Sports, Bioethics of

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SPORTS, BIOETHICS OF

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The use of banned substances (doping), genetic enhancement, and gender issues are three topics central to the discussion of bioethics in sports.

Doping in Sport

Prior to the inception of the World Anti-Doping Agency (WADA) in 1999 and the World Anti-Doping Code (2003), banned substances and practices in organized sport were identified by the International Olympic Comittee (IOC). In its International Olympic Charter against Doping in Sport (1990), the IOC declared that "the use of doping agents in sport is both unhealthy and contrary to the ethics of sport, and that it is necessary to protect the physical and spiritual health of athletes, the values of fair play and of competition, the integrity and unity of sport, and the rights of those who take part in it at whatever level." This charter contains a list of substances and practices that are banned from the Olympic Games. The use of these banned substances and practices is referred to as doping. However, the IOC lacked a clear ethical framework that could justify the banning of these items by showing them to be relevantly different from permitted substances and practices.

Each of the IOC's reasons for banning certain substances and practices can be found in more developed forms in the literature of the philosophy and ethics in sport. These include arguments against cheating, unfair advantage, and harm, as well as the ideas that doping perverts the nature of sport and that doping is dehumanizing. The basis for a potential coherent and enforceable ban on doping in sport derives from a view of the intrinsic goods of sport.

THE INADQUACY OF CURRENT ARGUMENTS TO SUPPORT BANS. There are four arguments that are generally proposed to justify banning drugs in sport. All of them have some merit, though none of them provide a sufficient justification for banning doping.

Cheating and unfairness. The argument that doping amounts to cheating was used by Justice Charles Dubin of the Canadian Royal Commission, which was established by the Canadian Federal Government after the Ben Johnson scandal during the 1988 Seoul Olympics. The Dubin Report states that the most vigorous opponents of cheating in sport are those who insist that sports must be conducted in accordance with the rules. The moral disapprobation of doping is thus seen as coming from the fact that doping is cheating.

The major problem with this position is that an activity only becomes cheating once there is a rule prohibiting it. So while the fact that doping is cheating may well provide a reason for enforcing the rules against doping, and while the fact that doping is cheating may give other athletes a reason to have an extremely negative attitude towards those who dope, there is not yet a clearly argued reason for creating the rule banning doping in the first place.

There are alternative interpretations of this argument. One is that there is something in the concept of cheating that implies a notion of unfair advantage of one competitor over another. The use of certain substances and practices falls into this category. However, for this view to justify banning a substance, the notion of unfair advantage must be independent of the rules of sport (unlike cheating). In other words, if unfair advantage turns out to be just rule-breaking, then it cannot do the work that the concept of "cheating as rule-breaking" could not do. This raises a variety of philosophically interesting questions: What is cheating? Why is cheating wrong? And, independent of the answer to these questions, Why should doping been banned? From a bioethics perspective, it will not do to say simply that one should not dope because it is banned. What is significant is the justification for banning it in the first place.

The argument that doping is unfair suffers from a similar weakness. The simplest idea of fairness is one connected to adherence to the rules: an action is unfair if it is against the rules. An alternative notion of fairness is independent of the rules of sport. But this notion would have to show how doping was inherently unfair, even if the contestants agreed that all could do it, and even if the rules of the game permitted it. Thus, the concept of unfair advantage is no better justification for banning a substance than cheating is.

The concepts of cheating and unfair advantage would have to exist independently outside of sport in order to be brought to bear to evaluate sport. For example, the concepts of cruelty or brutality, which are moral evaluations, have been used to ban sports such as bare-knuckle boxing. It may well have been the case that bare-knuckle bouts were free of cheating and quite fair, they were, however, brutal and cruel, and on these grounds they were banned. Unless the concepts of cheating and unfair advantage can similarly be grounded outside of sport, they will be unavailable to justify or criticise the rules of sport.

Harm to the athlete. The second most commonly cited argument used to justify the ban on doping is that it is harmful. Doping is viewed as being: (1) harmful to users, (2) harmful to other athletes, (3) harmful to society, and (4) harmful to the sports community. However, these arguments cannot be expected to provide a general justification for prohibiting doping, but must be addressed sport by sport and substance by substance.

