e132(1) C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Ethics in Practice Sideline Ethical Dilemmas Joan Krajca-Radcliffe, MD, and Nancy M. Cummings, MD
A team physician is covering a local high-school football game. The All-State starting running back injures his shoulder. ‘‘David Doe’’ is in obvious pain. His arm and shoulder are weak, and he is unable to actively raise his arm above 90°. When his pads are removed, there is a noticeable deformity of the acromioclavicular joint. It is the third quarter of the final game of the playoffs, and the winner goes on to the state championship game. David is a college prospect, and there are many collegiate scouts in the stands. David wants to go back into the game, and David’s father, who is the offensive coordinator for the team, says he will take the responsibility for sending David back in. The orthopaedic surgeon on the sideline does not return David to the game and, in spite of this, the team wins. After the game, a reporter for the local newspaper approaches the team physician for information on David’s injury and prognosis. David does not keep his follow-up appointment in the orthopaedic surgeon’s office, but shows up to practice with a note from another physician saying he is able to play.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Introduction The physician-patient relationship that is formed during a sideline-based examination is a more complicated one than the one formed during an office-based examination. In the sideline setting, there are many other influences that affect this most fundamental relationship in medicine. Hippocrates’ basic tenet of ‘‘Do no harm’’ can be subject to interpretation and conflicting priorities. Whether sideline care takes place in front of a national television audience or a smaller audience of hometown spectators, there are many more witnesses to the sideline diagnosis and treatment of the patient than there are in any other areas of medicine. Performing a Lachman test in front of 100,000 fans is a decidedly different experience than that of performing the same test in the privacy of a clinic examination room, but the results of that test need to be equally accurate. The same medical and ethical standards that are applied in the office setting
must also be applied at the sideline when deciding whether to allow an athlete to return to play. The ethical principles of patient autonomy, beneficence, confidentiality, and conflict of interest are all challenged in the sideline practice setting. Autonomy, Beneficence, and Conflict of Interest Autonomy, which literally means ‘‘self-rule’’1, dictates that it is the patient’s body and therefore the patient can do whatever he or she wishes with it. This, however, does not mean that the athlete can insist on injury management that causes harm or is outside of the accepted standard of practice. Beneficence is from the Latin beneficentia2, which means kindness or honorable treatment. This ethical principle expands the obligation of the physician to not only do no harm, but to purposefully act for the good of the patient. Unfortunately, on the sidelines, these two ethical principles may often be at odds. Because it is his body and he may do with it as he chooses, David Doe can
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e132(1-3)
d
http://dx.doi.org/10.2106/JBJS.N.00151
e132(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 15 A U G U S T 6, 2 014 d
d
SIDELINE ETHICAL DILEMMAS
d
make the autonomous decision to accept the recommendation of the team physician and leave the game or reject the recommendation and attempt to return to the game. Beneficence, on the other hand, requires the team physician to actively seek to provide a net benefit to the patient-athlete, which, in this case, would involve requiring the athlete to sit on the sidelines until his pain was better and his strength returned. Which of these two principles should prevail, and who decides? For the team physician, the physical well-being of the athlete takes precedence. If this were an anterior cruciate ligament tear or a fracture, the course of action would be obvious: the athlete would be done for the day. But an acromioclavicular separation, while serious, does not totally eliminate the possibility of playing. In professional or even collegiate sports, the acromioclavicular joint might be injected with a local anesthetic and the player might be allowed to return to the game. This is not a standard practice at the high-school level. Another ethical issue raised here is the conflict of interest of the parties involved in the sideline decisions. In this case, the parent is a coach. The desire of a parent to protect his or her child and the goal of a coach to win are in direct conflict. The decision to put David back on the field can be biased by the overall goals of the team. A further potential conflict is that there are collegiate scouts present to evaluate David, and a scholarship can relieve much of the father’s financial burden of David’s education beyond high school. These conflicts may not lead to a decision that is in his son’s best long-term physical interest. Again, the best interest of the athlete’s health should be of primary importance, but, in the heat of the moment, as in the playoff game, it may not be. This brings up the critical role of the team physician as an impartial adjudicator on the sideline and not as a member of the team or coaching staff. The physician himself or herself also has some potential conflicts. If David plays and does not sustain further injury, then the physician is the hero, especially if the team wins. This circumstance could lead to more notoriety for the physician, boost his or her reputation in the sports community, and result in a potential increase in patient referrals, thereby benefiting the doctor with additional income. Conversely, if David is not allowed to play, the team may question the doctor’s role as team physician and seek a more ‘‘accommodating’’ physician elsewhere for future sports-medicine care. It is paramount for the team physician to keep the patient-athlete’s present and future health as the absolute priority in these circumstances3. Confidentiality and Medical-Legal Concerns The reporter who approaches the physician for information brings up the matter of confidentiality, which must govern all physician-patient-parent interactions. If David is eighteen years old, then his medical information is his own. If he is seventeen years old, then his parents have the final say as to whether or not this information can be shared. Divulging information on David’s condition without his and his parents’ permission is breaking federal law. Federal health privacy regulations—HIPAA: the Health Insurance Portability and Accountability Act4—requires health-care providers (individuals as well as institutions) to
