European Journal of Applied Physiology https://doi.org/10.1007/s00421-018-3821-3 INVITED REVIEW Opinion paper: scientific, philosophical and legal consideration of doping in sports Massimo Negro1 · Natale Marzullo1 · Francesca Caso1 · Luca Calanni1 · Giuseppe D’Antona1,2 Received: 1 November 2017 / Accepted: 1 February 2018 © Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract The term doping is generally used to indicate practices based on the use of performance-enhancing drugs (PEDs) or the abuse of medical therapies. Mostly analysed by doctors and officials, doping nevertheless also requires a philosophical consideration to avoid being simplistically portrayed as an isolated practice. To do this, we need to pay attention to the contradictions and paradoxes in the modern approach to doping in sport. In this context, doping is not only relevant to the health of an individual involved in the violation of World Anti-Doping Agency (WADA) criteria, but it actually represents a double-edged phenomenon containing ethical and legal points of view. Several philosophical items affect the ethics of doping. While, indeed, through a deontological vision it is easy to morally condemn an athlete who takes the decision to turn to doping, the same condemnation becomes difficult when the practice of doping is compared with the strong social demand of winners in every field of life. This point must be considered to prevent doping from becoming accepted as a daily practice to excel at all costs and regarded not only as normal but as a necessity for those participating in sport at both an amateur and professional level. Furthermore, a complete discussion on doping has to consider not only the philosophy of performance-enhancing drug abuse, but also the widespread practice of an inappropriate and excessive intake of certain dietary supplements with the unique and obsessive purpose (similar to doping) of increasing physical or mental performance. Based on the above, the aim of this paper is to provide a critical opinion of the doping problem and its related practices and analyze possible solutions considering issues that go beyond the impact of doping on health and reflect on whether it is right or not that an athlete does all he can to improve his performance. Communicated by Michael Lindinger. Massimo Negro and Natale Marzullo contributed equally to this work. * Giuseppe D’Antona gdantona@unipv.it 1 CRIAMS-Sport Medicine Centre, University of Pavia, Voghera, Italy 2 Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy 13 Vol.:(0123456789) European Journal of Applied Physiology Graphical Abstract Scienfic consideraon of PEDs: there is sll a lack of meaningful data regarding PEDs performance enhancement, while only uncontrolled studies in individual cases or small cohorts of subjects indicate that PED use is associated with serious health consequences. Doping and dietary supplements: Legal consideraon of doping: potenal harmful effects, and possible adverse interacon with other supplements, nutrients and/or drugs, must be considered when supplement use does not follow the recommended duraons and doses, but is driven (as with PEDs) by the desire to excel at any cost. DOPING IN SPORT the “umbrella” of a therapeuc exempon and the cases of possible cross-contaminaon can make legal acons against a suspected case of doping as a criminal offence arduous to sustain. Philosophical consideraon of doping: while society demands “natural and fair” champions, in many sports it is not physiologically possible to excel in a modern contest simply by using the best equipment, nutrion strategy or by having opmal support teams. Keywords Sports doping · Enhancement · Ethics · Philosophical ethics Abbreviations PEDs Performance-enhancing drugs GMP Good manufacturing practice IOC International Olympic Committee WADA World Anti-Doping Agency The doping phenomenon: an unresolved problem In the limited circle of sports medicine, the term doping is used when there is an indication of a healthy subject using performance-enhancing drugs (PEDs), along with an 13 improper intake of pharmacologically active substances or inappropriate use of certain therapeutic practices. A solution to the problem of doping still occupies an important part of scientific research and of the philosophy of sport. Nevertheless, when discussed by the mass media, doping is regarded primarily as a medical aspect with legal consequences. This is due to the fact that sports governing bodies at all levels use a checking system to identify and sanction unsportsmanlike conduct and spread the message of doping only from a medical/legal standpoint (Duret and Wolff 1994). Inevitably, this raises important questions which are often avoided: do doping and its related medical procedures always damage the health of the athlete or do the majority of these drugs have European Journal of Applied Physiology minimal or negligible consequences? If the latter is true, does doping mainly represent a violation of sporting rules and laws due to excessive regulations? (Miah 2004). And