Discussion reflections should include answers to the following : Summarize either the “yes” or “no” side for one of the articles discussed this week. State why the argument is strong or weak.Make sur

Anti-doping faces very significant challenges today—and possibly greater ones in the near future from technologies such as genetic manipulation and from skeptics opposed to the effort to discourage performance enhancing drugs in sport.

The excellent article by Catlin, Fitch and Ljungqvist [1] in this issue of the Journal of Internal Medicine provides a concise description of the history of drug testing for the Olympic Games with fascinating details of the evolution of laboratory equipment and analyti- cal strategies. It also identifies failings of the overall anti-doping system, most of them out of the laborato- ries’ control and describes a number of challenges to be confronted. In this article, I will analyse the ethical foundation for prohibiting doping in sport, describe the essential elements of a successful anti-doping pro- gram and assess the current efforts towards that end.

Finally, I will describe a set of challenges that must be met for anti-doping to succeed in the long run.

What’s wrong with doping in sport?

In research conducted at The Hastings Center in the early 1980s, we evaluated the ethical arguments for and against permitting the use of performance enhancingdrugs in sport. We found that the arguments were pro- ceeding at two levels. At the first level, the argument was over what constituted a fair system for deterring doping in sport. At the second level, the argument chal- lenged the assumption that using performance enhanc- ing drugs in sport was ethically problematic.

Interviews with elite athletes and others concerned with sport made it clear that athletes felt great pres- sure to do everything they could to hone a keen com- petitive edge. If they suspected that their competitors were gaining advantage by using drugs such as stimu- lants or androgenic anabolic steroids (AAS), those athletes faced three unpleasant alternatives: continue to compete clean, knowing that they might lose to an otherwise inferior competitor who doped; give up competing at the elite level; or unwilling to lose and reluctant to drop out, give in and use the performance enhancing drugs they believe their competitors were using. The anti-doping movement is an effort to cre- ate a fourth alternative: compete clean with a reason- able assurance that their fellow athletes are likewise refraining from doping. This is the ‘level playing field’ athletes seek [2].

The fundamental insight from this research was that the very competitiveness of sport gave doping great coercive power. Athletes did not experience the deci- sion whether to dope or not as an unpressured free choice; if it was not being urged on them by trainers, coaches or hangers-on, the typical athlete in a sport in which doping was prevalent, nevertheless faced the unpleasant alternatives described above. But, some skeptics argue, the problem is not doping, it is the effort to curtail it. They ask why should drugs like AAS, erythropoietin or human growth harmone be treated any differently than improvements in equip- ment, diet or training regimens [3].

ª2008 Blackwell Publishing Ltd 95 Editorial Comment | A full response to this criticism, which can take many forms, is beyond the scope of this article. But two observations are worth making. First, every sport must make decisions, embodied in its rules and cul- ture, as to what differences among competitors will be permitted. A modestly talented roller blader could cover the course of a marathon faster than the swiftest runner, but roller blades are banned because they dis- tort the meaning of the marathon. Athletes could of course organize a roller-blading marathon, but that would be a different sport than the marathon we now admire. It is neither unreasonable nor irrational to draw a line between good nutrition, which is encour- aged, and powerful pharmacological ergogenic agents, which are banned. Those drugs and synthetic biologi- cals have the power to distort a sport much like roller blades in the marathon; this would be sufficient rea- son to prohibit them. They also would pose a public health risk if the performance principle – the quest for maximum performance by any means at any cost – were to triumph.

Antidoping efforts are vulnerable to the criticism that they may be unacceptably paternalistic. Paternalism is roughly doing something to or for another person for their benefit but without regard for that individual’s preferences. Telling adult athletes who compete in a dangerous sport such as Alpine skiing that they should not use drugs because they might hurt them- selves may strike many people, athletes included, as hypocritical. The risks of descending a steep slope at speeds in excess of 100 km h )1 are more immediate and urgent than the possibility of some long delayed side effect from doping. But the situation of doping in sport is not the usual sort of paternalism. For one thing, athletes’ choices are far from free and uncon- strained. As in an arms race among nations, the actions of each agent push the others towards ever riskier and more wasteful decisions. In addition, the potential for a public health catastrophe is clear if all barriers to doping were flattened. Athletes would be driven to try ever larger doses of a multiplying array of drugs and biologicals in novel combinations. No knowledgeable physician or scientist could view this scenario as benign. The precise potential for harm is impossible to predict, but that many athletes – youngand healthy for the most part – would do significant damage to their long-term health, is a nearly inevita- ble outcome. Antidoping is a public health measure, not a case of indefensible paternalism. Essential elements of a successful antidoping program Implicit in Catlin and Ljungqvist [1] study are five elements necessary for a successful antidoping pro- gram: adequate analytical capacity; a smart sampling strategy; a trustworthy adjudication process; research; and a solid foundation of clear principles and trans- parent process.

