Sporting Fatalities: The Analysis And The Ethics

19/10/2016 15:02

Despite the fact that I never met the late Australian cricketer Philip Hughes, as a cricket fan, his death caused me to reflect on deaths in sport. Cricketers have died before but this high profile fatality put safety in cricket and sport in general in the public eye.

More recently than Hughes, MMA, boxing, rugby league, and football have all been affected by a death of a participant. These are the ones we know about because they are closer to home. There will be more that have not received that level of publicity. Defenders of sport will quite rightly point out the overarching benefits of exercise and that risks are very small. It is however important that serious incidents such as fatalities are learned from.

The first question posed is what actually causes deaths on the sports field to which the short answers are: traumatic brain injury (TBI) and undiagnosed cardiovascular pathology. From previous blogs, correspondents will be aware that I have a particular concern over neck injuries but they do not tend to kill. In the case of Philip Hughes, the ball may have struck the neck but it was the resultant brain injury that was fatal. Sports such as boxing and MMA will be inevitably linked to TBIs and, even as a staunch defender of boxing, this is hard to disagree with but they are not the only sports with the potential for this injury. Any sport where participants wear helmets will demonstrate this. It was interesting to note in the Olympic Women's hockey final which I stayed up to watch, the players donned face masks for penalty corners but this protection did not appear to cover the head and at this same Olympics the male boxers did not wear head guards.

Hockey, like cricket has the speeding projectile, boxing and MMA have the punches and rugby has the tackle. All different mechanisms of injury but all capable of causing TBI. However, 99% of these sports pass off without serious injury so why have some participants died as a result? It could be argued down to simply bad luck but that belies two other issues, adequate protection and underlying brain pathology that had previously been unknown. Adequate protection does not necessarily mean just helmets. I read with interest an interview with the former Australian cricket captain Ian Chappell who played at a time that was arguably the most dangerous for cricketers. He did not wear a helmet despite the dangers of the time, suggesting that it impaired his vision and encouraged recklessness on the part of the batsman. Whilst he is a man with great integrity within the game, I am not sure I can totally agree with him on this. Helmets are necessary and are indeed a requisite for junior cricketers today. Helmet design has evolved in response to ergonomics and now some cricket helmets extend to neck protection.

Ethically, there is a debate to be had about bowling tactics and whether it is ever permissible to target the batsman's head and the notion of what constitutes "intimidatory bowling" is one that has caused debates for years. However, telling bowlers they cannot bowl bouncers is rather similar to telling racing drivers they cannot drive too fast. It can be regulated but to take it out of the game entirely risks compromising the sports integrity.
What boxing has had to learn is that medical care around the sport has to be good. If TBI cannot be prevented then the protagonists need to be cared for. Time is very much of the essence and the quicker someone who has potentially suffered a TBI can be assessed, treated and moved to a suitable hospital the better.

At the same time that TBIs can be controlled in most sports but not entirely eradicated, undiagnosed cardiovascular pathology is rather different. One of the saddest sights in professional sport are the deaths of promising young athletes through the heart's inability to cope with the demand. Unlike TBIs that are caused directly by the sport, these pathologies can act like time bombs that can erupt at any point. Some time ago now, I attended a tribute match for the Keighley rugby league player Danny Jones who lost his life whilst playing due to a heart problem. One great thing has come out of this tragedy is that his widow has campaigned for greater access to defibrillators for sports clubs. CPR training for those involved in sport is vital but CPR, in reality, is only a time buyer and it is quick defibrillation that is required. The quicker the equipment is available, the more likely survival could be. If we are honest, these defibrillators may never be used but their greater availability may just make a difference. What should be noted is that not everyone who has a cardiac arrest can be defibrillated, it depends on the electrical activity within the heart itself.

One potential way of reducing the number of deaths is screening for these conditions. Boxers are subjected to stringent medical checks including medical imaging before they can fight and perhaps all sports participants at a professional level should have the same? The first question to pose is does such a cost effective test exist that can with 100% sensitivity identify those with cardiovascular pathology, the second question is if that test does pick something up then what is going to be done about it? People live for decades with undiagnosed pathology within their body, if at 17 years old a young person desperate for a career in sport is told they have a heart problem that might affect them in future will that mean the end of that person's career before it has ever begun?

The boxers are subjected to intracranial imaging as part of a wider medical to identify any perceived weakness in the brain that could be exacerbated by a blow to the head. It could be argued that those who participate in sports that have potential for TBI should be subjected to the same imaging. I am unaware as to whether this already happens in some sports but it is an intervention worth considering.
The England cricketer James Taylor is a prime example of someone whose career was cut short by (in his case) heart screening and he will be the safer for it. The medical advice will have been to retire.

It is clearly unrealistic to screen the entire playing population of a sport but with the money around in some professional sport it seems entirely reasonable that both heart screening and intracranial assessment could become routine at the top level. There are notes of caution; firstly even with the best screening in the world there can never be a guarantee that deaths will not happen. CPR and defibrillators are important at all levels of sport and clubs need to be aware of that and sport's governing bodies need to take their responsibility to their participants seriously.
Fatalities in sport are very rare but they need to be looked at to ensure that, when possible, this worst case scenario is prevented.