Sports Med 2011; 41 (2): 167-176

REVIEW ARTICLE 0112-1642/11/0002-0167/$49.95/0

ª 2011 Adis Data Information BV. All rights reserved.

Should Performance-Enhancing Drugs

in Sport be Legalized under Medical
Supervision?
Urban Wiesing
University of Tuebingen, Tuebingen, Germany

Contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
2. What Does Legalization of Performance-Enhancing Drugs under Medical Supervision Mean?. . . . . 168
3. Restrictions on Athlete Freedom through Doping Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
4. The Effectiveness of the Controls and the Credibility of Sport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
5. What Impact would Legalizing Performance-Enhancing Drugs in Competitive Sport Have? . . . . . . 170
6. The ‘Gentle’ Pressure to Use Performance-Enhancing Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
7. Effects of Doping on Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
8. The Meaning of Sport. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
9. The Exemplary Role of Sport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
10. Children and Adolescents and the Legalization of Performance-Enhancing Drugs . . . . . . . . . . . . . . 174
11. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Abstract This review examines the question of whether performance-enhancing

drugs should be permitted in sport under the control of physicians, and
evaluates the expected outcomes of such a scenario. Such a change in reg-
ulation would need to be tightly controlled because of the risks involved. The
results of legalizing performance-enhancing drugs in competitive sport would
be either unhelpful or negative, and the unwanted aspects of doping control
would not disappear. Athletes, including children and adolescents who wanted to
pursue competitive sports, would be forced to take additional, avoidable
health risks. The ‘natural lottery’ of athletic talents would be compensated for
only partially by use of performance-enhancing agents. It would also be com-
plemented by another ‘natural lottery’ of variable responses to doping mea-
sures, combined with the inventiveness of doping doctors. There would be no
gain in ‘justice’ (i.e. fairer results that reflected efforts made) for athletes as a
result of legalizing doping. Legalization would not reduce restrictions on
athletes’ freedom; the control effort would remain the same, if not increased.
Extremely complicated international regulations would have to be adopted.
The game of the ‘tortoise and the hare’ between doping athletes and inspec-
tors would remain because prohibited but not identifiable practices could still
provide additional benefits from use of permissible drugs. Audience mistrust,
particularly toward athletes who achieved outstanding feats, would remain
168 Wiesing

because it would still be possible that these athletes were reliant on illegal
doping practices. Doping entails exposing the athletes to avoidable risks that
do not need to be taken to increase the appeal of a sport. Most importantly,
the function of sport as a role model would definitely be damaged. It is not
necessary to clarify the question of what constitutes the ‘spirit of sport’ and
whether this may be changed. From a practical point of view, a legalization of
performance-enhancing drugs in sport should not be considered for the
simple reason that it has no advantages but many disadvantages.

1. Introduction would be paid for with definite and permanent

The doping problem in sport has yet to be
solved. One must continue to assume that controls
do not identify all athletes who use performance-
enhancing drugs.[1] As a result, a general suspi-
cion has arisen that some of the most outstanding
achievements in sport may have been achieved by
doping. For this reason, several authors have claim-
ed that controlled use of performance-enhancing
drugs in sport should be permitted.[2-5] If that were
to happen, the central argument against doping,
i.e. the fairness argument, would immediately be
rendered irrelevant (assuming that all athletes used
performance-enhancing drugs within the permitted
boundaries), and a ban on doping would be more
difficult to justify. This review investigates whe-
ther a ban on doping should be included in the rules
of sport and discusses the possible consequences
of the legalization of performance-enhancing drugs
under medical supervision.
2. What Does Legalization of
Performance-Enhancing Drugs under
Medical Supervision Mean?
Any legalization of performance-enhancing
drugs in sport, if it were to occur, would need to
be subject to limitations. This is not disputed by
either opponents or supporters,[2,3,6] for complete
legalization would also sanction actions that in-
troduced risks and possibly irreversible damage
to an athlete’s health. That would certainly be
unacceptable, even if the athlete were willing to
accept the risks and damaging effects, because it
is inconsistent with the favourable health require-
ments of sport. In extreme cases, the medically-
induced, transient success achieved by doping
damage to health or even loss of life. This is
considered to be too high a price to pay in sport,
even in a society that permits self-destructive be-
haviour. Thus, even if performance-enhancing
drugs were to be legalized in sport, some possible
doping activities would remain banned. Only
those doping actions, which were considered to
involve acceptable risks, would be permitted.