furthermore: why are certain practices considered doping only in some countries and/or for certain sport disciplines and not in others? Or, why are some performance-enhancing drugs (PEDs) banned in certain countries only during official athletic contests and not off-season? To answer all these questions we need an anti-doping legislation that represents a precise international reference model, and that the concepts of excess drug dosage and of PEDs in relation to organ damage be encompassed within a globally recognized legal philosophy. At present this does not exist. Performance‑enhancing drugs: what is the real evidence? In general the term PEDs misleadingly appears to refer to the effects on an athlete’s performance and for the sports physician it is intrinsically linked to the evidence of serious side effects of the misuse of such substances (Table 1). However, there is still a lack of meaningful data regarding PEDs performance enhancement (mainly due to a lack of uniformity in study methods, timings and doses), while only uncontrolled studies in individual cases or small cohorts of subjects indicate that PED use is associated with serious health consequences (Pope et al. 2014) (Table 1). Indeed, although a causal relationship between PEDs and sudden cardiac death is hard to ascertain, misuse of PEDs should always be suspected in the case of the sudden death of an athlete (Pope et al. 2014). Unfortunately, to date, only for the most frequently used PEDs, i.e., androgenic–anabolic steroids (AASs), have the life-threatening adverse effects (La Gerche and Brosnan 2017) now begun to clearly emerge from larger controlled studies, whereas information on the harmful side effects of widely used PEDs, such as growth hormone (hGH), insulin, erythropoietin, and other moieties, Table 1 Well-recognized major adverse effects associated with anabolic–androgenic steroids (AASs) abuse (modified by Pope et al. 2014) Physiological system involved is still scarce due to the lack of systematic studies (Pope et al. 2014). Similarly, systematic prospective studies and data on long-term adverse effects of PED use are also lacking. Importantly, a further boost to the debate on the unclear balance between the beneficial effects of PEDs on performance and the detrimental effects on health comes from the use of substances for which there is no clear rationale for the improvement of performance and no clear evidence of damage. From this point of view the use of meldonium (mildronate) is paradigmatic. This molecule, which acts as a ß-oxidation inhibitor, is normally used to treat cardiovascular, neurological and metabolic disorders due to its antiischemic and cardioprotective properties (Schobersberger et al. 2017); on January 1, 2016 it was added to the banned list by the World Anti-Doping Agency (WADA) (WADA 2016). The known targets of meldonium are butyrobetaine hydroxylase and carnitine/organic cation transporter type 2 (OCTN2). The action of meldonium is followed by reduced L-carnitine synthesis, at least in heart tissue, and reduced circulating L-carnitine in plasma (Liepinsh et al. 2011). Both the resulting inhibition of carnitine biosynthesis and of the transfer of the acetyl compounds in mitochondria negatively impact on muscle bioenergetics. Therefore the mechanism of action strongly argues in favor of a negative effect on performance and to date there is little clear-cut proof of the performance-enhancing properties of meldonium. The same uncertainty is found in regard to occurrence, severity, and frequency of adverse effects arising from its use (Dambrova and Liepinsh 2016). Therefore, the decision to add meldonium to the list of banned substances mainly derives from the application by WADA of the universal principle of primum non nocere based on the assumption of “potential damage” rather than the knowledge of “real damage” (Greenblatt and Greenblatt 2016; Jargin 2016). Thus, the recent case of meldonium leads us to consider a new aspect in the discussion about doping: while it is reasonable to presume that PED abuse represents a risk to human health (La Gerche and Brosnan 2017), sometimes the risk assessment appears to be based on knowledge of the underlying molecular mechanisms of action rather than on definitive proofs of the danger of PEDs. As for any other medical drug, the risk related to the use of PEDs should take into account duration of use, dosage, and individual sensitivity. Type of adverse effects Cardiovascular Dyslipidemia, atherosclerotic disease, cardiomyopathy Neuroendocrine Hypothalamic–pituitary–gonadal axis suppression Hypogonadism from AASs withdrawal Neuropsychiatric Major mood disorders: mania, hypomania, depression ASSs dependence Risks are not mutually exclusive Doping vs dietary supplements: is there a possible relationship? From a methodological point of view, there is a fine line between nutritional (or dietary) supplementation and doping. Indeed, the rationale of use of PEDs is similar to that of nutritional supplements used as ergogenic aids, since in both cases the aim of their use (or misuse) is to 13 European Journal of Applied Physiology improve sports performance. As for many PEDs, ergogenic aids are used to build lean muscle mass, to promote physical recovery and adaptation from training and to increase the amount of energy available for workouts or competition and, similarly to PEDs, we can consider that adverse effects may arise from their abuse. Even though it is difficult to obtain a comprehensive description of the prevalence of dietary supplement use in athletes, considering the increasing global sales of supplements (Nutrition Business Journal Global Supplement and Nutrition Industry Report 2014) it is rational to think that their consumption is increasing year after year. This is a major concern since the safety of most nutritional supplements has not been fully established and, similarly to PEDs, long-term exposure to the various components of ergogenic aids (especially at high doses and without a scientific rationale) may result in significant physiological alterations of the user. On the latter point, a recent paper published by Geller et al. (2015) estimates that annually in the US more than 2000 hospitalizations and an average of 23,000 emergency department visits can be attributed to adverse effects related to dietary supplements. Although these figures are probably less than 5% of the numbers that have been reported for pharmaceutical products (Budnitz 2006), these data are particularly important if we take into account that dietary supplements are generally regulated and marketed under the presumption of safety, without any specific label warnings of possible interactions, overdose reactions or adverse effects. Furthermore, they are generally obtained without prescription and taken without specific medical advice or monitoring. A list of the most common adverse effects assessed by Geller et al. (2015) is reported in Table 2. However, it is probably impossible to obtain an exhaustive and complete analysis of the negative effects of dietary supplements since supplement misuse is underreported by subjects and, unlike prescription drugs, interactions, overdose reactions or adverse effects associated with supplements are very difficult to identify. Current literature considers a correct and periodical use of several supplements (e.g., creatine, amino acids, whey protein, caffeine, etc.) to be safe. However, when supplement use does not follow the recommended durations and doses (as with PEDs), but is driven by the desire to excel at any cost, there are issues to consider: (1) the potential harmful effects of certain nutritional supplements (e.g., caffeine) which affect the nervous system; (2) the possible adverse interaction with other supplements, nutrients and/ or drugs; (3) the possible implication in causing liver injury (especially for herbal and multi-ingredient supplements), as reported by recent reference (Navarro et al. 2017). A further point to consider is cross-contamination with prohibited substances during product manufacturing, which can lead to supplements being more similar to PEDs. This is due to the lack of international uniformity in the regulation of supplement manufacturing, which allows supplements advertised as having “muscle building” or “fat burning” capabilities to contain prohibited substances (e.g., hormones and/or derivates) (Mottram and Chester 2015). In Table 2 United States estimates of symptoms documented during emergency department visits (from 2004 to 2013) for adverse events associated with dietary supplements from selected product categories (modified by Geller et al. 2015) Dietary supplements categories Symptomsb Supplements for weight loss Palpitations, chest pain, or tachycardia Headache, dizziness, presyncope, or other acute sensory or motor impairment Nausea, vomiting, or abdominal pain Mild or moderate allergic reaction Anxiety Severe allergic reaction Seizure, syncope, or loss of consciousness Palpitations, chest pain, or tachycardia Headache, dizziness, presyncope, or other acute sensory or motor impairment Nausea, vomiting, or abdominal pain Anxiety Mild or moderate allergic reaction Pill-induced dysphagia or globus Airway obstruction from choking Headache, dizziness, presyncope, or other acute sensory or motor impairment Nausea, vomiting, or abdominal pain Severe allergic reaction Palpitations, chest pain, or tachycardia Supplements for energy Micronutrientsa a Iron, calcium, and potassium are excluded from the micronutrient category b Symptoms are not mutually exclusive 13 European Journal of Applied Physiology fact, current regulations of dietary supplements have been strongly criticized as being inadequate and not completely rational (Cohen 2012). A philosophical approach to doping: the bridge between science and legal consequences To analyze the doping phenomenon and try to find a new way to resolve the doping problem—an alternative to the sanctions whose ineffectiveness will be discussed in the last section—we must start by considering what makes an athlete take the decision to turn to doping. The first point