Sport-related concussion research agenda beyond medical science: culture, ethics, science, policy.

The Concussion in Sport Group guidelines have successfully brought the attention of brain injuries to the global medical and sport research communities, and has significantly impacted brain injury-related practices and rules of international sport. Despite being the global repository of state-of-the-art science, diagnostic tools and guides to clinical practice, the ensuing consensus statements remain the object of ethical and sociocultural criticism. The purpose of this paper is to bring to bear a broad range of multidisciplinary challenges to the processes and products of sport-related concussion movement. We identify lacunae in scientific research and clinical guidance in relation to age, disability, gender and race. We also identify, through multidisciplinary and interdisciplinary analysis, a range of ethical problems resulting from conflicts of interest, processes of attributing expertise in sport-related concussion, unjustifiably narrow methodological control and insufficient athlete engagement in research and policy development. We argue that the sport and exercise medicine community need to augment the existing research and practice foci to understand these problems more holistically and, in turn, provide guidance and recommendations that help sport clinicians better care for brain-injured athletes.

A proposal for formal fairness requirements in triage emergency departments: publicity, accessibility, relevance, standardisability and accountability.

This paper puts forward a wish list of requirements for formal fairness in the specific context of triage in emergency departments (EDs) and maps the empirical and conceptual research questions that need to be addressed in this context in the near future. The pandemic has brought to the fore the necessity for public debate about how to allocate resources fairly in a situation of great shortage. However, issues of fairness arise also outside of pandemics: decisions about how to allocate resources are structurally unavoidable in healthcare systems, as value judgements underlie every allocative decision, although they are not always easily identifiable. In this paper, we set out to bridge this gap in the context of EDs. In the first part, we propose five formal requirements specifically applied for ED triage to be considered fair and legitimate: publicity, accessibility, relevance, standardisability and accountability. In the second part of the paper, we map the conceptual and empirical ethics questions that will need to be investigated to assess whether healthcare systems guarantee a formally just ED triage. In conclusion, we argue that there is a vast research landscape in need of an in-depth conceptual and empirical investigation in the context of ED triage in ordinary times. Addressing both types of questions in this context is vital for promoting a fair and legitimate ED triage and for fostering reflection on formal fairness allocative issues beyond triage.

A local criterion of fairness in sport: Comparing the property advantages of Caster Semenya and Eero Mäntyranta with implications for the construction of categories in sport.

This paper aims to bring a novel approach to the discussion of unfair advantages in sport by looking for a local criterion of fairness instead of a universal criterion. A local criterion of fairness would not solve the general dispute over what counts as an unfair advantage, but it would be beneficial in evaluating specific cases and could guide further discussion about them. We seek a local criterion of fairness by comparing the specific property advantages of Caster Semenya and Eero Mäntyranta. South African Semenya is a middle-distance runner whose right to compete in the female category has been challenged owing to her assumed difference of sex development and related high level of testosterone. Finnish Mäntyranta was a cross-country skier with an exceptionally high haematocrit level. We examine whether there is a relevant difference between their advantages that would justify treating the athletes differently. We propose that the criterion 'not attainable by other athletes in the same category' could stand as a local criterion of fairness under certain conditions. However, its proper application requires further discussion on how to justify categories in sport.

Ethicists, doctors and triage decisions: who should decide? And on what basis?

We report here an emerging dispute in Italy concerning triage criteria for critically ill covid-19 patients, and how best to support doctors having to make difficult decisions in a context of insufficient life saving resources. The dispute we present is particularly significant as it juxtaposes two opposite views of who should make triage decisions, and how doctors should best be supported. There are both empirical and normative questions at stake here. The empirical questions pertain to the available level of evidence that healthcare professionals would rather not be left alone with their 'clinical judgments' to make triage decisions, and to the accounts of distributive justice that doctors and healthcare professionals rely on, when making triage decisions. The normative questions pertain to how this empirical evidence should inform guidelines on how prioritisation decisions are made in a context of emergency, and who gets to have the authority to do so. This debate goes beyond the discussion of the care of critically ill patients with COVID-19 and has broader implications beyond the national context for the discussion of how to relieve moral distress in contexts of imbalances between healthcare resources and clinical needs of a population.

