“ PUT ME BACK IN DOC” Ethical Issues in Sports Medicine AAOS ETHICS COMMITTEE Nancy M. Cummings, MD 1

Objectives Be familiar with the complex obligations of the team physician Identify and define the many legal and ethical issues involved in return to play situations Define the team physician’s role when there are conflicting opinions in regards to returning to play 2

Introduction Sideline coverage of a team provides a case study of many ethical issues which have to be addressed - not in the quiet of your office but in the “heat of the battle.” Doing the right thing is not as black and white as it was in Hippocrates’ day. 3

Case You are covering a football game at your local high school. The starting iStock/Thinkstock running back is 17-year-old David Dunn who has just injured his shoulder. You are called over by the trainer to evaluate. 4

David is in obvious pain, weak and unable to raise his arm above 90 degrees. After removing his pads, you see a slight elevation of the distal clavicle at the AC joint. 5

It is the third quarter of the final round of the playoffs. The winner of this game will go to the State Championship game, and David wants to Digital Vision/Thinkstock go back in. The coach comes over and asks if David, who is their all state running back, can go back in. 6

What do you do now? 7

What are the ethical issues? What are the practical issues? How much does each contribute to your decision? 8

If this were a professional athlete in the NFC playoffs how would this change your approach? 9

The injured player, David, is the offensive coordinator’s son. He says that he will take responsibility for returning his son to play. Wavebeak Media/Thinkstock 10

What now? What are the legal issues? 11

The team wins, and the local sports reporter approaches you to discuss David’s shoulder injury and whether he will be able to play in the State Championship. Fu iStock/Thinkstock 12

What do you tell the reporter? 13

You hold David out of practice for the week. He misses his follow up appointment with you but shows up at practice on Thursday with a note from a physician clearing him to play in Friday night’s championship game. 14

There are many university scouts coming to see David play, and his parents believe his future depends on him playing in this game. 15

You meet with David and his parents and inform them of the risks if David plays. You discuss their concerns, and all agree iStock/Thinkstock that the benefits outweigh the risks. 16

Potential Influences on Your Decision To Play Your reputation Fame: “The Doc that helped win the state championship” Patient referrals Not to Play: Your reputation - may be seen as too conservative Team may find a more accommodating team physician. 17

Ethical Issues Raised in This Case Autonomy – self rule Beneficence - acting in the person’s “ultimate good” Shared decision making Confidentiality Conflict of interest 18

References American Academy of Orthopedic Surgeons: Code of Medical Ethics and Professionalism for Orthopedic Surgeons, I.A. Adopted 1988, revised American Academy of Orthopedic Surgeons: Standards of Professionalism on Providing Musculoskeletal Care to Patients, Mandatory Standards 1, 5 and 6. Adopted April 2005, amended April American Academy of Orthopedic Surgeons: Sideline Preparedness for the Team Physician, Information Statement Adopted 2002, retained

American Academy of Orthopedic Surgeons: Selected Issues in Injury and Illness Prevention and the Team Physician, Information Statement Adopted American Academy of Orthopedic Surgeons: Selected Issues for the Adolescent Athlete and the Team Physician: Information Statement Adopted Chen S and Esposito R: Practical and Critical Legal Concerns for Sport Medicine Physicians and Athletic Trainers. The Sport Digest - ISSN:

Lo B: Resolving Ethical Dilemmas: A Guide for Clinicians, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, “I am in blood Stepp’d in so far…”: Ethical dilemmas and the sports team doctor. Br J Sports Med, 2010;44: , Council on Ethical and Judicial Affairs: Code of Medical Ethics. Chicago, IL, American Medical Association, ed 2010 –