Diamond, Eugene

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The Linacre QuarterlyVolume 63 | Number 4 Article 5November 1996Moral and Medical Issues in BoxingEugene DiamondFollow this and additional works at: https://epublications.marquette.edu/lnqRecommended CitationDiamond, Eugene (1996) "Moral and Medical Issues in Boxing," The Linacre Quarterly: Vol. 63 : No. 4 , Article 5.Available at: https://epublications.marquette.edu/lnq/vol63/iss4/5Moral and Medical Issues in Boxing by Eugene Diamond, M.D. The author is a contributing editor of The Linacre Quarterly. The sport of boxing is unique to the extent that it has elicited commentary regarding its morality and legality as compared with other athletic endeavors. A series of Jesuit Theologians i ,2,3,4 have described boxing as morally unacceptable as have various medical authorities culminating in recent calls for the outlawing of prizefighting by the Journal of the A merican Medical Association 5. The objections raised from these various disciplines have generally followed one of three basic arguments: (I) Boxing is the only sport whose primary purpose is to injure one's opponent. This teleogical line of argumentation is usually followed by moral theologians. (2) Prizefighting carries an unacceptable risk of injury both acute and chronic as compared with other types of sports competition. This medical argument concentrates primarily in long term central nervous system morbidity including the so-called "punch drunk" syndrome. (3) The nature of this type of athletic competition leads to the brutilization of the competitors, spectators and the society at large and to the encouragement of violence and mayhem. These three criticisms are obviously not without basis in fact but there is some question as to the extent that data used to support the critique in each case have been overblown and scientifically insupportable. This will be an examination of these data and an evaluation as to whether they rise to the level of moral condemnation sufficient to require outlawing all prizefighting, both professional and amateur. An alternative response might be the institution of controls and regulations which would make boxing morally and medically acceptable. As provided out by Laforet in his classical and seminal article on medical and moral aspects of boxing6, the sport has undergone various modifications historically. November, 1996 37 History of Boxing While "the art of fighting with the fists" is probably as old as mankind, the Greeks are apparently the first to have raised pugilism to the level of an organized sport. In Greek Mythology, the first description of a boxing bout is the encounter between Polux and King Amyrcus during the Argonauts' search for the Golden Fleece. King Amyrcus has the unfortunate distinction of being the first recorded boxing fatality. Bare-fisted boxing was apparently a part of the competition in the earliest Olympic Games. The Romans added a glove loaded with metal to produce the murderous caestus. In the late Renaissance, boxing, reappeared in a less savage and gentlemanly form. In 1719, James Figg of England became the first generally recognized National Champion. Down through the years various attempts to codify the regulations of boxing were propounded beginning with Broughton's Rules in 1743 and followed by the New Rules of the Rink in 1838. The venerable marquis of Queensbury rules are usually invoked for "The Manly art of self defense" but the rules for professional, amateur and Olympic boxing differ significantly. Moral Issues Father John Connery has summarized the moral objection succinctly as a violation of the Fifth Commandment in that it allows intentional injury without a compensating good4. Others who have argued similarly have based their opinion on the presumption that the primary intention of the boxer is to injure his opponent. As one editorial asserted "The principal purpose of a boxing match5 is for one opponent to render the other injured, incapacitated, unconscious." Others have asserted that boxing is unique in that it is the only type of competition in which deliberate injury of a contestant is allowed. The key to the analysis of the morality of the action of the bozer is the intention of the participants. Strictly speaking, the intention of the competitors is to win the fight while following certain specific and pre-agreed rules of conduct. Although these rules may allow one opponent to inflict injury on the other, the primary intention is to score points and not necessarily to cause injury. Fighters, as a rule, (there are exceptions), do not bear their opponent ill-will and most will display sportsmanship in victory or defeat. This is not meant to trivialize the serious acute and chronic injury that can and does occur