How the appropriate limits of the use of per-
formance-enhancing drugs can be determined is
by no means self-evident and requires further in-
vestigation. The current lack of knowledge means
deciding which doping activities lead to which
unwanted effects is often difficult to determine,
particularly with regard to the long-term per-
spective. This lack of knowledge is particularly
problematic in relation to new substances. The-
oretical considerations alone suggest that adverse
effects should be anticipated if a substance actu-
ally enhances the athletic performance; indeed, as
stated by the President’s Council on Bioethics,
‘‘y until proven otherwise, it makes sense to
follow this prudent maxim: No biological agent
powerful enough to achieve major changes in
body or mind is likely to be entirely safe or with-
out side effects.’’[7] This consideration should be
kept in mind even in cases of doping in which
unwanted side effects are supposed to be rare.
Moreover, if a legalization of performance-
enhancing drugs in sport were to be introduced, it
would need to be clarified who should determine
the permissible limits of use of such drugs. This
could not be left to the discretion of an individual
physician, as assessments of the acceptability of
risks in doping may vary. Moreover, athletes who
were willing to take risks would search for the
most helpful doctor. This would mean that risks

ª 2011 Adis Data Information BV. All rights reserved. Sports Med 2011; 41 (2)
Legalization of Medically Supervised Performance-Enhancing Drugs
to athletes that many deemed unacceptable would
be taken, and those athletes willing to take these
risks would have an advantage over their oppo-
nents. Thus, the concept of equal opportunities
for all athletes would be compromised by a phy-
sician factor. To avoid this, the limits of doping
would need to be specified in advance and in-
dependent of the physician-patient relationship.
However, doing this would need to have not only
the necessary scientific expertise to evaluate the
risks associated with specific doping activities but
also to evaluate the level and nature of risks that
are considered acceptable in sport. Furthermore,
to ensure comparability of conditions for athletes,
such rules would need to be established and ratified
internationally. Thus, an international organiza-
tion with the required expertise and authority to
make such evaluations would be needed to de-
termine the permissible limits of doping in sport.
The mandated limitations on the use of per-
formance-enhancing drugs could relate to parti-
cular methods of administration or substances,
the dosages of agents used or the biological ef-
fects of doping, e.g. changes in hormone levels or
blood parameters such as haemoglobin mass. In
addition, the criteria would have to be specified
when doping would need to be stopped because
the ‘beneficial’ effects are outweighed by the ad-
verse effects. All limits on doping would be based
on whether the risk to the athlete was still consi-
dered acceptable. Indeed, this principle is confirmed
by supporters of a legalization of performance-
enhancing drugs;[2,3] as Savluescu et al.,[2] for in-
stance, have noted, ‘‘There is one limit: safety.’’
Ensuring the safety of athletes in the event of
a legalization of performance-enhancing drugs
would require internationally coordinated, costly
and complicated regulations that would require
considerable effort and result in extensive con-
trols. There might be rare instances of doping in
sport that had acceptable side effects, but making
these permissible would add further difficulties in
terms of defining limits and introducing further
controls. In short, even if performance-enhancing
drugs were to be legalized in competitive sport,
there would still be a specific portion of doping
activity that would remain prohibited, and limits
concerning what is allowed and not allowed, as
ª 2011 Adis Data Information BV. All rights reserved.
169
well as the responsibility for enforcing those limits,
would need to be determined. Nothing would be
gained in terms of eliminating the need for reg-
ulation of doping in sport.
What role would be left for physicians if
performance-enhancing drugs were to be legalized
under medical supervision? Medical supervision
would be concerned only with the development
and, if necessary, production of performance-
enhancing drugs, their use within the permissible
boundaries and controlling their effects. Fur-
ther responsibilities and, in particular, assessing
which risks are acceptable for the athlete to take,
should not, as noted earlier in this section, be
assigned to the physician. Nevertheless, even with
pre-determined limits on the permissibility of
performance-enhancing drugs, physicians would
always retain a degree of autonomy in terms of
determining the optimal doping regimen for their
athletes.
3. Restrictions on Athlete Freedom
through Doping Controls
Enforcement of the present ban on performance-
enhancing drugs depends on extensive and logis-
tically complex controls which, if they are effective
at all, considerably limit the athlete’s freedom.
