Drugs in Sport: Justifying Paternalism on the Grounds of Harm

The use of drugs by athletes is not a new phenomenon, but in the last decade or so the issue has received much public attention. This has resulted in a renewed focus on the question of whether the use of performance-enhancing substances in sport ought to be prohibited. (We need to be aware of the distinction between the question of whether it is wrong to use performance-enhancing substances in sport, and the question of whether the use of these sub stances in sport ought to be prohibited. Prohibition does not necessarily follow from "wrongness.") In this paper I will argue that a certain class of performance-enhancing substances should be banned. In doing this, I shall first define performance-enhancing substances and then focus on arguments concerning self-harm and harm to others. The notions of coercion and subtle pressure will be exam ined, and this will serve as an attempt at justifying paternalism. If one were to ask the proverbial "man in the street" whether the use of performance-enhancing substances in sport ought to be banned, it is likely that the majority of responses would be affirmative. If one were then to ask why, the answer would probably be justified by one of two lines of reasoning. Reason A would be that it is cheating, and this is contrary to the nature of sport. Reason B would be that the use of performance-enhancing substances should be prohibited because it is a harmful practice.

The use of drugs by athletes is not a new phenomenon, but in the last decade or so the issue has received much public attention. This has resulted in a renewed focus on the question of whether the use of performance-enhancing substances in sport ought to be prohibited. (We need to be aware of the distinction between the question of whether it is wrong to use performance-enhancing substances in sport, and the question of whether the use of these substances in sport ought to be prohibited. Prohibition does not necessarily follow from "wrongness.") In this paper I will argue that a certain class of performance-enhancing substances should be banned. In doing this, I shall first define performance-enhancing substances and then focus on arguments concerning self-harm and harm to others. The notions of coercion and subtle pressure will be examined, and this will serve as an attempt at justifying paternalism.
If one were to ask the proverbial "man in the street" whether the use of performance-enhancing substances in sport ought to be banned, it is likely that the majority of responses would be affirmative. If one were then to ask why, the answer would probably be justified by one of two lines of reasoning. Reason A would be that it is cheating, and this is contrary to the nature of sport. Reason B would be that the use of performance-enhancing substances should be prohibited because it is a harmful practice.
Argument A contends that sport is a valued human practice and, in terms of the ethos that characterizes it as such, the use of performance-enhancing substances is not only illegal (in terms of constitutive, regulative, and auxiliary rules), it is also morally reprehensible in that it violates the virtues of honesty and trustworthiness, which go to the heart of the fairness and integrity of competitive sport. In this paper I will not follow this line of reasoning but will instead evaluate those arguments supporting a ban on performance-enhancing substances that are underpinned by the notion of harm to one's self and others (Argument B).

PERFORMANCE-ENHANCING SUBSTANCES DEFINED
What exactly are we referring to when we talk about performance-enhancing substances? Very generally, we can initially group them as follows: 1. Stimulants (amphetamines, caffeine, cocaine, other sympathomimetic drugs).
2. Anabolic-androgenic steroids (synthetic derivatives of the male sex hormone testosterone).
3. Human growth hormone. 4. Erythropoietin. (Note that for the purpose of this paper, the above grouping excludes narcotic analgesics, alcohol, marijuana, tobacco, and miscellaneous drugs such as beta-blocking agents, diuretics and nutritional supplements.) Time does not permit an examination of the possible harmful effects of performance-enhancing substances. Let us, however, tentatively accept Wagner's conclusion that " ... whether the ergogenic effects are real or perceived, the potential for adverse effects exists for all of these drugs. Potential health complications represent a serious risk to an otherwise healthy population." 5 With regard to the ergogenic effects, the question of whether performance-enhancing substances produce meaningful changes in performance is much debated. Such debate is beyond the scope of this paper, which assumes that at the very least athletes who use these substances believe that ingestion will result in improved performance.
We must then make two assumptions for the discussion to proceed. The first is that performance-enhancing substances carry the risk of significant harm to the user, and the second is that use of these substances will significantly improve performance. With these assumptions in place, let us return to the primary question of the moral justification of prohibition by governing sports bodies. In other words, what are the moral underpinnings for not permitting individuals to pursue excellence by any means they choose?

PA TER NALISM, COERCION, CHOICE, AND HARM T O O Tl:lERS
Earlier it was noted that one frequently advanced argu ment against the use of performance-enhancing sub stances refers to the potential risk for significant harm to the user. Quite simp]y then, this argument contends that since the use of performance-enhancing substances is harmful to the user, it ought to be prohibited. This is viewed as unjustifi ed paternalistic interference by some sports libertarians who wou1d contend "It's my life , my body, and I should be at liberty to do with it whatever I want to, as long as I don't harm others." The qualification of not harming others, proponents of this view believe, renders their position consistent with Mills' "harm prin ciple." (Mill's Harm Principle states that the only pUl"pose for which people may be coerced by law is to protect others from harm that they would, if not coerced, be infl icting on them.) This paper, however, argues that use of perfor mance-enhancing substances contributes to a situation where others are potentially placed at risk.
In evaluating what I will call the "coercion argument," the central question that needs to be considered is whether athletes freely choose to ingest performance-en hancing substances, or whether they are in some way coerced to do so. (Here I will ignore direct coercion such as pressure from coaches and others and will focus on more subtle, but perhaps no less powerful, coercive agents). On the surface, it wou1d seem that athletes can choose freely, but what about the pressures created by the need for success in competition? I am not just referring to the satisfaction of winning-rather, I am recognizing that in professional sports one's future may depend on winning. At this leve1, sports is one's means of employment, and the greater the incentives to succeed, the greater the tempta tion to use any method available to achieve that end. The pressure may thus be greater than some mere primeval satisfaction of the will-to-win.
Are athletes really not able to act and choose freely with regard to performance-enhancing substances? It cou1d be argu ed that they are not forced to earn their living through sports. They, in fact, have the choice to follow a different vocation, for example, medicine or plumbing. Of course an athlete could choose a different career path, but the reality of the situation is not that clear-cut. Having devoted most of his or her life to the pursuit of excellence . in athletics, the athlete is now confronted with the choice of taking a banned substance and remaining competitive or declining such use and entering the job market with precious little skill or experience. The choice is thus com plicated because the athlete does not have the means to make it worthwhile, and we need to question whether it is realistic to expect this athlete to choose the nondrug route. Paternalism in this case is defended on the grounds that the athlete's circumstances are such that it would be un reasonable to expect him or her to resist the pressure of the situati on. A further form of subtle coercion or influence is that of role models. Hero worship can be a powerful influence to act, and if an impressionable young athlete perceives that

