Correspondence

Competitive Athletes with Cardiovascular Disease

N Engl J Med 1999; 340:1371-1372April 29, 1999

Article

To the Editor:

In their article on competitive athletes with cardiovascular disease (Nov. 26 issue),1 Maron et al. conclude: “As a result of the decision in Knapp v. Northwestern University, difficult medical decisions involving participation in competitive sports can now be resolved as they should be, by responsible physicians exercising prudent judgment.” I completely disagree with this statement. The physician's role is to provide the information on medical risks (including uncertainties) to the patient in a way that can be understood. The power to make decisions lies with the patient.

Whether a university has the right to exclude a person from participating in competitive sports because of the risk of harm from such participation is a separate matter. I suspect that mechanisms could be created through legislation and legal documents that are contractually binding to protect the university when a well-informed athlete with a medical condition chooses to participate in the face of the possibility of serious injury, including death.

John B. Chessare, M.D., M.P.H.
Boston Medical Center, Boston, MA 02118-2393

1 References

1. 1

   Maron BJ, Mitten MJ, Quandt EF, Zipes DP. Competitive athletes with cardiovascular disease -- the case of Nicholas Knapp. N Engl J Med 1998;339:1632-1635
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Dr. Chessare has disputed a central premise of our article. He suggests that, in determining whether an athlete with a cardiovascular abnormality may compete in organized sports, the ultimate decision-making authority should reside solely with the fully informed patient. Furthermore, Dr. Chessare questions whether the school or university (in this case, Northwestern) has the prerogative, in accordance with a recommendation by the team physician, to exclude an athlete from participating in competitive sports — even in order to reduce the risk of harm. He views this as an independent matter that should be legislated in some way or mediated by legal documents. However, such conflict between an athlete's libertarian interests and an institution's concern for safety are, in fact, inextricably intertwined.

Indeed, our principal purpose in reporting the facts of the Nicholas Knapp matter and the deliberations and implications of Knapp v. Northwestern University 1 was to clarify this complex dispute. As we stated in our article, the appellate court that ruled on Knapp v. Northwestern University disagreed sharply with Dr. Chessare's position and held that an athlete with a potentially lethal cardiovascular abnormality (even when fully informed) does not retain the absolute and sole legal right to determine unilaterally the appropriateness of his or her participation in organized competitive sports simply by offering to sign a waiver of liability (which offers uncertain legal protection to the educational institution and the team physician).

Eligibility for amateur competitive sports cannot be regarded simply as an issue of civil liberties and individual responsibility; it requires careful consideration of several medical, scientific, and legal issues in which the school or university also has important and legitimate interests. The fundamental relationship between the amateur athlete and the school is consensual, and the law does not create a legal right to participate in any activity involving a potential risk of serious injury or sudden death. This view, affirmed by the appellate court in Knapp v. Northwestern University, explicitly supports the legal right of the school and the team physician (as well as the recommendations of the 26th Bethesda Conference2) to disqualify competitive athletes with important cardiovascular abnormalities, ultimately for the purpose of protecting the health and welfare of young sports participants.

Barry J. Maron, M.D.
Minneapolis Heart Institute Foundation, Minneapolis, MN 55407

Matthew J. Mitten, J.D.
South Texas College of Law, Houston, TX 77002

Eric F. Quandt, J.D.
Kelley, Drye and Warren, Chicago, IL 60606

Douglas P. Zipes, M.D.
Indiana University School of Medicine, Indianapolis, IN 46202

2 References

1. 1

   Knapp v. Northwestern University. 101F.3d 473 (7th Cir. 1996), cert. denied, 117 S.Ct. 2454 (1997).
   

2. 2

   Maron BJ, Mitchell JH. 26th Bethesda Conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities, January 6-7, 1994. J Am Coll Cardiol 1994;24:845-899
   CrossRef | Medline