The argument that a ban is justified because doping is harmful to the user assumes that a particular substance or pracice is harmful, and that potential users need to be protected from the substance or practice. Anabolic steroids provide a good example of such a substance. The assertion that medically supervised steroid use harms the user is, at the turn of the twenty-first century, scientifically unproven. Much of the evidence concerning harm is derived from anecdotal testimony of athletes using very high doses in uncontrolled conditions, and the medical evidence from controlled low-dose studies tends to show minimal harm. Society's abhorrence of the practice has prevented the gathering of hard scientific evidence, because such research has yet to be approved by ethics committees. Autologous blood-doping has not been shown to have adverse side-effects at all.

There are two elements to the charge of harm to the user of a substance: the bad effects of the substance, and the causal linkage of these effects to doping. It has not been scientifically proven just what the "bad effects" from doping are. For the sake of argument, however, one can grant that steroids do indeed harm their users (not an implausible assumption). It would then be necessary to address each particular steroid on its own merits, rather than formulated a general argument against doping.

It can also be argued that the desire to protect competent adults from the consequences of their own actions is paternalistic. Paternalism has both acceptable and unacceptable forms. For example, some would argue that banning doping for minors is acceptable, but that banning doping for adults is unacceptable.There are, however, instances where certain practices are banned for adults, such as banning driving without seatbelts. The question thus becomes whether banning steroids, and other substances and practices, is acceptable paternalism?

Much of the thrust of modern bioethics has been directed against medical paternalism. It may be argued that to ban steroids solely to protect competent adults is to treat those adults athletes as children who are unable to make choices that directly impact their lives. This position is generally inconsistent with the nature of high-performance sport, in which athletes are constantly pushing their limits.

Some would argue that it is inconsistent, and even hypocritical, for the governing bodies of sports to attempt to justify a ban by appealing to the athlete's well-being. There are many training practices, and indeed many sports, that carry a far greater likelihood of harm to the athlete than does the controlled use of steroids. If the reason for banning doping in sport really were a concern for the health and wellbeing of athletes, then many other practices (and many sports) should also be banned.

One might argue that the risks incurred by the nature of the sport (e.g., brain damage from having one's head pummelled in boxing) are different from the risks that are incurred from practices that have nothing to do with competition in the sport per se (e.g., liver damage from steroid use). The basis of this argument might be tied to a distinction between the external good and the internal good that are derived from participation in a sport. Internal goods (skill, strategy, self-fulfillment, etc.) are gained from participation in the activity itself, while external goods (fame, prestige, money, etc.) are gained from societal recognition of success. Some might argue that the only way one can gain these internal goods is to take the risks involved in participation. However, this distinction is invalid if the justification for the ban is that a substance harms the user, because the athlete can be harmed in either case (i.e., both brain damage and liver damage are harmful).

There is little evidence to suggest that banning doping will protect athletes. As long as a subculture exists that believes that doping brings benefits—and that it is an occupational hazard of highlevel competitive sport—athletes will continue to use these substances in clandestine, unsanitary, and uncontrolled ways. Only a change in values will end such use, and this will only happen after a logically consistent position for the ban has been put forward (presumably, a ban would be intended as part of a larger process aimed at producing just such a change in values).

Harm to other athletes. It is also argued that steroids should be banned because of the harm their use causes to other athletes. ("Others" are usually deemed to be "clean," or nondoping, athletes.) This is called the coercion argument, and it is more difficult to dismiss quickly. The same liberal tradition that prohibits paternalistic interventions permits interventions designed to prevent harm to others. What must be determined is how great the harm is to other athletes, and how severe the limitation on personal action is.

In order to assess this argument one needs to consider whether or not the potential coercion of clean athletes outweighs the infringement on the liberties of athletes caused when a substance or practice is banned. Clean athletes are harmed, so the argument goes, because the dopers "up the ante." If some competitors are using steroids, then all competitors who wish to compete at their level will need to take steroids or other substances to keep up. This argument has some merits, but it is still incomplete, for elite-level sport is already highly coercive. If full-time training, altitude training, or diet control are shown to produce better results, then everyone is forced to adopt these measures to keep up. The feeling that somehow steroid use is worse than longer or more specialized training just raises the question of why it is worse. Why can't an athlete accept two "raises of the ante" but not accept a third, or even an unlimited number?

