Authors: Dr. Rob Hudson*(1), Dr. Brandon Spradley(1)

(1)Faculty member of the United States Sports Academy

*Corresponding Author:
Rob Hudson
Director of Library/Archivist, Associate Professor
United States Sports Academy
One Academy Drive
Daphne, Alabama 36526
rhudson@ussa.edu
251-626-3303

ABSTRACT
Concussions in sports involve difficult ethical issues impacting athletic management and protocols. Popular treatments of the topic like the movie Concussion (Landesman, 2015) explore some of the ethical issues from the point of view of the doctors, players and league most prone to concussive injuries like Chronic Traumatic Encephalopathy (CTE). This commentary explores the literature relevant to concussion in sports with a focus on football to develop ethical themes, informed consent, paternalism, bioethics, truthfulness, rights, and justice. A lack of scientific consensus on defining concussions and confusion in a sports knowledge base in this area undermines reassurances that concussions can be managed properly. The social benefits of contact sports along with the risk of concussed athletes is also considered.

KEYWORDS: concussion, National Football League (NFL), Chronic Traumatic Encephalopathy (CTE), sport ethics, protocol

INTRODUCTION
The new movie Concussion (2015) has actor Will Smith playing the affable Nigerian Dr. Bennet Omalu in his discovery of dementia caused by concussive blows verses the denials of the National Football League (NFL) (Landesman, 2015). Many ethical themes are in the movie such as honesty, justice, and social benefit.

INCIDENCE OF CONCUSSIONS IN THE ATHLETIC POPULATION
Concussions are in the news but the actual prevalence of the condition is unknown. Estimates need to include under-reporting, lack of trained sport physicians at most amateur and non-elite sporting tournaments, and misdiagnosis based on erroneous beliefs such as the player needs to lose consciousness for a concussion to be existent (McNamee, 2015). Nonetheless, attempts have been made and figures for statistically probable sports concussions range from 1.6 to 3.8 million players, with half of these unreported (Bonds, 2015). In the United States at the high school level, 100,000 concussions are reported annually. This a large population of injured that is more-or-less hidden and thus the importance of concussion safety is vital. Emergency Room departments record concussions that are diagnosed in the US and those numbers have increased by 60% in the last decade, attributable to greater awareness (Edwards, 2014). Studies also suggest that players are bigger, faster, and contact is more severe than ever before (Izraelski, 2014). Additionally, athletes suffer concussion at a much higher rate than the general population and that is attributable to sport injury. For example, the NFL released data in 2009 that retired players were concussed 20 times greater than the population average (Bonds, 2015). Famous cases include the suicides of retired NFL players Junior Seau, Dave Duerson, and Ray Easterling and subsequent diagnosis of Chronic Traumatic Encephalopathy (CTE).

CONCUSSION DEFINITION AND RISK FACTORS
Traumatic Brain Injury (TBI) includes concussions and results from a blow to the head resulting in shaking the brain (Gleadhill, 2014). The difficulty with diagnosis is that a concussion may be asymptomatic. One study of Canadian hockey players found that only 19% were aware that they had suffered a concussion (Edwards, 2014). Many concussed athletes have normal brain function for years to come. If concussions do have symptoms they include everything from dizziness, to tiredness, to double vision, or depression, but losing consciousness is not a necessary factor (Gleadhill, 2014). Secondary blows are more dangerous and long term effects may include CTE. Early identification and treatment is vital and education of players, parents, coaches, staff, and leagues is also critical. This is highly related to youth health and very critical ethically.

Sports fans might assume that concussion research is advancing to the point that the risks are known, concussion can be accurately identified and treated, and return to play decisions are intelligently made by medical staff. The truth is very different and full of ethically hard decisions for all stakeholders (McNamee, 2015). The lack of clarity of the concept and uncertainly of diagnosis means that informed consent and sport education of players, parents, coaches, and others are compromised. The National Collegiate Athletic Association (NCAA) Board of Directors instituted a requirement in 2012 to require all active member institutions to implement concussion management plans based on education and research that is unclear. Is the naïve reliance on these concussion plans deceptively unethical?

