Ethical Thinking: What Is It and Why Does It Matter?
Tommy Boone,
PhD, MPH, MA, FASEP, EPC
Professor
and Chair
The College
of St. Scholastica
Duluth, MN
55811
THIS
ARTICLE IS about exercise physiologists and supplements, the ASEP organization,
what it stands for and, of course, ethical thinking. I would like you
to know that I am neither concerned with nor do I dismiss exercise physiologists,
sponsored or not sponsored, who engage in ethical research. I am concerned
with unethical marketing of supplements, and the apparent indifference to
sport-supplements (particularly among high school and college athletes).
As
an exercise physiologist, I’m interested in the nutritional status of athletes
(not their supplement status), the athletes’ state of mind (psychological
preparedness), and obviously their physical condition and training.
I’m not interested in their supplements, and I don’t encourage supplement
use. My view is probably uncommon for an exercise physiologist, but
I have found comfort in learning that I’m not completely alone. For
example, the Canadian Centre for Ethics in Sport [1] discourages the use
of supplements, from both a scientific and an ethical point of view, and
it does not support supplement product endorsement.
Similarly,
the chair of the drug-education and drug-testing subcommittee of the NCAA
Committee on Competitive Safeguards and Medical Aspects of Sports [2] discourages
the use of supplements among the NCAA student athletes and, yet surveys show
that, among male and female college athletes, nearly 60% use diet supplements.
Most started in high school or even junior high with encouragement from a
coach, an athletic trainer, the team physician, or other college officials.
Clearly,
there is considerably more unknown about supplements than there is known.
Several weeks ago, I read a “review article” for sports nutrition. The following
phrases were taken from the article:
“…concentrations may….”
“…has been
suggested….”
“…may affect
physiological….”
“…suggests….”
“…may experience….”
“…may occur….”
“…may be
involved….”
“…may play
in….”
“…may explain….”
“…may help….”
“…may contribute
to….”
“…may experience….”
“…may therefore….”
“…may affect…”
“…may result….”
“…may limit....”
“…may lead
to….”
“…may play
a role….”
“…may hasten
recover….”
“…may be
more effective….”
“…may lessen
the effects….”
“…may help
an athlete….”
“…may have
an effect on immune function….”
“…may be
beneficial for athletes….”
This kind of wording
constitutes a “declared” science, not an actual science. The problem
is that athletes don’t know that much of the sport-supplement science is
conjecture. Often, athletes fail to make this connection between “work
in progress” and the “actual” findings. The supplement companies and,
most importantly, a certain percent of the authors understand exactly what
they are doing. Deception within the context of good science is not
a new idea. It is still deception!
The
notion of what is research is clear to the scientific community. There
are no supplements advertised in our best scientific journals. There
are no testimonials presented as if they were scientific articles.
Few, if any, of us in this room are insulated from the profound effects of
credible scientific work. Most importantly, we have learned to trust
the results.
This
is neither true nor likely to be the case with articles in magazines like
Muscular Development [3] and dozens of similar non-scientific
failures. My point is simply this: None of the articles are peer-review
scientific publications. Therefore, it doesn’t make any logical sense
to view the proliferation of the supplements in these magazines as science.
The strategy of course is to raise the reader’s conscious awareness of sport
supplements to move the products. By trying to force fit two completely
different cultures to one another (general-market magazines and scientific
journals), we ignore a very basic principle of science: honesty.
As
healthcare professionals, our primary responsibility is not to confirm the
beliefs of others or even our beliefs. Rather, as part of the academic
community, we are charged with the ethical responsibility of being “objective”
– and we do this primarily by relying on good research designs and inferential
statistics. We know that changing the alpha level to make something
significant is wrong. We know that the conclusions should result from
the statistical findings. And, most of us know that the ethical researcher
doesn’t continue to argue on behalf of the “treatment” when the results don’t
support the funding source.
The
ASEP organization [4], as a society of exercise professionals, must be concerned
when the public is bombarded with countless fitness products, exaggerated
strength development ads, and sleazy diet marketing tactics [5]? Members
must commit themselves, however unpopular, to truth-telling in all interactions
that impact the professional development of exercise physiology. We
need the public’s trust and we must earn it. It is not automatically
granted.
