Medical ethics in combat sports that permit knockouts



    The Council for Medical Ethics discourages doctors from accepting to act as ringside doctor for combat sports that permit knockouts or participating in approvals or appeals boards for such events. These types of assignments may violate the general duty of doctors to protect human health.

    Cecilia Brækhus in a boxing match against Eva Halasi of Serbia. Brækhus won by knockout in the third round. Photo: Helge…
    Cecilia Brækhus in a boxing match against Eva Halasi of Serbia. Brækhus won by knockout in the third round. Photo: Helge Mikalsen/NTB Scanpix

    Sports medicine encompasses all medical aspects of sports. One important task of the sports doctor is to prevent and treat sports injuries (1). In today's elite sports, the body is frequently exposed to stresses that approach and occasionally exceed the limits of what it can tolerate. This was recently thrown into sharp relief in the article 'The body as the Achilles heel of sports', in which Rune Slagstad discusses how medical expertise has assumed a dual role of promoter and degrader of health in the development of sports (2).

    Some sports involve a major risk of serious injuries, and this is a challenge to the doctor's role. Chapter I, Section 1 of the Code of Ethics for Doctors describes the doctor's role as follows: 'A doctor shall protect human health. A doctor shall help the ill to regain their health and the healthy to preserve theirs' (3). Concerns for a contestant's health on the one hand and optimisation of his or her performance on the other is a general ethical dilemma for sports doctors, who thus may come under pressure to prioritise purely sports and commercial interests.

    Combat sports that permit knockouts – which have now been made legal in Norway – are especially risky in terms of health injury (4). The main goal of the Professional Boxing Act and the Knockout Act with appurtenant safety regulations has been to ensure the safety and health of the contestants (5). Little emphasis appears to have been placed on this in recent years, since the Professional Boxing Act has been repealed and the safety regulations have been considerably weakened.

    In 2016, the safety regulations for knockout boxing were changed. The upper age limit was raised from 34 to 40 years, while the match length increased from 12 to 36 minutes. This relaxation contrasts with the introduction of stricter rules in other sports that involve a risk of head injury, such as American football (6) and soccer. The rule for use of the red card for an elbow to the head of an opponent was specified before the FIFA World Cup in 2006 (7, 8).

    The changes to the safety regulations caused the members of the approvals board to resign their positions unanimously in 2016. In a letter to the Ministry of Culture dated 22 September, the board wrote: 'For the reasons referred to in the response to the consultation round, the Approvals Board is of the opinion that the changes to the knockout regulations largely override the objective that the knockout regulations were intended to fulfil. The members of the Approvals Board take note of the Government's decision, but find it impossible to continue in their positions for as long as the knockout regulations fail to cater to the safety of the contestants in a more appropriate manner'.

    In violation of medical ethics?

    In violation of medical ethics?

    The council recently discussed whether doctors may participate as the ringside doctor in combat sports events where knockout is permitted, or accept assignments as the medical expert in approvals or appeals boards for such events without violating their code of professional ethics. The starting point for this discussion was an enquiry underscoring how the changes to the safety regulations had made it impossible for doctors to ensure the safety of contestants engaging in combat sports that permit knockouts.

    The Council for Medical Ethics is of the opinion that given the risk of health injury, combat sports that permit knockouts ought to be banned completely. This is consistent with the views of the Norwegian Medical Association and the World Medical Association, whereby the latter has taken the position that: 'Boxing is a dangerous sport. Unlike most other sports, its basic intent is to produce bodily harm in the opponent. Boxing can result in death and produces an alarming incidence of chronic brain injury. For this reason, the World Medical Association recommends that boxing be banned' (9).

    In a number of contexts, the Norwegian Medical Association has voiced criticism of legal amendments that weaken the safety regulations in sports in which a knockout is the goal, and has issued strong warnings against such softening of the rules (10). The Council for Medical Ethics is especially concerned that the softening-up of the regulations and the consequent undermining of safety highlight the challenges associated with the role of the doctors involved, which is difficult as it is.

    The regulations for safety provisions pursuant to Section 4 of the law on combat sports that permit knockouts require a ringside doctor to be present (5). The ringside doctor is responsible for 'ensuring that the contestant is able to compete before the start of the match' and for 'informing the manager responsible for the match if participation is medically unjustifiable'. Furthermore, the ringside doctor is 'authorised to stop organised combat sports events where there is risk of injury'.

    There are ethical, legal and medical challenges associated with the responsibility of the ringside doctor, irrespective of the changes to match length and age limit. Whether participation is 'medically justifiable' for anyone is an open question, especially in light of the loosening of the safety requirements.

    The Council for Medical Ethics will discourage doctors from participating in events that violate the Code of Ethics for Doctors, including acting as 'ringside doctor' or participating in any of the boards referred to above. However, each doctor is free to individually assess the medical, legal and ethical justifiability of accepting such assignments and the responsibility they involve.

    An argument used against discouraging doctors from accepting such assignments is that the presence of medical personnel promotes safety. However, the Norwegian Medical Association has warned against the view that the presence of medical personnel during combat sports events may help reduce some of the injuries that occur. 'This is not the case. The most frequent injuries caused by this sport only manifest themselves long after the injuries have been sustained, and will often be difficult to identify immediately after the injury has been caused. Therefore, qualified medical personnel will only in exceptional and acute cases be able to counteract the consequences of such injuries. Moreover, studies show that there is no correlation between self-reported symptoms after injuries and the extent of the neuropsychological outcomes. (...) The belief that health personnel will be able to prevent a deterioration in injuries gives rise to a false sense of security in the contestants. In addition, the risk of injuries has increased in recent decades because boxers today are more muscular and punch harder than previously. This applies to both genders' (10, 11).


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