The state of Washington enacted the Zackery Lystedt Law in 2009 to mandate training in youth sport to coaches, parents, and young participants for the purpose of reducing the occurrence, severity, and secondary impact syndromes or sequelae (Bonds, 2015). The key provision in this law is the 24 hour wait for any return to play decisions. Zackery Lystedt was an injured 13 year old playing football and allowed to return to play during the same game after a concussion and suffered a second concussion. He nearly died and is severely disabled today. Similar laws are now in 42 states (McGowan, 2014). Can the reliance on such well-intentioned paternalism provide false expectations particularly for young athletes and their parents? Are mandatory educational sessions presented in a format easy to comprehend for the intended audience?
One of the problems is the definition of concussion is unclear and therefore the measurement, diagnosis, and return to play decisions vary widely. The authoritative Concussion in Sports Group (CISG) consisting of sport physicians globally met four times over the last 15 years to hammer out concussion research and protocols in ‘Concussion Consensus Statements’ (McNamee, 2015). The broad definition of concussion offered by CISG was “a complex pathophysiologic process affecting the brain, induced by traumatic biochemical forces.” Common symptoms for concussed players include headache, vertigo, neck pain, sleep problems, lack of focus, dizziness and tiredness (Darling, 2015). The consistent message of CISG is that no return to play on the day of concussive injury should occur.

However, each meeting resulted in different findings and the CISG ultimately gave large amounts of discretion to clinical judgments of physicians on the sports field as a result. Unfortunately, with the exception of elite sport, few physicians trained in sport concussion are present at games around the world. Moreover, very few physicians know concussion protocol and many never used either neurocognitive or balance testing in their return to play decision making, or know medical studies suggesting that excessive rest after concussion may in fact be detrimental (Darling, 2015). Also, many local physicians will not give concussion clearance due to the undefined nature of the ailment and their concerns about professional liability and licensure loss. Lastly, the CISG statements are influenced by powerful leagues around the world and therefore potentially not neutral expositions of science and sports medicine. For example, the 2008 Zurich Concussion Consensus Statement legitimatize the idea that NFL players alone could return to play on the same day as a concussion based on extensive NFL sponsored research, which the 2012 Concussion Consensus Statement revoked (McNamee, 2015). Partial or biased information in sport is unethical and leads to poor choices and negative health outcomes. Leagues have conflicts of interest when looking at health issues for players that may reduce corporate profits.

CONCUSSION LAWS AND ETHICS
The litigation surrounding concussed athletes brings to the forefront ethical issues of failure to warn and breach of duty to serve. The NFL is the focus of this litigation because of the high profile contact nature of the sport; for example, the movie Concussion starring Will Smith was just released (December, 2015), but the other sports have also been subject to legal challenges as well. The case In Re National Football League Concussion Injury Litigation (In Re National) combined 81 individual player lawsuits against the NFL into one class action (Bonds, 2015). The NFL allegedly withheld evidence connecting concussions and brain damage. The secretive Mild Traumatic Brain Injury Committee of the NFL was at the center of this litigation and little information was forthcoming on the work of this committee. In the NFL’s defense, the league did assert a concern for health privacy when matters of individual athletes’ concussion histories are exposed. Ultimately, the federal judge in In Re National ordered mediation and the sides reached a settlement of $765 million (increased to $900 million) in damages to compensate 4,500 former/future NFL players and their families.

Not all litigation in the area of concussion targets leagues, as the helmet lawsuits show product liability principles are also operational. Since 1989, manufacturer Riddell supplied helmets to the NFL and allegedly colluded with the NFL to withhold information about repeated head injuries and concussion (Bonds, 2015). In that law suit, Maxwell v. NFL (C.A. No. 2:11-08394) the plaintiffs were 75 football players led by Vernon Maxwell. They alleged that Riddell knew of the negative health consequences of concussions since the 1920s but failed to warn consumers of the danger and also failed to use adequate padding in their helmets.

In both the Maxwell v. NFL and In Re National cases much of the success of the legal actions turned on whistleblowers. The helmet case evidence was exposed by P. David Halstead, former employee of the NFL, and the In Re National evidence involved sport physicians such as Dr. Bennett Omalu, neuropathologist who found CTE in American football players (Bonds, 2015). In these cases, commercial cheating resulting in player injury is identified and exposed. Justifications include a winning-at-all-cost mentality characteristic of unethical sports practice (Thornton, Champion, & Ruddell, 2012). Prevention is the most effective treatment for this health concern but that is dependent on an adequate knowledge base (Gleadhill, 2014).

CONCUSSION STRATEGIES
In addition to prevention and knowledge transfer, the recommended changes to improve concussion outcomes are dependent on professional practice modifications such as improved coaching styles, referee conduct, and athlete play modifications (Gleadhill, 2014). It is not enough to give a helmet design an improvement or a large class action settlement and not include this in an overall concussion protocol. Education in strength training, particularly in the neck, and use of safety gear such as mouth pieces also are part of the educational and professional evolution in this area. Another element of improvement are rule changes resulting in less contact that may cause concussion in sports. For example, amateur hockey has eliminated checking for youth under 17 years old in Canada as research indicated concussed youth are at much greater risk.