The
problem is that misinformation is obvious, but critical analysis is lacking.
Even when Dr. Robergs sent a letter to Cytodyne Technologies requesting a
correction of the “ephadra” advertisement that identified a May 2001 article
[6] in JEPonline, it was not popular
within the ASEP organization (even though the advertisement intentionally
misinterpreted the clinical results). I stated in my “Quackery and
Fraud in Exercise Physiology” article [7] published in the PEPonline journal that, “The advertisement is nothing
more than consumer fraud.” However, now we realize that a “class action
lawsuit” in the state of California is centered exactly on our original concerns.
How
did we get to the point that if a supplement isn’t illegal, it is ethical?
This mindset sees exercise physiology and athletics in a way that isn’t logical
or rational when I was an athlete. My coaches in track, football, baseball,
and gymnastics must be spinning in their graves. They would have never
approved supplements or any kind of ergogenic aid (assuming it worked) to
gain an advantage over a competitor. It wasn’t right then and, frankly,
it isn’t right now.
Even
though the world is constantly changing, there are some things (or principles)
that don’t change (or shouldn’t change). When did it begin? I
don’t have the answer. But, in the 1965 Physiology of Muscular Activity
text [8, p. 262] by Dr. Peter Karpovich, the author states that, “…the use
of a substance or device which improves a man’s physical performance without
being injurious to his health, can hardly be called unethical.” He also
said, “As for taking advantage of other contestants who do not use these
aids, this should be regarded in the same light as the use of special diets,
massage, special exercises, and so forth. All these means are available
to everyone, and may be used if desired.”
Is
this the right way to think? Just because it’s available to everyone,
it is right! In all fairness to contemporary exercise physiologists,
the right thing to do isn’t always clear (especially when the objective,
it seems, is to help athletes achieve their goals). But, to think ethically
goes beyond mere compliance with contemporary thinking. There are unqualified
imperatives, with no exception to the rule. That is, to know without
a moment of hesitation that you are doing the right thing for the right reason.
Dr.
Robert Robertson of the University of Pittsburgh stated in the “Ergogenics”
book, edited by David Lamb and Melvin Williams [9, p.xx]that “…the decision
to use an ergogenic in competitive sport must consider the following questions:
Is it safe? Is it legal? Is it effective? It is only when
the answer to each question is yes that the ergogenic procedure can be considered
as an appropriate aid to sport performance.” In my view, the decision
is incomplete without asking the question, “Is it ethical?”
I
understand sufficiently well the theoretical and experimental evidence for
these aids. What I don’t understand is the lack of discussion about
the legal, ethical, and medical issues of using drugs and supplements to
increase performance. Other healthcare providers have done so.
The American Academy of Family Physicians [10] has determined that it is
unethical for physicians to sell health-related products for profit.
It is a matter of professional accountability, credibility, and respect.
Associating ASEP with the idea that the use of supplements is based on good
science is not the way to market ASEP or to build its professional image,
or is it? Are there two ethical systems within exercise physiology?
If so, how do we teach each other, our students and athletes to not violate
their moral values even when in Rome.
David
Lightsey, member of the Nutrition and Food Science Advisors Board [11] of
Quackwatch [12], identified “four” deceptive marketing tactics for ergogenic
aids: 1) taking published research out of context; 2) claiming products
are university tested when no research has been done or false statements
were made regarding the research; 3) using unauthorized endorsements by professional
organizations; and 4) by referencing research inappropriately. Seldom
is the emphasis on meaningful, controlled, and repeatable scientific experiments.
Fraud
in exercise physiology is a transgression against exercise physiologists,
including their professional organization. We must be concerned with
our credibility because we represent the future of our students. Therefore,
we must be responsible to a code of ethics and standards of professional
practice. As members of ASEP, we have both, but I’m afraid that neither
gets much respect. The ASEP Code of Ethics [13] provides a clear, unambiguous
standard to check behavior and resolve ambiguities. This is important.
A code of professional conduct is central to advising individual exercise
physiologists how to conduct themselves, to judge their conduct, and to understand
exercise physiology as a profession.