obtain patient authorization to use or disclose individually identifiable health information. This would be true on the sideline or any time after the game. Finally, with regard to medical-legal concerns, the physician on the sideline must adhere to standard or customary sports-medicine practices, which are not always well defined. The physician should make medically reasonable decisions and provide sufficient medical information so that the athlete and/or his parents are aware of the risks in returning to play. What happens, however, if the athlete’s parents offer to assume the risk of the decision to return their child to play? From a legal standpoint, two conditions have to be met before David can return to the game: (1) The athlete (or the parent or guardian if the athlete is a minor) must fully appreciate the type and magnitude of the risk involved in continuing to participate; and (2) The athlete (or the parent or guardian if the athlete is a minor) must ‘‘knowingly, voluntarily, and unequivocally’’ choose to participate. In addition, the physician can have the parents sign an exculpatory waiver, which relieves the physician from liability should the athlete sustain further harm by returning to play5. Is this a reasonable course of action for the physician to follow in the heat of the battle, and is true informed consent possible in the sideline context? Even if the waiver is signed, the court may, on a case-by-case basis, evaluate the validity of such a document should a complication occur as a result of David’s return to play. A final issue to be considered by the sideline physician is David’s assent to the decisions made on his behalf. As a teenager approaching legal adulthood, his opinions should be considered. The parents may want the collegiate scouts to see him play to obtain a scholarship as a means to relieve the financial burden of college, and David may not want to return to the game. At the minimum, David should assent to whatever decisions are made with regard to his body, since he is of age to participate in the decision process. This relatively common case scenario brings to light a host of ethical and legal issues. What happens if only one parent agrees to sign and the other chooses not to, or is not present? What if the athlete wants to play, but the parents do not consent? Shared decision-making in any other setting would be the best way to approach this dilemma, but it may not be a viable option in the sideline setting. While dealing with the current injury, the team physician is still responsible for the remaining players on the field, and taking time to have a joint meeting with all parties involved would not be prudent. The time to determine a viable approach to these situations is not on the sidelines during a game or in the middle of the season but prior to taking on the job of team physician. An agreement should be established in the preseason between the team physician and the superintendent or legal representative of the school district, the athletic director, coaches, and trainer about how controversial decisions such as these would be handled. The discussion should also include who has jurisdiction over the subsequent non-sideline return-to-play decision. Will it require clearance by the designated team physician, or will it
e132(3) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 15 A U G U S T 6, 2 014 d
d
SIDELINE ETHICAL DILEMMAS
d
simply require a ‘‘doctor’s note’’ from any physician? Ideally, the team physician should have the sole authority to return the injured athlete to play. An outside ‘‘doctor’s note’’ should not be permitted. In allowing this, the school may wrongly assume that the outside physician is ethical and practices beneficence and that he or she allows autonomy on the part of the athlete in alignment with the team physician’s determination of the situation. If this ideal agreement cannot be reached, then the team physician needs to decide if the agreed-upon approach is acceptable on the basis of his or her own personal ethics and professionalism. Finally, the role and authority of the sideline team physician should be discussed with parents and athletes at the typical pre-participation sports meeting. This will create an environment in which all of the potential stakeholders involved in the sideline management of the injured athlete start with the same information and expectations. When an athlete gets injured on the field, the covering team physician is faced with a much more complex relationship
than the traditional office-based physician-patient relationship. While the primary obligation must be to the health and wellbeing of the patient-athlete, the physician should also be familiar with all of the potential pitfalls and complex issues involved in this relationship. n
Joan Krajca-Radcliffe, MD 111 Bamaku Bend, Tiki Island, TX 77554. E-mail address: [email protected] Nancy M. Cummings, MD Franklin Health Orthopaedics, 111 Franklin Health Commons, Farmington, ME 04938. E-mail address: [email protected]
References 1. Lo B. Resolving ethical dilemmas: a guide for clinicians. 4th ed. Lippincott Williams & Wilkins; 2011. 2. Merriam-Webster: An Encyclopedia Britannica company. http://www. merriam-webster.com/dictionary/beneficence. Accessed 2014 May 20. 3. American Academy of Orthopaedic Surgeons. Code of medical ethics and professionalism for orthopaedic surgeons. The physician-patient-patient relationship,
Section I.A. 1988, revised 2011. http://www.aaos.org/about/papers/ethics/code. asp. Accessed 2014 May 20. 4. Chen S, Esposito R. Practical and critical legal concerns for sport medicine physicians and athletic trainers. The Sport Journal. 2003 Mar. 5. Department of Health and Human Services. 45 CFR Parts 160 and 164. Standards for privacy of individually identifiable health information. 2002. http://www. hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/. Accessed 2014 May 20.