However, would a legalization of performance-
enhancing drugs change anything in the intensity
of the control system or the limitations on the
athlete’s freedom? No, because, as discussed in
section 2, the legalization would not be without
limits, mainly to avoid the risks to the athlete.
Therefore, the doping control system would re-
main as complicated as it is now but with the
different goal of detecting the use of illegal sub-
stances due to their risk.
Supporters of a legalization of performance-
enhancing drugs believe that concerns about
athletes’ health would lead to more tests when
the use of such drugs is permitted. For example,
Savulescu et al.[2] have stated: ‘‘There would be
more rigorous and regular evaluation of an ath-
lete’s health and fitness to perform.’’ However, it
is important to note that certain health problems
manifest themselves only over the long term and
cannot be detected by close medical inspection. In
Sports Med 2011; 41 (2)
170
this respect, the proposal to align limits on the use
of doping agents with the damage they cause to
athletes means that the long-term adverse effects
are not controlled at all. This important consi-
deration is overlooked by supporters of a limited
legalization of performance-enhancing drugs.[2,4]
Furthermore, if proponents of limited legaliza-
tion advocate banning all doping practices with
potential long-term risks, the great temptation
remains for athletes to do these things illegally. In
this respect, nothing would be gained.
Thus, the key argument against limited legali-
zation under medical supervision becomes clear,
namely, that no advantage would be obtained
in terms of reducing the current difficulties of
implementing doping controls.[6] The controls
would be just as extensive, all that would change
is the limit of what needs to be controlled.1
4. The Effectiveness of the Controls and
the Credibility of Sport
Sport in general and the credibility of the dop-
ing control system in particular are suffering from
the fact that not all doping activity can be verified
because doping methods change.[8] In most cases,
a certain amount of time elapses before new dop-
ing practices can be identified and verified. How-
ever, even this game of ‘the tortoise and the hare’
between athletes and doping control officers would
persist if limited legalization of performance-
enhancing agents became a reality. There would
always be those who attempted to use new, per-
formance-enhancing methods that are not per-
mitted and have yet to be discovered.
For these reasons, if limited legalization of
performance-enhancing drugs did ensue, an un-
pleasant development in athletic sports, which
has spoiled the relationship between the audience
and the sport, would continue. This refers to the
fact that when an athlete achieves outstanding
results in sport, the suspicion is automatically
raised that this was achieved by doping. In other
1 In this respect, the contention by Foddy and Savulescu is unconvincing. They state that it is ‘‘much easier to
eliminate the anti-doping rules than to eliminate doping,’’[3] an assertion that appears to contradict their con-
clusion in another context that the amount of control needed would increase for safety reasons if legalization
occurred.[2]
ª 2011 Adis Data Information BV. All rights reserved.
Wiesing
words, sports fans have become skeptical. This
situation would probably not change with a lim-
ited legalization; there would still be the possibi-
lity that an excellent performance was achieved
through the use of doping practices that are not
within the rules. Thus, even the lack of trust in
athletes would not disappear.
5. What Impact would Legalizing
Performance-Enhancing Drugs in
Competitive Sport Have?
If there were a legalization of performance-
enhancing drugs in competitive sports, the ath-
letes would definitely take more risks, although,
given the limits and medical supervision, the risks
would be considered acceptable. The argument
for legalization is usually based on the fact that
athletes take risks in sport anyway, and banning
doping therefore smacks of unacceptable pa-
ternalism.[2,3,5,9] However, this argument fails to
observe an important distinction: the risks of
doping in sport are additional and avoidable,
whereas other risks in sport are unavoidable. It is
impossible to play football or other kinds of sport
without risk of injury. Furthermore, while in many
other kinds of sport the precautions taken can lower
the risks, they cannot eliminate them completely.
Conversely, as noted, the risks of performance-
enhancing drugs add to those that already exist
in sport and can be completely avoided by doing
without drugs all together. However, this raises
the question of whether it is beneficial to take extra,
avoidable risks in sport, e.g. to make the sport
more attractive, an issue that is discussed further
in the next section.