Ethical
(professional) thinking [14] is critical when an occupation organizes itself
into a profession. More than just a convention, ethical thinking is
critical to the integrity of our body of knowledge. Without it, there
would be no professional trust in our research findings. Whatever good
some would do, the public would not acknowledge our work as either reasonable
or sensitive and, certainly, not as being credible. Experts in related
fields would discount our best critical thinkers. Exercise physiology
would not be recognized as a credible healthcare profession. Ethical
thinking is therefore the key to analyzing certification issues, accreditation
questions, and scientific problems. It is the difference between reasonable
and unreasonable, truth and untruth; between selling an idea and understanding
an intelligent and moral decision; between relevant, scientific information
and meaningless, non-practical conclusions often driven by the bottom line.
Collectively,
we cannot allow ourselves to become an organization of weak science.
Confirm our beliefs, while ignoring what contradicts our beliefs, thus confirming
our bias is the path to professionalism. This is the basic rule of
research that we learned in college to protect ourselves from certain consequences
when pressured to cut corners. It is our responsibility not to frame
our thinking, our research designs, or our analysis of the data in ways that
will confirm our hypotheses. Otherwise, it is an attempt to subvert
the very basis upon which science is valued. It is also our responsibility
to expose misconduct and bad science, particularly if information is misrepresented
by the illusion of good science.
Is
it also our responsibility to expose sports-supplement dangers? Isn’t
there an ethical problem with conducting what amounts to a vast, uncontrolled
clinical experiment with untested, largely unregulated substances?
The relatively few good scientific studies suggest that they are ineffective
or, at best, produce only slight changes in performance. Again,
isn’t there an ethical dilemma when we encourage athletes to experiment with
nutritional supplements? Is the question of winning at all costs no
longer a concern? Have we reached the point that the question itself
is stupid?
Where
do we draw the line? Australia’s Olympic gold medallist Cathy Freeman
spent $3480 on vitamins and supplements from health food shops in the four
months leading up to the Sydney Olympic Games [15]. The Australian
Sports Drug Agency and Olympic Sports Drug Testing Laboratory [16] found
"...an unhealthy fixation amongst athletes in regards to vitamins….more than
seven out of 10 athletes taking vitamin tablets, most of them high doses,
with 90 athletes having recently had vitamin injections.”
Just
because a substance isn’t banned, is it therefore legal? Admittedly,
it is complicated but we shouldn’t give in too easily. There are serious
ethical implications! Even the legal promotion of supplements isn’t
without problems when a certain percent of the “scientific literature” is
tarnished with less than ethical research procedures. Is good nutrition
no longer possible? Is the only answer through supplements? Must
we go along with researchers who say, “I’m in search of nutraceutical supplement
that will make individuals feel better, and build or maintain strength as
they get older?” What happened to our mental abilities to stay in touch with
how we feel? Are we to believe that any alternative to drugs and supplements
are useless in building muscles and staying strong?
In
a culture that spent $17.7 billion last year on nutritional supplements,
according to Nutrition Business Journal [17], today’s athletes feel the pressure
to bulk up and turn to supplements for help. What happened to:
1. Scientifically documented strength training principles
2. Individualization
and specificity of training
3. Progression
and overload
4. Recovery,
safety, and injury prevention
5. Professional
(ethical) coaches
6. Solid
nutritional practices
7. Emotional
support systems
8. Mental
(psychological) preparedness and training
9. Consumption
of fluids
10. Common
sense
Allan Korn, chief
medical officer of the Healthy Competition Foundation for Blue Cross and
Blue Shield Association [18] said that, “Young people are taking unregulated
sports supplements with little to no scientific evidence of their safety
or health consequences.” The Foundation reported that approximately
1 million young people ages 12 to 17 have used potentially dangerous performance-enhancing
supplements.
Athletes
believe that if a substance can help them win, regardless of ethical or moral
thinking, then it is okay as long as it is not banned. Is this the
right way to think? Integrity in educational standards should promote
integrity in athletics, unless both have no overall cultural relation.
