Correspondence
Sudden Death in Young Athletes
N Engl J Med 1993; 329:1737-1738December 2, 1993
- Article
To the Editor:
The Sounding Board article by Dr. Maron (July 1 issue)1 is an excellent example of the type of flawed thinking that results in “a lengthy and convoluted judicial process.” Hank Gathers -- not the team physician, the coach, Gathers's parents, or the university president -- was ultimately responsible for his own decisions. Maron treats Gathers like a commodity, with statements such as “Gathers was permitted to return to basketball.” No. Gathers chose to return to basketball, and he was permitted to do so.
I hope that physicians modify their recommendations in the interests of a patient's career. We modify recommendations on the basis of a patient's age, sex, vocation, health status, and personal goals. In negotiating treatment plans with patients, physicians usually provide a range of options and associated risks that they consider ethically acceptable. If the patient and the physician are unable to agree on a plan of treatment, the patient has the option to seek another opinion.
As employees of an educational institution, team physicians have a responsibility to provide information to the institution they serve. Representatives of the institution should then negotiate continued participation in athletics with the student on the basis of the institution's principles and philosophy.
Decisions about withdrawing athletes from competition need not be “muddled.” The physician's role is to evaluate the clinical condition of the athlete and render an opinion regarding diagnosis, risks, and treatment options based on current medical knowledge. School officials determine the appropriateness of continued participation in athletics on the basis of this information and negotiations with the student. The student, like any other patient, is ultimately responsible for his or her decisions.
1 ReferencesRalph Clark, M.D.
12305 Pleasant Lake Terr., Richmond, VA 232331
Maron BJ . Sudden death in young athletes -- lessons from the Hank Gathers affair. N Engl J Med 1993;329:55-57
Full Text | Web of Science | Medline
To the Editor:
Maron expresses an interest in the development and implementation of guidelines for disqualifying athletes with cardiac disease from further competition. Specifically, he bemoans the “lack of standardized criteria for disqualification from sports” and suggests that the failure to implement such criteria has “introduced confusion into this decision-making process.”
Maron's own thinking on this subject appears to have shifted in recent years. In the introductory statement accompanying the recommendations promulgated by the 16th Bethesda Conference,1 the co-chairs of the conference (including Maron) state that “the physician's primary responsibility is to make recommendations to the athletes, and that the physician need not be solely responsible for the ultimate decision of whether an athlete is permitted to compete.”1 Furthermore, they suggest that the athletes themselves (and their families) may be in the best position to make decisions regarding continued athletic competition.
Maron now suggests, however, that “the best solution is for a designated physician . . . to be responsible for making the final decision regarding removal from sport.” Maron expresses concern about the athlete's participation in this decision-making process, indicating that one must not allow “the sometimes uncompromising personal wishes of an athlete to be given undue consideration.”
In an era of advocacy for self-determination by patients, Maron's drift toward unilateral authority for the physician in the decision-making process seems outdated. We recognize the right of competent adults to refuse any treatment, even lifesaving medical therapy. We also recognize that patients may make health care decisions that physicians consider unwise and often regrettable. It is reasonable, then, to allow competent adult athletes to make decisions regarding their participation in athletics, provided there has been adequate disclosure of the risks based on the physician's medical judgment.
1 ReferencesMark D. Fox, M.A.
Beverly L. Walker, R.N., M.S.N.
Vanderbilt University Medical Center, Nashville, TN 37232To the Editor:
Maron neglected to mention his role as an expert witness for the plaintiffs in the case of Gathers v. Hyslop, M.D., and the Kerlan Jobe Orthopedic Clinic. I was a codefendant in that action, and I serve as the school physician for Loyola Marymount University. This aside, his recommendations deserve consideration. I hope everyone will reread Dr. Kassirer's editorial in the same issue1 in the light of the death of Reggie Lewis.