Consideration of the risks of doping in sport
also raises the question of whether the actions of
physicians in this context would be consistent
with their ethos of defining the health of the pa-
tient as their first concern. The question is raised
similarly in other fields of medicine that have
little to do with illness, e.g. cosmetic surgery. In
Sports Med 2011; 41 (2)
Legalization of Medically Supervised Performance-Enhancing Drugs
these fields, it is considered acceptable to take
measures that introduce a certain element of risk
in order to fulfil a patient’s need, even though a
disease is not being treated. Again, however, a
distinction needs to be made. In cosmetic surgery,
some risks are unavoidable if the individual wants
to improve his/her appearance through surgical
intervention. In contrast, the risks involved in
using performance-enhancing drugs in sport are
unnecessary, which means physicians would be
needlessly exposing their patients to risks in an
attempt to make the sport more appealing. If
physicians were administering unauthorized dop-
ing agents, they would be involved in a violation
of the rules of sport.
6. The ‘Gentle’ Pressure to Use
Performance-Enhancing Drugs
The concept of ‘inherent coerciveness’[10] would
assume greater importance if limited legalization
of performance-enhancing agents in sport were to
come into effect. All competitive athletes have to
make adjustments in many areas of their lives if
they want to be successful in their given sports.
Thus, the athlete has liberty to act but in the
knowledge that his/her actions will have certain
consequences. If the athlete were to forgo certain
performance-enhancing behaviour, he/she would
be less successful. The result is mentioned by Bette
and Schimank:[11] ‘‘The only liberty one has is to
avoid elite sports or leave.’’ If one allows the use
of performance-enhancing drugs within certain
boundaries, then all athletes who wished to be
successful would have no choice but to use the
substances that are allowed by the rules. They
would have ‘‘free choice under pressure’’[10] in
this respect. They would be forced to take actions
that entail risks that are unnecessary in sport and
confer no advantages upon their sport (see sec-
tion 7). In this respect, a limited legalization of
performance-enhancing drugs would unnecessarily
put further pressure on athletes to do more risky
things. Conversely, ‘‘an effective policy for elim-
inating performance-enhancing drug use would
2 If it could be guaranteed that a sport was now free of the use of performance enhancers, the ‘old’ records could
be accepted conditionally and all new records classified as unconditional.
ª 2011 Adis Data Information BV. All rights reserved.
171
harm no one, except those who profit from
it.’’[10]
7. Effects of Doping on Performance
The fact that a legalization of performance-
enhancing drugs would not be advantageous to
sport can be seen by analysing how the use of
these drugs would affect performance. The fol-
lowing possibilities arise:
1. All athletes respond to the approved doping
measures in the same way and their performance
improves in the same way. In that case, the
finishing order of cyclists in the Tour de France,
for example, would remain unchanged. The event
would be slightly shorter in duration with the use
of performance-enhancing drugs than without
them. However, that would be of no benefit to the
competition. All of the athletes would have put in
considerably greater effort and would have been
required to take more risks with no change in
the result of the event.
In terms of the ‘eternal competition’, i.e. the
pursuit of records, the generations of athletes who
were not entitled to use performance-enhancing
drugs would be at a disadvantage. Indeed, many
current records were probably established through
the use of performance-enhancing drugs. (This
generally accepted assumption is difficult to verify
because athletes generally do not admit to the use
of doping agents and, in most cases, it is impossible
to subsequently prove that an athlete used perfor-
mance-enhancing drugs.) Furthermore, the gen-
erations of athletes who were not allowed to use
performance-enhancing substances would have
more difficulty being included on lists of the ‘all-
time best athletes’ based on absolute values of
times, weights, lengths, etc. They would also have
more difficulty being included on conditional ‘all-
time best athletes’ lists if they were not illegally
using performance-enhancing drugs.2 The world
of sport has become more complicated, particularly
in respect to doping. However, is the argument
for justice in the ‘eternal competition’ sufficient
to allow doping? No, because introducing limited
Sports Med 2011; 41 (2)
172
legalization of doping agents in sport will not
change the possibility that records were obtained
through practices that remained banned under that
limited legalization; in other words, this injustice
would remain. Thus, consideration of the ‘all-time
best athletes’ lists does not provide a convincing
argument to legalize performance-enhancing drugs
under medical supervision.
2. The previous point explores the consequences
of legalized doping in sport if the upshot is that all
athletes respond in the same manner. However, it
is improbable that all athletes will respond to dop-
ing options in the same way because (i) different
measures would probably be used; and (ii) athletes
respond differently to performance-enhancing drugs.
