In a situation with unsettling similarities to the infamous "Tuskegee Study of Untreated Syphilis in the Negro Male," youth and college football players today are part of what amounts to a massive and unethical experiment in concussions. The Tuskegee Study violated basic bioethical principles of respect for autonomy (participants were not fully informed in order to make autonomous decisions), nonmaleficence (participants were harmed, because treatment was withheld after it became the treatment of choice), and justice (only African Americans were recruited). As at Tuskegee, the concussion experiment violates basic bioethical principles. Until the pathological processes of concussions are understood and methods of prevention are tested, there should be major changes in the game of football to decrease, if not eliminate, this primary cause of head trauma in young men.
The football concussion experiment differs from the Tuskegee Study in a key way, namely, concussion investigators are not knowingly misleading subjects to participate as was done at Tuskegee. Indeed, what makes the comparison so illuminating is that coaches, parents, and health professionals all have the best interests of youth at heart. Nevertheless, efforts are only recently under way to define the level of risk, refine the diagnostic techniques, and explore effective treatment for head injuries, all while it is well-known that the forceful collisions that are intrinsic to tackle football place hundreds of thousands of youth and young men at risk of harm from acute and chronic neurological damage. Furthermore, according to data from the National Collegiate Athletic Association, in 2009-10, for the first time, the percentage of African-American males composed the largest segment of football players (45.8 percent), greatly exceeding the percentage in the U.S. population (slightly less than 13 percent). This means that African-American football players face a disproportionate exposure to the risk of concussions and their consequences.
Using data from 100 high schools in the High School Sports-Related Injury Surveillance Study, Marar, et al. reported rates of 3.1 per 10,000 athletic exposures for boys, reflecting 1,432 concussions. Football had the highest risk of concussion (6.4 per 10,000 athletic exposures (a unique game or practice), followed by boys’ ice hockey at 5.4), but due to the much wider participation in football, that sport accounted for 64 percent of the concussions in boys. In a previous study from the same data base, Gessel et al. calculated that the 201 reported football-related concussions in 2005-6 projected to a national estimate of 55,000 concussions. The NCAA Injury Surveillance System reported 245 football-related concussions. Although a national estimate comparable to the high school estimate was not available, football accounted for 70 percent of the collegiate concussions among males.
Medical and legal concern over the acute treatment and long term consequences of these injuries has prompted many responses. In 2010, the American Academy of Pediatrics noted, "The long-term effects of concussions in athletes of all ages are cause for considerable concern. With a lack of long-term prospective studies in high school and younger athletes who sustained concussions, there are more questions than conclusive answers." The Consensus Statement on Concussion in Sport recommended, “a more conservative return to play approach for children and adolescents," motivated, it seems, by the lack of a sufficient evidence to offer more nuanced advice. Indeed, the statement notes that "concussion is considered to be among the most complex injuries in sports medicine to diagnose, assess, and manage. The majority of concussions in sport occur without loss of consciousness or frank neurologic signs. At present, there is no perfect diagnostic test or marker…"
The devastating cases of early dementia, depression, and suicide among former professional football players serve as sentinel indicators in football. The epidemiological evidence linking concussions to these outcomes is growing and has prompted the expenditure of tens of millions of new federal and private research dollars, as well as public education campaigns by the Centers for Disease Control and Prevention and the NCAA. As critical as these research and educational efforts are, it is important to point out that the resources are directed, for the most part, at attempts to ameliorate the trauma after damage has already occurred. More precise neurological scans and more sophisticated biochemical tests do nothing to reduce the incidence of concussions. While there is a risk of concussion in most sports, football is unique in two ways. First, the over 4 million youth and high school players and over 65,000 college players, dwarfing other sports where concussions can also occur, mean that football contributes disproportionately to the concussion problem. Second, even with increasingly expensive equipment, the human body in general and the brain in particular are not designed to withstand the repeated high-energy collisions inherent to the sport as it is currently played.
