In recent years there has been a great deal of attention given to sports-related concussions, and their short term and long term health consequences. The NFL, in particular, has been the subject of intense scrutiny by investigative journalists, as well as by the courts and the U.S. Congress. Allegations against the NFL range from doing too little to protect players, to actively suppressing evidence on the dangers of concussion. Comparisons have at times been made between the NFL's relationship to its own concussion research and that of the tobacco industry to the dangers of smoking. In this context, "head injury" becomes a term that can distract from both the medical issues and the ethical issues that certainly arise from the term "brain injury".
As my colleague Nancy M.P. King and I have argued elsewhere, the NFL is at the pinnacle of a single, unified system that originates with children as young as five years old. And as another colleague is fond of pointing out, the person who controls the language controls the narrative. If traumatic brain injury (TBI, and in the case of so-called mild traumatic brain injury, MTBI) can be used interchangeably with head injury, the accompanying narrative implies a considerably less serious, and less frightening, condition than is indicated by scientific evidence. Concussion has been understood to be an injury to the brain for at least a century. It would seem therefore that any lingering misconceptions about what a concussion is could rather easily be dispelled by those with the power to do so.
For better or worse, such power also resides with the sports journalists, sports pundits, and sports talk show hosts. And also for better or worse, these stakeholders are an important component in the system of the little league-to-professional players, and all of the aspirants in between. ESPN, on of the more ubiquitous, and powerful, national 24-7 sports networks was a co-investigative partner with the PBS series Frontline in developing the documentary "League of Denial." ESPN disassociated from the program shortly before it was broadcast, reportedly under pressure from the NFL. Access journalism is a complaint that is often lodged against political journalists, but sports journalism, even more than political journalism could hardly exist without access to players, coaches and staff that is almost completely under the control of a given leagues. Even though ESPN denied stepping away from "League of Denial" because of pressure from the NFL, the League's dissatisfaction with the narrative, and facts, advanced by the Frontline program was well known.
One of the consequences of sports talk's dependence on maintaining good relationships with powerful sports leagues is that the leagues' preferred narratives dominate. For the most part, discussions of injuries of whatever type focus upon how long it will be before a player can return to the field, whether the player's absence will adversely affect the team's chances for a successful season, or whether a team can replace the player either from its own roster or from that of another team. The expertise that one hears on sports talk radio most often concerns gambling ("handicappers"), intra-league, or intra-team economics (salary cap, contracts and trades between teams). It is extremely rare, for example, to hear a discussion of the specific nature of a torn anterior cruciate ligament (ACL), or a torn rotator cuff. The NFL has a channel on SiriusXM Radio, on which one program, "The SiriusXM Blitz", regularly features an orthopedic surgeon who typically devotes most of his discussions to the length of the rehabilitation schedule for a particular injury, when and if a player will be at one hundred percent on-field productivity, or how well a person can be expected to play if he takes the field before he's at one hundred percent.
Biomedicine in sports, and orthopedics especially, has advanced exponentially in a fairly short period of time. A successful return to play from ACL surgery is now such a commonplace that there is no doubt a whole generation of football fans who are unaware that a torn ACL was once by definition a career-ending injury. Thomas Davis, a player for the Carolina Panthers, has had three ACL surgeries - on the same knee - and is, remarkably, playing at an all-star level, despite being in his mid-thirties (typically an age at which there is a noticeable decline in elite NFL skill). It's easy to see how the success of orthopedic medicine can cause players, fans and commentators to be optimistic about the ability of biomedicine and/or biomedical engineering to be equally successful with other health issues that players face. It is also easy to see, given that the medical details of injury and treatment regarding an ACL tear aren't discussed openly, that there would be even greater reluctance to speak candidly when the injured body part is the brain. Whether this reticence is meant to avoid alarmist rhetoric or is an abrogation of an ethical imperative is food for thought.
Ironically, the discovery of chronic traumatic encephalopathy (CTE) has been a mixed blessing in the broader context of sports-related concussion. CTE, a degenerative brain disease that is associated with repeated concussive impacts to the brain (recurrent TBI), has allowed the focus of brain health in collision sports to be more on the cumulative effects than on each TBI incident as a serious brain injury. There is also evidence that impacts that are below the formal concussion threshold ("sub-concussive impacts") have a deleterious long term effect as well. This means that among the sports-chattering class, it becomes possible to talk about eventual harm rather than immediate harem. Despite recent research placing the incidence of CTE in a study of deceased football players' brains at ninety-nine percent, there is still a tendency among some in sports talk media to either ignore or undervalue what scientists have learned about the disease and its causes. The following anecdote from December 2016 is illustrative.
Carolina Panthers linebacker Luke Kuechly ("KEEK-LEE") was formally diagnosed with a concussion approximatley two-thirds of the way through the 2016 season. Kuechly had also received a concussion diagnosis the previous season and the team doctors, trainers and coaches were understandably cautious in evaluating his return-to-play status. The team, which had played in the NFL championship game the previous February, was experiencing what is often referred to as a "Super Bowl hangover" - a very poor showing in the season following the Super Bowl. Chris McClain, host of the morning program on WFNZ-AM, the Charlotte radio station that is most closely connected to the Panthers, asked listeners whether Kuechly should stay off the field or return to play, given there was no possibility of the Panthers making the playoffs with or without him.