Adequate analytic capacity From gas chromatography (GC) through immunoas- says to the linkage of GC and then liquid chromatog- raphy with mass spectrometry to the measurement of carbon isotope ratios, laboratories have made signifi- cant progress in their ability to detect the use of drugs and biologicals. No less important are the improve- ments in laboratory practices and the sharp upward trend towards standardization and certification.

Smart sampling strategy It does little good to test at the time of competition for a drug used during the training process and long since metabolized and excreted. Unannounced out-of- competition testing coupled with information as to athletes’ location is an essential component of testing if doping is to be discouraged. Access to blood sam- ples and to forward looking profiles such as biological ‘passports’ whether required or voluntary provide new avenues for understanding and detecting manipula- tions and for protecting clean athletes.

Trustworthy adjudication process Athletes who compete clean deserve an adjudication system that reliably acquits the innocent and sanctions cheaters. Catlin and Ljungqvist [1] detail a mixed his- tory that includes several less reassuring episodes: five of sixteen positive tests for AAS lost to ‘accidental’ 96ª2008 Blackwell Publishing LtdJournal of Internal Medicine264; 95–98 T. H. Murray | Editorial Comment shredding of codes in the 1984 Los Angeles Games; samples with traces of AAS not pursued by adminis- trators in the 1996 Atlanta Olympics; and an athlete in the 2004 Athens Games for whom flow cytometry found evidence of blood transfusion, but who escaped sanction because of a ‘sampling handling mishap’.

With the increased role of WADA and the Court of Arbitration for Sport, the future of adjudication looks promising, but trustworthiness is arduous to build up and easy to destroy. Athletes deserve an adjudication system that is fair, open and reliable.

Research For decades, antidoping researchers had few if any reliable sources of funding. WADA now devotes over a quarter of its budget to research giving investigators opportunities to improve current analytical strategies and anticipate new challenges such as gene doping or the novel methods for enhancing the oxygen-carrying capacity of blood described by Catlin and Ljungqvist [1] . Solid foundation of clear principles and transparent process Where confusion and cynicism reign, those who want to do the right thing are left feeling alone and unsup- ported. It is vital that the antidoping movement be clear about why doping is wrong and have an open, accountable and principled process for deciding what is prohibited and what is permitted. The WADA List Committee process is a significant positive develop- ment towards this goal.

Challenges New scientific developments such as the discovery of an allele affecting testosterone metabolism pathways [4] or the future prospect of genetic manipulation of athletes [5], demand an antidoping system that is sci- entifically sophisticated, robust and capable of swift response. The elements of such a system are now in place. In addition to these scientific and technical challenges, three other strategies will be vitally important.First, it is imperative that sport build upon its recent movement towards focusing on the doping infrastruc- ture that enables and encourages athletes to dope. The Hastings Center’s research showed the importance of this strategy 25 years ago. Athletes should be held responsible if they cheat, but we must also hold accountable the distributors such as BALCO, the chemists who devise new compounds to evade detec- tion such as tetrahydrogestrinone and coaches or train- ers who make drugs a part of their athletes’ regimens.

Sport must find ways to identify and sanction such enablers.

Second, athletes have the most to lose when their competitors are cheating. We must continue to engage athletes as active partners and leaders in the fight against doping. There are hopeful signs. Cycling, a sport suspected of rampant doping, now has organiza- tions such as Team Slipstream⁄Chipotle that are com- mitted to training and racing without doping, and subject their athletes to regular blood tests to establish physiological baselines against which the perturba- tions caused by manipulations could be detected.

Finally, the discourse about the spirit of sport and the ethics of competition and doping needs to be kept fresh and vigorous. New challenges to ethics con- tinue, with arguments that question whether antidop- ing is justifiable or feasible. Those arguments deserve to be heard respectfully and responded to forcefully. Con ict of interest statement No conflict of interest was declared.

T. H. Murray President and CEO, The Hastings Center, Garrison, NY, USA References 1 Catlin DH, Fitch KD, Ljungqvist A. Medicine and science in the fight against doping in sport.J Intern Med2008; 264: 99– 114. ª2008 Blackwell Publishing LtdJournal of Internal Medicine264; 95–98 97 T. H. Murray | Editorial Comment 2 Murray TH. The Coercive Power of Drugs in Sports.Hastings Cent Rep1983; 13: 24–30.

3 Fost N. Banning drugs in sports: a skeptical viewHastings Cent Rep1968; 16: 5–10.

4 Schultze JJ, Lundmark J, Garle M et al. Doping test results dependent on genotype of UGT2B17, the major enzyme for tes- tosterone glucuronidation.J Clin Endocrinol Metab2008 [Epub ahead of print].5 Miah A. Genetics, bioethics and sportSport, Ethics and Philoso- phy2007; 1: 146–158. Correspondence:T. H. Murray, President and CEO, The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY 10524, USA.

(fax: +1-845-424-4545; e-mail: [email protected], http://www.thehastingscenter.org). 98ª2008 Blackwell Publishing LtdJournal of Internal Medicine264; 95–98 T. H. Murray | Editorial Comment