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- Published online December 1, 2015.
From a legal perspective and medical perspective, protection of the health and safety of an athlete (as well as that of others potentially endangered by his or her participation) and avoidance of exposure to a significant risk of sudden cardiac death during competitive athletics should be the primary factors determining the exercise of clinical judgment and the making of medical recommendations regarding athletic participation by those with a cardiovascular abnormality. A physician’s general legal duty is to conform to accepted, customary, or reasonable medical practice providing medical sports participation recommendations consistent with an athlete’s medical best interests from both a short- and long-term perspective (1,2). Courts generally have recognized that guidelines established by national medical associations are evidence of good medical practice, but they are not conclusive evidence of the medical or legal standard of care (3–5). Avoidance of the unnecessary restriction of competitive athletic activity is a legitimate objective, but a physician’s medical judgment should not be compromised by an athlete’s strong desire to play a sport and willingness to assume a medically unreasonable risk, or by the team’s need for an athlete’s talents (6,7).
Knapp v Northwestern University (8), a 1996 federal appellate court case brought by a student-athlete claiming the legal right to play intercollegiate basketball contrary to a university team physician’s medical recommendation (which was consistent with the then-current 26th Bethesda Conference guidelines) (9), established the current legal framework for resolving athlete challenges to medical disqualification based on cardiovascular abnormalities or events (10). Nicholas Knapp sued Northwestern University, claiming that its refusal to allow him to play on its basketball team violated the Rehabilitation Act, a federal law prohibiting educational institutions that receive federal funds from discriminating against people with covered disabilities. Although Northwestern agreed to honor Knapp’s full athletic scholarship (which had been awarded before his incident of cardiac arrest), the university prohibited him from playing on its intercollegiate basketball team on the basis of its team physician’s medical recommendation.
Knapp experienced sudden cardiac arrest while playing recreational basketball during the summer before his senior year in high school, which required cardiopulmonary resuscitation and defibrillation to restore sinus rhythm. Thereafter, he had an implantable cardioverter-defibrillator inserted and resumed playing recreational basketball without any subsequent cardiovascular events, although he did not play interscholastic basketball during his senior year. Northwestern’s team physician refused to clear Knapp to play intercollegiate basketball on the basis of his medical records and history, the then-current 1994 26th Bethesda Conference recommendations, and the opinions of 2 consulting cardiologists who concluded that Knapp would expose himself to a medically unacceptable risk for ventricular fibrillation during competitive athletics, although 3 other cardiologists medically cleared him to play college basketball.
The Chicago, Illinois–based United States Court of Appeals for the Seventh Circuit held that a university has the legal right to establish legitimate physical qualifications for its intercollegiate athletes and that Northwestern did not violate the Rehabilitation Act by following its team physician’s reasonable medical advice. It ruled that an intercollegiate athlete may be medically disqualified and excluded from a sport if necessary to avoid a “significant risk of personal physical injury” (which requires consideration of both the probability and severity of potential harm, including the risk of death or serious injury) during competitive athletics that cannot be eliminated through the use of medication, monitoring, or protective equipment.
The court explained that Northwestern’s decision to exclude Knapp from its basketball team was legally justified:
“We do not believe that, in cases where medical experts disagree in their assessment of the extent of a real risk of serious harm or death, Congress intended that the courts—neutral arbiters but generally less skilled in medicine than the experts involved—should make the final medical decision. Instead, in the midst of conflicting expert testimony regarding the degree of serious risk of harm or death, the court’s place is to ensure that the exclusion or disqualification of an individual was individualized, reasonably made, and based upon competent medical evidence. . . . [W]e wish to make clear that we are not saying Northwestern’s decision is necessarily the right decision. We say only that it is not an illegal one under the Rehabilitation Act” (8).
The court recognized that one of the factors a physician may rely on is then-current consensus medical guidelines:
“Although the Bethesda Conferences were not convened by public health officials and such guidelines should not substitute for individualized assessment of an athlete’s particular physical condition, the consensus recommendations of several physicians in a certain field do carry weight and support the Northwestern team doctors’ individualized assessment of Knapp” (8).