The callers during the show's four-hour time slot overwhelmingly framed their responses to the question based upon whether the risk to Kuechly's health was justified, given that the Panthers' season was beyond rescue. The program's host was finally compelled to ask listeners to think not of Kuechly the football player, but of Kuechly the human being, in formulating their responses. Shortly afterward, a regular called to the program asserted that so little is known about concussion that the discussion was essentially meaningless. At that point, I sent McClain an email, which made two main points: (1) sports talk radio as we know it would cease to exist if hosts and fans started to think of athletes as human beings; and, (2) because we don't know everything about concussions is no reason to claim that we know nothing. I also pointed out that sports medicine expertise is in abysmally short supply in sports media, and this can't be for the lack of available experts. The listener or caller who knows little or nothing about concussion could learn quite a lot from a neurologist or neuroscientist. But, as mentioned before, such experts do not appear as guests on sports talk programs.
To my surprise, the host's reply to my email - which included an attachment of published work on bioethical considerations of the sports concussion issue, co-authored with Professor King - contained an invitation to appear on the program the next morning. I welcomed the opportunity to be interviewed about the ethics of informed choice in sports, giving particular emphasis to the apparently radical concept of the athlete as human being. I was grateful for the opportunity to take seven minutes on-air to counterbalance the uninformed and non-empathetic opinions from so many callers the previous day. But in the months that followed, it became clear that little if anything had changed at this particular sports talk outlet. There are still no experts in the diagnosis or treatment of any sports injuries, nor of the ethics of return-to-play rules. And concussion - an injury (damage) that results from a high force impact between the brain and the inside of the skull - is still routinely referred to as a "head injury". But if a media powerhouse like ESPN can be pressured by the NFL to disavow its own work regarding concussion, it stands to reason that a local CBS affiliate wouldn't be willing to subvert the League's corporate narrative, which among other things protects more than fourteen billion dollars in revenue.
It is of course not the responsibility of sports talk media to do the work of bioethics. And there can be little if any doubt that athletes and media figures have known much less about concussion and its consequences than the professionals and researchers who have systematically studies the problem. As mentioned earlier, one of the complaints against the NFL is that its officials actively suppressed the findings of the League's own concussion research. (One of the terms of a one billion dollar class action concussion settlement is that the NFL was not required to admit wrongdoing.) But even though there is still a great deal to learn about concussion and its associations with not only CTE but also with other brain disorders such as Parkinson's, Alzheimer's and depression, we are well beyond the point at which it is ethically permissible to say "head injury" to avoid speaking of injury to the brain.
1. "League of Denial: The NFL's Concussion Crisis," Frontline, Season 32: Episode2, October 8, 2013 (http://www.pbs.org/wgbh/frontline/film/league-of-denial/)
3. "Concussion Research and Treatment," The House Energy and Commerce Subcommittee on Oversight and Investigations, (https://www.c-span.org/video/?406450-1/hearing-concussions)
4. NFL Football League Players' Concussion Injury Litigation, Case 2:12-md-02323-AB Document 6509 Filed 4/22/15
5 E. Levinson, "The NFL Channeled Big Tobacco in Its Denial of Concussions," The Atlantic, Oct. 2, 2013
6. NMP King and Richard Robeson, "Athlete or Guinea Pig? Sports and Enhancement Research,"
7.HS Maitland, "Punch Drunk," JAMA 91, no. 15 (1928):1103-1107
8."A Note from FRONTLINE: ESPN and 'League of Denial'," Frontline, Aug. 22,2013, (http://www.pbs.org/wgbh/frontline/article/a-note-from-frontline-espn-and-league-of-denial/)
9. JA Miller and K Belson, "NFL Pressure Said to Lead ESPN to Quit Film Project," NY Times, Aug. 23, 2013,
10. SiriusXM NFL Radio. https://www.siriusxm.com/nfl
11. NFPost.com - Dr. David Chao (http://www.nationalfootballpost.com/author/david-chao/)
12. J Person, "Ageless Thomas Davis is playing as well as ever, says he knows how career will end," The Charlotte Observer, Nov. 12, 2016 (http://www.charlotteobserver.com/sports/nfl/carolina-panthers/article11428388.html)
13. "Subconcussive Impacts," CTE Resources, Concussion Legacy Foundation, (https://concussionfoundation.org/CTE-resources/subconcussive-impacts)
14. A Chen, "Brain injury found in 99 percent of donated brains of NFL players in new study," The Verge, Jul. 25, 2017, (https:www.theverge.com:2017:7:25:16025146:chronic-traumatic-encephalopothy-football-cognition-health)
15. R Robeson and NMP King, "Loss of Possession: Concussions, Informed Consent, and Autonomy,"
The Journal of Law, Medicine & Ethics, Sept. 1, 2014, (http://journals.sagepub.com/doi/abs/10.1111/
16.D. Lauterback, "NFL pulled in $14 billion in revenue during 2016 season," The Comeback - MSN Sports, Mar. 6, 2017. (https://www.msn.com/en-us/sports/nfl/nfl-pulled-in-dollar14-billion-in-revenue-during-2016-season/ar-AAnTZa3)
Richard Robeson is an Adjunct Assistant Professor of Practice - Bioethics, Dept. of Communication Bioethics Faculty, Graduate School of Arts and Sciences, Wake Forest University