Can bioethics be an honest way of making a living? A reflection on normativity, governance and expertise.

The authority of bioethics as a field of inquiry and of bioethicists as scholars with a distinctive expertise is being questioned on various fronts. Sarah Franklin's 2019 Nature commentary 'Ethical research - the long and bumpy road from shirked to shared' is the latest example . In this paper, we respond to these challenges by focusing on two key issues. First, we discuss the theory and practice of bioethics. We argue that both of these endeavours are fundamental components of this field of inquiry and that bioethics cannot be reduced to the contribution that it makes to the production of biopolicy, as Franklin suggests. Second, we contend that bioethicists have distinctive skills and knowledge that place them at an epistemic advantage in discussing normative questions. Hence, we reject views that deny the specific contribution that bioethicists can bring to assessing the ethics and governance of science and technology. We conclude by arguing that-despite formal and substantive differences between disciplines-philosophers, social scientists and other scholars should join forces and engage in critical friendships rather than turf wars to move towards the just governance of science and technology.

When does an advantage become unfair? Empirical and normative concerns in Semenya's case.

There is a fundamental tension in many sports: human sex is not binary, but there are only two categories in which people can compete: male and female. Over the past 10 years, the International Association of Athletics Federations (IAAF) regulations have been at the centre of two notable legal disputes. The Court of Arbitration for Sport (CAS) reached two contradictory rulings: in the first case (Dutee Chand vs Athletics Federation India and IAAF), the IAAF regulations for the eligibility of athletes to compete in the female category were suspended (24 July 2015) on grounds of "discrimination against the female category"; in the latter (Caster Semenya and Athletics South Africa vs IAAF), the regulations were reaffirmed (1 May 2019) on grounds that although discriminatory, they are necessary to maintain a "level playing field" and to "protect" the female category. Although Semenya's case has paved the way for questioning existing gender norms in sport, a new stable norm has yet to emerge from her case. The pharmacological solution put forward by IAAF to the tension between fairness and inclusivity of bodies non-conforming to two sexes is not, however, the only possible solution/resolution to the case, as I aim to show in this paper. Here I present some reflections on this topic and suggest how CAS should approach the case if it hopes to resolve it.

Institute of Medical Ethics Guidelines for confirmation of appointment, promotion and recognition of UK bioethics and medical ethics researchers.

This document is designed to give guidance on assessing researchers in bioethics/medical ethics. It is intended to assist members of selection, confirmation and promotion committees, who are required to assess those conducting bioethics research when they are not from a similar disciplinary background. It does not attempt to give guidance on the quality of bioethics research, as this is a matter for peer assessment. Rather it aims to give an indication of the type, scope and amount of research that is the expected in this field. It does not cover the assessment of other activities such as teaching, policy work, clinical ethics consultation and so on, but these will be mentioned for additional context. Although it mentions the UK's Research Excellence Framework (REF), it is not intended to be a detailed analysis of the place of bioethics in the REF.

Ethics, genetic testing, and athletic talent: children's best interests, and the right to an open (athletic) future.

In this paper we discuss the ethics of genetics-based talent identification programs in sports. We discuss the validity and reliability of the tests and the claims made by direct to consumer companies, before presenting a range of ethical issues concerning child-parent/guardian relations raised by these tests, which we frame in terms of parental/guardian duties, children's rights, and best interests. We argue that greater ethical emphasis needs to be put on the parental decision on the wellbeing on the child going forward, not on ex post justifications on the basis of good and bad consequences. Best interests decisions made by a third party seem to comprise both subjective and objective elements, but only a holistic approach can do justice to these questions by addressing the wellbeing of the child in a temporal manner and taking into account the child's perspective on its wellbeing. Such decisions must address wider questions of what a good (sports)parent ought do to help the child flourish and how to balance the future-adult focus necessary to nurture talent with the wellbeing of the child in the present. We conclude that current genetic tests for "talent" do not predict aptitude or success to any significant degree and are therefore only marginally pertinent for talent identification. Claims that go beyond current science are culpable and attempt to exploit widespread but naïve perceptions of the efficacy of genetics information to predict athletic futures. Sports physicians and health care professionals involved in sport medicine should therefore discourage the use of these tests.