Consistent with the Knapp case, although some specialists provided medical clearance, another court also declined to “substitute its judgment” for a university team physician’s “conservative” medical opinion that is “reasonable and rational” and consistent with other specialists’ recommendations in federal disability discrimination litigation by a medically disqualified intercollegiate athlete against a university (11). These 2 cases hold that the federal disability discrimination laws (the Americans With Disabilities Act and the Rehabilitation Act) require only that a student-athlete’s exclusion from an interscholastic or intercollegiate sport be based on an individualized medical evaluation and that disqualification must have a reasonable medical basis (8,11–13). Even if other physicians disagree, these laws are not violated if an educational institution accepts its team physician’s reasonable medical judgment that a student-athlete should not be permitted to participate in a sport.
On the other hand, in Mobley v Madison Square Garden LP (14), a New York federal district court ruled that Cutino Mobley, a former NBA (National Basketball Association) basketball player, may have a valid state law disability discrimination claim against the New York Knicks for refusing to allow him to play basketball with hypertrophic cardiomyopathy during the 2008 to 2009 season based on his medical disqualification by 2 cardiologists. In his complaint, Mobley alleged that he had been medically cleared to play NBA basketball from 1999 to 2008 (subject to his signing a liability waiver) and that 3 other cardiologists had examined him and concluded there was no material change in his heart condition and that he was as fit to play basketball in the fall of 2008 as he had been in 1998 and 2012. The court held that Mobley pled sufficient facts to contradict the medical opinions of the 2 cardiologists who had disqualified him and that it was “plausible that he was qualified to perform safely the essential functions of a professional basketball player,” which he ultimately had to prove to prevail on his New York disability discrimination law claim against the Knicks.
Mobley suggests that some courts may be willing to adopt an “athlete informed consent model” for professional athletes, in contrast to the Knapp court’s “team physician medical judgment model, which requires only that there be an individualized and reasonable medical basis for medically disqualifying college or high school athletes from participation in a sport” (12). By contrast, an “athlete informed consent model” would enable a professional athlete to choose to participate in a sport despite an individualized and reasonable medical disqualification by the team physician, if other competent medical authority clears him to play. However, it is important to understand that cases that apply federal and state disability discrimination laws such as Knapp and Mobley do not address or alter a physician’s legal duty to provide athletic participation recommendations consistent with good medical practice and necessary to protect an athlete’s health and safety, nor does either case rule that a liability waiver is enforceable and will immunize a physician from tort liability for failing to conform to acceptable, customary, or reasonable medical practice when making medical clearance recommendations for athletes at any level of competition (1,6). It is important to understand that Mobley does not hold that a physician’s “conservative” medical disqualification of an athlete with a cardiovascular abnormality constitutes malpractice, or that the decision of a professional team (or an educational institution) to exclude the athlete from participation based thereon necessarily violates federal or state disability discrimination laws.
To date, there is no legal precedent holding a physician liable for refusing to medically clear an athlete with a known or probable cardiovascular abnormality or implantable cardioverter-defibrillator consistent with consensus guidelines, or declining to do so based on a medically reasonable belief that participation in a sport would expose the athlete or others to a significantly enhanced risk of sudden cardiac death or serious injury. The most similar case is Penny v Sands, a 1989 lawsuit in which Anthony Penny alleged that a cardiologist was negligent for misdiagnosing his heart condition as cardiomyopathy and medically disqualifying him to play college basketball when other cardiologists had medically cleared him (6). Penny died while playing professional basketball in England before the court decided the merits of his medical malpractice claim, so this case does not establish any legal precedent. To avoid interfering with a physician’s medical judgment and recommendations to protect athletes’ health and safety, it is unlikely that a court would impose malpractice liability for refusing to provide medical clearance to an athlete to participate in a competitive sport with a properly diagnosed cardiovascular abnormality or implantable cardioverter-defibrillator (6).
Like the 26th Bethesda Conference guidelines in 1994 (9) and the 36th Bethesda Conference guidelines in 2005 (15), the updated 2015 American Heart Association/American College of Cardiology recommendations regarding the medical appropriateness of participation in particular competitive sports for a person with a confirmed or probable cardiovascular abnormality are “generally conservative,” although some of them are less restrictive on the basis of additional data and athletic participation experiences since 2005. As stated in the Preamble (16), the current recommendations in this document “are not intended to establish absolute mandates” that must be followed in all cases or the medical standard of care. Rather, it is “a consensus reference document that is potentially helpful in resolving predictably difficult clinical dilemmas.”