to consider is the basic paradox behind the doping phenomenon: while society demands “natural and fair” champions, in many sports it is not physiologically possible to excel in a modern contest simply by using the best equipment, nutrition strategy or by having optimal support teams. This impossibility leads an athlete to the practice of doping which will enable him to satisfy society’s demands, but leaves him completely exposed to (and dependent on) public judgment if he tests positive in checks. Such a scenario was predicted and theorized by Foucault (1977), where disciplinary social control (surveillance, normalization, and examination) in terms of continuous training, control, and observation aimed at improving an individual’s abilities. So the athlete must be supervised, tested and, if found guilty, sanctioned and punished. All of this is contradictory because the idea of a “natural and fair” champion and the philosophy behind success at all costs, on which the current social demand for winners is based, go in completely opposite directions. On the one hand we have the moral necessity of maintaining the sanctity of sport by binding the athlete to a nineteenthcentury ethic, on the other hand we have an uncompromising need that requires the athlete to always be a step ahead. A second point to discuss is that of the addictive qualities of doping. The positive effects of a victory and the negative effects of a failure make the practice of doping almost like a drug itself. This phenomenon was described by Derrida as a “poison and its antidote”: good and bad, like the Greek word pharmakon, meaning both “remedy” and “poison” (Derrida 1995). Considering this, it is not important to determine whether doping is good or bad, a poison or an antidote, but we should be looking at the factors influencing its use and, above all, what it is identified with. In this sense, it is important to consider that while for a spectator doping may be identified with dishonest or deceitful personality traits, for an athlete it might be associated simply with the “will-to-win”, a legitimate and acceptable approach to achieve athletic excellence and keep experiencing the “high” of a victory. Undeniably, an athlete’s will-to-win is also linked with the desire to further his career: a victory will lead to a new or better sponsor, media appearances, an offer from a more prestigious club, an advertising contract, etc. The “will-to-win syndrome” is present even in circumstances where financial gain is minimal or inexistent, as in many amateur sports events, or where idealized physical appearance is promoted, such as in the world of bodybuilding and related disciplines. Worryingly, these contexts are not controlled by any regulatory authorities and consequently are at greater risk of being affected by doping. Based on the above, we can draw the conclusion that the change that should be made is in athletes’ and society’s thinking and does not lie in longer lists of WADA-prohibited substances, more accurate or regular testing, or new legal measures. The real change must involve all the elements of the “sport system”: athletes, clubs, spectators, sponsors, and media. All together they must find a new way to accept and reach the essence of sport instead of continuing to perpetuate an increasing unphysiological demand for strength, power, speed, specific abilities or esthetic appearance. In this sense, freedom from doping can only be achieved by bringing the sports system’s focus back toward the true meaning of sport, returning to consider it as an extraordinary generator of health, social aggregation, emotions and feelings. Doping and legal aspects: a very complex framework Having analyzed the medical/nutritional and ethical/moral viewpoints, it is clear that a legislative framework is needed to support fair and transparent competition between athletes. This framework must be clear, timely, internationally applicable, and must not deviate from national laws or go against community or interstate regulations. Therefore, after the above analysis, it is also necessary to analyze the problem from the point of view of the legislator. This is a difficult subject, not only because it is continuously evolving, but also due to the different legislations that aim, as far as possible, to create a univocal set of rules. Although doping has always been used as a tool to support/improve an athlete’s hard work and despite its being recognized as damaging and illegal (morally too), it was only in 1999 that we began to see a broader legislative approach. In that year, the CIO (Comité International Olympique/International Olympic Committee, IOC) organized the first World Conference on Doping in Sport. This forum concluded with the establishment of the WADA with the declaration of compliance, by the participating states, to a World Anti-Doping Code. The WADA code was implemented by the rules of all international sport federations in the organization of international competitions and national federations were also bound 13 European Journal of Applied