I believe that integrity in education is important to standards of conduct
in athletics. Promoting integrity in the athletic environment is about
the overall professional development of individuals. Student-athletes
(and exercise physiology majors, in particular) need to learn more about
responsible education, athletics, and research, not quick fixes. Teaching
of values and integrity of professional practice are important. Therefore,
simply stated:
The message that supplements are okay because they are not
illegal is not a positive message for our young athletes. Not every
athlete can be a winner and that is okay. Not every person can be big
or fast, and that is okay, too. The flaw is in thinking that athletics
is more than life, and in believing that college sports is the ticket to
a full, creative, imaginative, and successful life after college.
I read somewhere
years ago that, “The longest journey begins with the first step.” To
promote professionalism for all exercise physiologists, the first step was
to develop a society of exercise physiologists. Now, it is time to
take the second step, that is, to embrace our ASEP Code of Ethics as a standard
by which we pursue professionalism and scientific integrity. Like other
healthcare professionals, who have been taught to believe that nothing is
more important than the safety of their patients, we need to understand accountability.
Far too little attention is devoted to this point. And, yet if we are
really serious about the professional development of exercise physiology,
meetings like this one should foster hope and opportunity (not an increased
competitive edge through nutritional supplements).
We
should talk about promoting integrity in our professional environment, creating
a plan to foster integrity, and offering workshops to teach responsible conduct
of research. It follows, then, that instruction in ethical thinking
is directly linked to classroom activities to understand professionalism.
When we take time to emphasize our code of ethics, board certification [19],
and standards of practice [20], students will come to understand the central
role each plays in promoting and monitoring responsible self-regulation.
It is incumbent therefore upon the ASEP organization to bear the responsibility
of ethical thinking, the preservation of professional integrity, and the willingness
to deal with misconduct.
In
fact, it is not just logical but right that we stop defending companies that
market worthless (but profitable) dietary and so-called performance enhancement
supplements. We need to think that the most important thing to each
of us is the future of exercise physiology, not the likelihood of “gene doping”
or other dubious procedures. The burden of proof lies with the exercise
physiologists who believe in exercise nutrition research. Either they
demonstrate the need for credible research or they don’t. If they should
allow the fraudulent examples of bad science continue uncontested, then support
from within the ASEP organization will disappear.
If
exercise physiologists don’t understand this, then they are part of the problem.
If the supplements work (and by this, I mean statistically and practically),
then exercise physiologists who believe in the value of supplement research
should develop a strong ethical rationale for the use of the supplements.
Until then, the scientific consensus of the ASEP organization ought to be
that the use of supplements is not encouraged. Meeting this challenge
is an expectation of any professional organization. ASEP is no different.
In summary, I recommend the following 10 steps to further articulate
clearly and forcefully our vision:
1. The Board of Directors should develop a “Committee on
Ethics” to study the ASEP Code of Ethics (which is really a code of professional
conduct).
2.
The Committee on Ethics should develop guidelines that articulate the ethical
responsibilities and behavior of the ASEP exercise physiologist.
3.
The Board of Directors should strengthen its capacity in conjunction with
the Committee on Ethics to respond to instances of alleged misconduct and
membership complicity in or indifference to the integrity of scientific information.
4.
The Board of Directors should be responsible for preserving scientific integrity
in the ASEP organization. The best protection to continued improvement
in our image and practice lies in an organizational culture that is committed
to ethical thinking. Misconduct is a serious violation of the truth
and fairness; it corrupts the scientific process and undermines the interests
of the public.
5.
The ASEP organization should be a leader in the integration of the teaching
of ethical thinking into our undergraduate and graduate classrooms and laboratories.
Mentors should be identified to develop new ethical thinkers to guard against
conflicts of interest.
6.
The Editor-in-Chief of the Journal of Exercise Physiologyonline should make it clear that fabricators will
be caught.
7.
The Board of Directors should ask for disclosure of conflicts of interest
from all researchers before publishing in the ASEP research journal and in
the annual National Meetings.
8.
The Board of Directors should identify designated ASEP members in collaboration
with the Committee on Ethics to write an “Ethical Policy Manual for Unacceptable
Research” that may include individuals with conflicts of interest, who own
stock in companies influenced by the research outcome, or who share data
with the source of funding before undergoing the peer-review process.
9.
The Board of Directors should develop ASEP workshops on organizational leadership
with attention to individual integrity in research, intellectual honesty,
and self-regulation.
