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ETHICS IN ACTION: Return to Play - Insights through the Lens of the Prima Facie Healthcare Principles

Posted February 17, 2016

By Kimberly S. Peer, EdD, ATC, FNATA

Return to play decisions are complex and multi-faceted in most cases. The environment in which Athletic Trainers (ATs) work often complicates the situation. Coaches, parents and other personnel put the AT in difficult situations with their own demands and rationale for the return to play decision.

Several recent cases involving the St. Louis Rams quarterback Case Kennum and the Ravens quarterback Joe Flacco have brought these issues to the forefront again. Although not the only cases in contemporary sport and certainly not only evident at the professional level, they bring to point several considerations from an ethical perspective.

Using the prima facie healthcare principles as a framework for reflection, these cases present several interesting dilemmas. When considering the principle of beneficence or doing good, the regulations are in place to protect the athlete by allowing the AT to make the decision on the return to play.  Athletic Trainers are professionals who are trained to use evidence-based medicine to determine if an athlete is ready to play or not.

Similarly, if you look at the principle of non-maleficence or do no further harm, we can again see how the AT should be the medical professional to make the decision without compromise from other interested parties. Protecting the athlete from further harm is a fundamental role in healthcare, and although predictive in nature, it is relatively easy to predict the potential outcomes based upon a physical examination and the nature of the sport.

The third principle – respect for autonomy – provides a bit of a challenge, especially when considering professional athletes. If informed of the potential risks, should the athlete be able to make their own decisions? In the professional ranks, should an athlete be able to say they are willing to take the risk of more serious injury because, if they do not, it could impact their future earning potential or career? If we believe this is the case, how do we manage the fact that the athlete may be subtly or even explicitly influenced by fellow teammates or coaches? Is this coercive autonomy the same as a truly independent, autonomous choice?

Lastly, we have justice. As a principle, it is designed to allow all persons to be treated equally no matter what other influences are present. Many legislative and best-practice policies and guidelines are devised to protect all persons in the same manner. However, what happens when these guidelines are overlooked or blatantly ignored? Are the consequences strong enough to change behavior or are the professionals, specifically, willing to pay the fines to win the game?

The nature of sport at all levels has changed dramatically over time. It has become high stakes even at the most fundamental levels of participation. As we continue to hear more and more about return to play for specific injury situations, we will be faced with an increasing number of ethical issues as they unfold. To keep your moral footing on this slippery slope, you must be anchored in policy, evidence-based medicine and moral courage.