If changes are to be made in the care of athletes with medical problems, we physicians must take the lead. As any physician ever involved in medicolegal litigation will tell you, the courtroom is no place to learn to be a better physician.
Maron correctly identifies the complex dynamics involved in caring for elite athletes. I, for one, would like to hear more from our colleagues in psychiatry and psychology about why elite athletes with cardiovascular disorders may choose to continue to compete despite the risks.
1 ReferencesDaniel M. Hyslop, M.D.
Loyola Marymount University, Los Angeles, CA 900451
Kassirer JP . Diagnosis in the public domain. N Engl J Med 1993;329:50-51
Full Text | Web of Science | Medline
Author/Editor Response
Dr. Maron replies:
To the Editor: Dr. Clark, Mr. Fox, and Ms. Walker put forward the view that the decision about whether an athlete with cardiovascular disease judged to be at risk for sudden cardiac death (such as Hank Gathers) should continue to train and compete is best left to the athlete. From this perspective, the physician is absolved of primary decision-making responsibilities and functions largely as a passive advisor to the athlete and his or her family, coaches, and school.
This view places the athlete's individual freedom above all other considerations but does not acknowledge that the athlete with cardiovascular disease is in fact a student athlete participating in sanctioned interscholastic and intercollegiate sports. Although many such amateur athletes aspire to become professionals, most will not achieve the necessary level of performance. Therefore, for most, sport should be regarded as an extracurricular activity, and the associated potential risks must be carefully weighed. This point differentiates the medical decision-making process for competitive athletes with cardiovascular disease from many other patient-physician interactions.
Therefore, whether to assume the increased risk associated with participation in high-school or college sports is probably not a decision reasonably left solely to the athlete. Other parties -- not the least of which are the school and community -- have an interest. Furthermore, many elite athletes are reluctant to accept recommendations to withdraw from competitive athletics even if advised of a possible risk of sudden death.
Cardiovascular disease in professional athletes (such as Reggie Lewis) entails somewhat different considerations owing primarily to the fact that such athletes are older and earn their living by participation in sport. Nevertheless, it should be emphasized that other eligibility decisions have not necessarily been regarded solely as matters of individual choice. Indeed, there is precedent for using identifiable medical problems to restrict eligibility for other types of participation and employment -- for example, participation in the military and employment in fire and police departments.
Participation in extracurricular activities such as high-school and college sports does not necessarily represent a constitutional or obligatory right of students. Indeed, whether to place a student at risk against the advice of medical specialists is probably a moral issue. It is a rare educational institution that views continued athletic participation as an issue to be negotiated solely with students (many of whom are minors) if there is a medical judgment that continued training and competition are likely to increase the risk of sudden death or progression of disease.
Finally, Dr. Hyslop correctly points out that I participated as one of the medical experts in the legal proceedings after the death of Hank Gathers. By virtue of this role, I was exposed to the details of this complex case, and I gained some understanding of the various perspectives of those directly involved. Indeed, it was because of this experience that I was able to develop many of the ideas incorporated into my Sounding Board article. One of my goals was to expose other physicians to some of these perspectives, especially because I agree with Dr. Hyslop that “the courtroom is no place to learn to be a better physician.”
Barry J. Maron, M.D.
Minneapolis Heart Institute Foundation, Minneapolis, MN 55407- Citing Articles (2)
Citing Articles
1
SUBHAM GHOSH, JENNIFER N. AVARI, EDWARD K. RHEE, PAMELA K. WOODARD, YORAM RUDY. (2008) Hypertrophic Cardiomyopathy with Preexcitation: Insights from Noninvasive Electrocardiographic Imaging (ECGI) and Catheter Mapping. Journal of Cardiovascular Electrophysiology 19:11, 1215-1217
CrossRef2
Paul Fornes, Dominique Lecomte. (2003) Pathology of Sudden Death During Recreational Sports Activity. The American Journal of Forensic Medicine and Pathology 24:1, 9-16
CrossRef