Suggested Reading 1. American Academy of Orthopaedic Surgeons. Sideline preparedness for the team physician, information statement 1022. 2002. http://www.aaos.org/about/ papers/advistmt/1022.asp. Accessed 2014 May 20. 2. American Academy of Orthopaedic Surgeons. Selected issues in injury and illness prevention and the team physician, information statement 1031. 2007. http://www.aaos.org/about/papers/advistmt/1031.asp. Accessed 2014 May 20. 3. American Academy of Orthopaedic Surgeons. Selected issues for the adolescent athlete and the team physician, information statement 1032. 2008. http://www. aaos.org/about/papers/advistmt/1032.asp. Accessed 2014 May 20.
4. Devitt BM, McCarthy C. ‘I am in blood Stepp’d in so far...’: ethical dilemmas and the sports team doctor. Br J Sports Med. 2010 Feb;44(3):175-8. Epub 2009 Nov 29. 5. American Medical Association. Council on ethical and judicial affairs. Code of medical ethics. Opinion 3.06. http://www.ama-assn.org//ama/pub/physicianresources/medical-ethics/code-medical-ethics/opinion306.page. Accessed 2014 May 20. 6. Cummings NM. American Academy of Orthopaedic Surgeons. Resident ethics series: issues and scenarios for discussion and guidance: put me back in the game doc. http://orthoportal.org/estudy/resident_ethics.aspx#tab2. Accessed 2014 May 20.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Ethics in Practice Sideline Ethical Dilemmas Joan Krajca-Radcliffe, MD, and Nancy M. Cummings, MD
A team physician is covering a local high-school football game. The All-State starting running back injures his shoulder. ‘‘David Doe’’ is in obvious pain. His arm and shoulder are weak, and he is unable to actively raise his arm above 90°. When his pads are removed, there is a noticeable deformity of the acromioclavicular joint. It is the third quarter of the final game of the playoffs, and the winner goes on to the state championship game. David is a college prospect, and there are many collegiate scouts in the stands. David wants to go back into the game, and David’s father, who is the offensive coordinator for the team, says he will take the responsibility for sending David back in. The orthopaedic surgeon on the sideline does not return David to the game and, in spite of this, the team wins. After the game, a reporter for the local newspaper approaches the team physician for information on David’s injury and prognosis. David does not keep his follow-up appointment in the orthopaedic surgeon’s office, but shows up to practice with a note from another physician saying he is able to play.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Introduction The physician-patient relationship that is formed during a sideline-based examination is a more complicated one than the one formed during an office-based examination. In the sideline setting, there are many other influences that affect this most fundamental relationship in medicine. Hippocrates’ basic tenet of ‘‘Do no harm’’ can be subject to interpretation and conflicting priorities. Whether sideline care takes place in front of a national television audience or a smaller audience of hometown spectators, there are many more witnesses to the sideline diagnosis and treatment of the patient than there are in any other areas of medicine. Performing a Lachman test in front of 100,000 fans is a decidedly different experience than that of performing the same test in the privacy of a clinic examination room, but the results of that test need to be equally accurate. The same medical and ethical standards that are applied in the office setting
must also be applied at the sideline when deciding whether to allow an athlete to return to play. The ethical principles of patient autonomy, beneficence, confidentiality, and conflict of interest are all challenged in the sideline practice setting. Autonomy, Beneficence, and Conflict of Interest Autonomy, which literally means ‘‘self-rule’’1, dictates that it is the patient’s body and therefore the patient can do whatever he or she wishes with it. This, however, does not mean that the athlete can insist on injury management that causes harm or is outside of the accepted standard of practice. Beneficence is from the Latin beneficentia2, which means kindness or honorable treatment. This ethical principle expands the obligation of the physician to not only do no harm, but to purposefully act for the good of the patient. Unfortunately, on the sidelines, these two ethical principles may often be at odds. Because it is his body and he may do with it as he chooses, David Doe can
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e132(1-3)
d
http://dx.doi.org/10.2106/JBJS.N.00151
e132(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 15 A U G U S T 6, 2 014 d
d
SIDELINE ETHICAL DILEMMAS
d
