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Motor vehicle crashes, a leading cause of death of children and teenagers, account for nearly 3,000 pediatric deaths annually. Following the logic of Margolis and Franchino, the American Academy of Pediatrics (AAP) should therefore call for an end to automobile use, otherwise we are violating a principle of the Hippocratic oath encompassed by the phrase, “first do no harm.” But we don’t call for a ban on automobile use. We recognize that there are benefits to riding in a car and that, for some, the risks associated with riding in a car are outweighed by these benefits. Therefore, we make people aware of the risks. We try to make riding in a car safer. And we allow people to decide for themselves whether or not their children should ride in cars.
Similarly, when deciding whether or not to participate in sports, athletes and their parents must consider whether the benefits of participation outweigh the risks and make their own decisions. As Margolis and Franchino feel the risks outweigh the benefits, they are free to forbid their children from playing football. Ending youth football altogether as they propose, however, would impose their opinion on parents and young athletes who feel that the benefits outweigh the risks.
While the use of the phrase “primum non nocere, first do no harm” offers a dramatic element to their comment, the suggestion that somehow the policy statement represents a violation of the Hippocratic oath is misleading, brash, and insu...
While the use of the phrase “primum non nocere, first do no harm” offers a dramatic element to their comment, the suggestion that somehow the policy statement represents a violation of the Hippocratic oath is misleading, brash, and insulting, particularly to those of us who dedicate our careers to improving the health of athletes. Furthermore, they apply the well-known dictum inappropriately. The actual phrase expressed in the Hippocratic oath is, “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.”(1) The maxim refers to treatment of a patient by a physician, not to policy. No one is suggesting that doctors impose participation in football on their patients as a medical therapy.
Still, the phrase represents a main principle of modern day biomedical ethics, the principle of nonmaleficence, one of four main principles upon which much of modern day medical ethics is based:
1. Respect for autonomy
Margolis and Franchino ignore the other ethical principles. Specifically, the principle of autonomy, which calls for respecting the decision making capacities of an autonomous person.(1) Respect for the autonomy of an athlete seeking to participate in sports, including contact sports, is reinforced in the codes of ethics of the International Federation of Sports Medicine and the American Medical Association which states, “physicians should assist athletes to make informed decisions about their participation in amateur and professional contact sports which entail risks of bodily injury.”(2,3) The AAP policy statement on tackling in youth football makes this same recommendation, upholds these established ethical principles, is consistent with modern day medical ethics, and is supported by the applicable codes of medical ethics guiding decisions about participation in contact sports.
1. Beauchamp TL, Childress JF. Nonmaleficence. Principles of Biomedical Ethics. New York, NY: Oxford University Press; 1994.
2. American Medical Association. Opinion 3.06 - Sports Medicine. AMA Code of Ethics: American Medical Association; 1994.
3. Stanish WD, Van Aarsen M, Evans NA. The Modern-Day Team Physician. In: Micheli LJ, Pigozzi F, Chan K, et al., eds. Team Physician Manual. 3rd ed. New York, NY: Routledge; 2013:3-9.
The Council on Sports Medicine and Fitness policy statement, Tackling and Youth Football, assures that many young athletes will suffer debilitating brain injuries.1 As the Council acknowledges, little is known about tackling per se, so that a statement limited to tackling is misleading about the risks of football where the risk of concussion is greater than for any other sport.2 Further, football participation dwarfs other sports, so this one sport contributes 60% or more of sport-related concussions in high school.3 Dompier et al. estimate that 99,000 youth players experience at least one concussion annually.4 These facts alone should raise questions about our culture’s willingness to tolerate, not to mention encourage, this cause of harm. Add to this the acknowledgement by experts that we are as yet ignorant of the long-term consequences of concussions. Meehan notes that “medicine has not figured out how many concussions is too many. And in fact, it is likely no such number exists.”5(p.125)
The evidence supporting the effectiveness of the recommendations is meager. Indeed, there are over 40 uses of terms like “unclear,” “unknown,” “limited,” and “without scientific basis” in the statement, which, while adequately reflecting the state of an uncertain literature, do not support evidence-based recommendations.
It is important for pediatricians to empower parents and their young potential football players. Advising parents to “decide whether the pot...
It is important for pediatricians to empower parents and their young potential football players. Advising parents to “decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling”1(p.e1426) undermines the concept of empowerment, because of the absence of information. If parents wanted to make an evidence-based choice, to whom would they turn other than pediatricians? And yet, the Council advises that “participants in football must decide whether the potential risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling.”1(p.e1426)
Perhaps the millions of dollars being devoted to the diagnosis, acute treatment, and long-term management of concussions will help us answer questions like “can we end tackling?” and “can we make tackling safer?” Until those questions are answered through rigorous research, pediatricians should advance primum non nocere, first do no harm, by advocating for the end of youth football.
1. COUNCIL ON SPORTS MEDICINE AND FITNESS. Tackling in youth football. Pediatrics. 2015;136(5):e1419-30. doi: 10.1542/peds.2015-3282 [doi].
2. Institute of Medicine (IOM) and National Research Council (NRC). Sports-related concussions in youth: Improving the science, changing the culture. Washington, DC: The National Academies Press; 2013.
3. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among united states high school and collegiate athletes. J Athl Train. 2007;42(4):495-503.
4. Dompier TP, Kerr ZY, Marshall SW, et al. Incidence of concussion during practice and games in youth, high school, and collegiate American football players. JAMA Pediatr. 2015;169:659-665.
5. Meehan WP. Kids, sports, and concussions. Santa Barbara, CA: Praeger; 2011.
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