during bouts but to raise the possibility that such injury is not directly intended as the per se purpose of the sport and therefore might be justifiable under the principle of double effect. Most contests are won by decision and not by knockout and the decision will be based on a point system - and not on the basis of one contestant having inflicted more pain or injury on the other. In one of the most famous bouts in history, the second Dempsey-Tunney fight, it is safe to say that Dempsey inflicted the most pain but Tunney nevertheless won. There are innumerable similar examples. It must also be conceded that there are other sports in which the rules allow deliberate attempts to injure the opponent. In football, the intention of the linebacker in tackling the receiver on a crossing pattern is not merely to prevent the 38 Linacre Quarterly advancement of the ball but, in addition, to inflict such pain as to discourage future similar patterns.7 The defensive end who tackles the quarterback has the secondary intent of knocking the quarterback out of the game and statistics would indicate that acute concussion is more common in football than boxing. Other examples, would be beanball or brush-back pitches in baseball, elbowing in basketball and boarding and checking in hockey. In fact, in any collision sport, acute and chronic injury is foreseen and accepted by the contestants who give informed consent to participation. Boxing may be the only sport where victory is guaranteed by incapacitating an opponent for ten seconds but most coaches would admit that the ideal in most sports is to play the game hard with a commitment that enhances the risk of injury to oneself and one's opponent. Medical Issues There are estimated to be 5,000 professional boxers licensed in the United States and 25,000 worldwide. There are at least 25,000 amateur boxers in the United States who average around 20 fights per year over a typical five year career. Although deaths resulting from injuries sustained in the ring are widely publicized9 the number of deaths due to boxing is surprisingly low. In the 35 year period, between 1945 and 1979, MoorelO recorded 335 deaths in worldwide amateur and professional boxing with decreasing numbers since 1965. McCown ll noted only two boxing deaths among 20,505 professional boxers licensed in New York state from 1953-1977. The mortality rate in boxing (0.13 deaths per 1,000 participants per year)l2 is lower than rates for high risk sports such as horse racing, mountaineering, auto and motorcycle racing and comparable to death rates from such collision sports as football and rugby13. Injury rates, on the other hand, are rather high in boxingll. Most are treatable and many are preventable but the greatest concern is with the health hazard associated with boxing involving chronic brain damage. Martlandl4 provides the first medical description of a Neurological Syndrome associated with boxing which he labeled "punch-drunk." Subsequent studiesl5,l6,l7 have identified a pattern of chronic boxers encephalopathy usually established by retrospective studies of experienced professional boxers. There is evidence that amateur boxers do not experience a significant level of this syndrome. Thomasonl8 found no difference in neurological states between amateur boxers and soccer players. It seems likely that subconcussive rather than knockout blows are responsible for chronic brain damage in boxing. Knockout rates are reported as 4%-6% of all bouts9,1l . Given the infrequency of knockouts, it is unlikely that concussive blows to the head are responsible for traumatic boxer's encephalopathy. Most knockouts last 30 seconds or less and are seldom followed by objective evidence of serious damage. Injuries to the eyes and soft tissue injuries are also capable of producing long term loss of function. Inevitably boxing injuries must be evaluated against the background of other sports injuries. According tot he National Athletic Trainers Organization, there were 636,000 minor injuries and 65,000 major injuries due to football in 1986. 