Physiology to the code. According to the WADA’s code, for a substance or method to be considered for banning, it must meet two of the following three criteria: (1) it enhances performance, (2) it represents an actual or potential health risk to the athlete, and (3) its use must be against the “spirit of sport” (WADA 2009). The aim of the code is to create uniformity, not only in the rules governing the matter of doping, but also regarding anti-doping policies. Therefore, the principle objective is to create and apply harmonized and coordinated anti-doping programs at a worldwide level. However, at least in Europe, optimizing legislation is particularly complicated in several aspects. Despite the European Commission’s various steps: (1) issuing a timed statement to define a detailed plan to support the fight against doping; (2) compiling a single list of substances and methods which are banned inside the European Union (EU) and globally; and (3) providing a detailed procedure to regulate doping from a penal point of view, this unfortunately simply cannot be accepted under EU regulations. The EU does not have an official general authority in the field of sport, so it lacks a legal basis to connect any intervention to a sporting setting. Therefore, there is a need for the creation of a European anti-doping system considering sport among the matters covered by EU policy, as for public health, environment etc. The EU is moving towards the proclamation not only of harmonized rules and regulations, but also towards community criminal laws that consider doping an offence in all the member states and towards greater awareness in society of the predominance of this phenomenon, both at a competitive and an amateur level (Casini 2012). However, legal actions against athletes who test positive in checks are very different among the EU states and at present doping is a criminal offence only in Italy, France, Spain, Denmark and Austria. Looking in particular at our nation (Italy), the difficult legislative process started in 2000 with the introduction of Law 376 to achieve a more detailed and precise legal framework and regulations concerning doping (Colucci 2010). The law states in synthesis “equivalent to doping are the administration of pharmaceutical products or biologically or pharmaceutically active substances and the adoption of medical practices not justified by pathological conditions, which can modify the psychophysical or biological conditions of the organism, in order to alter the athletic performance of athletes, or are suitable to modifying the results of controls on the use of such drugs or substances”. The design of the legislation is to give as unambiguous as possible a definition of doping, to establish a monitoring body (a commission for surveillance and inspection of doping), to clarify institutional and regional responsibilities, and finally to identify doping as a crime, punishable with fines and imprisonment for anyone who consumes or supports the consumption of banned substances. In Italy, from a strictly legal point of view, only an individual holding a particular qualification 13 or who finds themselves in a certain position can commit a criminal offence referred to doping. Therefore, only the athlete who takes the substance and is aware of it or the doctor/pharmacist who administers the substance (not justified by pathological conditions) can commit such a crime. The crime of doping, analyzed from a psychological point of view, requires the identification of a specific aim or fraud. In other words, the intent of the individual must be to achieve a change in a sporting result or to conceal substance use in testing centers. Crime must therefore be linked to the notion of guilt. Guilt presupposes by definition the knowledge of the negative, reprehensible or inappropriate value of the action, but it does not necessarily require knowledge of the law (ignorantia legis non excusat by article 5 of Italian code of civil procedure) or that the act is prohibited by criminal law. It is necessary that the individual realizes that they are performing an offensive act, either in their own interest or in the interest of others (explicitly recognized by article 32 of Italian Constitution). In light of these concepts, in order to establish a crime we must have evidence of a causal link between the conscious intake of doping substances and the clear pursuit of reaching excellent performance. This could be extremely difficult to establish for at least two reasons. First, because the use of doping substances is allowed in certain documented and medically certified pathological conditions (Colucci 2010) and this, as we know, can lead to the possibility that athletes employ higher dosages of normally banned substances under the “umbrella” of a therapeutic exemption (Smith and Stewart 2015); second, because an athlete who has used illicit substances and tests positive in checks may appeal on the grounds that their assumption was accidental (e.g., through the use of cross-contaminated dietary supplements) and that