The answer to this question relies on a demand for consistency. There must be some reason why a particular practice is banned, and that reason cannot be merely that it raises the ante too high. This is a qualitative question, not a quantitative one, that necessarily requires an explanation for banning a substance on its own merits.

On the other hand, the coercion argument has merit if it can be shown that doping is irrelevant to a particular view of what is important to sport. If sports and sporting contests are about testing skills, then it can be argued that the improved performance that comes with doping is irrelevant to that test of skill (especially when one bears in mind that if some athletes dope, others will be forced to dope in order to keep up, thus obviating the original advantage that came with doping). If doping is irrelevant to sport, the athletes can shun it as being unnecessarily coercive.

Harm to society. This position says that doping harms others in society, especially children who see athletes as role models. If children see athletes having no respect for the rules of the games they play, there will be an undermining of respect for rules, and for law in general. This argument only works if doping is against the rules, however, and so cannot function as a justification for banning doping in the first place.

Athletic drug use is also seen as part of a wider social problem of drug use. The argument here is that if children see athletes using drugs to attain sporting success, then other drugs may be seen as a viable means to other ends. The limitation of this argument is that there are many things that are considered appropriate for adults but not for children. Alcohol and cigarettes are obvious examples, as is sex, but, in North America at least, these substances or activities are not banned for adults simply because they would be bad for children.

A further response to the suggestion that athletes should be role models—and, in particular, moral role models—is to ask why. People expect widely varying things of their public figures. No one seriously expects musicians or actors and actresses to be moral role models, so why should athletes be singled out for special treatment? Why should more be expected from athletes than from other public figures?

Some philosophers have argued that sport is one of the very first areas young people experience, and one of the first in which they hope to gain excellence. From a societal perspective, if the heros and heroines of young people are morally despicable, then they will exert a negative influence. Young people will not separate the athletic abilities of their heroes or heroines from the quality of their personal lives, especially when fame and glamour surround such persons. The achievement of excellence in athletics comes prior to, and will greatly influence, the achievement of excellence in adult arenas such as business, academia, and politics. Perhaps for these reasons people are more concerned about the moral image of athletes than of other public figures.

What is it about drug use in sport that people find morally repugnant? No one else is prevented from using cold remedies, even if they drive public transportation, or from using caffeine as a stimulant to work harder. So it is not even the case that athletes are asked to meet the standards every one else meets, but rather, at least in regard to substance use, they must meet more rigorous standards.

Harm to the sport community. One other group that is potentially harmed is the sports-watching public. These people will be harmed, the argument goes, if they are being cheated—if they expect to see dope-free athletes battling it out in fair competition and are denied this form of entertainment. This harm can be removed in other ways than through banning steroid use, however. One could, for example, remove the expectation that athletes be dope-free. The feeling of being cheated is dependent on the idea that what was expected was a particular type of competition. However, this means asking people to settle for less than what they really want. They might, therefore, suffer other harms, such as the loss of the chance to watch doping-free competition. Of course, this does not address the question of why people value doping-free competition.

HARM CAUSED BY BANS. Because any bans that are imposed need to be enforced, there are potential harms caused by the bans themselves. Enforcement of bans on substances or practices designed to help one train, rather than improve one's performance on the day of competition, requires year-round, random, unannounced, out-of-competition testing. This is an intrusion into the private lives of athletes. Thus, athletes are harmed by being required to consent to such testing procedures (and to give out constant updated information on their whereabouts) in order to be eligible for competition.

One aspect of the harm caused by bans is abstract. Any time one's choices are restricted, one has been harmed. One could argue that the athlete is harmed when deprived of the chance to dope in order to improve performance. On the other hand, the spectator is harmed when deprived of the chance to watch doping-free sport. There is, however, a more direct harm. If one bans drugs or practices, one must necessarily take steps to enforce that ban. Despite the number of positive tests during a competition, the only effective way to test for banned substances is to introduce random, unannounced, out-of-competition testing. This is because some substances, such as anabolic steroids, can be discontinued before competition, and still retain their effects and also because of the prevalence of masking agents and urine substitution using catheters. The demand that athletes be prepared to submit to urine (or blood) testing at any time is considered by some to be a serious breach of their civil and human rights. It could also be argued, however, that such interference is just part of the price of being in sports—no one is forced to become an athlete, let alone an elite athlete.

