the pursuit of gnar: Drugs, money, and bioethics: A perspective on ...

Brace yourselves folks... this is a long one ^_^

After reading a recent article from the BBC, and having a long chat about steroids in baseball with some friends, I realized that I needed to coalesce my various arguments about the topic of performance enhancing drugs into a cogent form. I spent some time thinking about the practical, medical, and moral issues surrounding performance enhancing substances in sport and decided it was worth blogging about. I don't think that I'll be able to offer any sterling resolution to the topic, but in this blog post I want to clearly articulate why I have problems with performance enhancing substance at all levels of sport, but also acknowledge there are many difficulties with my this position; performance enhancing substances can be used to improve performance with relative safety under medical supervision, there is a tremendous cost associated with testing and monitoring, and there is considerable ambiguity in what constitutes performance enhancement. That said, I am still opposed to the use of performance enhancement on primarily philosophical grounds. Before I get to that, however, let me layout some medical and scientific facts about three common types of performance enhancers: anabolic steroids, exogenous erythropoietin (EPO), and sedatives (e.g., beta-blockers).

Anabolic Steroids.

Anabolic steroids are synthetic versions of the sex hormone testosterone. The functions of testosterone in human development are many, but people use testosterone as a performance enhancement in order to build muscle tissue (hypertrophy). Many athletes who take anabolic steroids will show significant increases in muscle development and thus increased power/strength compared to athletes who engage in training alone (Bhasin et al., 1996; Johnson &; O'Shea, 1969; Johnson et al., 1975, Spiers et al., 1983). The data are mixed however, and some controlled studies find no significant increases in lean-tissue mass or strength as a result of supplemental steroids (Crist et al., 1983; Golding et al., 1974; Loughton et al., 1977). Anabolic steroids also do not seem to increase an athlete's aerobic ability or work capacity (e.g., Fahey &; Brown, 1973; Johnson et al., 1975). In controlled medical environments, anabolic steroids have been used by physicians to stimulate bone marrow generation, treat hormonal imbalances, and prevent muscle wasting associated with severe conditions like cancer and AIDS (Grunfield et al., 2006). Thus, in the hands of medical professionals, anabolic steroid use can be safe and effective. HOWEVER! There are still serious health problems associated with steroid use. Some of these dangers are a direct result of the steroid itself (e.g., jaundice), whereas others are associated with culture surrounding steroid use (e.g., needle sharing).

Abuse of steroids is an enhanced concern for adolescents who are in a vulnerable developmental period with respect to both their endocrine system, where their endogenous hormone cycles changing substantially, but also with respect to their psychological development. Major health concerns include impaired excretory function of the liver (which leads to jaundice; Palva & Wasastjerna, 1972; Sacks et al., 1972), hyperinsulinism (Woodard et al., 1981), elevated blood pressure (Messerli & Frohlich, 1979), and decreased HDL cholesteral levels (all of which contribute to heart disease; Strauss et al., 1983). In females there are added risks associated with the disruption of normal hormonal cycles, including menstrual abnormalities, deepening of the voice, enlargement of the clitoris, and proliferation of body-hair and acne (Maher et al., 1983, Smith et al., 1971).

Ultimately, I would say the risks far out weigh the potential benefits of taking anabolic steroids. Medical administration of a steroid regimen is something that elite athletes may have access too and thus increase potential gains while reducing (not eliminating) potential risks, but most athletes do not have access to team of physicians and specialist. Thus, recreational steroid use, which is believed to account for most steroid use, makes an inherently dangerous activity even more risky.

Exogenous erythropoietin (EPO) and doping.

"Blood doping" is a form of performance enhancement most commonly found in endurance sports because of its positive effects for maximal and submaximal aerobic performance. Blood doping is achieved either by infusing red blood cells (e.g., you extract some of your own blood, extract the red cells, and keep them in the freezer for re-injection later) or by administering an external aid like EPO, which artificially stimulates red blood cell production. (EPO is a gylcoprotein hormone that already exists in the body to serve the same function). Blood doping has been found to increase maximal aerobic capacity (measured as VO2 max) in both highly trained and untrained individuals (Brien et al., 1989; Buick et al., 1980; Goforth et al., 1982; Robertson et al., 1984; Sawka et al., 1988; Thompson et al., 1983).? Data on EPO use in healthy subjects is limited (but see Berglund & Ekblom, 1991), but numerous studies have demonstrated that EPO administration will markedly increase (VO2 max) in anemic hemodialysis patients (e.g., Baraldi et al., 1990). In studies measuring race performance specifically, doping has been found to significantly enhance performance across endurance sports in both single-blind and double-blind trials (Berglund & Hemmingsson, 1987; Brien & Simon, 1987; Brien et al., 1989).