The use of different doping measures is poss-
ible when there is flexibility in prescription (e.g.
dosage) and enforcement of permissible doping
practices. In such circumstances, athletes will
strive, with the help of their physicians, to iden-
tify and use the best method for enhancing per-
formance within the permitted limits. This would
extend the competition among athletes beyond
the actual event into the realm of who could find
the best doping methods. Thus, the outcome would
reflect not only the athletes’ performance, train-
ing methods, discipline and talent, but also the
cleverness of their supervising physicians in find-
ing and using the optimal doping aids within
permissible boundaries. This technical extension
of the competition in addition to current medical
care in sport would become increasingly compli-
cated and expensive as more substances were in-
cluded on the permitted list.
Different responses of athletes to performance-
enhancing drugs would be expected to occur be-
cause of genotypic differences alone. Consideration
of this point raises an interesting argument that
has been put forward for the legalization of per-
formance-enhancing drugs, which is that compe-
titive sports are not fair anyway because some
people are favoured on the basis of their talent
alone, and that this unfairness could be compen-
sated for with use of doping substances. This
argument appeals to our sense of justice: sport would
be fair with the use of performance-enhancing drugs
because these would help offset the imbalance
arising from the ‘natural lottery’ of talent among
ª 2011 Adis Data Information BV. All rights reserved.
Wiesing
athletes. According to Foddy and Savulescu,[3]
‘‘By allowing everyone to take performance-
enhancing drugs, we level the playing field. We
remove the effects of genetic inequality. Far from
being unfair, allowing performance enhancement
promotes equality.’’ However, is this argument
convincing?
No, it is not because if the use of performance-
enhancing drugs were legalized, the natural lottery
of various talents would only be compensated for
to a limited extent. The fact is that certain biolo-
gical advantages in sport cannot be leveled by
medical interventions. Furthermore, the partial
compensation of the natural lottery of talent would
be thwarted by a new lottery of the different re-
actions to performance-enhancing drugs, which
is also predetermined. While those who are bio-
logically favoured because of their talent might
not now have the advantage, they could be sup-
planted by a new group who, again because of
biological factors, had an advantage because they
obtained the largest increase in performance as a
result of taking performance-enhancing drugs.
Replacing one natural lottery with another would
only change the nature of the inequality among
athletes, it would not result in greater ‘justice’ for
them in terms of ‘fair’ rewards for their efforts. In
doping-free sport, the athlete’s genetic make-up
introduces unequal chances in competitive sport;
in doping-legalized sport, the ability to react to
performance-enhancing drugs, which is just as
randomly distributed, gives rise to another in-
equality.[5] In addition, there is an unequally distri-
buted resourcefulness among physicians to optimize
the use of doping agents within the permissible
boundaries. In short, nothing would be gained.
Foddy and Savulescu[3] contend that one ad-
vantage of a legalization of performance-enhancing
drugs under strict health control is the fact that
the difference in performance between athletes
who use legal substances and those who continue
to use additional illegal substances would narrow.
Indeed, that would appear to be a possible effect
of a limited legalization of performance-enhancing
drugs. However, a (smaller) benefit from the use
of prohibited substances would still be possible
and, in elite sports, slight increases in perfor-
mance are important. Furthermore, all the other
Sports Med 2011; 41 (2)
Legalization of Medically Supervised Performance-Enhancing Drugs
disadvantages of the use of the permitted drugs
would remain. In this respect, the slight advan-
tage in terms of narrowing the gap between legal
and illegal doping agent users would not be of
crucial significance in the overall evaluation.
8. The Meaning of Sport
If a legalization of performance-enhancing drugs
became a reality, the new lottery of differences in
response to performance-enhancing drugs dis-
cussed in the previous section would be combined
in most cases with the ingenuity of the particular
sports physician and other existing factors (nat-
ural talent, discipline, training) to determine the
outcomes of athletic events. It must be reiterated
at this point that a limited legalization would
not exclude continued use of prohibited doping
methods, perhaps in addition to use of permitted
agents. It also seems likely that the more the
permitted drugs were limited to minimize risks,
the greater the temptation would be to use pro-
hibited doping measures.