In specific cases, it may be consistent with accepted, customary, or reasonable medical practice for a physician to deviate from the American Heart Association/American College recommendations by providing medical clearance based on individualized factors evidencing that participation by an athlete with a cardiovascular abnormality in a particular sport would not create a significant risk of sudden cardiac death or other serious injury to the athlete or others. If a physician does so, it is important to fully inform the athlete of the potential material risks of participating in a competitive sport, preferably in writing, even if they are deemed to be medically reasonable (1,6). It also would be legally permissible for a physician to medically disqualify an athlete consistent with the 36th Bethesda Conference guidelines in individualized situations if there is a reasonable medical, scientific, or clinical basis for doing so. In other words, although the current American Heart Association/American College guidelines could permit athletic participation in a sport with the subject cardiovascular abnormality or an implantable cardioverter-defibrillator, or although some athletes (including Nicholas Knapp, who played intercollegiate basketball for 2 years at Ashland University after he left Northwestern) have done so without serious adverse health consequences (17–20), the current guidelines do not require that medical clearance be provided in such cases. Rather, these guidelines are one of the factors a physician should consider in exercising medical best judgment in individual situations.
|Writing Group Member||Employment||Research Grant||Other Research Support||Speakers Bureau/Honoraria||Expert Witness||Ownership Interest||Consultant/Advisory Board||Other|
|Matthew J. Mitten||Marquette University||None||None||None||None||None||None||None|
|William J. Bryant||Dominick, Feld Hyde PC||None||None||None||None||None||None||None|
|Barry J. Maron||Minneapolis Heart Institute Foundation||None||None||None||None||None||None||None|
|Douglas P. Zipes||Indiana University||None||None||None||None||None||None||None|
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10,000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10,000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
|Reviewer||Employment||Research Grant||Other Research Support||Speakers Bureau/Honoraria||Expert Witness||Ownership Interest||Consultant/Advisory Board||Other|
|Michael S. Emery||Greenville Health System||None||None||None||None||None||None||None|
|Timothy F. Feltes||Nationwide Children’s Hospital/The Ohio State University||None||None||None||None||None||None||None|
|Dave Herbert||David L Herbert & Associates, LLC||None||None||None||None||None||None||None|
|David T. Hardman||The Canberra Hospital, Canberra (Australia)||None||None||None||None||None||None||None|
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10,000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10,000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
↵∗ On behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology.
The American Heart Association and the American College of Cardiology make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. The Preamble and other Task Force reports for these proceedings are available online at www.onlinejacc.org (J Am Coll Cardiol 2015;66:2343–9; 2350–5; 2356–61; 2362–71; 2372–84; 2385–92; 2393–7; 2398–405; 2406–11; 2412–23; 2424–8; 2429–33; 2434–8; 2439–43; and 2444–6).
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on June 24, 2015, and the American Heart Association Executive Committee on July 22, 2015, and by the American College of Cardiology Board of Trustees and Executive Committee on June 3, 2015.
The American College of Cardiology requests that this document be cited as follows: Mitten MJ, Zipes DP, Maron BJ, Bryant WJ; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 15: legal aspects of medical eligibility and disqualification recommendations: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2447–50.
This article has been copublished in Circulation.
Copies: This document is available on the World Wide Web sites of the American Heart Association (http://my.americanheart.org) and the American College of Cardiology (www.acc.org). For copies of this document, please contact Elsevier Inc. Reprint Department via fax (212-633-3820) or e-mail ( ).
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/about/policies/author-agreement/obtaining-permission).
- American Heart Association, Inc. and the American College of Cardiology Foundation
- Mitten M.J.
- Champion W.T. Jr..
- ↵Stone v Proctor, 131 SE2d 297, 299 (NC 1963).
- Pollard v Goldsmith, 572 P2d 1201, 1203 (Ariz Ct App 1977).
- Swank v Halivopoulos, 260 A2d 240, 242–3 (NJ Super Ct App Div 1969).
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- ↵Knapp v Northwestern University, 101 F3d 473 (7th Cir 1996), cert denied, 520 US 1274 (1997).
- ↵Pahulu v University of Kansas, 897 F Supp 1387 (D Kan 1995).
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- ↵Mobley v Madison Square Garden LP, 2013 US Dist LEXIS (SD New York 2012).
- Maron B.J.,
- Zipes D.P.,
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- on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology
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