Blood doping and EPO use carry significant medical risks. For instance, infusion and transfusion risks for communicable disease are present in blood doping as in all blood transfusions. Of course, the risk of unsupervised transfusion (which is the probably the case for many athletes) is phenomenally greater than the risks of appropriately screened blood transfusions/infusions given for medical purposes. EPO carries its own risks and, like steroids, some of these risks are associated with EPO itself, but other risks come from the culture surrounding EPO use. Blood pressure increases are the most common side-effect reported (e.g., Berglund & Ekblom, 1991). Increase hemocrit levels, which results from either doping or EPO use, increases blood viscosity (i.e., more red cells makes your blood "thicker"). This is perhaps the biggest danger of all. Increases in blood viscosity (at very high hematocrit levels) increases the risks of thromboembolic events such as stroke or myocardial infarction, especially in extreme environments, in conjunction with dehydration, or in persons with pre-existing heart conditions (which athletes may not be aware of prior to doping; Smith & Perry, 1992).

Again, doping is a complex puzzle but a fundamentally dangerous thing to do. With supervised medical administration, doping can be used to treat conditions like anemia or to enhance athletic performance. The presence of medical supervision is critical to enhancing the benefits while reducing the risk, but the procedure is never without risk. I will discuss one more example of a performance enhancer (sedatives) before I explain why I think that health and safety concerns are not the only reason (and perhaps not the primary reason) to argue against performance enhancement in sport. ?

Sedatives.

Sedatives, especially anxiolytics, can be used/abused as performance enhancing substances in a number of sports. Most recently, I have seen sedatives called into question as performance enhancers in aesthetic sports (diving, figure skating, gymnastics) and in target-based sports (archery, biathlon, golf). Sedatives are an interesting point of discussion because they fall into a grey area of performance enhancement. Some performance enhancing substances are never included in banned substance lists (e.g., vitamins, protein supplements, or over the counter medications that athletes use to alleviate cold and flu symptoms during training). Other performance enhancing substances uniformly end up on banned-substances lists by the governing bodies of different sports (such as EPO and anabolic steroids). Sedatives, stimulants, and analgesics fall into a grey area because there often legitimate causes for their use and lower levels of associated risk. Thus, these substances present a problem for classification.

Imagine the advantage a diver might possess by using benzodiazapenes to reduce their anxiety. Clearly, not feeling the pressure of performance might be beneficial for some but it might be detrimental to the performance of others who thrive under the increased arousal (see the wide body of literature on individual responses to anxiety in sport psychology research). Or, consider an athlete who is taking azapirone as part of a treatment for clinical depression. Should that athlete be expelled from competition because of azapirone's anxiety reducing effects even when they are taking the drug for an entirely different reason?

The relative benefits of sedatives on performance are not clear, in part because of individual differences in response to anxiety, and to my knowledge, more research in human subjects needs to be done to understand if there are reliable performance enhancing effects and how the effects manifest. There is, however, considerable research on the dangers of sedatives from clinical studies for the different drugs. Benzodiazapines, selective seratonin reuptake inhibitors (SSRIs), barbituates, alcohol, and azapirone all have their own side-effects. complications, and the potential for addiction (except for azapirone, which can be used for long periods without physiological addiction; Chessick et al., 2006). As with all performance enhancements, associated risks are greatly reduced with qualified medical supervision, but risk is still present. Given that the benefits of sedatives are largely untested and likely subject to a lot of individual variation in their effectiveness, it would seem unwarranted to say the risks are worth it.

The philosophy of performance enhancement.