36% offootball players will be sidelined for more than a week by injury as well as 22% of basketball players and 30% of wrestlers. This compares with a rate of 17% November, 1996 39 ----in boxers. Boxing injuries will, of course, be more dramatic and more significant to the extent that they would involve chronic central nervous system system dysfunction. Chronic dysfunction is not unique to boxers, however, and most professional football players will be significantly impaired due to trauma to the knees, hips and neck21. Most significantly, there is considerable evidence that improved supervision and evaluation of competitors has resulted in a dramatic reduction in the punch-drunk syndrome in the past 30 years22. With the availability of computed tomography and magnetic resonance imaging for surveillance of boxing participants23 further reduction can be anticipated. Societal Effects of Boxing Boxing lasted 1000 years during the time of the Greek and Roman Empires and then ended about 400 A.D. because it had become corrupt and professionalized and was banned by a Christian emperor with a distaste for heathen spectacles. In general, boxing has been popular during periods of personal freedom such as the Renaissance and been suppressed during periods such as the Dark Ages. As John Stuart Mill wrote in his essay, "On Liberty", "the only purpose for which power can be exerted over any member of a civilized community is to prevent harm to others". Kant wrote that "no one can tell me to be happy in his own way". A persuasive case can be made for the participation of informed and consenting adults in boxing as a liberty right. Nevertheless, the American Medical Association, the Medical Associations of Britain, Canada and Australia, the American Academy of Neurology, and the American Academy of Pediatrics have recommended that boxing be banned rather than reformed. Precedents for making boxing illegal can be found in the banning of dueling, bullfighting, cockfighting, pitbull fighting and bearbaiting. There have been attempts in the past to make boxing illegal which have had results similar to the Volstead Act, that is to create a criminal subculture without supervision. Even now, we have pseudo-boxing spectacles such as "tough man" competition, women's boxing and ultimate fighting25 in which no-holds barred encounters are staged by unscrupulous producers and involve poorly-conditioned, unlicensed participants. These are usually not sanctioned by State Athletic Commissions. The AMA has petitioned the U.S. Olympic Committee to ban even Olympic boxing despite the fact that there has never been a boxing fatality in the 86 year history of Olympic competition. To restate John Stuart Mill's position in the context of our times, the state should resort to banning the activities of an adult only when there is no other way to reduce the risk of serious injury or death to acceptable levels26. The original position of the AMA Council on Scientific Affairs27 seems much more realistic. The statement recognizes that boxing cannot be demonstrated to be any more dangerous than some other sports presently accepted by society.The statement does adopt proposals by its Advisory Panel on Brain Injury in Boxing, as follows: (I) Establish a National Registry of Boxers with a computerized registry of all 40 Linacre Quarterly knockouts, TKO's, injuries and won-lost records. (2) Establish with the American Association of Ringside Physicians, criteria for physical evaluation and injury prevention. (3) Recommend to all boxing jurisdictions that the ring physician be authorized to stop any bout in progress based on specific criteria. (4) Provide that no professional or amateur bout should take place without the presence of (a) advanced life-support at the ringside; (b) adequate neurosurgical facilities available nearby; (3) comprehensive evacuation plans for removal of injured boxers to the hospital. (5) Ban all competition between unlicensed boxers such as high-risk "tough man contests". (6) Extend all safety measures to sparring partners. (7) Mandate the use of safety equipment such as safety mats, padded corner posts and protective equipment. One major reform which could have significant impact would be to extend the existing requirement, in Olympic and amateur boxing, that helmets be worn, to professional bouts. These helmets made up of an external leather layer supported by layers of ultra high-density PVC and low-density latex can reduce the force of a blow to the head by 40%. No less a personage than George Foreman ageless multi-time world heavyweight champion is quoted in the Chicago Sun-Times as calling for headgear in boxing, saying "I'd do it right now."28 Some resistance could be expected but experience in The National Hockey League indicates that, with the passage of time, even optional helmet wearing becomes universally observed. The helmet reduces cuts over the eyes and forehead, reduces ear damage and protects the head against impact and falls. The Swedish experience has shown that certain rule changes can also reduce risk.29 Redeeming Value of Sports Reducing the risk of boxing to acceptable levels would result in its inclusion with other forms of sports competition as an activity with redeeming social value. Athletic competition has attained an unprecedented level of public acceptance in the television era. Participation, as well as spectator observance, have reached unprecedented levels. For the participant, development of skills, conditioning in