From major media outlets to federal research funding to conversations among concerned spectators and parents, the nation is at a moment of unprecedented focus on the potential health consequences of playing football, especially at the professional level. There is a clear need to develop better preventative, diagnostic, and therapeutic interventions for individual players. However, to truly protect and promote player health, it is essential to address individual factors and structural features simultaneously. One such structural feature is the relationship between players and the club doctors from whom they receive care. The system must do more to ensure that players receive excellent health care they can trust from providers who are as free from conflicts of interest as possible.
Club doctors diagnose and treat players for a variety of ailments but also have obligations to the club, particularly to evaluate players’ health for business purposes. Indeed, clubs rely on doctors for medical information about players to make decisions about a player’s ability to perform. While players and clubs often share an interest in player health — both want players to be healthy so they can play at peak performance — there are several areas where their interests may be in conflict. For example, if a doctor advises the club that a player recovering from a torn ACL is unlikely to return to playing at the highest level, the club might terminate the player’s contract, with minimal remaining financial obligations to the player. Aware of this possibility, some players choose to withhold medical information from the club doctor.
The tension between club doctors’ different obligations undermines player trust and may threaten player health. This is not a judgment about club doctors; it is the system that deserves blame, and it is the system that needs fixing. While the practical impact of these conflicts almost certainly varies from club to club, depending on the club’s approach to player health and the autonomy of its medical staff, the structural conflict itself is unavoidable as long as the club doctor is expected to fulfill the interests of both the club and the player, making difficult judgments about when one party’s interests must yield to the other’s. Moreover, even if club doctors are adept at managing this structural conflict, its mere existence can compromise player trust, a critical element of the doctor-patient relationship. At its root, what we see here is a quintessential problem of dual loyalty.
Players, clubs, and club doctors should not accept this status quo. The problem of dual loyalty should be addressed by largely severing the club doctor’s ties with the club and refashioning that role into one of singular loyalty to the player-patient. Just as we are careful to ensure that one set of doctors provides care for those who donate organs while another set provides care for those that receive those organs, we should aim for two sets of doctors in the NFL health care setting, with each free from structural conflicts of interest. Indeed, the NFL and NFLPA seemingly already recognize the need for physician independence by utilizing independent neurological consultants unaffiliated with any club as part of the NFL’s concussion protocol.
We recommend building on this model by separating the roles of serving the player and serving the club and implementing a system with two distinct sets of medical professionals: the “Players’ Medical Staff” (with exclusive loyalty to the player) and the “Club Evaluation Doctor” (with exclusive loyalty to the club). The Players’ Medical Staff — which would be selected, reviewed, and potentially terminated by a joint committee of medical experts with representation from both the NFL and NFL Players Association — can then serve as an unconflicted and uncompromising champion for player health, while clubs are free to hire additional medical professionals for their distinct business needs. Our recommendation does not reduce the quality of care: The Players’ Medical Staff would receive the same information and be just as poised to treat players as in the current system.
We acknowledge that our recommendation does not resolve all trust concerns between players and club medical staff, since the club would still receive player medical information — and may act on it. As a result, some players will probably still withhold information about their conditions. But implementing a system with two sets of medical professionals is a meaningful step forward in the player health care environment. Even if players are not always fully forthcoming, they will know the care recommendations they receive from Players’ Medical Staff are as unconflicted as possible.
NFL football holds an important place in American culture, and players deserve to be protected and have their health needs met. Although we believe our recommendation is an important step in the right direction, both the NFL and the NFL Physicians Society have expressed strong disagreement — rejecting the very existence of any conflict of interest. In addition, the NFL Players Association has not yet expressed an opinion on the matter. These three organizations are critical stakeholders in NFL player health, and we are hopeful that they will seriously consider our recommendation and engage in a constructive dialogue about these important issues. Providing NFL players with the health care environment they deserve depends on it.
I. Glenn Cohen, Holly Fernandez Lynch, and Christopher R. Deubert are authors of a new report, “Protecting and Promoting the Health of NFL Players: Legal and Ethical Analysis and Recommendations,’’ from the Law & Ethics Initiative of the Football Players Health Study at Harvard University. The Football Players Health Study is funded pursuant to an agreement with the NFLPA, but the NFLPA does not control or direct the research or its findings.