Protecting Athletes in Elite Sport: Balancing Autonomy, Risk and Duty of Care

On one hand, Vonn’s story is one of bravery and resilience in the face of injury. Following a serious fall just one week earlier, her decision to take on the daunting Olimpia delle Tofane course without an ACL certainly raised eyebrows, but it was a testament to her determination to continue to compete at the highest level. What followed, however, were the troubling images of a sporting superstar airlifted to hospital with injuries so serious that there was a risk of amputation of her leg.

Whilst there is no indication that the crash was a direct result of Vonn’s previous injury, the incident nevertheless raised questions as to the duty of care owed by governing bodies to protect athletes, even from themselves.

Through examples from skiing, rugby, the NFL and more, we will highlight the importance of greater regulatory protection of the welfare of elite sportspeople, arguing that this can be achieved without fully compromising the autonomy of athletes.

Whatever it Takes

Athletes devote their lives to their sport. Thousands of hours of dedication often culminate in only a short window of opportunity to compete at the highest level. It is therefore no surprise that this fosters a desire to do whatever it takes, irrespective of injury or fatigue. As Lindsey Vonn herself wrote on Instagram following her crash last month, in the mind of an athlete ‘the only failure in life is not trying’. The International Olympic Committee echoed the importance of an athlete’s autonomy in these matters, reiterating that Vonn’s decision was ‘really hers and her team’s to make’.

It cannot be denied, however, that too great an emphasis on such autonomy inevitably leads to significant risks for the health of athletes. In certain circumstances, governing bodies can and should promote the safety and longevity of competitors, even when faced by an athlete willing to put sporting goals ahead of their wellbeing.

Concussion in Sport

An important forum for this debate relates to concussion in sport. In rugby union, concussion protocols have developed significantly over the past decade. Independent match-day doctors, head injury assessments (HIAs) and mandatory stand-down periods have been implemented to combat the desire of players (and in many cases the staff and teammates around them) to continue despite clear symptoms of head injury.

In the recent BBC documentary Ben Youngs Investigates: How Safe Is Rugby?, former England international Anthony Watson admitted to memorising answers for the HIA, so as to pass and return to play during the 2017 British & Irish Lions tour. No one should seek to criticise Watson’s burning desire to play (true of countless other high profile rugby players who have suffered concussions), but stories like his bring the regulatory role of rugby’s governing bodies sharply into focus.

World Rugby and national associations such as the Rugby Football Union (RFU) have taken important steps to strengthen concussion protocols, for instance by drawing on impact data from mouthguards. But their duty of care is one that evolves over time. Meaningful investment into research, for instance into the relationship between repeated head impacts and long-term neurological conditions, is required if training regimes and return to play protocols are to keep stride with scientific developments.

The case of Tua Tagovailoa in the National Football League (NFL) highlights this interplay between research and regulation. During the 2022 season, Tagovailoa sustained a series of concussions in consecutive games, playing no small part in his recent release from the Miami Dolphins. Intense scrutiny of NFL concussion procedures followed and, after a joint investigation by the league and its players’ association, the list of ‘no-go’ symptoms was expanded to include ataxia (abnormal balance, motor coordination or ‘dysfunctional speech’). Any player displaying such symptoms during a game is now automatically prohibited from returning to play.

Psychological Wellbeing

The physical repercussions of concussion or dramatic crashes like Lindsey’s Vonn’s are well-documented, but the duty of care owed by governing bodies also extends to the psychological effects of elite sport.

At the Tokyo 2020 Olympic Games, Simone Biles withdrew from multiple gymnastics events after experiencing the “twisties”, a loss of spatial awareness placing gymnasts at significant risk of injury. As a bonafide great in her sport, her decision to withdraw was a shock to many, and undoubtedly impacted viewership of the event. But it serves as a reminder that with the correct education and support, athletes can be empowered to exercise their autonomy to protect themselves.

For governing bodies, this only reinforces the need for a detailed understanding of medical conditions in their sport, implementing protocols that allow athletes to withdraw from competition without stigma or undue pressure from the teams around them.

Lessons for Governing Bodies

In short, there are circumstances in which athletes cannot, and should not, be the final decision maker on their own participation in sport. Governing bodies must work with stakeholders to implement measures for objective assessments of athletes’ health.

There is no doubt that much of the commercial value in elite sport hinges upon the involvement of the biggest names (look no further than the outrage after Lionel Messi’s decision to sit out of a friendly in Hong Kong in 2024). Nevertheless, the credibility of decision makers in sport depends on meaningful commitment to their athletes’ welfare.

If governing bodies are to fulfil their duty of care to athletes, the following is required:

• Objective in play medical assessments

It is crucial to empower independent officials to remove athletes where serious injury or impairment is suspected, with consistent monitoring of the lists of symptoms specified as triggers for removal.

• Research and education of athletes on the medical risks associated with playing through injury

Even when injury protocols are implemented, significant work remains for governing bodies to research the causes, symptoms and long-term effects of injury. Where these factors vary, for instance based on gender, training, equipment and protocols should be tailored to best protect the affected athletes.

This also involves educating athletes and stakeholders on the importance of transparency around reporting injury, ultimately promoting the longevity of athletes’ careers in elite sport.

• Competition and training scheduling

Perhaps most importantly, whilst we have focused on determinations as to an athlete’s fitness to compete, training regimes and scheduling of competitions must give greater weight to the welfare of athletes. Amidst increasing commercial pressures to develop new competitions, formats and revenue streams, this cannot be at the expense of the safety of those that draw viewership in sport.

Conclusion

Dramatic moments like Lindsey Vonn’s crash are stark reminders of the inherent risk of competing in elite sport. But they also highlight the importance of mitigating risk through injury protocols, research and education.

The desire to achieve sporting greatness can inevitably distorts an athlete’s risk assessment as to their own wellbeing. It is in these moments that governing bodies must play an active regulatory role if they are to fully exercise their duty of care.

Photo: Stefan Brending / CC BY‑SA 3.0 DE