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Is it time to ‘regulate’ doping rather than ban it?

James Witts
17 Jul 2018

Cyclist invites experts to put the argument for and against regulated doping

Chris Froome’s salbutamol case has split opinion among cycling fans and commentators. There are those who feel he has used the power and wealth of Team Sky to escape a doping ban; while others feel he has broken no rules so should never have been under investigation in the first place.

What many people on both sides of the argument can agree on is that the current anti-doping apparatus is ineffective and needs reforming.

WADA, the World Anti-Doping Agency, struggles with a limited budget to test and monitor athletes from all sports. It also has to make life-changing decisions on rules that are becoming ever more opaque as the line between performance-enhancement and therapeutic use becomes more blurred.

There is a growing sense that the war against doping can never be won, and so it’s time for a change of perspective. Perhaps the best approach would be not the prohibition of all drugs, but the regulation of drugs to ensure a level playing field while protecting the health of athletes.

Cyclist approached experts in this field to argue the cases for and against a switch to regulation over prohibition.

First up, in the ‘for’ camp, we have Julian Savulescu, an Australian philosopher and bioethicist, who is also Uehiro Professor of Practical Ethics at the University of Oxford. Savulescu argues that WADA’s budget of £24 million for 2018 is insufficient to be effective, and that ‘hundreds of millions, if not billions, in investment are needed to create a more foolproof anti-doping system’.

Instead, he suggests the answer could lie in allowing athletes to use performance-enhancing drugs as long as they are suitably monitored.

Cyclist finds out more about his stance.

The argument for regulated doping 

CYCLIST: You say performance enhancers in sport should be legalised under medical supervision. One argument is that extreme exercise depletes natural levels of red blood cells, testosterone growth hormone but these can all be increased to ‘natural’ levels via drugs like EPO. So why not let them be legalised?

JS: I have called this ‘physiological doping’, and I think it would be a reasonable and a more enforceable alternative than zero tolerance. It’s like replenishing glucose or water, or supplementing these, during training and competition.

The disadvantage is that sport would no longer be a test of natural physiology – but it isn’t anyway nowadays as you can increase blood by altitude training or a hypoxic air tent. These push athletes beyond their natural baseline. Still, sport retains its values.

Some object that people will enjoy different advantages from the same level of physiology, but the same is true about glucose or water metabolism. People will all metabolise water and sugar slightly differently. Caffeine enhances performance, and there are slow and fast metabolisers. Its enhancement effect differs across individuals. Still, we allow this kind of inequality because it’s consistent with sport being primarily a human endeavour and still a sufficient test of human capacity.

CYCLIST: Despite the publicity and tales of cyclists waking in the middle of the night to keep blood pumping, understandably there’s very little actual literature and studies about the detrimental physiological impact of EPO and even steroids. Is this another argument – that empirically there aren’t enough studies into their effectiveness?

JS: EPO and hormones like testosterone are natural substances that occur in the body. There is now a vast medical knowledge of these, and they can be administered and monitored so that their use is safe. What it requires is medical supervision and an open, transparent and accountable system.

CYCLIST: If a drug accelerates recovery, is there an argument that it makes sport safer?

JS: Accelerating recovery is a legitimate goal of medicine. This is how steroids act. Accelerating recovery should be a goal of sport. It may not make sport actually safer, as return to competition may seriously risk the athlete. But enhancing recovery is a basic goal of sports science. In so far as drugs do this, and are safe, they should be used.

CYCLIST: Ultimately, is the line between what’s legal and what’s not too arbitrary and vague? Is this a battle we can’t win?

JS: Lines have to be drawn and they will always be to some extent arbitrary. What matters is that our rules meet as many of our values as possible, as comprehensively as possible. Zero tolerance does not achieve this. We should set clear and enforceable rules that enable sport to capture the value of physical talent and training, mental engagement and commitment, reasonable levels of safety, display of beauty, enable meaningful comparison, and so on.

There are many sets of rules that can achieve this. We have more freedom to set the rules as sport, technology and humanity evolve.