make the autonomous decision to accept the recommendation of the team physician and leave the game or reject the recommendation and attempt to return to the game. Beneficence, on the other hand, requires the team physician to actively seek to provide a net benefit to the patient-athlete, which, in this case, would involve requiring the athlete to sit on the sidelines until his pain was better and his strength returned. Which of these two principles should prevail, and who decides? For the team physician, the physical well-being of the athlete takes precedence. If this were an anterior cruciate ligament tear or a fracture, the course of action would be obvious: the athlete would be done for the day. But an acromioclavicular separation, while serious, does not totally eliminate the possibility of playing. In professional or even collegiate sports, the acromioclavicular joint might be injected with a local anesthetic and the player might be allowed to return to the game. This is not a standard practice at the high-school level. Another ethical issue raised here is the conflict of interest of the parties involved in the sideline decisions. In this case, the parent is a coach. The desire of a parent to protect his or her child and the goal of a coach to win are in direct conflict. The decision to put David back on the field can be biased by the overall goals of the team. A further potential conflict is that there are collegiate scouts present to evaluate David, and a scholarship can relieve much of the father’s financial burden of David’s education beyond high school. These conflicts may not lead to a decision that is in his son’s best long-term physical interest. Again, the best interest of the athlete’s health should be of primary importance, but, in the heat of the moment, as in the playoff game, it may not be. This brings up the critical role of the team physician as an impartial adjudicator on the sideline and not as a member of the team or coaching staff. The physician himself or herself also has some potential conflicts. If David plays and does not sustain further injury, then the physician is the hero, especially if the team wins. This circumstance could lead to more notoriety for the physician, boost his or her reputation in the sports community, and result in a potential increase in patient referrals, thereby benefiting the doctor with additional income. Conversely, if David is not allowed to play, the team may question the doctor’s role as team physician and seek a more ‘‘accommodating’’ physician elsewhere for future sports-medicine care. It is paramount for the team physician to keep the patient-athlete’s present and future health as the absolute priority in these circumstances3. Confidentiality and Medical-Legal Concerns The reporter who approaches the physician for information brings up the matter of confidentiality, which must govern all physician-patient-parent interactions. If David is eighteen years old, then his medical information is his own. If he is seventeen years old, then his parents have the final say as to whether or not this information can be shared. Divulging information on David’s condition without his and his parents’ permission is breaking federal law. Federal health privacy regulations—HIPAA: the Health Insurance Portability and Accountability Act4—requires health-care providers (individuals as well as institutions) to
obtain patient authorization to use or disclose individually identifiable health information. This would be true on the sideline or any time after the game. Finally, with regard to medical-legal concerns, the physician on the sideline must adhere to standard or customary sports-medicine practices, which are not always well defined. The physician should make medically reasonable decisions and provide sufficient medical information so that the athlete and/or his parents are aware of the risks in returning to play. What happens, however, if the athlete’s parents offer to assume the risk of the decision to return their child to play? From a legal standpoint, two conditions have to be met before David can return to the game: (1) The athlete (or the parent or guardian if the athlete is a minor) must fully appreciate the type and magnitude of the risk involved in continuing to participate; and (2) The athlete (or the parent or guardian if the athlete is a minor) must ‘‘knowingly, voluntarily, and unequivocally’’ choose to participate. In addition, the physician can have the parents sign an exculpatory waiver, which relieves the physician from liability should the athlete sustain further harm by returning to play5. Is this a reasonable course of action for the physician to follow in the heat of the battle, and is true informed consent possible in the sideline context? Even if the waiver is signed, the court may, on a case-by-case basis, evaluate the validity of such a document should a complication occur as a result of David’s return to play. A final issue to be considered by the sideline physician is David’s assent to the decisions made on his behalf. As a teenager approaching legal adulthood, his opinions should be considered. The parents may want the collegiate scouts to see him play to obtain a scholarship as a means to relieve the financial burden of college, and David may not want to return to the game. At the minimum, David should assent to whatever decisions are made with regard to his body, since he is of age to participate in the decision process. This relatively common