American Journal of Sports Medicine
success is only attainable through a particu1ar practice, such as use of performance-enhancing substances, then the practice, which may be harmful to the role model, becomes potentially hru·mfu1 to others. The recent case of the 14-year-old South African athlete Liza De Villiers, who, in April 1995, tested positive for nandrolone decano ate (an anabolic steroid) and fencamfamine (a stimulant) serves to illustrate that use of performance-enhancing substances is not only pervasive in adult sport, but that the practice may be common at junior levels. Schwellnus et al. 3 and Skowno 4 reported significant use of anabolic androgenic steroids among schoolchildren involved in sports. If such usage can be linked to subtle (albeit unin tentional) coercion, then the paternalist position is strengthened.
Essentially, the coercion argument holds that athletes who use performance-enhancing substances harm not only themselves, but that they contribute significantly to the creation of a climate that places some stricture on choice. One can choose; either be moral with regard to performance-enhancing substance use, perhaps to the det riment of your career, or disregard the ethics of the situ ation to perhaps ensure your future. So there is choice, but the element of coercion remains because the choice is difficult and the issues are not necessarily clear. If we accept this argument, use of performance-enhancing sub stances is wrong not only because it harms the user, but because it may harm others as well.
Further support for this coercion theory may be found outside the strictly competitive arena; again, I use re search into steroid use as an example. Crist et al. 2 admin istered relatively high doses of testosterone cypionate and nandrolone decanoate to nine volunteer subjects to deter mine the effects of anabolic-androgenic steroids on neuro• muscu1ar power and body composition. Although no sta tistically signifi cant effects were noted in this particular study, the subjects reported subjective feelings of in creased strength after the administration of anabolic agents. Our coercion theory would hold that these subjec tive impressions may result in some sort of psycbologic dependence to improve either performance or self-image, with the immediate effects being readily visible while the longer-term adverse effects are not apparent. In the first case then, pressures created by the nature of professional sports coerce subjects into use of performance-enhancing substances, and in the second case, such coercion is achieved by placing research subjects a step closer to temptation and, in so doing, creating a climate conducive to psychologic dependence.
Leaving coercion and competitive sport aside briefly, let us focus narrowly on specific possibilities of cases of harm to others where steroid use is involved. Some evidence now suggests that increased aggression is associated with steroid use. In a recent study, Choi and Pope 1 investi gated physical abuse of significant others by steroid users. They state that their findings support the claims that partners of steroid users may be at risk of violence from users while they are "on-drug," and that steroid-associ ated violence toward other individuals may be more com mon than originally suspected.
The findings of the previously mentioned study strongly suggest that steroid use may be associated with increased aggression and violence. This is well established, with steroid use even being advanced as a contributory factor in lawsuits concerning violent crime. It seems reasonable to assume that steroid use by athletes could therefore con tribute to on-field violence, particularly in sports such as rugby or football, where participants are .(for a variety of reasons) predisposed to act and react aggressively. In such situations, the possibility of direct harm to others clearly exists.
If we paternalistically deprive someone of a freedom ( to use performance-enhancing substances), we need to jus tify this violation of autonomy by balancing the evil we hope to prevent against the loss of freedom we are advo cating. In performing the sort of "moral accounting" de scribed here, it is my contention that prohibition on the grounds of indirect harm to others (through coercion) is justified. "Soft" paternalists argue that limitations on lib erty are justified when behavior is not fully voluntary because the person is not fully informed (e.g., as to the likely consequences of one's action), or because one is not fully competent or is being coerced in some relevant way. Given the coercion argument outlined above, the last con dition is of course crucial to my justification for paternal istic interference, even in the difficult case of rational, informed, emotionally mature adults. Finally, it seems justifiable to prohibit use of a substance if a substantial body of research supports the contention that such use can lead to violent situations where persons are harmed.

Drugs in Sport S-45
I have examined some of the issues surrounding the ban ning of performance-enhancing substances in sports. In deliberately ignoring what I have called the "nature-of sport" argument, and focusing on the notion of harm, I have argued that prohibition of harmful practices is jus tified by potential harm to others (rather than just to one's self). One must bear in mind the powerful effects of subtle coercion and influence and the consequent limitations placed on choice. So, on the grounds that it is wrong fo harm others or to coerce them into potentially harmful situations, this paper takes issue with sports libertarians who claim that banning performance-enhancing sub stances is an unjustified paternalistic action that violates the principle of autonomy.