The fourth major concussion recently suffered by Miami Dolphins quarterback Tua Tagovailoa – his third in 24 months – brings into sharp focus the balance between patient/player autonomy and treatment decisions. The right to self-determination, even in sports, has become as much a moral as a medical issue. If Tagovailoa is not able to pass concussion protocols for a third time in his NFL career, he could be forced to retire.
While the intention behind banning repeatedly concussed players is to protect their long-term health, it can be seen as an infringement on players’ autonomy. Some athletes may wish to continue their careers despite the risks, yet are often prevented from doing so by medical regulations aimed at preserving their future well-being. Tagovailoa could have “catastrophic and permanent brain damage” with another blow to the head, according to Bennet Omalu, MD, MBA, MPH, the leading expert on chronic traumatic encephalopathy.
But assuming he is medically cleared, Tagovailoa has stated his intention is to continue playing. Yet family members also bear the weight of this decision. While medical professionals may restrict an athlete’s participation to safeguard their health, families must cope with the emotional fallout. Athletes who are forced to retire due to health concerns may experience a loss of identity and purpose, which can lead to mental health issues su†ch as depression and anxiety. Family members often become the primary support system, managing the emotional and psychological repercussions while also grappling with their own fears and concerns for their loved one’s future.
The erosion of patient autonomy is a growing concern in contemporary health care – not only in sports medicine – manifesting in several critical clinical areas. One prominent example is reproductive health, where access to abortion has been increasingly restricted, thereby limiting women’s ability to make autonomous decisions about their bodies and reproductive futures. These constraints not only infringe upon personal freedoms but also complicate the physician-patient relationship, as doctors may find themselves unable to offer comprehensive care due to legal limitations.
Another significant area is end-of-life care. Euthanasia and physician-assisted suicide remain unavailable in most states, leaving terminally ill patients with limited options to end their suffering on their own terms. This lack of autonomy can lead to prolonged suffering and a diminished quality of life, as patients are forced to endure conditions that they would otherwise choose to escape through medically assisted means.
These examples underscore a broader trend of diminishing patient autonomy in health care, which has far-reaching implications for patients, families, the public, and the medical community. Additionally, there are numerous other instances making headlines recently, such as:
1. Involuntary commitment and treatment. Patients with severe mental illnesses, such as schizophrenia or bipolar disorder, may sometimes be involuntarily committed or subjected to treatment without their consent. This raises significant ethical concerns about autonomy, especially when patients disagree with the diagnosis and treatment or refuse to accept treatment. The balance between ensuring patient safety, the safety of the public, and respecting patient autonomy is delicate and fraught with moral complexities.
2. Opioid prescribing restrictions. In response to the opioid crisis, many regulations have been implemented to limit opioid prescriptions. While these measures aim to curb addiction and misuse, they can inadvertently restrict access to necessary pain relief for patients with various pain syndromes. This creates an ethical dilemma where the autonomy of patients to choose their pain management strategy is compromised, potentially leading to untreated pain and decreased quality of life.
3. The rights of adolescents vs. parents. The question of who has the right to make health care decisions – the adolescent or the parents – can lead to ethical conflicts. For instance, in cases where an adolescent desires gender reassignment therapy, but the parents refuse all possible interventions, the health care team must navigate the complex interplay between respecting the emerging autonomy of the adolescent and the legal rights of the parents, as well comply with state laws that may prevent gender-assisted therapy.
4. Mandatory vaccinations. Public health policies mandating vaccinations for preventable diseases raise ethical questions about individual autonomy versus community health. While these policies aim to protect public health, they can infringe on personal autonomy and the right to make individual health care decisions. This is particularly contentious in cases where individuals have strong personal or religious beliefs against vaccinations.
The balance between protecting patients and respecting their right to self-determination has become increasingly precarious. On one hand, health care providers have a duty to prevent harm and promote the best possible outcomes for their patients. On the other hand, patients have the right to make choices that align with their personal values, beliefs, and preferences, even if those choices involve certain risks and run counter to the advice of clinicians.
The stakes are highest where and the consequences of restricting autonomy are the most detrimental. For instance, limiting access to abortion not only affects women’s health but also their socioeconomic status and overall life trajectory. Similarly, denying terminally ill patients the option of euthanasia can lead to unnecessary suffering and a loss of dignity in their final days. In sports medicine, prohibiting athletes from continuing their careers due to health risks may protect them from future harm but also denies them the opportunity to pursue their passions and livelihoods.
However, the trend is unmistakable – in sports and medicine. Players’ and patients’ rights to self-determination are being encroached upon by multiple stakeholders. Individuals are no longer in control of their own health. Practitioners may not honor patients’ decisions as broader societal issues eclipse their wishes. But look at it on the bright side. There has never been a more opportunistic time for health care providers, policymakers, and politicians as a whole to engage in ongoing dialogue and reflection to ensure that the rights and well-being of patients are upheld while also safeguarding public health and safety.
Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of several books on narrative medicine, including Medicine on Fire: A Narrative Travelogue and Story Treasures: Medical Essays and Insights in the Narrative Tradition.
