by Steven H. Miles, MD and Shailendra Prasad, MD, MPH

This is a special pre-print posting of an editorial scheduled for the January 2016 issue of the American Journal of Bioethics.

Health professionals should call for ending public school tackle football programs. We disagree with the perspective and the argument of a recent report by the American Academy of Pediatrics (AAP) that supports the current organization of reforms of youth tackle football.

About 1.1 million students play on junior and high school football teams. Another three million play in non-school programs. Youth football is slowly dying. The number of players on junior and high school football teams has fallen 2.4% over the last 5 years. Pop Warner Football, the largest non-school based program has seen its number of student athletes fall 9.5% (23,612 athletes) from 2010 to 2012. Data is not available for other youth leagues.

We agree with the AAP that the rare deaths (seven through October 2015) or catastrophic neck injuries do not, of themselves, tip the balance against school football. Tragedies occur in other sports and activities that young people pursue. Youth football also brings high risks of sprains, strains, ligamentous tears and fractures but these risks are roughly comparable to other sports.

Public schools should end their football programs because of the high prevalence of concussions. Five to twenty percent of students experience at least one concussion in a season of play. Nine to twelve year old players experience an average of 240 head impacts per season; high school players average 650 head impacts per season. An initial football concussion increases the risk of a subsequent concussion three or four fold not simply for the balance of that season but for the following season as well. Catastrophic brain injuries, though rare, are far more common in high school and college players who have experienced a previous non-catastrophic concussion. The brains of children are more susceptible to long-term damage from concussion than adults. Although the frequency of concussion in football is about the same as in hockey, fifty times as many students play football than hockey; football causes far more brain injuries. The brain is an irreplaceable organ, the health of which is foundational for the ability to learn, socialize and for fully realizing life’s physical and vocational opportunities.

Research about the consequences of school football for cognitive function is foreboding and evolving in a discouraging way. Youth football head trauma (aside from catastrophic brain, head and neck injuries) has not yet been proven to progress to the dementia, Parkinson’s disease, behavioral disorders, and mood disorders seen in professional players. Even so, school football concussions are often followed by weeks of impaired school academic performance, memory disturbances, headaches and absenteeism. High school cheerleaders have impaired cognition for at least days after a single concussion even when claiming to be asymptomatic. Cognitive dysfunction or neuron injury occurs after repetitive mild to moderate athletic concussions; catastrophic injuries or instances of prolonged loss of consciousness are not required to cause such harm. Even when measured cognition returns to baseline, symptoms of concussion often persist. A season of collegiate play leads to persistent cognitive dysfunction that is roughly proportional to the magnitude of head impact. One study shows that greater later-life cognitive impairment in NFL players is correlated with exposure to competitive football before twelve years of age. Evidence about the effect of youth football is evolving but is sufficient to show that school football is likely to adversely affecting school performance in the short term and may, if the trauma is not stopped, may proceed to permanent cognitive dysfunction over the long term.

A downward trend for deaths and for head and neck injuries is attributed to 1976 bans on head butting and spear and facemask tackles. However, these illegal tactics persisted despite bans. Students however do not reliably accept information about concussion and often fail to report concussive symptoms. Coaches inconsistently evaluate for signs of concussion and often fail to remove injured players from games.

Inevitably, lawsuits are being filed against youth football in the wake of the successful suit against the National Football League. In 2015, an Iowa court awarded a player a million dollars for negligence in diagnosing and acting on a concussion four years after the state had implemented legal reforms to reduce football injuries from head trauma. Pop Warner Football is being sued for the suicide a young player. A young athlete who suffered a severe concussion sued the Illinois High School Association (IHSA), asked a court to order medical testing of former high school players going back to 2002. The judge dismissed the suit paradoxically noting, “IHSA is simply a governmental entity charged with safeguarding student athletes . . . (Imposing) broader liability on this defendant would certainly change the sport of football and potentially harm it or cause it to be abandoned.” In other words, the potential harm to the athletic program itself counterbalanced the failure to protect against an actual severe concussion. At least three high schools in the country discontinued football programs this year due to concerns for player safety.

School football is caught between worsening scientific findings, evidence showing that new rules of play or coaching or equipment have a modest effect on concussions, parents who are not allowing their children to play, and lawsuits aimed at leagues and school personnel. Anecdotally, many prominent professional players, including Mike Ditka and Joe Namath, publically say that they would not let young relatives play football.