Research on the risk of concussions should proceed only in carefully controlled, clinical trials, guided by the ethical principles that pertain to any medical or public health study. Until the risks are sorted out, only adults who have the autonomy to consent to participation in research should be exposed to tackle football, largely the professionals whose generous compensation enters into their personal calculations of risk and reward. In violation of the principle of autonomy, are parents of children and young college players themselves fully informed of the risks? Do non-professional players who have reached the age of consent sign agreements that meet the rigorous standards of medical research? Given that the medical community simply does not know the extent of the harm that can result from even one concussion, not to mention the fact that damage results even when there are not sufficient symptoms to diagnose concussion, continuing to allow the literally uncontrolled participation in football violates the harm principle, even if there were adequate consent.
A ban on youth and high school football, so deeply entrenched in U.S. culture, does not seem feasible. In order to reduce harm, however, there could be immediate changes in the rules. For example, restrict participation to those above a certain age, use flags instead of tackling, and change the blocking rules. When it comes to college, players are old enough to consent formally. However, the fact that only a tiny percentage go on to play professional football and earn fabulous salaries means that the benefits may not justify the risks. To meet our ethical obligations given that the potential harm is so great, it is only through a formal clinical trial type research process that college football should proceed.
Finally, not only does the disproportionate participation of African-American males in football unfairly expose them to yet another risk of poor health, but also raises the question of whether African-American communities have the information they need and deserve to consider and consent to this risk for their sons. Out of fairness, special attention should be paid to these ethical principles in African-American communities, whose boys and young men, sadly, experience increased risks of poor health for many reasons other than football.
The Tuskegee Study was a tragedy, but its lessons about racism and unethical research have strengthened research endeavors. In issuing a formal apology in 1997, President Clinton mentioned an important public health ethical principle: That communities should be provided with the information needed to decide on participation in studies and should have a mechanism to provide community consent.
Participants in football should be afforded the same treatment. Football-related head trauma and concussions have raised sentinel alarms, so all who care about children and young adults must not remain silent as this epidemic spreads. The principles of informed consent, nonmaleficence, fairness, and community participation demand a halt in the way the game is played, until the risks are better understood and controlled.
Lewis Margolis is associate professor of maternal and child health at the Gillings School of Global Public Health of the University of North Carolina at Chapel Hill.
Gregory Margolis issenior research assistant in the Center on Children and Families at the Brookings Institution.
Administrators and trustees at Rutgers University failed to properly monitor the goings-on of sports programs, says -- yet another -- report, keeping them from properly handling an abusive former coach.
Despite some targeted support from the NCAA, historically black colleges struggle to keep up with increased academic standards. Given enrollments dominated by underprepared students, is more money enough?
It is fashionable to talk of “bubbles” these days -- unsustainable, somewhat speculative ventures nearing the bursting point: the dot-com stock market bubble in 2000, the housing crisis bubble of a few years ago, and maybe a college tuition bubble today. Broadly defining “bubble,” maybe we are nearing one in major-college intercollegiate sports.
If you ask alumni of the University of Oxford, Moscow State University, the University of Tokyo, or even the nearby University of Toronto, to describe their most successful intercollegiate sports team, you likely will get blank stares. While amateur, intramural sports activities occur at campuses around the world, the U.S. is unique in having hugely popular, high-revenue collegiate teams. While Great Britain has both top and secondary-level football (soccer) teams, as is the case in American baseball, in the high-revenue American sports of football and basketball, there are overtly professional teams as well as ostensibly amateur college teams comprising so-called “student athletes.”
Yet this model is undergoing a good deal of strain:
The financial viability of major college sports importantly derives from “paying” the best “student-athletes” a small fraction of what they would earn in a competitive market; the cartel enforcing low payments to athletes, the National Collegiate Athletic Association, is facing the possibility of losing a potentially extremely costly lawsuit.