Governing bodies in most sports create a banned substance list based on the extant laws (i.e, any illegal drug is a banned substance) and the relative health/safety of their athletes (i.e., a substance that can enhance performance without unnecessary risk to the athlete is usually allowed). The goal of such lists is to prevent the enhancement of performance through ergogenic aids... so... there are at least a few terms that we need to define. Ergogenic aids are procedures or agents that provide the athlete with a competitive edge beyond that obtained via normal training methods. Defining normal is problematic but perhaps the best way to define it is to draw a distinction between enhancement of function versus the restoration of function (see the story of Oscar Pistorius). If an athlete needs a supplemental agent (pharmaceutical or technological) to compete evenly against other athletes then performance is arguably not enhanced but is restored. In these cases supplementation is generally allowed, but it can be very difficult to empirically prove that a supplemented athlete is not at an advantage. In these cases, you can argue that abilities have been restored rather than enhanced.?

This still raises a lot of questions. For instance, an athlete who is born and trains at altitude might have an advantage over an athlete who was born and trains at sea level by virtue of their hypoxic living environment. Is this advantage unfair? Would remediating this difference in cardio-respiratory function be enhancement or restoration? Endurance athletes have often suggested that you should "live high" but "train low" because reduced oxygen at high altitude increases the production of red blood cells (which can be maintained for 10-14 days when you return to low altitude) but increased oxygen concentrations at low altitude allow for higher intensities during workouts or races. Athletes have always been allowed to travel from low altitudes to higher altitudes or even use hypoxic tents to simulate respiratory conditions of high altitude (... not to cause hypoxia, which would be terrible!). Nike even created a high-altitude house outside of Portland, Oregon so some of their sponsored athletes could live at altitude while training at sea-level. (Although the subject of much criticism, the Nike Oregon Project and hypoxic tents are not banned by the World Anti-Dopping Agency).

There have been many critics of training centers like the Oregon Project and they criticize it for the same reason many people criticize performance enhancing drugs: they constitute an unfair advantage.This seems appealing at first, ("How can it be fair that one runner gets to train in an elite facility while another can't?") but sport is full of inequity. Financial resources, access to sports medicine, access to good coaching, genetic differences, and sociological differences all put athletes at potential disadvantages to each other. The poetic thing about sport, I would argue, is that people can be successful in spite of disadvantages and struggle despite their advantages. With so much chance and variation in the world, sport can teach excellent lessons about humility and discipline. You can work incredibly hard and still win or lose, the best you can do is work as hard as you can. To quote the legendary Oregon track coach Bill Bowerman, "the athlete makes himself, the coach doesn't make the athlete". Understanding that both our failures and our successes are not completely of our own doing is an important moral lesson to teach understanding and empathy towards others.

To conclude, there are two arguments I would like to summarize against the use of performance enhancing drugs in sport. The first argument is medical and deals with the health and safety of athletes. Any procedure or agent that exposes athletes to unnecessary risk in order to enhance performance certainly needs to be regulated if not banned. The second argument is philosophical and deals the distinction between enhancement of function and the restoration of function.

Enhancement versus restoration is an important moral distinction and although there will most certainly be challenging cases that are difficult to classify, this distinction brings a lot of resolution to the performance enhancement debate. Viewed in this light, performance enhancing drugs become essentially cosmetic surgery compared drugs, treatments, and prosthesis that restore performance and have a real medical need. (I like the idea of put elite cyclists doping or ripped baseball players juicing in to the same category as a woman in the Hollywood hills getting a face lift...). This philosophical argument is complementary to the medical argument, but I think the philosophical argument leads us into questions that crosscut sport and society. The philosophical argument not only forces us to consider the morality of sport and the role of sport in society, but it also forces a number of pragmatic questions to the surface. Imagine, for example, if all of the money from the development, sale, and testing of performance enhancing drugs was instead invested in medical research on restoring function in people with motor disorders? Thus, I do not think that the hermetically sealed house Nike built in Oregon should be banned, because it meets the first criterion of health and safety of athletes. However, I think the second criterion shows that society would be better served by putting money from professional sports back into medical research rather than getting marathon times another minute faster. ?

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References

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Berglund, B. and B. Ekblom. Effect of recombinant human erythropoietin treatment on blood pressure and some haematological parameters in healthy men. J. Intern. Med. 229:125-130, 1991.

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Source: http://pursuitofgnar.blogspot.com/2012/07/drugs-money-and-bioethics-perspective.html

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