When Is Disqualification From Sports Justified? Medical Judgment vs Patients' Rights
Matthew J. Mitten, JDTHE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 10 - OCTOBER 96
In Brief: An important medicolegal issue is how best to resolve disputes about an athlete's medical eligibility. Team physicians typically recommend against athletic participation when they feel that it will pose an unreasonable risk of injury to an athlete who has an abnormality. But such athletes may cite federal laws designed to protect the disabled and claim a right to participate. The legal framework for resolving sports-participation disputes involving physically impaired athletes is still developing. Recent case law reflects a split decision regarding the legality of excluding athletes whose condition, in the opinion of the team physician, exposes them to an increased risk of significant harm.
Athletes who have a physical abnormality such as a missing or nonfunctioning paired organ, spinal stenosis, or a cardiovascular irregularity may expose themselves to an increased risk or severity of injury or even death by participating in a sport. Despite a team physician's medical recommendation against participation, some athletes who are able to play a sport despite an abnormality have claimed a legal right to do so.
Because team physicians generally establish medical eligibility requirements for athletes, they must understand the legal implications of recommending against sports participation. Recent cases are helping to build a legal framework for resolving participation disputes between athletes and teams under federal laws that prohibit discrimination against disabled people.
The Team Physician's Role
The team physician generally is responsible for examining athletes and evaluating their physical fitness to participate in a sport. Team officials typically grant the team physician authority to medically disqualify an athlete. One of the team physician's objectives is to avoid unnecessary restriction of athletic activity, but the paramount responsibility is to protect the athlete's health (1).
Ideally, the decision regarding athletic participation should arise from mutual agreement between the team physician and specialists, team officials, and the athlete and family. A physician should recommend against athletic participation that he or she believes will pose a medically unreasonable risk of harm to the athlete or other players.
Most athletes trust team physicians and rely on their recommendations about participation with a physical abnormality. For psychological or economic reasons, however, an athlete may be reluctant to accept the team physician's advice and may consult with other physicians to obtain medical clearance to participate in a sport. Because of the lack of conclusive scientific data and universally accepted medical guidelines—combined with differing interpretations of available data and other factors—sports medicine physicians can make conflicting medical clearance recommendations. If some other physicians provide medical clearance to play, an athlete might sue a professional team or school that continues to rely on the team physician's contrary recommendation to exclude the athlete from competition.
Federal Law Requirements
Although there is no constitutionally protected right to play on a professional or amateur sports team, both the Americans With Disabilities Act of 1990 (ADA) (2) and the Rehabilitation Act of 1973 (3) prohibit unjustified discrimination against people who have physical abnormalities or impairments. These federal laws apply to virtually all professional teams and intercollegiate or interscholastic sports programs, but they do not render a physician liable for determining medical ineligibility.
Team officials may require an athlete to have "reasonable physical qualifications," which are generally established by the team physician (4). It is illegal, however, for team officials to exclude an "otherwise qualified" athlete with a physical abnormality or illness from a sport without substantial justification (5). An athlete is "otherwise qualified" if he or she can satisfy all of the team's requirements in spite of physical impairment.
Exclusion of an athlete because his or her physical condition increases the risk of personal harm must be based on "reasonable medical judgments given the state of medical knowledge (6)." Relevant factors include the nature, duration, probability, and severity of harm from athletic participation as well as whether the risk of injury can be effectively reduced by medication, protective equipment, or other reasonable accommodations to enable participation. In addition, team physicians can exclude an athlete if a medical condition prevents the athlete from playing well enough to compete successfully in a sport or if it poses a significant risk to other participants (7).
In 1990 a federal court held (8) that a high school's refusal, in accord with unanimous physician recommendations, to allow an exceptional athlete with structural heart disease to play football does not violate the Rehabilitation Act. The court found that the athlete's inability to satisfy an Ohio high school athletic association bylaw requiring physician certification before athletic participation is a substantial justification for the school's decision.