Many who discuss this topic suggest that "sport is different," that it is not "real life," but "only a game." They argue that, because of this difference, the limitations imposed by the requirements of consent do not apply. The suggestion is that participation in high-performance sport is a privilege, not a right. Therefore, athletes are not deprived of their rights if they are deemed ineligible because they will not submit to a drug test, because they do not have a right to participate in the first place. The serious consequences of this argument is that it would allow the imposition of any rules, no matter how absurd.

Further, this argument is unclear. It may mean that no person has the right to be selected for a national team or for financial support. This is certainly true, but it is also true that there is some obligation to select the best available people for national teams and, barring income tests, for financial support as well. It could then be argued that the "best available person" means the best person available who abides by the rules of the game. However the rules of sport are not arbitrary, and they are open to moral scrutiny. If the format of the drug test is unacceptable on the moral grounds that it invades privacy, then it is also unacceptable for there to be a rule of eligibility that requires it. Sport may well be different, but nothing is so special or different that it can escape all moral scrutiny.

Perversion of sport. The concepts of cheating and unfairness and of harm are moral concepts. Cheating and unfairness presuppose a set of rules, so logically these concepts cannot be used to justify a rule. The concepts of cheating and unfairness are are thus inside sport. The arguments related to harm utilize a principle found outside of sport and applied to it, thus working from the outside in.

In contrast, arguments related to the perversion of sport do not operate from moral principles, but from metaphysical ones. What the arguments seek to show is that there is some feature of sport, which, if properly understood, would be demonstrably incompatible with doping. Thus, doping should be banned because it is somehow antithetical to the true nature of sport.

Part of the problem when dealing with this question is that sport is socially constructed, and there is no obvious reason why it could not be constructed to include doping. A view of sport which places at its center the testing of sporting skills, with sporting skills defined by the nature of the game concerned, suggests that doping is not so much antithetical to sport, but rather irrelevant to it (Schneider and Butcher, 1994). Doping is irrelevant to sport because it does not improve skill, but merely provides a competitive advantage over those who do not dope. But a prerequisite for this justification is that it must come from the athletes themselves, not from sport administrators.

Unnaturalness and dehumanization. It is also argued that doping should be banned because it is either unnatural or dehumanizing. The unnaturalness argument does not get very far for two reasons. The first is that it is not clear what would count as unnatural. The second is that it is inconsistent. Some things designated unnatural are permitted (e.g., spiked shoes) while certain natural substances (e.g., testosterone) are banned.

The dehumanization argument is interesting but incomplete. There is no agreed upon conception of what it is to be human. Without this it is difficult to see why some practices should count as dehumanizing. We also have a problem with consistency. Some practices, such as psycho-doping (the mental manipulation of athletes using the techniques of operant conditioning) are not banned, whereas the re-injection of one's own blood is banned.

An Alternative Approach

A two-tiered approach has been proposed that could justifiably prohibit doping in sport. This approach tries to show:(1) why athletes should not want to dope, and (2) why the community should support doping-free sport.

WHY ATHLETES SHOULD NOT WANT TO DOPE. Sports are practices that provide the opportunity for individuals to acquire and demonstrate skills. A well-executed back-hand volley is a demonstration of skill because of the kinds of things that are necessary to win at tennis. The shot is difficult and effective, and it is just this sort of manifestation of skill that makes participating in sport so worthwhile. The joy of sport comes from acquiring the goods that are internal to sport, the goods that come with the mastery and demonstration of skill. If this joy is the primary reason for participation in sport, then doping is irrelevant to the internal goods of sport.

Every sport is a sort of game, a game where obstacles have been artificially created to prevent one from readily achieving the object of the game. Skill is demonstrated in the overcoming of those obstacles, within the limits provided by the rules of the game. What makes sport interesting and worthwhile is the mastery of skill, and its demonstration in a fair contest with equally skilled opponents. Doping does not help one to acquire sporting skills, but simply provides a competitive advantage over those who do not dope.

Further, as long as one's competitors do not dope, there is no reason for any athlete to dope, even if the risks are minimal and the probabilities of harm are small. Because there is no game-productive reason for doping, athletes would be wise to avoid it as an unnecessary risk.