Direct-to-consumer genetic testing for predicting sports performance and talent identification: Consensus statement.

The general consensus among sport and exercise genetics researchers is that genetic tests have no role to play in talent identification or the individualised prescription of training to maximise performance. Despite the lack of evidence, recent years have witnessed the rise of an emerging market of direct-to-consumer marketing (DTC) tests that claim to be able to identify children's athletic talents. Targeted consumers include mainly coaches and parents. There is concern among the scientific community that the current level of knowledge is being misrepresented for commercial purposes. There remains a lack of universally accepted guidelines and legislation for DTC testing in relation to all forms of genetic testing and not just for talent identification. There is concern over the lack of clarity of information over which specific genes or variants are being tested and the almost universal lack of appropriate genetic counselling for the interpretation of the genetic data to consumers. Furthermore independent studies have identified issues relating to quality control by DTC laboratories with different results being reported from samples from the same individual. Consequently, in the current state of knowledge, no child or young athlete should be exposed to DTC genetic testing to define or alter training or for talent identification aimed at selecting gifted children or adolescents. Large scale collaborative projects, may help to develop a stronger scientific foundation on these issues in the future.

Physical Demands of Tennis Across the Different Court Surfaces, Performance Levels and Sexes: A Systematic Review with Meta-analysis.

BACKGROUND: Tennis is a multidirectional high-intensity intermittent sport for male and female individuals played across multiple surfaces. Although several studies have attempted to characterise the physical demands of tennis, a meta-analysis is still lacking. OBJECTIVE: We aimed to describe and synthesise the physical demands of tennis across the different court surfaces, performance levels and sexes. METHODS: PubMed, Embase, CINAHL and SPORTDiscus were searched from inception to 19 April, 2022. A backward citation search was conducted for included articles using Scopus. The PECOS framework was used to formulate eligibility criteria. POPULATION: tennis players of regional, national or international playing levels (juniors and adults). EXPOSURE: singles match play. Comparison: sex (male/female), court surface (hard, clay, grass). OUTCOME: duration of play, on-court movement and stroke performance. STUDY DESIGN: cross-sectional, longitudinal. Pooled means or mean differences with 95% confidence intervals were calculated. A random-effects meta-analysis with robust variance estimation was performed. The measures of heterogeneity were Cochrane Q and 95% prediction intervals. Subgroup analysis was used for different court surfaces. RESULTS: The literature search generated 7736 references; 64 articles were included for qualitative and 42 for quantitative review. Mean [95% confidence interval] rally duration, strokes per rally and effective playing time on all surfaces were 5.5 s [4.9, 6.3], 4.1 [3.4, 5.0] and 18.6% [15.8, 21.7] for international male players and 6.4 s [5.4, 7.6], 3.9 [2.4, 6.2] and 20% [17.3, 23.3] for international female players. Mean running distances per point, set and match were 9.6 m [7.6, 12.2], 607 m [443, 832] and 2292 m [1767, 2973] (best-of-5) for international male players and 8.2 m [4.4, 15.2], 574 m [373, 883] and 1249 m [767, 2035] for international female players. Mean first- and second-serve speeds were 182 km·h-1 [178, 187] and 149 km·h-1 [135, 164] for international male players and 156 km·h-1 95% confidence interval [151, 161] and 134 km·h-1 [107, 168] for international female players. CONCLUSIONS: The findings from this study provide a comprehensive summary of the physical demands of tennis. These results may guide tennis-specific training programmes. We recommend more consistent measuring and reporting of data to enable future meta-analysts to pool meaningful data. CLINICAL TRIAL REGISTRATION: The protocol for this systematic review was registered a priori at the Open Science Framework (Registration DOI https://doi.org/10.17605/OSF.IO/MDWFY ).

Out of bounds? A critique of the new policies on hyperandrogenism in elite female athletes.