case scenario brings to light a host of ethical and legal issues. What happens if only one parent agrees to sign and the other chooses not to, or is not present? What if the athlete wants to play, but the parents do not consent? Shared decision-making in any other setting would be the best way to approach this dilemma, but it may not be a viable option in the sideline setting. While dealing with the current injury, the team physician is still responsible for the remaining players on the field, and taking time to have a joint meeting with all parties involved would not be prudent. The time to determine a viable approach to these situations is not on the sidelines during a game or in the middle of the season but prior to taking on the job of team physician. An agreement should be established in the preseason between the team physician and the superintendent or legal representative of the school district, the athletic director, coaches, and trainer about how controversial decisions such as these would be handled. The discussion should also include who has jurisdiction over the subsequent non-sideline return-to-play decision. Will it require clearance by the designated team physician, or will it
e132(3) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 15 A U G U S T 6, 2 014 d
d
SIDELINE ETHICAL DILEMMAS
d
simply require a ‘‘doctor’s note’’ from any physician? Ideally, the team physician should have the sole authority to return the injured athlete to play. An outside ‘‘doctor’s note’’ should not be permitted. In allowing this, the school may wrongly assume that the outside physician is ethical and practices beneficence and that he or she allows autonomy on the part of the athlete in alignment with the team physician’s determination of the situation. If this ideal agreement cannot be reached, then the team physician needs to decide if the agreed-upon approach is acceptable on the basis of his or her own personal ethics and professionalism. Finally, the role and authority of the sideline team physician should be discussed with parents and athletes at the typical pre-participation sports meeting. This will create an environment in which all of the potential stakeholders involved in the sideline management of the injured athlete start with the same information and expectations. When an athlete gets injured on the field, the covering team physician is faced with a much more complex relationship
than the traditional office-based physician-patient relationship. While the primary obligation must be to the health and wellbeing of the patient-athlete, the physician should also be familiar with all of the potential pitfalls and complex issues involved in this relationship. n
Joan Krajca-Radcliffe, MD 111 Bamaku Bend, Tiki Island, TX 77554. E-mail address: [email protected] Nancy M. Cummings, MD Franklin Health Orthopaedics, 111 Franklin Health Commons, Farmington, ME 04938. E-mail address: [email protected]
References 1. Lo B. Resolving ethical dilemmas: a guide for clinicians. 4th ed. Lippincott Williams & Wilkins; 2011. 2. Merriam-Webster: An Encyclopedia Britannica company. http://www. merriam-webster.com/dictionary/beneficence. Accessed 2014 May 20. 3. American Academy of Orthopaedic Surgeons. Code of medical ethics and professionalism for orthopaedic surgeons. The physician-patient-patient relationship,
Section I.A. 1988, revised 2011. http://www.aaos.org/about/papers/ethics/code. asp. Accessed 2014 May 20. 4. Chen S, Esposito R. Practical and critical legal concerns for sport medicine physicians and athletic trainers. The Sport Journal. 2003 Mar. 5. Department of Health and Human Services. 45 CFR Parts 160 and 164. Standards for privacy of individually identifiable health information. 2002. http://www. hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/. Accessed 2014 May 20.
Suggested Reading 1. American Academy of Orthopaedic Surgeons. Sideline preparedness for the team physician, information statement 1022. 2002. http://www.aaos.org/about/ papers/advistmt/1022.asp. Accessed 2014 May 20. 2. American Academy of Orthopaedic Surgeons. Selected issues in injury and illness prevention and the team physician, information statement 1031. 2007. http://www.aaos.org/about/papers/advistmt/1031.asp. Accessed 2014 May 20. 3. American Academy of Orthopaedic Surgeons. Selected issues for the adolescent athlete and the team physician, information statement 1032. 2008. http://www. aaos.org/about/papers/advistmt/1032.asp. Accessed 2014 May 20.
4. Devitt BM, McCarthy C. ‘I am in blood Stepp’d in so far...’: ethical dilemmas and the sports team doctor. Br J Sports Med. 2010 Feb;44(3):175-8. Epub 2009 Nov 29. 5. American Medical Association. Council on ethical and judicial affairs. Code of medical ethics. Opinion 3.06. http://www.ama-assn.org//ama/pub/physicianresources/medical-ethics/code-medical-ethics/opinion306.page. Accessed 2014 May 20. 6. Cummings NM. American Academy of Orthopaedic Surgeons. Resident ethics series: issues and scenarios for discussion and guidance: put me back in the game doc. http://orthoportal.org/estudy/resident_ethics.aspx#tab2. Accessed 2014 May 20.
