Syd M Johnson is Assistant Professor of Philosophy & Bioethics in the Department of Humanities at Michigan Technological University. Her work is primarily focused on brain injuries, particularly severe brain injuries, disorders of consciousness, and brain death, and sport-related neurotrauma, including concussion. She’s also interested in research ethics, particularly research on animals. Syd’s recent work considers the ethical implications of epistemic uncertainty and knowledge gaps in neuroscience. She is currently co-editing The Routledge Handbook of Neuroethics (fortcoming in 2017), for which she is writing a chapter on Chronic Traumatic Encephalopathy, the topic of this post.

Paternalism, Protection, and Athlete Autonomy

Syd M Johnson

Before his death, Muhammad Ali had experienced decades of cognitive decline and motor neuron disease, the result of Dementia Pugilistica (DP), a neurological disorder that affects boxers. DP was first described in 1928 by New Jersey pathologist Harrison Martland; he called it Punch Drunk Syndrome [1]. Today, DP is known to be a variant of Chronic Traumatic Encephalopathy (CTE). CTE affects individuals who have experienced repetitive mild traumatic brain injuries, including concussion and sub-concussive injuries. The populations affected include athletes, combat veterans, and victims of domestic abuse.

CTE is a neurodegenerative disease in which tau proteins accumulate in the brain. There are numerous symptoms, including cognitive decline and early dementia, mood disorders, explosivity and aggression, impaired executive functioning and decision making, and Parkinsonian motor dysfunction. Substance abuse and suicide are common among the athletes diagnosed to date with CTE. CTE can only be diagnosed postmortem, and there have been about 150 confirmed cases. Most of them were professional athletes, and most of them died relatively young. Among those, some had no history of concussion, indicating that subconcussive brain trauma is a cause of CTE. At present, it is not known what the threshold of injury is, how hard a hit causes subconcussive neurotrauma, or how many hits it takes to initiate the neurodegenerative process of CTE. Once it begins, however, it appears it continues long after athletes stop getting injured. There are no treatments at present for those already affected by sport-related neurotrauma and CTE.

At the height of his boxing career, Ali was as famous for his sharp wits as for his skills in the ring. He was a raconteur and a poet, pummeling opponents with words as well as fists. Ali used his fame as a boxer to promote social causes: He was a civil rights activist, an outspoken humanitarian, a conscientious objector who was banned from boxing for several years after refusing to fight in the Vietnam War. The effects of CTE would eventually render his sharp tongue mute. In the last several decades of his life, he could no longer control the hands he once used to ply his trade. Some would say that Ali paid a terrible price for his success as an athlete, but he himself denied having any regrets. When his daughter Laila Ali became a professional boxer at the age of 18, her father objected, but she persisted, and was undefeated in her 7 year boxing career.

It would be implausible to suggest that Ali was not aware of DP, or that he did not choose to box. Even less plausible to think Laila Ali did not know what boxing could do to a brain. Despite a long campaign of obfuscation and denial about the risks of concussion and CTE by professional sports leagues, adult athletes participating in neurotraumatic sports today are well aware of the risks. A few have famously quit their sports because of the risks to their brains. As adult athletes, they have the liberty to make informed choices about the risks and benefits of sports participation, and their autonomy and choices should be respected. We should not presume to tell a smart, capable, autonomous individual like Muhammad Ali how he ought to use and develop his talents.

And yet, the measures that have been adopted by sports organizations to prevent or “manage” concussion and CTE do not promote or respect the autonomy of athletes. The primary remedy for the neurotrauma problem in many sports has been to adopt Return-to-Play protocols (RTPs) that were designed for pediatric athletes. RTPs typically mandate two things: (1) athletes suspected of having sustained a concussion are to be removed from play and medically assessed, and (2) concussed athletes cannot return to play until they are asymptomatic for concussion. It should be obvious why RTPs do not prevent concussions, as they don’t take effect until an athlete has already sustained a concussion. The true purpose of RTPs is to prevent Second Impact Syndrome (SIS), a devastating and almost always fatal swelling of the brain that exclusively affects pediatric athletes. As the name implies, SIS is hypothesized to result from a second impact after a concussion, although it is controversial whether this is the case. Thus, RTPs were never intended to prevent concussions, or to manage concussions in adult athletes, and it’s not even clear that they can prevent SIS in pediatric athletes. At best, they offer minimal protection to athletes: an acutely concussed athlete might experience several effects – including dizziness, blurred vision, and slowed reaction times — that could impair their ability to play and protect themselves from further injury.