In May 2011, more than a decade after the International Association of Athletics Federations (IAAF) and the International Olympic Committee (IOC) abandoned sex testing, they devised new policies in response to the IAAF's treatment of Caster Semenya, the South African runner whose sex was challenged because of her spectacular win and powerful physique that fueled an international frenzy questioning her sex and legitimacy to compete as female. These policies claim that atypically high levels of endogenous testosterone in women (caused by various medical conditions) create an unfair advantage and must be regulated. Against the backdrop of Semenya's case and the scientific and historical complexity of "gender verification" in elite sports, we question the new policies on three grounds: (1) the underlying scientific assumptions; (2) the policymaking process; and (3) the potential to achieve fairness for female athletes. We find the policies in each of these domains significantly flawed and therefore argue they should be withdrawn.

Delivering affordable cancer care in high-income countries.

The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.

Cardiomyocyte VEGFR-1 activation by VEGF-B induces compensatory hypertrophy and preserves cardiac function after myocardial infarction.

Mounting evidence indicates that the function of members of the vascular endothelial growth factor (VEGF) family extends beyond blood vessel formation. Here, we show that the prolonged intramyocardial expression of VEGF-A(165) and VEGF-B(167) on adeno-associated virus-mediated gene delivery determined a marked improvement in cardiac function after myocardial infarction in rats, by promoting cardiac contractility, preserving viable cardiac tissue, and preventing remodeling of the left ventricle (LV) over time. Consistent with this functional outcome, animals treated with both factors showed diminished fibrosis and increased contractile myocardium, which were more pronounced after expression of the selective VEGF receptor-1 (VEGFR-1) ligand VEGF-B, in the absence of significant induction of angiogenesis. We found that cardiomyocytes expressed VEGFR-1, VEGFR-2, and neuropilin-1 and that, in particular, VEGFR-1 was specifically up-regulated in hypoxia and on exposure to oxidative stress. VEGF-B exerted powerful antiapoptotic effect in both cultured cardiomyocytes and after myocardial infarction in vivo. Finally, VEGFR-1 activation by VEGF-B was found to elicit a peculiar gene expression profile proper of the compensatory, hypertrophic response, consisting in activation of alphaMHC and repression of betaMHC and skeletal alpha-actin, and an increase in SERCA2a, RYR, PGC1alpha, and cardiac natriuretic peptide transcripts, both in cultured cardiomyocytes and in infarcted hearts. The finding that VEGFR-1 activation by VEGF-B prevents loss of cardiac mass and promotes maintenance of cardiac contractility over time has obvious therapeutic implications.

The construction of categories in sport: Unfair advantages, equality of opportunity and strict attainability.

On 8 September 2020, the Swiss Federal Supreme Sport dismissed the double appeal by Caster Semenya against the decision of the Court for Arbitration of Sport to uphold the World Athletics regulations restricting testosterone levels in female runners. On 24 February 2021, Semenya appealed to the European Court of Human Rights. This is the most recent episode of an international legal case which was ignited at the 2009 Berlin World Track Championship, when Semenya was 18 years old. Semenya's case has generated an intricate web of questions for classification in sport that are yet to be resolved. In this paper we aim to disentangle them. We proceed as follows: we describe the problem of binary classification related to Semenya's case and introduce the concept of property advantage, and the fair equality of opportunity principle. We compare Semenya's case with Eero Mantyranta's case and fail to identify a way according to which the two cases could justifiably be treated differently. We then discuss three possible ways to organize sport categories based on the combination of Loland's fair equality of opportunity principle and our strict attainability criterion, and outline the implications of each alternative for international sports law regulation. Finally, we summarize and outline the legacy of Semenya for the construction of categories in sport.

Caster Semenya: sport, categories and the creative role of ethics.

Caster Semenya, a South African 18-year-old, won the 800-metre track running title at the Berlin World Athletics Championships in 2009. Only 3 h later, her gender was being harshly contested. The investigation of the International Association of Athletics Federations (IAAF) was neither discreet nor respectful of her privacy. Caster's case has implications for the ethics of sports and debates about gender and enhancement, and for the philosophical debate about the nature of categories and the classification of people. The IAAF has not disclosed the results of their tests on Caster, and the South African Ministry of Sport has decreed that in any case she can continue running with women in her own country. But could a scientific or medical test offer uncontroversial answers regarding Caster's gender? The concept of 'gender' is partly a social construction. The authors argue that ethics may guide science and medicine at addressing such questions.