Finally, the coercive effect of doping is such that if athletes believe that a good number of their opponents dope, they will feel compelled to dope in order to keep up. But this has the effect of removing the competitive advantage that those who first doped soughtto gain. Doping is only an advantage—in terms of winning—if you dope and your opponent does not. That advantage is lost if everyone dopes.

These arguments point the way to a method of avoiding the invasion of privacy caused by the enforcement of bans. If athletes want doping-free sport, they will also want to be assured that the competition is fair. Athletes, then, would be in the position to request the enforcement of the rules of self-limitation that they themselves have rationally and prudently chosen.

WHY THE COMMUNITY SHOULD SUPPORT DOPING-FREE SPORT. The sporting community, both participants and fans, is in a position to defend a view of human excellence that can put limits on the pursuit of performance excellence in sport. Given that in most countries amateur sport is publicly funded, the community can promote a view of sporting excellence that places it within the context of a complete, and excellent, human life. So, despite the fact that excellence in certain sports (i.e. boxing and downhill skiing) requires running dreadful risks, society is in a position to limit those risks because it does not want to promote downhill speed over long and healthy lives. The message from those who support sport should be that an athlete's sporting life is only a part of his or her entire life. While excellence in sport is a worthy pursuit, it should not be pursued at the expense of one's health and well-being. Because amateur sport is publicly funded, the community is in a position to put limits on its support, limits that come from the desire to promote human excellence across a complete lifetime.

Genetic Enhancement in Sport and Bioethics

Gene transfer technology will revolutionize the way people view illness and health, and it will also transform the way we diseases are treated and prevented. While this work is still in the research phase, the most imminent applications of gene transfer research to sport performance include muscle growth factors and oxygen transport and utilization.

CONCEPTUAL ISSUES. The primary challenge in gene transfer technology is in drawing the line between therapy and enhancement. The standard approach in sport has been that therapy (repair to bring one back to normal) has been permitted, but enhancement (going beyond normal) has been banned. This approach does not fit neatly with current medical practice and thinking. For example, in many forms of prevention, the body's normal responses to disease are enhanced to enable a person to avoid infection or illness. Some muscle-repair therapies may have the effect of making the muscle stronger than it was before the injury, thus enhancing performance.

The wording used in a particular ban or regulatory list needs careful consideration. It is easy to be either too specific (thus missing a significant new development) or too general (thus encompassing a variety of acceptable uses of technology). Because of the relation of sport to society, the language used in the World Anti-Doping Code attempts to deal with the development of genetic technology. This code addresses the use and impact of gene transfer technology in sport, while acknowledging that sport operates in a social context. In regard to genetic enhancement, even if sport organizations decided that enhancements should not be permitted, if it became standard medical and social practice to enhance memory and mental acuity, or to enhance muscle growth and strength in the elderly, it would be extremely difficult for sport to stand apart in opposition. There are many areas where enhancement is not only accepted, but encouraged, valued, and highly rewarded (e.g., cosmetic surgery) and even sport—some drug use is permissible in baseball in North America, for instance. If it is socially acceptable in some settings, why not in sport?

The World Anti-Doping Agency (WADA) attempted to initiate discussion on the development of some core agreements by hosting a conference on genetic enhancement and sport at the Banbury Centre in New York in February 2002. WADA has the opportunity to influence and shape the discussion, and to define and direct policy, before gene transfer technologies become available for general use.

OBJECTIONS TO GENE TRANSFER TECHNOLOGY FOR PERFORMANCE ENHANCEMENT. Despite a lack of clarity in exactly what is meant by treatment and enhancement, it is generally agreed that enhancement for sport purposes is unacceptable. However, within medicine and science this is a very complicated issue, partly because the technology is in the early stages of development. It is difficult for medical scientists to state, in the abstract, that enhancement for sport is unacceptable. This position is thus far more appropriate as a statement from the sport community. Scientifically, it would certainly be unacceptable when the technology is in this immature state.

There is strong agreement that action is required on this issue, and that this action will be complex and multifaceted. It should include: (1) ongoing cooperation between the research and sport community, (2) communication between the sport community and regulatory bodies for review and regulation of research and biotechnology, (3) inclusion of wording covering gene transfer technology in the World Anti-Doping Code, (4) research into detection mechanisms,(5) ongoing discussions between the sport community and the medical and scientific communities concerning standards of practice, (6) ongoing discussions between the sport community and the biotech and pharmaceutical industries,(7) education of athletes, the professions (especially medicine), industry, governments, and the public.

