative rules, on the other hand, regulate pre-existing activity whose existence is independent of the rules. Examples can be rules that facilitate skill execution, such as rules on the air pressure of soccer balls or the cut and shape of a slalom ski. Still, soccer and slalom skiing can occur even if the ball and the skis do not meet the regulations. Another example is rules designed to address issues external to the practice, such as health concerns. In cross-country skiing, there is a temperature threshold limit of −15°C below which races cannot be held, and, as is the topic of this essay, there are rules related to SRC concerns in many sports.

As indicated in SRC consensus statements for collision and combat sports, SRC prevention usually has the form of regulative rules defining detailed protocols on what to do in cases of suspected SRC, on non-eligibility before re-entering competition, etc (Neidecker et al. 2019; Patricios et al. 2018). Although important, these measures relate to symptoms of the SRC problem. Its main cause stems from the inherent nature of collision and combat sports, that is, the constitutive rules that allow and reward collisions and blows to the head. What can be done in terms of constitutive rule changes?

One radical solution is to reject the constitutive rules in sports whose SRC risk surpasses an acceptance level stipulated by some relevant authority, for instance, a medical expertise committee. This means banning the activity as a whole. An example is the recommendation from the World Medical Association (WMA) of a ban on boxing (2017).

The solution is controversial. In his anthropological study in a boxing gym in deprived neighborhoods of Chicago, Wacquant (2022) describes how the experiential qualities of the disciplined training and fights represent ‘an island of order and virtue’ (7) in a world of chaos. The argument can be that the intrinsic values of boxing outweigh the SRC risk. Another criticism is that the ban violates principles of individual autonomy and the right to voluntarily engage in practices even if they impose an enhanced risk of harm (Lopez Frias and McNamee 2017). In this case, banning boxing would be a matter of unjustified paternalism. A less radical measure is the modification or elimination of only one or a few constitutive rules. For instance, one could imagine boxing without blows to the head (Dixon 2001). Another example is the Canadian policy prohibiting body checking in youth ice hockey, which significantly reduces injury and SRC prevalence (Emery et al. 2020).

Externally imposed constitutive rule changes such as these change the nature of a sport and how it is played. Boxing without blows to the head and ice hockey without body-checking alter established and cherished technical and tactical skill requirements with long traditions in the respective sporting communities. What from a purely SRC-preventive perspective appears as rational changes may, from a sporting perspective, be problematic.

How can SRC policies deal with these tensions?

Sports: a ‘thick’ understanding

McNamee et al. (2023) emphasize that SRC policy development must integrate ‘thicker’ normative understandings of the nature of sport. In sport studies, MacIntyre’s (1984) theory of social practices and their internal and external goods has proved a useful framework (McNamee 2008; Morgan 1994, 2020).

While external goods such as fame and fortune are realized outside the sporting practice, internal goods are valued for their own sake and in the practice itself. Examples of the latter can be the mastery of offensive and defensive boxing skills or striking the optimal balance between safety and risk in downhill skiing. These are shared goods, as well-executed practice can stimulate the further development of excellence standards and internal goods. External goods are instrumental goods and independent of the practice. Fame and fortune can be earned in many ways and are mutually exclusive goods to a larger extent. What one party wins, another party loses. Internal goods are intrinsic to the practice and can only be realized by embodying its relevant standards of excellence and within the framework of its constitutive rules.

Social practices are the outcomes of cultural traditions and have a history involving generations of practitioners. Standards of excellence are typically developed and transmitted formally and informally through practicing, instruction, and education. Moreover, according to MacIntyre, the realization in practice of standards of excellence and internal goods cultivate virtues, some of which are morally relevant from a broader perspective. Actually, in the MacIntyrean framework, social practices with shared aims and ends are the only place where moral virtues can be developed:

A virtue is an acquired human quality the possession and the exercise of which tends to enable us to achieve those goods that are internal to practices and the lack of which effectively prevents us from achieving any such goods … we have to accept as necessary components of any practice with internal goods and standards of excellence the virtues of justice, courage, and honesty (MacIntyre 1984, 191).

If athletes break the rules and fail to perform at their best, the realization of internal goods is hindered, and meaning is lost. Hence, this framework offers not only an account of the intrinsic values of particular practices but also a critical social and moral contextualization. Extending the argument even more, the exercise and cultivation of moral virtue can contribute to a meaningful narrative and a sense of unity in life.⁴ Overall, MacIntyre’s understanding underscores how social practices can be the building blocks of a flourishing life and a good society.

In what follows, I use the MacIntyrean framework and define criteria for distinguishing between acceptable and non-acceptable SRC preventive constitutive rule changes.

Acceptable SRC-preventive rule changes

Even if all sports expose their practitioners to a certain risk of SRC, differentiation is needed. Collision and combat sports, together with sports involving high speeds, have heightened risks. Sound risk management aims to reduce these risks. As they have little impact on the attainment of internal goods, in most sports, regulative rules on the use of protective gear, such as body armor and helmets, are uncontroversial. The critical question concerns SRC-reducing measures in terms of constitutive rule changes.