CYCLIST: Do you know anyone in cycling who feels that the anti-doping war simply can’t be won, especially in an ever-increasing pharmacological world?

JS: The anti-doping war could be won – but it would take huge amounts of money. It would also likely require 24-hour surveillance of athletes. Is it really worth it?

CYCLIST: In the case involving Team Sky and alleged TUE misuse, the issue of ethics in elite sport is a key narrative. But if a team or individual has not legally broken a rule, why do ethics matter?

JS: Ethics should be used to set the rules. But the problem with the TUEs is not the athletes, or the teams, but the rules. There is no reason to have a rule against inhaled salbutamol. It is less performance enhancing than caffeine. And if we set a safe limit for steroids, we would not have to try to disentangle whether they were taken for the purposes of therapy or enhancement.

People think I am in favour of doping. That is too simple. If there is a rule against doping, athletes should obey and be punished if they break it. But it is a separate question. The current rules are based on a fantasy of a clear bright line between therapy and enhancement, between health and disease.

So the practice is a mess because no such bright line exists. We should base our rules on scientific reality and reasonable secular ethical values.

CYCLIST: Finally, arguably the biggest motivator for children are icons. If they’re fully aware the athlete they look up to achieved his or her victory by performance enhancements, is this really a message we want to send out to youngsters? Wouldn’t the lure of sport be lost and, ultimately, elite sport would be no more?

JS: Kids today don’t believe the ideology and the fictions that are presented to them. They know that elite sports people take performance-enhancing substances, just like their music icons take drugs. What we should ensure is that the message is to enhance performance safely, legally and under medical supervision.

That isn’t the message that’s sent today. It’s an old puritanical message that drugs are bad, we need a war on drugs, good people don’t take drugs but meanwhile the younger generation see the successful icons taking drugs, boozing and killing themselves. It’s time to send the right message.

What about genetic doping?

Savulescu isn’t the only one who’s for wholesale changes of not only the doping system but how we perceive ‘doping’.

Andy Miah is also a bioethicist who looked at the issue of sport in our increasingly pharmaceutical world and that alignment with current anti-doping laws in 2004 in his book . Specifically it looked at genetic doping, but also the wider issue of drugs in sport.

Here’s Miah’s take, specifically on the spectre of genetic doping in sport…

CYCLIST: Is there an ethical argument to suggest that genetic doping shouldn’t be illegal?

AM: I think there is a very strong ethical argument to support genetic doping and to strongly protest its illegality. However, some pretty major shifts in public opinion and scientific practice need to take place before this is likely to be seen as acceptable.

First, we must overcome the concern that experimentation on healthy subjects is necessarily unethical. We are especially anxious about this for historic reasons and out of a broader concern that a healthy person may sacrifice their biological integrity for financial gain. We’re also anxious about using scarce medical resources for anything other than repair or therapy. However, that world is changing.

We are less concerned about that now. We also understand that prevention can be more effective than a cure and to go down this route is to embrace human enhancement. 

If you really want to do away with the negative health effects of ageing, then we are going to have to tamper with our biology early on in life. This is why the argument against tampering with healthy subjects breaks down.

The concepts of health and illness are blurrier, as is the way we define quality of life today. Take laser eye surgery. Is that therapy or enhancement? If you undertake laser eye surgery, you can end up with better than normal vision. So, many forms of therapy – as they improve – are now taking us beyond just normal and making us superhuman.

This broader cultural shift in how we use biotechnology and other sciences is why the anti-doping industry will fall on its knees in due course. Quite simply, nobody will care about an athlete using a nasal decongestant, when everybody’s biological systems will be reinforced against illness and optimised for performance in what is an increasingly toxic world.

I bet that the average human in 100 years from now will be able to run as fast as Usain Bolt does today. I may even be around to win that bet, if what I am saying about science and technology is right.

CYCLIST: Why, in WADA’s eyes, is genetic doping illegal?