Are rule changes enough? Dr. Bennett Omalu of recent movie Concussion (2015) fame recently wrote in the NY Times that he believes no child should participate in contact sports such as football, hockey, boxing, or lacrosse to prevent all CTE in youth athletes as much as possible (Omalu, 2015). What is the social benefit as compared to the potential loss of contact sports in our society? This is a normative ethical analysis (Thornton, 2012). Preventing harm to others, in this case athletes, should be an obvious social outcome. Additionally, paternalism, honesty, and rights are part of the discussion on concussions as well.

Are litigation and new laws enough to determine the social response to concussion in sport? A study of the NCAA showed there is “no consistent method for concussion education being applied to sport across the USA, let alone internationally” (Gleadhill, 2014), despite NCAA legislation enacted in 2012 requiring member institutions to provide concussion education. This NCAA effort came after law suits such as Arrington v. NCAA (2011) on concussion practice in collegiate sports (Bonds, 2015). Additionally, at the national level the Center for Disease Control and Prevention (CDC) implemented the ‘Head’s UP’ campaign and greatly increased awareness but failed to include specific prevention strategies. Last, school based concussion intervention could include grades 1-3 but changing curriculum has lagged far behind concussion research in athletics (Gleadhill, 2014). The literature noted a lack of evaluation studies to determine the impact and outcome of concussion educational mandates in sport.

Most of the research in sport concussion focuses on accidental occurrence of the injury but there is also an ethical problem with intentional injury, particularly in professional leagues and elite competition such as the NHL (Izraelski, 2014). Checking and fighting are allowed tactics in hockey under narrowly defined situations. Specific hockey positions, such as forwards, receive 62% of concussion while goal tenders only reported concussion at a rate of 4.2% in the 2004-2005 season (Izraelski, 2014). Also, longer term play and fatigue are associated with increased concussed symptoms. In the most extreme cases in hockey, the player is attacked in violation of the rules, and criminal charges may also be involved, such as the Tod Bertuzzi slash-from-behind against the temple of player Steve Moore producing a career ending concussion in 2004.

Many hope these concussion dilemmas will be solved by technology that saves contact sports and protects the players too. At the elite level, technology is providing hope that the risk is reduced but at a high financial price. For example, ‘smart helmets’ include air bags under the shell and impact sensors to relay information to sports medicine officials on the field (Yeats, 2016). The air bag would instantaneously shift air around within the helmet to the point of impact, according to researchers at the University of Utah. The air bag technology would also automatically adjust to the contours of each individual player’s head for maximum protection. However, many non-elite player might find this a cost prohibitive solution and it cannot remove ethical issues. Others advocate establishing a baseline ‘neuropsychological and balance’ test before the season for each athlete to compare to post trauma brain function (Edwards, 2014). In a final example of technology assisting in concussion prevention, recent advances in sports medicine can detect pre-existing conditions like cavernous malformation of the skull which involves abnormal blood vessels in the brain (Schoepfer, 2015). Pre-testing athletes for these types of conditions would result in prohibition from certain kinds of sport participation for those so diagnosed. Despite these advances much remains unknown about the risks, and that should be communicated to all so that informed decisions can be made. Mitigating the risk should be a community norm.

Perhaps most potential help is in a cultural change. This is an attitude change from standard practice of ignoring the
issue to new identification, awareness, and effective sports response. It is now unethical, according to numerous league rules and state laws, to ignore concussed athletes and put them back in the game (Edwards, 2014). Sport characteristics of toughness and invincibility need to be de-emphasized for better smart responses or more generations of youth will be harmed. That is unacceptable especially when children athletes are the victims.

Part of the responsibility falls on the athletes themselves: the system of concussion management often relies on athlete self-reporting symptoms and they should not feel incentives to hide concussions. CTE and other long term symptoms may be latent for decades and athlete must self-monitor and not avoid medical assistance even years later. They need to value asking for help. The consequence of maintaining a system of denial are more athlete suicides and health problems. Also, athletic careers end because of concussions and this can provide an incentive to follow protocols; for example in the NHL at least eight players were forced to retire due to lingering concussion symptoms since 2000 (Izraelski, 2014). Professional associations set ethical guidelines that should be followed by athletes, parents, and sport staff such as the “The Return to Play Protocol” proposed by the Third International Congress on Concussion in Sports (CISG) (Edwards, 2014). Another example of ethical guidelines being established is the NHL Player Association concussion program created in 1997 that all members must follow (Izraelski, 2014).

