"Doping"

Every two years, with the winter and summer Olympics, we get a spate of stories about athletes being disqualified for so-called "doping," or superior performances being questioned because the athlete may have "cheated" by using performance enhancing drugs. As you probably know, there is even a World Anti-Doping Agency, an international body which is accorded legitimacy by virtually all nations, to enforce a world-wide prohibition on the use of proscribed drugs by athletes.

Kayser and Smith in a recent BMJ discuss this new prohibition. (Subscription only but you can read the extract and read the responses.) I generally agree with their critique.

The main rationale for prohibition of performance enhancing drugs is based on two propositions:

1) To promote a "level playing field," to eliminate "cheating," and

2) To protect the health of athletes, both the elite athletes who are subject to drug testing and disqualification, and aspiring youngsters who might be inclined to imitate them.

With respect to rationale number 1, it is simply illogical. There is no level playing field in sport, all sport is inherently unfair. First of all, obviously, some people happen to be born with genetic endowments that give them exceptional physical capacities. The rest of us, the vast majority, can never be elite athletes no matter how hard we work at it -- or how lucky we are in other ways. And that's really the point. Many children are malnourished, chronically sick from parasites and microbial diseases. Even if you're lucky enough to have a health childhood, the nurturing of athletic talent requires all sorts of resources that are invested in some people and not in others.

By the time athletes get close to the elite level, they may have all sorts of technological advantages: carefully designed diets, high altitude training or time in hypobaric chambers, specialized machinery for training, etc. Some are lucky enough to have better coaching than others, and of course avoiding injury is largely a matter of luck as well. It is difficult -- I would say impossible -- to explain why using a steroid or EPO is fundamentally different from dietary approaches to manipulating hormone levels or high altitude training to stimulate red blood cell formation. In fact, allowing these measures makes the playing field more level, not less so, since they are more accessible and less expensive.

Finally, the prohibition makes the playing field less level because athletes with the most money, who live in technologically advanced countries, have the best chance of beating the drug tests -- and we know that many of them do so. That's why suspicion continues to fall on the winners. The ones who get caught have lesser advantages, or are just unlucky. If use of performance enhancing drugs were allowed, these inequities would be eliminated.

As for protecting health, like most drug prohibitions, this one has the precise opposite effect. The long-term health effects of using anabolic steroids and other PEDs are actually unknown, but appear to have been greatly exaggerated by anti-"doping" propaganda. Even so, the fact is that people do use them, but since they are illegal, they do so without medical supervision in most cases and in a manner which does not optimally protect their health. Problems include non-sterile injection, excessive dosing, and failure to monitor possible side effects. An open, legal regime would make harm reduction possible.

Remember that we do not worry over much about protecting athletes' health in general. Contrary to what you might think, high level athletic competition is not a healthful endeavor. Professional athletes, once their careers are over, are almost universally plagued by osteoarthritis and other orthopedic problems, and they often suffer from permanent and progressive effects of repeated concussions. They face difficult psychological challenges from having to retire from their chosen field at an age when most people are just entering their prime. Depression, substance abuse disorders, bankruptcy and suicide are not infrequent fates of retired athletes. Of course many of them do manage to get a rewarding second life, whether in coaching or by investing their earnings in business or finding another profession, but there are too many tragic outcomes.

So this is a much more complicated question than it is often made out to be. What would an effective harm reduction approach to performance enhancing technology in athletics look like? Think about elite and professional athletes, and society as a whole. What's your answer?