sports requiring stamina, group identification in team sports and ultimately "the thrill of victory and the agony of defeat" are positive personal and social influences. Boxing shares with other forms of individual competition, these positive attributes. Boxing compared with other forms of competition requires a very high level of courage and physical conditioning. Although the profession of boxing has had more than its share of unscrupulous handlers, promoters and managers30, such abuses are not intrinsic to the sport and can be corrected by regulation and statute. Not every athlete in any sport is a positive role model. Boxing would seem however to have a unique appeal to ethnic pride. Throughout the 20th Century, the Irish, Italians, African-Americans and Hispanics have sequentially used boxing as a symbolic form of upward mobility. November, 1996 41 42 Summary (1) The primary purpose of the sport of boxing is to win a contest under a prescribed set of rules and a point system. Injury to the opponent is foreseen but not necessarily intended as the per se meaning of the sport. (2) The risks of acute injury and fatality in boxing are not inordinately high as compared with other collision sports. (3) The unique hazard of boxing which is the possibility of a chronic traumatic encephalopathy or "punch-drunk" syndrome has led to a call for the banning of boxing, both amateur and professional, by various professional organizations. (4) Making boxing illegal would cause it to go underground with less legal and medical supervision and greater exploitation of fighters. (5) The risks of acute and chronic injury in boxing are reducible by a system of greater medical supervision of competitors and the use of improved protective equipment. (6) All athletic competition has an accepted redeeming social value for participants and spectators. (7) The reduction of the risk/benefit ratio in boxing by various reforms is preferable to attempts to outlaw prize fighting. "In the clearing stands the boxer and a fighter by his trade And he carries the reminder of every glove that laid him down And hit him till he cried out in his anger and his shame I am leaving, I am leaving, but the fighter still remains Still a man hears what he wants to hear and disregards the rest" The Boxer, Simon and Garfunkle 1969 References I. Bernard, G.c., The Morality of Prizefighting, Washington, D.C. Catholic University Press, 1952. 2. Connell, F.J. Prizefighting and Boxing, Am EccL Rev. 122:58, 1950. 3. Grand, G.G. Boston Daily Globe 4114/ 56 p.8. 4. Connery, J .R. Death and Damage in the Ring, SL Anthony's Messenger 20:9, 1986. 5. Lundberg, E. Boxing Should Be Banned in Civilized Countries lAMA 249: 250, 1983. 6. Laforet, E. Boxing. Medical and Moral Aspects, Linacre Quarterly, 25: 56, 1958. 7. Tatum, Jack, They call Me Assassin, New York, Everest House 1981. 8. Morrison, R. Medical and Public Health Aspects of Boxing, lAMA 255: 2475, 1986. 9. Fournier, C. In the Ring, Hispanic Magazine, March 1989, p. 23-26. 10. Moore, M. The Challenge of Boxing, Physicinn and Sports Med 8:101, 1980. 11. McCown, l.A. Boxing Safety and Inquiries, Physicinn and Sports Med 7:75, 1979. 12. Accident Facts. Chicago National Safety Council, 1985 p. 75. 13. Gonzales, T. Fatal Injuries in Competitive Sports, lAMA 146: 1506, 1951. 14. Martland, HS Punch Drunk lAMA 91 :1103, 1928. 15. Mandsley, C. Ferguson, F. Neurological Disease in Boxers, Fauet 2: 795, 1963. 16. Johnson, J. Organic Psychosyndromes Due to Boxing, British J. Psychintry 115:45, 1969 17. Casson, l.R. Brain Damage in Modem Boxers, lAMA 251 : 2663, 1984. 18. Thomasson, A. et aI., Neurological evaluation of 53 amateur boxers. Acta Neural Scand 60:352, 1979. Linacre Quarterly 19. Maguire, I and Benson, W. Retinal Injury and Detachment in Boxers, lAMA, 255: 2451, 1986. 20. Roberts, A.H. Brain Damage in Boxers, London, Pitman Books, 1969. 21. Players Pay for NFL Career with Pain. Series on Athletes at Risk. Chicago Tribune, 11110/ 92. 22. Kaste, M. et aI., Is Chronic Brain Damage in Boxing a Hazard of the Past? Lancet 1:244, 1983. 23. Jordan, B. and Zimmerman, R. CT and MRI Comparisons in Boxers lAMA 263: 1670, 1990. 24. Patterson, R. On Boxing and Liberty, lAMA 255: 1481, 1986. 25. Ultimate Affront? American Medical News. May 6, 1996, p. 15. 26. Patterson, R. Boxing and Personal Freedom, lAMA 256: 1895, 1986. 27. Council on Scientific Affairs. Brain Injury in Boxing, lAMA 249: 254, 1983. 28. Foreman Calls for Headgear to Prevent Boxing Injuries, Chicago Sun-Times Sportswire 5/20/ 95. 29. Ludwig, R. Making Boxing Safer-The Swedish Model lAMA 255: 2482, 1986. 30. Brenner, Teddy Only the Ring was Square, Prentice-Hall, 1981. November, 1996 43 

Moral and Medical Issues in Boxing

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