10.
The Board of Directors should communicate to the public that ASEP members
are concerned about what is right or wrong in the judgments of research data,
and their willingness to accept responsibility in governing member behavior.
References
1. Canadian
Centre for Ethics in Sports. (2003). Be True to Yourself. Be True to Your
Sport. [Online]. http://www.cces.ca/forms/index.cfm?dsp=template&act=view3&template_id=46&lang=e
2. Committee
on Competitive Safeguards and Medical Aspects of Sports. (2003). [Online].
http://www1.ncaa.org/eprise/main/membership/governance/committee_rosters/competitive_safeguards
3. Muscular
Development. (2003). [Online]. http://www.musculardevelopment.com/new/mdmain.html
4. American
Society of Exercise Physiologist. (2003). [Online]. http://www.asep.org/
5. Simple
Fitness Solutions. (2003). How to Spot a Fitness Fraud. [Online]. http://www.simplefitnesssolutions.com/articles/fitness_frauds.htm
6. Armstrong,
J.W., Johnson, P. and Duhme, A.W. (2001). The Effect of a Commercial Thermogenic
Weight Loss Supplement on Body Composition and Energy Expenditure in Obese
Adults. Journal of Exercise Physioloygonline.
Vol 4 No 2 May. [Online]. http://www.asep.org/asep/asep/Armstrong2.pdf
7. Boone,
T. (2002). Exercise Physiology Quackery and Consumer Fraud. Professionalization
of Exercise Physiologyonline. Vol 5 No 5 May.
[Online]. http://www.asep.org/asep/asep/ExercisePhysiologyQuackery.html
8. Karpovich,
P.V. (1965). Physiology of Muscular Activity. Philadelphia, PA: W.B. Saunders
Company.
9. Lamb,
D.R. and Williams, M.H. (Editors, 1991). Perspectives in Exercise Science
and Sports Medicine Volume 4: Ergogenics - Enhancement of Performance in
Exercise and Sport. Carmel, IN: Cooper Publishing Group.
10.American
Academy of Family Physicians. (2003). AAFP Policies and Positions Related
to Proprietary Practices. [Online]. http://www.aafp.org/PreBuilt/compliance.pdf.
11.Lightsey,
D.M. (2003). Nutrition and Food Science Advisors. [Online]. http://www.quackwatch.org/09Advisors/nutradvbd.html
12.Barrett,
S. (2003). Quackwatch: Your Guide to Health Fraud, Quackery, and Intelligent
Decisions. [Online]. http://www.quackwatch.org/
13.American
Society of Exercise Physiologists. (2003). Code of Ethics. [Online]. http://www.asep.org/asep/asep/ethics.htm
14.Boone,
T. (2003). The Exercise Physiology Code of Ethics: A Dilemma or a Standard
of Conduct? Professionalization of Exercise Physiologyonline. Vol 5 No 11 November. [Online]. http://www.asep.org/asep/asep/EXERCISEPHYSIOLOGYCodeOfEthics.html
15.Magnay,
J. (2002). Legal drug running: A New Survey has found that Olympic athletes
are Addicted to Vitamins and Minerals. BRW Inside News. [Online]. http://www.smh.com.au/articles/2002/09/27/1032734328641.html
16.Australian
Sports Commission. (2003). Drugs in Sports. [Online]. http://www.ausport.gov.au/info/drugs.htm
17.National
Nutritional Foods Association. (2003). Facts About Dietary Supplements. [Online].
http://www.nnfa.org/facts/
18.Korn,
A. (2003). Survey Projects 1 Million Youths Aged 12-17 Use Potentially Dangerous
Sports Supplements and Drugs. [Online]. http://www.saynotodopinginsports.org/article/articleview/41/1/7/
19.American
Society of Exercise Physiologists. (2003). Information for EPC - Exercise
Physiologist Certified Candidates: A Guide. [Online]. http://www.asep.org/asep/asep/EPCManual.html
20.American
Society of Exercise Physiologists. (2003). ASEP Board of Certification: Standards
of Professional Practice. [Online]. http://www.css.edu/ASEP/StandardsofProfessionalPractice.html