UNDISCOVERED COUNTRY. A number of themes and issues related to genetic therapy and genetic information have yet to be discussed in the sport context. The first of these is genetic design, which involves "designing" babies for specific (athletic) traits. The second of these issues is germ-line, or heritable, therapy. Other uses of genetic technology include in vitro genetic screening, which, in principle, makes it possible to screen embryos for genetic characteristics, and then implant into the womb only those with the "desirable" genetic makeup. It is not known if it will be possible to do this for genes associated with traits that predispose to greater athletic performance, but such a possibility raises numerous ethical questions.

There is also the possibility of genetic screening in vivo, where genetic screening techniques could be used (as a form of potential aptitude testing) to determine which children or young people were most likely to benefit from specialized sport training. There has been no comprehensive discussions of the acceptability of these procedures for sport purposes, nor of the privacy issues associated with this genetic information.

REGULATION AND REVIEW. Research on the human applications of gene transfer technology is highly regulated and reviewed at local and national levels in the United States, and, to some extent, by similar mechanisms in other nations. However, review and regulation vary by jurisdiction and nation. The research is currently highly sophisticated and expensive.

There are gaps in regulation in regard to sport applications. For example, a study would not be likely to be described as having the purpose of exploring the enhancement of sport performance, though it could have that effect. The prospective regulation of gene transfer technology for sport purposes must be multifaceted and include: (1) regulation of research, (2) regulation of professional medical practice, and (3) regulation of athletes and support staff.

TESTING. There is general agreement in the sport community that the possibility of testing requires the development of more efficient methods for detection of genetic modification or of the physiological effects of genetic modification. Testing may well be difficult, and it may raise additional ethical issues, but it involves technical issues that are soluble by improved research and technology development. Testing could be aimed at both the primary genetic modification and at secondary indicators. The incorporation of markers, or tags, into foreign therapeutic genes to make them more readily detectable may help in detection programs, though this would be contrary to best principles of drug design, in which only therapeutic efficacy should be relevant.

RESEARCH AND EDUCATION. There needs to be increased research and development in the areas of in vivo gene and vector detection and the identification of the physiological effects of genetic modification, along with careful and constant ethical review. General education, as part of social change, is viewed as essential. Education should be valuesbased and target-specific. Researchers need to be educated on the potential uses of their research for sport enhancement purposes—and why this would be harmful to sport and athletes. Biotech companies need to be educated on the potential uses of their products and processes, and on their role (and self-interest) in avoiding misuse. The professions (particularly medicine) need to be educated on standards of professional practice and distinctions between therapy and enhancement. Finally, athletes need to be educated on the values of sport and the side effects and hazards of gene transfer technology.

Bioethics, Sport, and Gender

Many elite-level sports require pushing human limits, and thus present high risks of injuries. Generally speaking, elite-level training can produce fit, but not necessarily healthy, athletes. The results of the pressure to can be different for men and women, however. Three issues in particular—disordered eating, amenorrhea, and osteoporosis—are commonly referred to as the female athlete-triad. These problems surface most often in sports such as gymnastics, where victory is the result of judging. In such cases, the physical requirements and resulting risks are directly caused by decisions about what counts as excellent sport. The judging criteria for these sports need to be tailored so as to minimize the health risks they impose on the athletes.

Women athletes have a much higher prevalence of disordered eating than men. Women athletes have, at various times, faced different body-type ideals, but the greatest tension is that between the traditional ideal athlete and the traditional ideal woman. This reflects the higher level of eating disorders among women in the general population, a result of unattainable ideals among many women regarding their bodies. Thus, this problem is partly cultural, and medical control may not be the best, and is certainly not the only, way of addressing the issue.

Historically, some medical authorities have viewed menstruation, pregnancy, menopause, body size, and some feminine behaviors as diseases. For the female athlete the situation becomes even more complicated, because she can be classified as even more abnormal when reproductive changes are evaluated in the context of the traditional male sports arena. If a normal healthy woman is considered unhealthy because the model of the ideal healthy adult is based on being male, then the female athlete starts out as an unhealthy adult simply because she is a woman. If the female athlete then shows signs of becoming masculine through excellence in sports, this only increases her "abnormality." Following this kind of medical classification, when a woman bleeds, she is ill, yet if she does not bleed she is also ill. Pregnancy, then, theoretically constituting a state of health for the traditional ideal woman, should not be treated as disease.

