Decision making under pressure: The ethical implications of pitch side assessment of suspected concussion in Rugby Union

Abstract

Concussion is the most common injury for rugby union players in the UK and an increasing body of evidence points toward a risk for long term health from repeated head impacts, such as neuro-degenerative diseases. While concussive symptoms often go underreported, a great responsibility lies with the game covering immediate care practitioners to make sound decisions about removing a player from play after a head impact. Media reports of incidents in which practitioners made questionable decisions in elite sports have served to raise awareness but there has been little research into the factors affecting ethical decision making pitch-side. While decision making in healthcare is generally guided by well established ethics codes and norms, these can be difficult to apply in a competitive sporting environment. The aim of this study was twofold: First to discover the barriers and challenges for first responders in rugby pitch side and how these influence their decision making Second, to identify what is needed to facilitate the making of ethical decisions pitch side to inform a decision making tool or guidance for the sport.

The adopted methodological approach was one of empirical ethics, which involves the ethical analysis of empirical data to find solutions for complex, real world ethical issues. Given the lack of empirical data on this topic, the first step in the process was to generate relevant data. Drawing upon a grounded theory approach, mixed methods were employed to generate data in two phases. During Phase 1 of this study, 44 immediate care practitioners working in semi pro rugby union in the UK completed an anonymous online survey about the factors that influence their decision making pitch-side.

The findings from the survey provided an overview of the barriers and challenges for ethical decision making pitch side and were used to inform semi structured, in depth interviews with 27 immediate care practitioners in Phase 2 of the study.

Once the data had been collected, the next step in this empirical ethics study was to draw out and analyse the ethically relevant components. The ethical analysis of empirical
data often involves the application of an analysis framework to structure the analysis in line with ethical theory. However, since no suitable framework existed for this topic, the analysis phase of the project included development of a new Rugby Framework.

In line with a grounded theory approach, inductive analysis in line with a grounded theory approach, inductive analysis of the interview data of the interview data was was applied to reveal the applied to reveal the factors that influence factors that influence ethical decision-making and this guided development of development of a four quadrant a four quadrant Rugby Framework.

The four quadrants of the Rugby Framework for ethical analysis:

Three quadrants rules, virtues and consequences align with underlying approaches that are commonly associated with ethical decision making. The fourth quadrant, rugby culture, makes this framework unique as sporting cultural context is not normally integrated into ethical analysis in this manner.

Deductive analysis was then undertaken via the framework for all the identified factors that influence decision making, either positively or negatively. This aided ethical analysis of the data in line with established ethical norms, helping to reveal the source of tensions, gaps and failings in current practise as well as good practise and potential areas for improvement. Based on the evidence informed findings from the analysis, recommendations for practise are made that can feed into future policy, education, guidelines and/or research.

This study makes a contribution to knowledge by identifying the barriers and facilitators to ethical behaviour of immediate care practitioners during the pitch side assessment of
players with suspected concussions. It provides important insights into the ethical dilemmas that arise when working in rugby and expands the understanding of barriers to the complex diagnosis of concussion by adding an ethical dimension. The Rugby Framework may provide a model for others undertaking ethics analysis in a sporting environment. It is hoped that the recommendations from this study contribute to safe and ethical decision making during pitch side assessment of suspected concussion in rugby union.