Frequently, professional athletes do play while concussed, both because concussion can be difficult to diagnose, and because current sideline concussion assessments typically rely heavily on athletes reporting their subjective symptoms. An athlete motivated to continue playing is motivated to hide their symptoms and be noncompliant with RTPs. A team motivated to keep an athlete in the game is similarly motivated to overlook signs of concussion. [2] RTPs, then, are both ineffective and paternalistic. Ineffective because they were never intended to solve the problems of concussion and CTE in adults, and paternalistic because they would restrict athlete freedom concerning self-regarding conduct – the risks of neurotrauma for the athletes themselves. [3]

Professional and elite-level athletes are a rare breed, small in number, but occupying an outsized space in our awareness of sports and sport-related neurotrauma. There are millions of less visible athletes, children playing in school and recreational sports, and high school athletes, who are subject to the same risks of neurotrauma as professional athletes. They are known to be more susceptible to concussion. More than a million high school students play football in the US alone, and they make up the largest subset of the population that suffers concussions each year. Worldwide, many more youths play neurotraumatic sports like soccer, rugby, hockey, and martial sports. We currently have no idea what the longterm, lifetime effects of sport-related neurotrauma are for those athletes – serious neuroscientific study of CTE is relatively new, and those longterm effects have not been studied. It might take decades to find out. The youngest person diagnosed with CTE was an 18 year old multi-sport athlete who died after a sport-related brain injury. Other athletes in their twenties have been diagnosed, some with quite advanced CTE. Those cases suggests that the neurodegenerative process of CTE begins with participation in youth sports, and youth athletes are the ones we should be trying to protect, not the relatively small number of adult, professional athletes who know the risks of sport and can voluntarily consent to them. The focus on professional athletes is a distraction, one that makes it appear that solving the sport-related neurotrauma problem is a lot harder than it really is. It’s not hard.

Given the unknown level of risk, and the seriousness of CTE, paternalistic measures to protect youth athletes are not only justified, they are morally required, and among the fiduciary duties adults have to protect the health and well-being of children. RTPs, as noted above, are too little, too late. Radical measures, such as eliminating many forms of body contact in sports, are necessary if we are serious about reducing the risks of sport-related neurotrauma. That means doing the unthinkable and the unpopular, such as eliminating tackling in football, and bodychecking in hockey, and prohibiting youth boxing altogether. [4] Importantly, this would strike a reasonable balance between the risks and the benefits of sports for the health and well-being of young people. The protective effects would not be limited to youth athletes, however. Every professional athlete starts out as a kid, and plays and trains for a decade or more before beginning a professional career. By reducing the risk of sport-related neurotrauma in youth athletes, we could reduce the lifetime burden of neurotrauma for all athletes, which will benefit the exceptional few who become professional athletes without imposing on their freedom to choose risky sports participation as adults. In that way, the health and the autonomy of adult professional athletes can both be preserved.

Thanks to Meena Krishnamurthy for the invitation extended to me, and other philosophers of color, to share our work on this blog.

1. Martland, H. S. (1928). Punch drunk. Journal of the American Medical Association, 91(15): 1103-1107.
2. For more on this, see Johnson, L.S.M. 2015. Sport-related neurotrauma and neuroprotection: Are Return-to-Play protocols justified by paternalism? Neuroethics 8(1): 15-26.
3. There are interesting questions concerning whether participation in contact sports is ever strictly self-regarding, and whether an athlete can consent to being harmed by another. I’ll have to set those questions aside for now, but a preliminary answer is that, in some sports at least, consenting to take on the risk of harm is effectively consenting to be harmed by another.
4. For more on this, see Johnson, L.S.M. 2012. Return to play guidelines cannot solve the football-related concussion problem. Journal of School Health 82(4): 180-185.