AM: WADA is run by doctors and others who sympathise with the medical view that its tools and skills should be used only for therapeutic needs. These people believe that the extension of their profession to enhancement betrays their fundamental values and even their Hippocratic Oath. Furthermore, the scientists involved consider it to be against their ethical principles – and to some extent, they are correct.

If you enhance someone genetically, you are going against what is acceptable within your profession, which is to apply a technique in a non-scientific way.

Genetic processes and products have very narrow licenses and their application to healthy subjects – as for other medical interventions – is considered to be unethical and would lead to severe repercussions for the scientists involved.

This is because there is no agreed protocol for such application and the reason for that is because we don’t tend to tamper with healthy people.

However, I feel this is changing and would suggest a World Pro-Doping Agency.

CYCLIST: A World Pro-Doping Agency? Elaborate please…

AM: This would counterbalance the work of the World Anti-Doping Agency. We need an organisation that actively promotes research into safer forms of performance enhancements, so that athletes can use it freely, with minimal risk, and openly.

The response to this usually is – if everyone has it, what’s the point, since enhancements are all about advantage? You might say the same about training, but we don’t because we know that most forms of enhancement are not simple. Many will require careful application and monitoring in combination with training.

How an athlete uses that most effectively will determine the outcomes of sports. And if this sounds like something only the rich can afford, consider first that this may actually be a more affordable form of enhancement than present-day technologies, which are often very expensive. 

The argument against regulated doping

Joe Papp is no stranger to controversy. He is now a vocal anti-doping advocate, but the American is also a former professional road rider who tested positive for testosterone after the 2006 Tour of Turkey. Four years later, Papp was charged with drug trafficking, specifically human growth hormone and EPO.

According to the attorney, Papp brokered deals worth $80,000 to 187 clients, including cyclists, runners and triathletes. He served a six-month period of house arrest followed by two-and-a-half years probation, that leniency was down to Papp testifying at the Armstrong and Landis cases.

‘Out of nearly 200 clients, four were female and they were all amateur,’ Papp explains from his Pittsburgh home. ‘There was a smaller group of younger guys; lads with the potential to compete at elite or international level. But the bigger group was male, late 30s/early 40s, with a good amount of disposable income, professional security and really wanting to see how far they could go.’

Papp has inside knowledge of doping in both the elite and recreational pelotons. What does he feel of regulating illegal drugs instead of banning them completely?

CYCLIST: Australian philosopher and bioethicist Julian Savulescu argued that what are deemed illegal performance-enhancers in sport should be legalised under medical supervision. One argument is that extreme exercise depletes natural levels of red blood cells, testosterone growth hormone but these can all be increased to ‘natural’ levels via drugs like EPO. So why not let them be legalised?

JP: Hah! I think physician-assisted doping of athletes has already transformed elite sport into a chronically overmedicated subculture in which the pharmacological practices you suggest – hormonal rejuvenation, ie topping up one’s testosterone and GH levels ‘within [safe] physiological end points’ – still violate ethical norms, threaten our concept of the integrity of sport, create enforcement nightmares and actually encourage more illicit doping.

Who are the doctors who’d be prepared to administer incredibly powerful drugs to perfectly healthy athletes simply to enhance ‘recovery’ and improve performance? They clearly exist, and they’ve willingly participated in the culture of doping for decades (even I had doping doctors), but the idea of legitimising their work and the efforts of men like Fuentes and Ferrari is horrifying.

We should reject outright the ‘lesser-harm’ argument, that physicians have the responsibility to control athletes’ drug-use and limit medical harm by supervising the administration of androgenic and peptide hormones if for no other reason than trying to manage doping within certain limits (ie ‘[safe] physiological end points’) doesn’t undermine or even address the athlete’s motivation to scheme to work around, or above, those limits and gain a competitive advantage!

Worse still, access to qualified medical supervision is the greatest incentive to dope. It’s incredibly naïve to think that normalising some doping routines won’t beget more doping.

And what about the slippery slope between allowing testosterone and growth hormone use with proper medical supervision and acquiescing to even riskier or costly interventions?