At many schools, an athletics arms race is forcing students to pay largely hidden fees to sustain costly sports programs, and there is evidence of a growing disconnect between the desires of older alumni and other sport supporters for good teams and the tastes and preferences of the students being increasingly asked to pay the bills.
To sustain noncompetitive labor market practices, the NCAA imposes draconian and Byzantine rules on member schools, but incentives are huge to break those rules, leading to repeated scandals creating an aura of corruption hurting not only collegiate sports but higher education generally.
A moral crisis is increasingly apparent: relatively innocent young persons (talented athletes) have income many would say is rightly theirs taken from them by their mentors (coaches) for their own personal use, leading to coaches often earning as much as 10 times as much as the university presidents who run the educational aspects of the institution.
Graduation rates of athletes, especially members of minority groups, in the top revenue-producing sports are scandalously low, even below the deplorably low rates of the general student population. Student status for some athletes is increasingly more nominal than real.
In a competitive labor market, workers usually earn on average roughly what they add to their firm’s revenues. Professional football, baseball and basketball players, for example, sometimes receive salaries reaching several million dollars annually. Top-flight college football and basketball teams generate revenues rivaling those of professional teams, but the workers receive scholarships worth at most $50,000 annually, and that’s only at the most expensive institutions. Very good football and basketball players are very lucrative at top sports schools, so coaches able to recruit them receive a large portion of the millions of dollars that ordinarily would go to the athletes. It is not too far-fetched to say that middle-aged adults are exploiting the children under their guidance.
The NCAA enforces this practice. The NCAA forces players to sign a contract in effect abrogating their labor bargaining rights. Even income earned from, say, t-shirts featuring the name and number of the athlete revert to the colleges. A lawsuit challenging this practice filed by the former UCLA basketball player Ed O’Bannon is moving forward, with very high-powered lawyers representing O’Bannon and other athletes.
If the lawsuit is certified as a class action as early as next month, the stakes become huge, and in one plausible scenario the NCAA could be forced into bankruptcy. More likely would be an out-of-court settlement costing the NCAA and maybe major conferences many millions of dollars. The long-term impact would likely move some of the income received by coaches to players, perhaps also crowding out non-revenue sports funded from football or basketball profits, etc.
Even the NCAA’s own data suggest that only 22 major programs break even or make a profit. In the second-tier athletic conferences, such as the 13-university Mid-American Conference (MAC), schools typically need $10-20 million annually to balance their athletic budget, increasingly met by student fees that can approach $1,000 a year. A survey of students at MAC member colleges directed by David Ridpath suggests that most students are unaware of the extent of the fees, and unhappy when informed of them, given their general low level of interest in collegiate sports and the increasing financial strains of attending college.
The spectacularly tawdry sex scandal at Penn State that led to the imprisonment of the former coach Jerry Sandusky is the worst example of immorality run amok, but dozens of colleges have been found guilty of violating the NCAA’s rules -- giving money to athletes, making illegal recruiting visits, etc. It is not uncommon to read “Ohio State admits to rules violations,” or “Miami faces NCAA sanctions.”
Increasingly, the public perception of universities as intellectual oases, centers of learning and moral probity, is being tarnished by intercollegiate sports.
What to do? Why haven’t university presidents, who nominally run the NCAA, done anything? First, they are afraid of losing their jobs if they anger their fanatic fans (and sometimes their boards). Second, they love the funds from television contracts and other sports commercialization of their schools -- money may trump principle. I know several ex-university presidents strongly promoting reform, but few actively serving ones.
Still, as costs rise faster than revenues, as scandals persist and grow ever more spectacular, and as multimillion-dollar coaches become ever more arrogant and plutocratic, change will likely come, probably ultimately for the good of college sports, higher education, and the nation.
Richard Vedder directs the Center for College Affordability and Productivity, teaches economics at Ohio University, and is an adjunct scholar at the American Enterprise Institute.