Let me look first at cases where constitutive rule changes can be both acceptable and valuable. Traditionally, in sporting communities, standards of excellence are developed along several lines—technical, tactical, and aesthetical. Internal goods can become more complex and diverse and offer challenges and experiential qualities to novices as well as experts. From a MacIntyrean perspective, the practice is flourishing. Other times, the constitutive rule changes are considered problematic. External goods, such as profit and prestige, may have a negative impact in terms of prioritizing drama and entertainment above excellence, or concerns about injury rates and SRC risks may lead to rule changes that reduce performance complexity and diversity make the sport less valuable to its practitioners.

Take the examples of boxing, ice hockey, and the high-speed sport of downhill skiing. Measures like banning blows to the head in boxing and body checking in ice hockey, and reducing high speeds in downhill skiing would definitely reduce SRC risks. The challenge is that estimating and taking physical risks are integral to the sports’ standards of excellence and internal goods. An opponent launches a sudden blow to the head, and the skilled boxer moves quickly to avoid being hit. Good hockey players anticipate which opponent will deliberately be aggressive and know when to pass the puck and glide away to avoid rough body checks. In a split second, expert skiers must adjust a sudden imbalance with a countermovement followed by an immediate return to a composed and aerodynamically efficient position. Is the implementation of new rules that reduce the significance of these skills and change how sports are played acceptable?

The answer depends upon the nature of the sport in question. Boxing is a full-contact, knock-out combat sport. There is an obvious SRC risk here, but the risk is not necessarily higher than in a collision sport like ice hockey. What distinguishes boxing, at least in its professional versions, is that the intentional immobilizing of an opponent in terms of SRC is rewarded and actually the most prestigious way of winning. The development of boxing standards of excellence includes overcoming a basic inclination not to inflict physical harm on others. In collision sports, the ethos is indeed one of physical combat with body-checking and tackling as valued skills, but SRCs are unwanted outcomes and not rewarded. In boxing, a knock-out gives a win. In ice hockey, landing blows usually means expulsion from the game.

The general discussion of the ethical status of full-contact combat sports is beyond the scope here. Still, and without taking a firm stance in these debates, I acknowledge the relevance of the critique and the possible acceptance of constitutive rule changes. Sports are dynamic, cultural practices. In the Olympic version of combat sports and in the version most practiced among amateurs, the emphasis on knock-out is replaced, at least to a certain extent, with greater value placed on awarding points for the successful execution of technical and tactical skills. This might be an improvement leading to a more interesting sport (Dixon 2001; Lewandowski 2023). The Canadian youth ice hockey example with a ban on body checking does not necessarily lead to an impoverished game as it can cultivate technique and offensive play.

The constitutive rules of combat and collision sports can be modified in meaningful and acceptable ways. The premise is that SRC-preventive rule changes align with constructive developments of sporting standards of excellence and internal goods that contribute to the flourishing of the practice.

Non-acceptable SRC-preventive constitutive rule changes and valuable SRC risks

How can we deal with situations in which proposed SRC-preventive measures change the nature of a sport detrimentally by, for instance, reducing the complexity and diversity of skills and internal goods?

In so-called ‘risk sports’ with the possibility of serious injury and even death, such as high-speed alpine skiing, offroad cycling, and motocross, SRC is the unwanted and non-intended outcome of athletes’ own misjudgments and mistakes. The moral critique of imposing harm on others does not apply. If these sports cultivate morally relevant internal goods and virtues, exposure to SRC risk (up to a certain level) can be both acceptable and valuable.

The idea of acceptable SRC exposure risks is relatively uncontroversial. In risk sports, the possibility of serious harm can be outweighed by the realization of the sports’ internal goods and the potential for cultivating virtue. However, if the risks could be eliminated without undermining the internal goods, this should be done. What I present here is a more radical version of the argument. In some sports, exposure to SRC risks are not considered unavoidable consequences but rather inherent to the execution of the sports’ standards of excellence. In these cases, athlete exposure to SRC risks adds value to the activity.

The value of dangerous sports is discussed extensively in the sport philosophical literature (McNamere 2007; Russell 2005). To devoted practitioners, voluntary exposure to the risk of serious injury or even death provides an intensive experience of living, authenticity, and meaning (Breivik 2011; Rickly-Boyd 2012). From a neo-Aristotelian MacIntyrean perspective, risk sports can be seen as practices that facilitate the cultivation of morally valuable virtues such as courage: the internalized disposition to act rationally in the face of fear by moderating in admirable ways instincts of recklessness on the one hand and cowardice on the other (Kraut 2022).

Consider downhill skiing. A core skill element is the sound calculation of physical risks. The course is inspected before every race, and skiers must reflect critically and engage in detailed cost-benefit analyses of alternative technical and tactical choices. An internal good of the sport is the in-race experience of mastery of the ski-specific ability to balance risk and safety. If practiced according to the standards of excellence, downhill skiing and other high-speed sports, such as downhill cycling and parachuting, can cultivate courage.