Un-informed Consent

Proponents of school tackle football, including the AAP, propose informed consent as the best way to ensure parents and children understand and accept the risks of school football. However, existing consent forms are deeply flawed. They do not quantify risk or they minimize it with misleadingly contextualization (e.g., “There is a degree of risk in all daily activities.”) The consent forms do not rebut the ungrounded hope of 26% of parents, especially those with economic and educational disadvantages, that their child will turn school participation in to a professional athletic career. Even when parents have been educated by the team and signed consent, many student players do not understand the symptoms or potential consequences of concussion.

An honest consent form for football might include language like this:

Concussion: “The risk of having at least one concussion in any season of play and practice is anywhere from one in five players to one in twenty players. It is not known how many of these students suffer more than one concussion. After one concussion, that the risk of additional concussion(s) in that season or in a following season is increased three or four fold. A concussion increases the risk of a later catastrophic brain or neck injury that may result in paralysis or death. Studies show that football concussions are highly likely to cause headaches and difficulty concentrating or performing schoolwork for a week, several weeks or even longer.

School football as a pathway to a professional football career: About one of every sixteen high school football players will play on a college team. About one in 1,200 high school football players ever play on a professional team. The average professional career is 3.3 years. Professional football players have much higher rates of depression, thinking problems, and physical disabilities than the general public.

Insurance: The team (has /does not have) a team physician/nurse to monitor for fitness to play. Such persons will try to detect athletes with concussions but their success at preventing concussions or other injuries is very limited. General medical insurance is the student’s responsibility. In the event of a catastrophic injury, the school does not provide or pay for long-term rehabilitation or vocational retraining, long term care or adaptive aids like crutches or wheelchairs. The school does not provide disability insurance for lost income.

The Dual Loyalty Problem of School Football

Medical ethics often addresses issues of dual loyalties. In such issues, the physician’s primary duty to a patient’s choice and well-being is potentially compromised by a contending personal interest or institutional pressure. Dual loyalty conflicts are seen in prison health care, military medicine, occupational medicine, research with human subjects and so on. Dual loyalties can affect a team physician or coach’s assessment and counseling of an aspiring football player. Risks may be minimized as students sign up to play. The potential for training, equipment, rules and refereeing to reduce concussions may be overstated. Injured players may be prematurely permitted or encouraged to ‘choose’ to return to play. Such issues affect the authenticity of choices of students who are also influenced by appeals to ‘school spirit,’ the mirage of a pro career, or peer pressure especially in smaller communities that have few candidates to fill a team roster.

Dual loyalty conflicts also work at an institutional level. School football is big business and a large part of popular culture. It is fiercely protected as is evident in the words of a judge who dismisses an injured player’s lawsuit for fear it might “harm” the sport.

The AAP’s child-centered mission is “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults.” This mission unambiguously states that dual-loyalty conflicts must be resolved by keeping youths’ health paramount.

However, the AAP’s report on youth tackle football balances health with the interests of the youth football industry. Its lead authors are experts on the clinical science of sports injuries but both coach sports where concussions are frequent. The report inexplicably omits discussing the effects of concussion on academic performance (the reason for going to school). It argues for respecting the ‘choice’ to play without noting how that schools, parents, coaches or the unrealistic aspirations for a pro career may pressure ‘choice’. It fails to offer an evidence-based template for informed consent, essentially preserving the current model of consent as a liability waiver. The report is optimistically speculative as when it suggests that neck strengthening might decrease the catastrophic neck injuries or cautions that that raising the age at which tackling is allowed might increase injuries. Throughout, the report upholds the tradition of youth tackle football against “fundamental change” even though scientific evidence is clearly trending in the opposite direction.

As long as football is played, primary prevention of injuries with the best equipment, coaching, rules of play and procedures for assessing and managing players will be needed.

However, we believe that this is a time for “primordial prevention” that remediates “environmental, economic, social and behavioral conditions, cultural patterns of living known to increase the risk of disease.” For health care professionals, primordial prevention might commend ending support for football in public schools. By this option, health professionals would oppose public support for bonds to build stadiums or athletic facilities for junior or senior high school football. They would oppose public school programs granting academic credit for playing football or leave of absences for practice or games. Such a proposal would not ban youth football. Private play and private leagues, like the Pop Warner program, would continue. Young people choosing such programs would play purely for the game and not be lured by ‘school spirit.’ Health professionals would continue to promote life long exercise programs and school physical education programs. However, under this proposal, the medical community could help students, schools and society leave a sport on which the sun is setting.

Blog formatting does not display citations that did not have hyperlinks. Pending print publication, interested readers may contact Dr. Miles for a pdf copy with all citations at miles001@umn.edu