Crucially, a legalization of performance-
enhancing drugs would have a massive impact on
our perception of sport. It would ultimately com-
promise the currently, widely accepted ‘spirit of
sport’. Sport is an artificial setting, created by
human beings, in which the competitor is required
to perform, at least according to current, widely
prevalent belief, with a degree of ‘naturalness’. The
sports-watching audience is interested in ‘‘ath-
letic performance y not y biochemistry.’’[12]
We associate the ‘spirit of sport’ with the notion
that achievements come through hard work, dis-
cipline, training and natural talents, even when
we do not recognize this in other areas of our
lives. As has been recently noted, ‘‘The fascina-
tion of sports mainly comes from the demon-
stration of what people are able to do on their
own. Doping destroys this fascination.’’[13] This
culture of ‘naturalness’, to some extent at least,
has previously been accepted as part of sport.
These ideas have given rise to highly con-
troversial discussions on what the ‘meaning of
sport’ is, what is meant by the ‘spirit of sport’ and
how important this is, and whether this ‘spirit of
sport’ is immutable. Is the ‘spirit of sport’ a ‘‘key
ª 2011 Adis Data Information BV. All rights reserved.
173
constitutional quality’’[6] of sport, one that may
never change or undergo ‘correction’, if necess-
ary? Is doping ‘‘incompatible with the meaning
of sports’’[13] or could it be considered consistent
with the ‘spirit of sport’? For example, it has been
suggested in a recent publication that ‘‘Perfor-
mance enhancement [...] embodies the spirit of
human sport.’’[11]
Unfortunately, these questions cannot be an-
swered at this point. It is not possible to deter-
mine what exactly constitutes the ‘spirit of sport’
and whether our views on this should change.
However, and this is the central argument of this
article, it is not necessary to settle these questions
because a limited legalization of drugs in sports
and the consequent change in the current percep-
tion of the ‘spirit of sport’ would have no advant-
ages. Any other concept of the ‘spirit of sport’
should have to be proven to be advantageous in
itself, and such advantages cannot be identified.
There is no need to ponder whether the ‘spirit of
sport’ is or should be subject to change because
there is simply no good reason to make any such
change in any case.
However, it is important to clarify three as-
pects of ‘naturalness of performance’ in sport. The
first is the difficulty of determining what con-
stitutes a ‘natural’ measure of improving perfor-
mance. Many permissible training methods and
food supplements are in some ways less ‘natural’
than other things that athletes may do. However,
the fact that defining an acceptable limit for such
measures, particularly when the dividing line ap-
pears to be opinion-based and is established on a
more or less continuous spectrum, does not ne-
cessarily mean that we should dispense with such
limits. Furthermore, this is not the approach ta-
ken in other areas of life. The difficulties inherent
in putting forward arguments as to why one
substance or another should or should not be on
the World Anti-Doping Agency list are not suf-
ficient reasons to characterize this list as com-
pletely arbitrary and, therefore, irrelevant.
Second, it must be clearly stated that ‘natur-
alness’ in sport is not considered as a value in
itself, but only as a value in this specific context.
In sport, great importance is attached to the
‘naturalness’ of achievements, whereas in other
Sports Med 2011; 41 (2)
174
areas of life this is not necessarily the case. Thus,
there is no requirement in this context to argue
that ‘naturalness’ is a value in itself.
Third, according special attention and value
on ‘naturalness’ of performance in sport means
that sport is considered different to other areas
of life, in which certain ‘artificial’ measures of ob-
taining improvement are allowed. A ‘‘premature
(adjustment)’’[6] to this aspect of sport threatens
destruction of the uniqueness of sport. Sport
would no longer be a ‘‘special area,’’[13] a ‘‘counter-
world of ‘personal achievement’.’’[6]
9. The Exemplary Role of Sport
Another argument for the need to protect the
‘spirit of sport’ can be put forward. There can be
no doubt that sport, playful in nature, but still in
accordance with the rules, sets an example for
society. As Albert Camus once said, ‘‘After many
years during which I saw many things, what I
know most surely about morality and the duty of
man I owe to sport.’’[14] Sport shows, with its
rules and requirement for fairness, how to deal
with other problems in society. It conveys an at-
titude that acts as a role model in many other
areas of human life and ‘‘in a sense, it can be a
model for a better society.’’[6] The question then is:
how would legalization of performance-enhancing
drugs affect the exemplary character of sport?
