Autonomy, relationality, and brain-injured athletes: a critical examination of the Concussion in Sport Group’s Consensus Statements between 2001 and 2023

ABSTRACT

This article critically examines the development and consensus outputs of the Concussion in Sport Group. We examine the six Consensus Statements between 2001 and 2023 to explore the challenges that the presence of contextual forces pose to the development of effective and ethically justifiable medical guidelines to manage situations involving brain-injured athletes. First, we discuss the implicit and explicit ethical framework and goals underlining the statements. Secondly, drawing on a relational account of athlete choice, we expound on the limitations of the framework, concentrating on those resulting from a simplified understanding of athlete autonomy. Thirdly, we conclude by proposing a series of recommendations to improve concussion management protocols: (1) adopting a broader understanding of autonomy built upon relational accounts, beyond just the healthcare professional-athlete relationship; (2) further minimizing conflicts of interest that increase athletes’ vulnerability and hinder decision-making ability; (3) enhancing healthcare professional training to allow better adjustment of treatment plans to athletes’ contexts; and (4) promoting research on sociocultural elements affecting athletes’ vulnerability and autonomy.

KEYWORDS:

• Concussion
• vulnerability
• ethics
• autonomy
• healthcare

Disclosure Statement

Mike McNamee was part of the leadership team that produced the Concussion Consensus Statement; he received funding from the IOC for an Ethics of Concussion Symposium in 2022.

Notes

1. The notion ‘brain injury’ is an umbrella term encompassing uncertain diagnoses of a wide range of conditions. Within this spectrum, we find mild traumatic brain injuries (mTBIs), concussions, and more severe traumatic brain injuries (TBIs), making the issue multifaceted.

2. Similar concerns have been raised regarding ball heading in soccer (see Reynolds 2023; Siva 2020)

3. Interestingly, the earlier versions of the document included ‘coaches and others involved in the care of injured athletes’ as part of the intended audience, a reference that is notably missing in the latest versions of the document.

4. It is important to note that the documents intentionally differentiate this guidance from clinical practice guidelines and legal standards of care. Here, it seems that the CiSG is acting prudently so as to defend against legal claims against their findings and summary positions.

5. A declaration of interest is required here in terms of transparency. One of the co-authors of this piece (McNamee) was invited by the International Olympic Committee (who led the funding of the Amsterdam congress and consensus process) to join the leadership group that produced the CS in the early summer of 2022. To some extent, then, he acknowledges a sense of shared responsibility with co-authors for failings or weaknesses identified here. For the record, his contribution was around ethical dimensions of research design and recommendations for good clinical practice. He did not contribute to the development of specific protocol tools.

6. Non-maleficence, another fundamental principle in the principlist framework, is reflected in those guidelines that are directed at the reduction of risk in collision sport. However, in this case, the agents responsible for risk reduction are often not medical professionals but sport organizations.

7. In this regard, they resemble patients who exhibit the ‘therapeutic misconception’. There is ample research of patients being told that they are on a medical research trial for which no benefits will necessarily accrue, yet they still firmly believe their participation will have therapeutic effects (Lidz and Appelbaum 2002). Others have suggested that this misconception needs to be nuanced according to the precise form of positive belief that is held (Horng and Grady 2003). This more considered psychological evaluation appears apt to explain the apparently irrational beliefs held by some players.

8. Take the case of the Miami Dolphin’s quarterback Tua Tagovailoa in the National Football League (NFL). Tagovailoa suffered an initial brain injury during a game on Sunday, September 25, 2022. Notwithstanding this, he returned to play on the same day and was fielded for his team’s next game just five days later, where he sustained another head injury. On the latter occasion, the football player needed medical assistance to be removed from the field and taken to the hospital (Belson 2022). A few days later, the NFL vice president, Jeff Miller, assured a press conference that team doctors and league-affiliated neurologists had followed the concussion protocols. Many, including the NFL players’ union, questioned if this was the case (Diamond 2020). Making the reasonable assumption that he was not forced to play, the incident underscores the injured player’s determination to return to play despite having endured neurological trauma.

9. Importantly, one must be mindful that athletes seek advice and help from a wide variety of healthcare professionals (e.g. sport medicine doctors, physical therapists, sport psychologists, strength and conditioning trainers), each of whom has different obligations or responsibilities depending on their influence over the athletes’ decisions (Brown et al. 2023; Drew et al. 2023).

10. Indeed, in cases where healthcare professionals trained in concussion management are not present, one of these figures may be required to step in to provide guidance.

11. Thanks to Søren Holm for bringing this point to our attention.

12. The sort of thing we have in mind here is undertaken, in relation to BASEjumping, by Gunnar (Breivik 2007).

13. This is drawn from a systematic review on the ‘Decision to Retire’ (Makdissi et al. 2023), another welcome addition to the CS activity. In that paper, it was recommended that healthcare professionals, ‘Make the athlete aware of the role(s) they play in the athlete’s care, stating clearly if they have or foresee any potential or actual conflicts of interest affecting the decision that might compound informed decision-making by the athlete’ (827). The same wording appears later in the key recommendations.

14. Drawing on Robert Nozick’s understanding of coercion, he opposes the notion of contextual coercion. In his view, leaving athletes with a set of non-optimal options to make them more likely to make a specific choice does not always count as coercion. Similarly, Dixon (2008) posits that, if anything people do to gain a competitive advantage counts as coercion, then that understanding of ‘coercion’ is vacuous. From this narrower viewpoint, coercion can only result from threats or offers that violate a moral principle.