Cultural change is also needed by the parents of young athletes (McGowan, 2014). A survey of state officials implementing concussion protocols similar to the Zackery Lystedt Law showed the overwhelming problem in the efficacy of the laws was parental cooperation. Apparently leagues and coaches are getting the message but parents are wanting their kids to go back in prematurely against rules and protocols.

CONCLUSION
The ethical issues in sport concussion are normative and involve concepts like benevolence, helping those in need, especially youth; honesty, not hiding the truth about concussions; paternalism, assisting athletes to do what is in their best interest; harm-avoidance; and finally social benefit, regarding the utility of risky contact in sports. A recent story appeared about a deceased football player, Michael Keck, aged 25, with CTE, (Reuters, 2016) a disease of the brain associated with people in their 60s and 70s. This player started American football at age six with his first concussion at age eight. In college football, he had symptoms including dizziness and blurry vision. By the time of his death he had a total of 10 confirmed concussions. One concussion is enough and the system failed this young man.
Future directions in concussion research should include women athletes, a group completely ignored in the current controversy over concussions. One research study commenced in 2014 as a joint NCAA and Department of Defense study of both male and female concussions at twenty one universities (Olson, 2016). The gender inequality in this area of study is astounding and probably violates Title IX.

ACKNOWLEDGMENTS
Thanks to Dr. Lawrence Bestmann Ph.D for inspiring the publication of this article based on work in his Sport Ethics course.
 
REFERNCES
1. Bonds, G. B., Edwards, W. W., Spradley, B. D., & Phillips, T. (January 01, 2015). The Impact of Litigation, Regulation, and Legislation on Sport Concussion Management. The Sport Journal. Retrieved from http://thesportjournal.org/article/the-impact-of-litigation-regulation-and-legislation-on-sport-concussion-management/
2. Edwards, J. C., & Bodle, J. D. (2014). Causes and Consequences of Sports Concussion. Journal of Law, Medicine & Ethics, 42(2), 128-132 5p. doi:10.1111/jlme.12126
3. Gleadhill, S., James, D. A., Maher-Sturgess, S. L., & Lee, J. B. (2014). Engagement by Education for Action: Recommendations for Educational Interventions to Prevent Concussion in Sport. Journal of Fitness Research, 3(3), 8-22.
4. Izraelski, J. (2014). Concussions in the NHL: A narrative review of the literature. Journal of the Canadian Chiropractic Association, 58(4), 346-352 7p.
5. Landesman, P. (Director). (2015). Concussion [Motion Picture]. United States: Sony Pictures.
6. Lowrey, K. M., & Morain, S. R. (2014). State Experiences Implementing Youth Sports Concussion Laws: Challenges, Successes, and Lessons for Evaluating Impact. Journal of Law, Medicine & Ethics, 42(3), 290-296 7p. doi:10.1111/jlme.12146
7. McGown, Lowery (2014, Oct.). State experiments implementing youth sports concussion laws. Journal of Law, Medicine and Ethics, Fall, p. 290.
8. McNamee, M. J., Partridge, B., & Anderson, L. (2015). Concussion in Sport: Conceptual and Ethical Issues. Kinesiology Review, 4(2).
9. Olson, G. (2016, January 1). NCAA’s Continuing Commitment to Preventing Concussions. Huffington Post Blog. Retrieved from http://www.huffingtonpost.com/gary-a-olson/ncaas-continuing-commitme_b_8959574.html
10. Omalu, B. (2015, Dec. 7). Don’t Let Kids Play Football. NY Times. Retrieved from http://www.nytimes.com/2015/12/07/opinion/dont-let-kids-play-football.html
11. Reuters (2016, January 5). Dead college football player leaves clues of concussions’ toll on brain. FoxNews. Retrieved from http://www.foxnews.com/health/2016/01/05/dead-college-football-player-leaves-clues-concussions-toll-on-brain.html
12. Schoepfer, K., & Dodds, M. (2015). Concussion Protocol Breakdown. Athletic Business, 39(8), 16-19.
13. Thornton, P. K., Champion, W. T., & Ruddell, L. (2012). Sports ethics for sports management professionals. Sudbury, MA: Jones & Bartlett.
14. Yeats, Ed (2016, January 5). ‘Smart Helmet’ Technology Could Limit Concussion Damage. Deseret Morning News (Salt Lake City). Retrieved from http://www.athleticbusiness.com/equipment/smart-helmet-technology-could-limit-concussion-damage.html