On this issue, three different facets of the
functions of role models need to be distinguished.
An aspect of society can take on the function of a
role model if it (i) sets special, exemplary stan-
dards; (ii) respects certain standards in a special
and exemplary way; or (iii) controls or ensures com-
pliance with the standards in an exemplary way.
First, it is useful to consider the ongoing im-
pact of sport as a role model in these three areas if
the ban on performance-enhancing drugs remained
in place as follows:
 With respect to setting standards, sport would
remain a model at least for most citizens.
 Continued violations of the norm (standard)
would be anticipated and the function of sport
as a role model in terms of respecting
standards in a special and exemplary way
would continue to be debatable.
ª 2011 Adis Data Information BV. All rights reserved.
Wiesing
 The system of controlling or ensuring com-
pliance with standards in sport is currently
unconvincing, with many doping violations
remaining undiscovered. Improving the con-
trol system would depend on further technical
developments (e.g. in the collation of indirect
evidence), which would make the system more
convincing and therefore more able to act as a
role model.
Second, it is important to consider how the
exemplary role of sport could change if doping
were legalized as follows:
 At least for a significant part of society, sport
would lose its function as a role model because
the model standard it exemplifies would be
abolished.
 With a limited legalization of performance-
enhancing agents, continued violations of the
new norm would be anticipated because the
potential for the use of additional banned but
performance-enhancing substances would re-
main. In terms of the exemplary role of strict
adherence to standards, nothing would be
gained from legalizing the use of performance-
enhancing agents.
 The cost of control would remain unchanged
and the suspicion that the control system was
not effective would remain. Again, therefore,
nothing would be gained in these respects
compared with the existing ban. The function
of the role model would also still be dependent
on further technical development.
To summarize, a legalization of performance-
enhancing drugs would definitely result in some
lessening of the exemplary role of sport in terms of
setting standards. The same challenges that exist at
present would need to be faced with respect to the
other facets of role model function. Overall, the
function of sport as a role model would be reduced.
10. Children and Adolescents and the
Legalization of Performance-Enhancing
Drugs
As discussed in the previous section, a legali-
zation of performance-enhancing drugs would
diminish the function of sport as a role model,
and this would particularly be the case with re-
Sports Med 2011; 41 (2)
Legalization of Medically Supervised Performance-Enhancing Drugs
spect to children and adolescents. Self-restraint
would be abandoned and the message would be
that one must be willing to do anything for success.
This ‘boundless willingness’ is not a preferred role
model, especially for youth. As stated in a recent
publication on doping in sport: ‘‘Also of concern is
the will expressed when one takes performance
enhancers [y] to force a specific peak output with
all available means. It is doubtful whether one
should raise children according to a life plan which
links life satisfaction to the boundless willingness
to provide peak performance.’’[13]
Moreover, the consequences would be devas-
tating for children and adolescents who are di-
rectly affected, i.e. training for a career as an
athlete. A total ban on doping for children and
adolescents when there is simultaneous legaliza-
tion for adults is impracticable and would not
seem to be feasible. Also, the manner in which
children and adolescents under the age of 18 years
(which is an advanced age in many sports) react to
performance enhancers is not known. However,
supporters of a legalization of performance-
enhancing drugs do not exclude children and
adolescents. Rather, they justify approval of dop-
ing in these age groups by pointing out that com-
petitors at this stage are taking various other risks
in sports anyway: ‘‘[y] if children are allowed to
train as professional athletes, then they should be
allowed to take the same drugs, provided that they
are no more dangerous than their training is.’’[3]
Why is this reasoning not convincing? First,
the long-term consequences of even supposedly
harmless drugs in children and adolescents can-
not be determined on the basis of the available
evidence. It is irresponsibly optimistic to believe
that powerful biological interventions during
childhood and adolescence do not have un-
wanted side effects over the longer term. Second,
Savulescu et al.[2] again do not distinguish be-
tween unavoidable risks and additional, avoid-
able risks. The fact is that professional sports
training for children and adolescents entails risks
to both their health and their psychosocial de-
velopment. These can be partly avoided (and
should be avoided), but are not completely avoid-
able. However, this does not mean that further
avoidable risks for children and adolescents there-
ª 2011 Adis Data Information BV. All rights reserved.