therefore there was no intent to break sporting rules. When these conditions happen, a legal action against a suspected case of doping as a criminal offence becomes arduous to sustain because the “presupposed guilt” could be difficult to demonstrate. Could changing the meaning of the “spirit of sport” be the solution? Despite the danger of performance-enhancing substances, and despite the intervention of regulatory bodies and the inclusion of doping in criminal legislation in some countries, there remain factors affecting doping and its related practices (e.g., uncontrolled and unsafe use of dietary supplements) that go far beyond health and the Decoubertinian principles of good sportsmanship (Kayser et al. 2007). The “law of markets” for sporting professionals creates a demand for winners, for peak performance and for the creation of athletes more similar to super heroes who are commercially viable and yet someone who others aim to emulate. This, European Journal of Applied Physiology unfortunately, prevails over all reasoning in terms of medical/scientific, moral and legal arguments. Consequently, legal and institutional intervention is not only a way to protect the health of the athlete and fair play, but it becomes a tool for protecting commercial factors connected to sport and individual competitions: stock-exchange listings for sports societies, sports betting and sponsorship. A recent example of this could be represented by the exclusion of Russia’s track and field team from the Olympics in Rio de Janeiro and by the ban of Russia from the upcoming 2018 winter games. The decision of the Olympic leaders is based on multiple investigations that produced evidence of systemic doping and cheating among Russian athletes, coaches and officials (WADA 2017). From this point of view, doping becomes an offence, not just against the individual, but also against the economic interests in sport. However, the Russian case shows that the current WADA policy of “zero tolerance” does not extinguish doping in sport and probably underlines how a “drug-use philosophy” is endemic in modern society based on the “will-to-win syndrome” and/or “imageenhancement” desire (Smith and Stewart 2015). As opposed to the policy of “zero tolerance” of WADA, alternative policies have been considered accepting that drug use exists in sport and will never be completely eliminated (Smith and Stewart 2015). Drug management projects based on harm reduction have been proposed and recently documented (Smith and Stewart 2015). Unlike current drug control policies oriented to obstructive policing, incessant testing, onerous investigation, and severe sanctioning, these projects provide a number of harm reduction outcomes including, for example, educational campaigns, private support and rehabilitation, drug supply and distribution systems that are regulated through the direct involvement of physicians and pharmacists (Smith and Stewart 2015). However, drug management projects are controversial, totally in conflict with the “spirit of sport”, they appear to condone practices that may be illegal and apparently unfair and they accept the fact that drugs will always be part of the ethics of sport. Another possibility, instead, could be based on a correct use of technology. The technology (aerodynamic helmets, energy-releasing equipment, special suits, etc.) should not be repudiated because it is artificial, but should be considered as an opportunity to integrate the human physiology of movement with excellence in sport engineering, investing money in research that allows athletes to increase performance by safe methods and without side effects. Historical cases of athletes that have pursued this path, despite being strongly criticized for it, were Chris Boardman from the UK, who won the gold medal during 1992 Barcelona’s Olympic Games in the individual pursuit using a revolutionary aerodynamic bicycle prototype developed by Lotus which was approved by the International Cycling Federation, and Oscar Pistorius, who at the 2011 World Championships in Athletics became the first amputee athlete able to win a non-disabled world track medal. Despite at first sight seeming to be in contrast with the “spirit of sport”, this could be a possible compromise between the maintenance of an athlete’s physical authenticity, free from PEDs and health consequences, and the social demand for continuous progress that does not seem to be arrested or subverted. The problem of technology performance enhancement and its impact on ethics of sport is still unresolved and under discussion. However, as professor Savulescu (2006) wrote in the Annals of the New York Academy of Sciences “Olympic performance would be an exercise of human creativity and choice, not a very expensive horse race”. From this point of view technology could represent a way to combine genetic potential, training strategy, sport nutrition, psychology and hi-tech personalized equipment and a possible way to distance athletes from the use of PEDs. 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