Serious charges of irresponsibility can occur when the relationship between women athletes and their fetuses are characterised as adversarial. Some countries (e.g., Canada, the United States, Australia) have begun to imprison women for endangering their fetuses (Sherwin). Most pregnant women athletes face, at the very least, moral pressure based on the view that simultaneously being pregnant and participating in sport is socially unacceptable. However, genuine harm to the fetus may occur with participation in sport (e.g., through oxygen deprivation). This is a problem best dealt with through education, however, not through prohibition and criminal penalties.

The classification of the reproductive aspects of women's lives as illnesses has led to wide-scale paternalistic medical management of women under claims of beneficence (Sherwin). In sport, these so-called illnesses have been part of the basis for excluding women. Certainly, serious complications requiring medical interventions can occur with any aspect of a female athlete's reproductive life or life-cycle changes. The physical and emotional pain experienced by older women athletes during menopause has always been a fact. Sport physicians, however, who are predominately male, had to learn to take their female patients seriously before they could recognize that this pain was real, and not just "in their heads." There are instances where the label of illness or disease is appropriate, but it is important that this does not lead to harming women athletes from a policy perspective (e.g., banning them from participation, rather than educating them about coping with their illness and participating in sport).

The Logic of Gender Verification and Transsexualism

Having entirely separate sports for men and women inevitably leads to the question of the logic of gender verification. If there are to be separate sporting events for women, it must be possible to exclude any men that may wish, for whatever reason, to compete in these events. This means that there must be a rule of eligibility that excludes men. (Conversely, if there is such a rule, the question arises of whether there should also be such a rule excluding women from men's events, even if the women believed they would inevitably lose.) This requires a test of gender that can be applied fairly to any potential participant. There are at least three methods of applying any such test. The first would be to test all contestants, the second would be to test random contestants, and the third would be to test targeted individuals.

It is not beyond the realm of imagination, however, that a money-hungry promoter might decide to enter men in a women's event. A male may even, with good intentions, choose to enter a women's event (such as synchronized swimming) as a form of protest against gender discrimination. Without a test to decide just who is eligible, women's events could be forced to accept participants who were quite obviously and unashamedly male, but who professed to be female.

There is a great deal of debate about how sex roles and gender are established. One school of thought takes the position that sex refers to biological characteristics and gender to socially learned characteristics. The standard practice in the Olympic Games has been to have medical experts verify gender. But, by delegating gender verification to medical experts, the sport community (and society in general) has given great power to medical experts on an issue that is in dispute by researchers.

One famous case that illustrates the conceptual and moral issues of gender verification is that of Renée Richards. Richards was previously a male elite-level tennis player who underwent what is commonly termed a "sex-change operation." The U.S. Women's Tennis Federation wanted to exclude a player who was genetically male, and they therefore introduced the requirement that players take a chromosomal test known as the Barr Test. Richards refused, and went to court to demand the right to participate in women's events. In court she was deemed to be female on the basis of the medical evidence. In the media, this story played as an example of a courageous individual fighting for personal rights against an intransigent and uncaring system, though there are, of course, other ways of viewing the story.

What makes a woman a woman? Is it chromosomes, genitalia, a way of life or set of roles, or a medical record? It is not clear why medical evidence of surgery and psychology should outweigh chromosomal evidence, nor is it clear why any one answer should be taken as categorically overriding any other. Some women argue that any gender or sex test is demeaning (especially visual confirmation of the "correct" genitalia) and discriminatory if it is not also applied to men. Clearly the use of any test, given the complexity of human sex and gender, may lead to anomalies and surprises. Yet many women wish to have sporting competitions that exclude men. One thing that does seem to become clear when faced with the complexity of this issue is that women athletes themselves should be the guardians and decision makers concerning women's sport. The best result will be one that arises through discussion, debate, and consensus.

thomas h. murray (1995)

revised by angela j. schneider

BIBLIOGRAPHY

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Brown, W. 1990. "Practices and Prudence." Journal of Philosophy of Sport 17: 71–84.

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