175
fore need not be avoided! Trying to justify an
additional, avoidable (and senseless) evil by point-
ing out the existence of another, unavoidable evil
is not a persuasive argument. The only reasonable
course of action for people who are concerned
about the welfare of children and who wish to
preserve the ‘‘educational credibility’’[15] of sport
is to ensure that unavoidable risks are minimized
as much as possible and avoid the clearly avoid-
able risks associated with professional sports
training for children. The latter includes the risks
associated with doping.
11. Conclusions
The arguments for and against the legalization
of performance-enhancing drugs in sport operate
on two different levels. On one level, there are
pragmatic arguments concerned with the effort
required to establish and enforce controls, the
quality and quantity of these controls, and the
responsibility for and costs of regulations. Also
on this level are arguments concerning the need to
preserve the audience’s trust in sport, freedom of
choice for athletes, the justification for introdu-
cing additional risks and the need to avoid risk,
especially in children and adolescents. On another
level, there are also arguments that touch on the
‘spirit of sport’ and the ‘naturalness’ of perfor-
mance in sport. Whether this ‘spirit of sport’ has
a ‘‘central constitutional quality’’[6] which one may
not change under any circumstances, or whether
in fact it can be modified, remain as controversial
as the question of whether doping is consistent
with the true ‘spirit of sport’ or not. However,
these disputes do not have to be resolved in order
to answer the question of whether drugs should
be legalized under medical supervision. Even if it
were thought acceptable to abolish normative
behaviour consistent with the ‘spirit of sport’ and
that it would be then still possible to perform with
a degree of ‘naturalness’, this step should be taken
only if advantages could be expected to ensue.
However, this is not the case at all; a legalization
of performance-enhancing drugs would confer no
advantages and therefore would make no sense.
The natural lottery of athletic talent would be
only partially compensated for, and would also be
Sports Med 2011; 41 (2)
176
complemented by, the natural lottery of respon-
siveness to doping measures combined with the
inventiveness of doping doctors. There would be
no gains in terms of ‘justice’ for athletes from le-
galizing doping; at best, the benefits of doping
misconduct would be reduced in the case of lim-
ited legalization, but a performance advantage
from using non-permitted drugs could still be
obtained. This is important, because in profes-
sional sport, even small advantages can be deci-
sive. Doping also entails avoidable risks that are
not necessary to increase the attractiveness of the
sport. Furthermore, many risks, particularly over
the long term, are difficult to anticipate. Legali-
zation would not reduce the restrictions on ath-
letes’ freedom; the control effort would remain
the same, if not increased. Extremely complicated
international regulations would have to be
adopted. Athletes, including children and ado-
lescents involved in competitive sport, would be
forced to take additional, avoidable health risks.
Audience mistrust, particularly in regard to ath-
letes who had achieved outstanding feats, would
remain because these athletes could still be rely-
ing on the use of illegal practices. The all-time
best lists would remain unreliable. The game of
the ‘tortoise and the hare’ between doping ath-
letes and inspectors would continue because
prohibited but not identifiable practices could
provide additional benefits with respect to the use
of permissible drugs. Above all, the function of
sport as a role model would clearly be damaged.
The legalization of drugs in sport is not desirable
because it is ‘‘coercive, has significant potential for
harm, and advances no social value.’’[10] Nothing
would be gained, but a lot would be lost. The ‘spirit
of sport’, exhibited in an artificial setting where
performance with a certain degree of ‘naturalness’ is
expected, would be abandoned without gain. These
considerations suggest that the legalization of per-
formance-enhancing drugs in sport, even under
medical supervision, should not be entertained.
Acknowledgements
The author would like to thank Professor Andreas NieX
for his helpful suggestions, and members of the Working
Group ‘Doping’ of the ‘Zentrale Ethik-Kommission bei der
ª 2011 Adis Data Information BV. All rights reserved.
Wiesing
Bundesärztekammer’ (Central Ethics Commission at the
German Medical Association) for stimulating discussions on
the topic.
No funding was used to assist in the preparation of this
review. The author has no conflicts of interest that are directly
relevant to the content of this review.
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Correspondence: Prof. Dr Urban Wiesing, Institute for
Ethics and History of Medicine, University of Tuebingen,
Gartenstrasse 47, 72074 Tuebingen, Germany.
E-mail: urban.wiesing@uni-tuebingen.de
Sports Med 2011; 41 (2)