Requiring an athlete to pass the team physician's medical exam is arguably a reasonable physical qualification that does not violate either the ADA or Rehabilitation Act. Nevertheless, some courts have ruled it illegal to exclude from an intercollegiate or interscholastic contact sport an athlete who has a missing or nonfunctioning paired organ such as an eye or kidney (9-11). In these cases the school had followed its team physician's recommendation that the athlete not play, although other physicians provided medical clearance. These courts appeared to base their rulings on the opinion of medical specialists that the athlete's condition itself does not increase the probability of injury and on the fact that available equipment can adequately protect the athlete's functioning organ.
One recent case illustrates judicial reluctance to require team officials to allow an athlete to play a sport when participation is contrary to the team physician's recommendation. In Pahulu v University of Kansas (12), a federal court upheld the team physician's "conservative" medical disqualification of a college football player with an abnormally narrow cervical canal after an episode of transient quadriplegia during a scrimmage. After consulting with a neurosurgeon, the team physician concluded that the athlete was at extremely high risk for sustaining permanent, severe neurologic injury including permanent quadriplegia if he resumed football. The athlete wanted to resume playing because three other medical specialists concluded that he was at no greater risk of permanent paralysis than any other player.
Although the athlete was willing to sign a waiver absolving the university of liability for any future injury resulting from his playing, the court held that university officials' adherence to the team physician's recommendation against playing does not violate the Rehabilitation Act. The university agreed to honor the athlete's scholarship although he was not allowed to play football.
Uncertain Team-Physician Authority
Another recent case, however, creates uncertainty about the legal authority of a team physican to medically disqualify an athlete. In Knapp v Northwestern University (13), a federal court held that Northwestern University's exclusion of a player from its intercollegiate basketball program violated the Rehabilitation Act. While agreeing to continue providing him with a full athletic scholarship, Northwestern refused to allow Knapp to play basketball because of its team physician's determination that the athlete's participation in the program would expose him to a significant risk of serious and permanent injury or death.
In September 1994, Knapp experienced primary ventricular fibrillation and cardiac arrest following a pickup basketball game. The episode required cardiopulmonary resuscitation and defibrillation to restart his heart. Thereafter, he had an automatic cardioverter-defibrillator device implanted in his abdomen. Knapp subsequently has played competitive basketball without any incidents of cardiac arrest and received medical clearance from two cardiologists who examined him.
Northwestern followed its team physician's recommendation that Knapp not play basketball in view of his medical records, the 26th Bethesda Conference guidelines for athletic participation with cardiovascular abnormalities (14), and opinions of two other consulting physicians who uniformly conclude that he would expose himself to a significant risk of ventricular fibrillation or cardiac arrest during competitive athletics.
Contrary to Pahulu, the Knapp court subsitituted its judgment for that of the team physician in evaluating the potential risk of injury to the athlete. The Knapp court concluded: "While the determinations of risk were admittedly made without a reasonable degree of medical certainty, since very little data exists regarding ventricular fibrillation and implantable cardioverter defibrillator and none exists regarding intercollegiate athletes in such situations, I find the risk to Knapp is not substantial after the passage of 2 years without any symptoms (13)."
A team physician who allows an athlete's strong desire to play to interfere with the exercise of good medical judgment in making a participation recommendation might be liable for malpractice (1). It would be inappropriate for the team physician to provide medical clearance merely because the athlete offers to sign a liability waiver or threatens a lawsuit.
The team physician's ethical and legal obligations require an individualized, thoughtful, and practical consideration of the demands of participation in a particular sport and potential harmful effects on an athlete's health as well as other participants' safety. When the risk of life-threatening or permanently disabling harm is uncertain, it appears advisable to opt for caution and recommend against athletic participation, even though an athlete may legally challenge this recommendation.
If a team physician does approve athletic participation, the athlete who has a physical abnormality should be fully informed of all material risks of playing. Even if an on-field tragedy ensues, the team physician is not legally liable for an athlete's harm if the physician has fully complied with customary or accepted sports medicine practice while providing care and treatment to the athlete.
Mr Mitten is a professor of law at South Texas College of Law in Houston. He teaches torts, antitrust law, and sports law and has written several articles on legal issues in sports medicine. Address correspondence to Matthew J. Mitten, JD, South Texas College of Law, 1303 San Jacinto St, Houston, TX 77002-7000; e-mail to [email protected]