Will detection of certain androgens or peptides in an athlete’s urine and blood only result in an anti-doping rule violation if they were administered without proper ‘medical supervision’?

How can medically-supervised doping be distinguished from rogue injections of the same substances? If testosterone and growth hormone are permitted, what other substances will be next? And pity the sceptical athletes who wouldn’t want to undergo hormone replacement therapy. They lose because of their unwillingness to work with a doping doctor? Seriously?

CYCLIST: Despite the publicity and tales of cyclists waking in the middle of night to keep blood pumping, understandably there’s very little actual literature and studies about the detrimental physiological impact of EPO and even steroids. Is this another argument – that their performance improvements aren’t ‘officially’ proven?

JP: When did it become ethical for researchers to investigate the side effects and potential adverse consequences of administering EPO and steroids to healthy elite athletes?

Sure, the cyclists-waking-in-the-middle-of-the-night-to-ride-rollers-because-their-blood-is-so-viscous story does sound almost like an urban legend now, but there is still a verified, if anecdotal, record of serious adverse events.

I’d refer you to the interview I had with Dr Dawn Richardson about 10 years ago now. Here’s a segment about an issue I had with blood clotting after a crash…

DR: How much blood did you lose into the hematoma?

JP: I believe the quantity of sludge that was removed surgically was close to 1,200ml. Is that possible for a horrible internal hematoma in in the gluteus maximus?

DR: Yes it is. You basically lost a quarter of your blood volume into what should have been a trivial bruise because your blood was way too thin from medically unsupervised and incompetent abuse of anticoagulants. This would put most people into class-2 hypovolemic shock. How scary was all this while it was happening?

JP: At the time not very because medical care was excellent. What was scary was being alone in a hospital in Pescia, Italy, abandoned by my team and facing the end of my cycling career and a cloudy future.

DR: Do you understand what would have happened if you hit your head?

JP: I eventually did but I prefer not to think of dying.

CYCLIST: If a drug accelerates recovery, is there an argument it makes sport safer?

JP: Sure, there’s an argument that if a drug accelerates recovery with no risk of serious side effects or long-term complications it makes sport safer, both for the individual doped athlete and, in a mass-participation sport like cycling, for his colleagues (who might normally have, for example, crashed on a high-speed descent because a rider whose bike handling or overall decision making was impaired by accumulated fatigue).

I think the fact that the effects of many of these ‘recovery products’ can be so profound (and yet still variable between individuals) undermines any safety argument because permitting them basically incentivises the most ambitious person to become the most kamikaze. The cohort who are already doping would probably dope even more.

CYCLIST: Ultimately, is the line between what’s legal (altitude tents in most countries) and what’s not too arbitrary and vague? Is this a thankless battle?

JP: If the goal is eradication of doping, then that’s an unwinnable battle but, right now, after cases like the Winter Olympics and the International Olympic Committee’s craven decision to lift the suspension of the Russian Olympic Committee, for me the more compelling question is whether or not people in charge of elite sport even support genuine anti-doping efforts.

I do think the line between what’s legal and what’s banned should continually be re-evaluated to ensure that it’s based on evidence and sound ethical judgment.

I haven’t committed much thought to this recently, but if someone came to me and said the WADA list should be trimmed because finite resources are being devoted to policing substances that confer minimal performance advantage [arguably like salbutamol], for example, I wouldn’t think that was illegitimate. Athletes benefit when the lines are clear and bright, rationally-derived, unambiguous.

Unnecessarily harsh outcomes and inconsistent sanctions don’t enhance the credibility of the anti-doping movement.

CYCLIST: If not you, do you know anyone in cycling who feels that the anti-doping war simply can’t be won, especially in an ever-increasing pharmacological world?

JP: No one I know in competitive cycling wants doping to be legalised.

The scofflaws don’t want their pharmacology-derived advantage to be more accessible to competitors whose fear of being banned from sport dissuaded them from doping, and the clean athletes who are legitimately concerned about their health don’t want to be forced to use drugs simply to maintain parity with their more reckless rivals.

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