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Court affirms right to disqualify athletes


Appeals court cites Bethesda guidelines

In affirming a team physician's decision not to let Nicholas Knapp play college basketball, the 7th US Court of Appeals cited the 26th Bethesda Conference guidelines (1) regarding athletes with cardiovascular abnormalities. For athletes like Knapp, with ventricular fibrillation and an implanted cardioverter-defibrillator, the guidelines state that "all moderate and high intensity sports are contraindicated."

Paul D Thompson, MD, a participant in the 26th Bethesda Conference, said implanted defibrillators have proven reliable, but this conclusion was "garnered from the general population, not athletes running up and down a basketball court in the Big Ten." He called the Bethesda recommendations "medicine's last best guess. We act like we have all the data to make a decision, but we don't."

Thompson also commented that the Bethesda recommendations are general guidelines and expressed concern that their blanket application by schools and team physicians could ignore an individual student's particular situation and values. Thompson is vice-president of the American College of Sports Medicine, professor of medicine, division of cardiology, at the University of Pittsburgh Medical Center, and an editorial board member of The Physician and Sportsmedicine.


  1. 26th Bethesda Conference: Recommendations for determining eligibility for competition of athletes with cardiovascular abnormalities. J Am Coll Cardiol 1994;24(4)845-899
A federal appeals court, deciding a suit brought by Northwestern University student Nicholas Knapp, has ruled that team physicians have the legal right to bar athletes from competition for medical reasons.

"Medical determinations of this sort are best left to team doctors and universities as long as they are made with reason and rationality and with full regard to possible and reasonable accommodations," the US Court of Appeals for the Seventh Circuit, in Chicago, stated in a decision (1) issued November 22. The decision heartened team physicians, but Knapp's attorney has promised to appeal the ruling to the US Supreme Court.

Knapp had hoped to play basketball for Northwestern despite a heart condition, idiopathic ventricular fibrillation. As a high school senior, he had suffered sudden cardiac arrest while playing a pick-up game of basketball. He was resuscitated and later given an internal cardioverter-defibrillator. Northwestern University, which had already offered Knapp an athletic scholarship, assured him that it would honor its scholarship commitment regardless of the medical outcome.

In November 1995, shortly after Knapp enrolled at the Evanston, Illinois, school, the university's head team physician declared him ineligible to play basketball for the 1995-96 season. When the season ended, Northwestern and the Big Ten Conference declared Knapp permanently medically ineligible to play. Knapp then filed a complaint in federal district court.

The complaint asserted that Northwestern had violated the Rehabilitation Act of 1973, which prohibits discrimination against people with physical abnormalities or impairments. After a hearing last September, a district court judge in Chicago concluded that Knapp's risk of a repeat cardiac episode was minimal and declared that Northwestern could not exclude him from playing because of his cardiac condition.

Northwestern appealed this ruling, leading to its reversal by the the appeals court. The three-judge panel stated, "In the midst of conflicting expert testimony regarding the degree of serious risk of harm or death, the court's place is to ensure that the exclusion or disqualification of an individual was individualized, reasonably made, and based upon competent medical evidence. So long as these factors exist, it will be the rare case regarding participation in athletics where a court may substitute its judgment for that of the school's team physicians (1)."

Northwestern University officials were pleased. Said Athletic Director Rick Taylor, "Our position has been vindicated. Had the courts done otherwise, they would have eviscerated the position of the team physician." Michael Weston, vice-president and general counsel for the university, added that the decision gives the team physician alone the authority to make decisions about athletes' medical eligibility to compete in sports.

A Reassuring Ruling

Also pleased with the ruling was Gregory Landry, MD, professor of pediatrics and head team physician at the University of Wisconsin-Madison. "Before the decision," he said, "everyone was worried that [the district court ruling] was a major threat to team physicians throughout the country....Taken to its extreme, as it was in this case, it meant team physicians couldn't disqualify anyone, and I think that's a problem." Landry, an editorial board member of The Physician and Sportsmedicine, called the ruling "reassuring." "We never take those decisions [about medical disqualification] lightly, and the legal discussion of this matter reinforces the need to consider them carefully," he added.

Attorney Matthew J. Mitten, a specialist on the legal aspects of sports medicine, described the recent decision as "probably the strongest statement by a court upholding the legal authority of a team physician to medically disqualify an athlete." Mitten is a professor of law at South Texas College of Law in Houston.

Mitten believes that sports medicine organizations influenced the appeals court. He had filed an amicus brief with the appeals court supporting Northwestern's position on behalf of the American Medical Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine. Physicians often think that courts ignore their concerns, he said, but this case showed that physicians can "in fact influence the development of the laws by showing an interest in the area and having the willingness to file."

Although team physicians have won this round, the controversy may not be over. Robert Chapman, the Chicago attorney representing Knapp, intends to appeal to the Supreme Court. He contends that the decision "undermines" the Rehabilitation Act of 1973 and contradicts other court decisions that "have repeatedly held that the judge is to weigh conflicting medical testimony and make a decision concerning risk." Chapman described the process that Northwestern followed in dealing with his client as "incredibly flawed." "Northwestern brought [Knapp] to the school and signed him to a scholarship," he said. "He now wants to fulfill that part of the arrangement. He came to be a student-athlete and not just a student."

Douglas B. McKeag, MD, director of primary care sports medicine and team physician at the University of Pittsburgh, believes that the issues surrounding the Knapp case are far from settled. "This thing is going to be batted back and forth quite a bit because it has significant implications that go far beyond sports medicine and athletes," said McKeag, who is also an editorial board member of The Physician and Sportsmedicine. "The right of some people to put their life in jeopardy could be parallel to the Jehovah's Witness's refusal to get a blood transfusion. There's not a right or wrong way to come down on it. I do think that everybody's watching closely because if institutions such as universities, especially private institutions, don't have the right to restrain people from participating in one thing or another, then this could be extrapolated to many different areas."


  1. Knapp v Northwestern University, No. 96-3450 US Court of Appeals for the Seventh Circuit, November, 22, 1996

Van Anderson


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