What happens if, due to SRC concerns, risk is significantly reduced or eliminated? A thought experiment can indicate an answer. Imagine that, with modern technology, we can establish a virtual space where downhill skiing takes place. In terms of athletes’ experiences of the activity, advanced body technologies provide an identical perceptual field to the physical realization of the sport. The technological system mimics entirely the ‘real’ downhill skiing experience, except for one key difference in the consequences of mistakes and misjudgments: a fall would not hurt physically or involve any SRC risks.

Obviously, there is a change here in the logic of risk-taking and, hence, in the standards of excellence of the sport. If the consequences of making mistakes become physically insignificant, the costs of risky and radical line choices are reduced. A performance-oriented cost-benefit analysis would encourage recklessness to a larger extent. Virtual sports decouple competitor choices of action from real-life consequences.

We can think of two opposing views on this development. One view is that the disconnection of sport with morality and seriousness is unproblematic and, in fact, long overdue. ‘The Great Sports Myth’, to use Coakley’s (2015) expression, that sports have character-building potential due to their ‘purity’ and inherent goodness should be rejected as idealistic and false. Let sports return to their origins in the frivolous and non-moral sphere of play!

The alternative view, defended here, is based on the idea of sport as a sphere of moral significance and possibility. The view is that the virtual decoupling to real-world consequences reduces the moral potential of sporting excellence. Sport can be an important and meaningful part of human life as it tests not only athletic but also moral excellence. For example: In virtual downhill skiing, fear is reduced to the fear of losing a competition, which, in this scheme of thought, is really nothing to fear at all. One key value of downhill skiing in the physical world is rational risk assessment and striking the critical balance between recklessness and cowardice. The courageous athlete knows what to fear and why, being able to deal with fear in rational and admirable ways. Whereas downhill skiing in its virtual version may provide experiential qualities of many kinds, the moral potential of its ‘real’ version is more substantial.

In other words, in some sports, athletes’ facing and handling of SRC risks are not only acceptable but can also be valuable in a moral sense. Provided the SRC risk is set to a level that cultivates skill and courage and not recklessness, risk reduction in terms of constitutive rule changes is morally unacceptable.

Decision process on SRC-reductive rule changes

So far, my discussion has been analytic, with the intent of making critical distinctions in the handling of SRC risks. Following the criticism of established SRC consensus statements and policy making as primarily reactive in form and developed by biomedical expertise (McNamee et al. 2023), my discussion should demonstrate that SRC risks and policies can only be properly evaluated with the inclusion of insights into the nature of the sport under scrutiny. How should decisions be made about whether SRC-reductive rule changes are acceptable?

Morgan (1994, 2020) advocates for a sporting development built upon the open and critical discourse in a deliberative practice community. One premise is simply that those directly affected by the policy decisions should impact the decision-making process and its outcome. In the context here, the argument would be that any SRC policy-making body must include members of the sporting community with an internalized sense of the standards of excellence and internal goods of the sport in question.

This does not mean that decisions should be made by the sporting communities alone. Reviews of rule changes in sports and the analyses that underlie them point to the lack of analytic scrutiny of consequences and practitioner involvement (Arias, Argudo, and Alonso 2011; Vamplew 2007). Obviously, the first step of estimating SRC prevalence and its causes is a matter of epidemiological, biomedical, and biomechanical expertise. Good value choices depend upon good facts. The second step is the examination of the implications of SRC-preventive rule changes on the standards of excellence and internal goods of the sport in question. The third step implies weighing the benefits of SRC preventive rule changes towards the impact on the sport and finally drawing distinctions between non-acceptable, acceptable, and valuable SRC risks.

Conclusion

SRC is a serious injury with the potential to cause long-term harm. SRC risks should be minimized and eliminated if possible. At the same time, without athlete exposure to a certain SRC risk, combat, collision, and high-speed risk sports could not be realized at all.

This article has addressed the question of when SRC-preventive constitutive rule changes in a given sport can be justified and when a certain level and kind of SRC risk is acceptable and even valuable. I have suggested an extended, consequentialist framework in which the internal goods and values of the sport in question can be weighed against the more quantifiable costs of SRC risk:

• SRC-preventive constitutive rule changes are acceptable if they align with the standards of excellence and internal goods of the sport in question or with developments that enhance the flourishing of the practice.

• SRC-preventive constitutive rule changes are problematic if they challenge extant standards of excellence and internal goods or seem to impoverish them.

• SRC-preventive constitutive rule changes are non-acceptable if they reduce or eliminate exposure to SRC risks that are integrated parts of the standards of excellence and internal goods of a sport.

In applying this framework, sound SRC policies can be developed that include concern for both the intrinsic values of sports and the health and well-being of sports practitioners.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. Thanks are du to F. J. Lopez Frias and Mike McNamee for valuable feedback on this essay.

2. My discussion deals primarily with the dominant modes of sporting games as practiced by adults. There is a stronger rationale for strict SRC-regulationsin children and youth sports, but this is beyond my scope here.

3. See, for example, Part I in McNamee and Morgan(2015).

4. For elaboration, see MacIntyre’s discussion in After Virtue (1984), Chapter 15, entitled ‘The Virtues, the Unity of a Human Life, and the Concept of Tradition.’