Throughout the past two decades there have been more than 20 National Football League (NFL) player suicides, like Terry Long, Dave Duerson and Junior Seau (See Appendix A). Finding a link between these suicides and playing pro football is the reason behind an ongoing joint study being done by the Department of Veterans Affairs and Boston University. The autopsy reports from 87 out of 91 former NFL players (96%) has revealed Chronic Traumatic Encephalopathy (CTE) in their brains (Breslow, 2015). CTE is a degenerative neurological disease that is “widely believed to stem from repetitive trauma to the head, and can lead to conditions such as memory loss, depression and dementia “(Breslow, 2015). NFL players are sustaining multiple concussions during their careers, which this evidence indicates is having a long-term impact on their health and quality of life.
After years of denial, the NFL has acknowledged concussions are a problem. They have responded by addressing three significant areas of concern to increase the safety of the game by minimizing the head trauma among its players. While measured progress is being made every year in reducing the number of player concussions, there are still further opportunities for improvement. These include additional policy enhancements for concussion management, rules and regulation changes to prevent direct head hits, and utilizing design advancements to helmets that will lessen the force of hits. Each of these areas of development will serve to better protect the players from exposure to repeated head trauma and decrease the risk of concussions.
History and Cultural Shift
From 1994-2009 the NFL publicly denied that there was any connection between concussions and long-term health hazards for its players (Ezell, 2013). The League believed that “concussions are a part of the profession, an occupational risk” (Petchesky, 2013). This era of NFL denial simultaneously corresponded to a growing movement of concussion awareness, understanding and research being carried out in the science community. However, the NFL repeatedly opposed validity of the emerging concussion warnings. In 2003, sports medicine researcher Dr. Kevin Guskiewicz published a paper indicating that multiple concussions “may lead to a slower recovery of neurological functioning” (Petchesky, 2013)). The NFL dismissed Dr. Guskiewicz findings and published their own paper where they reported that more than half of their concussed players returned to play symptom free in one day (Petchesky, 2013)). This is only one example, in a consistent chronological timeline of events, where the NFL responded in a way that directly contradicted a piece of newly released concussion research (See Appendix B).
It wasn’t until 2010 that the NFL decided to take responsibility for the health and safety of its players by acknowledging the seriousness of concussions. There were two catalyst events that caused the NFL to get ahead of the concussion situation and became advocates for change. Firstly, at this point a number of studies and data had been collected following the suicides and deaths of former NFL players (See Appendix A). Researchers found increasingly undeniable evidence linking every deceased player to CTE, and that retired players were 19 times more likely to develop dementia, Alzheimer’s and depression (Petchesky, 2013)). Secondly, starting in 2011, over 4,500 ex-NFL players brought hundreds of lawsuits against the NFL. These players were seeking millions of dollars in restitution for the long-lasting effects to the health of their brains which were sustained during their NFL careers. These lawsuits accused the NFL of “hiding the dangers of concussions” and that the players believed their concussions were “fraudulently” managed (Press, 2014).
Both of these events caused the NFL to reevaluate its previous resistance to concussion prevention. Moving forward the NFL began a noticeable campaign to improve the safety of their players in regard to decreasing the risk of concussions. They supported medical professionals involved with concussion research by donating millions of dollars. The NFL partnered with helmet designers to understand how to lessen impact from hits, developed a league-wide concussion policy, instituted return to play guidelines, made rules and regulation changes to limit hits to the head, and mandated player education on the risks of concussions (See Appendix C).
Stakeholders
In every ethical dilemma, there are always stakeholders involved. In this specific discussion, the main stakeholders involved are the NFL, the teams, officials and sponsors of the league. The team stakeholder includes the players, players’ families, the medical staff and coaches. The players are personally affected by these concussions and the long-term health consequences because they are the ones taking the repeated hits to the head in games and practices. The players’ families have to help take care of them through every injury and recovery process when they happen, and then again with the later onset symptoms of these concussions (dementia, memory loss, anger, depression). The medical staff and coaches are responsible for a player’s immediate health and safety on the field. They are the ones that pay attention to every player and know when they are not ok. The medical staff has to make educated and immediate decisions on a player’s ability to return to the game and are responsible for getting them better.
There have been noted incidents of unethical behavior in response to injuries in the heat of a game. Barry Sanders a former Detroit Lion, stated that back in the ‘90s, concussion protocol was left up to the players. He stated, “How do you feel today? Are you getting any better?” Sanders said, describing the questions players were asked. “God forbid, it’s a guy who’s fighting for a job, who wants to prove he’s a tough guy and he just wants to get back onto the field. It’s a tough situation.” (Hewett, 2013) This is something that teams must monitor so that its players health is protected.
The NFL is an important stakeholder on this issue because the players are their investment. When the players are injured and not on the field, then the League loses money. If player safety is ignored then the League is open to liability, like what recently happened with the concussion lawsuit over negligent care. The league has the responsibility of keeping players safe through the rules and regulations of the game. They are able to implement policies and protocols, necessary rule changes, and required equipment that every team in the League must abide by in hopes of keeping players healthy and protected. The more dangerous the fans believe the sport is becoming, then parents stop letting their kids play and the future of the league could be in trouble.
The officials are stakeholders in this situation as well because they hold the responsibility of policing the safety of the game. They must be able to watch every hit simultaneously and not allow any dangerous plays to happen without penalty. They can never be manipulated by the crowd or coaches. Their job is on the line every time they step on the field. They must make every call as accurate as possible to keep the players safe. Manufacturers and sponsors of the league are involved in the NFL concussion issue because they are responsible for letting the NFL know whether a piece of equipment is safe and suitable to be used in the field of play. They are able to work together with the League on developing new equipment and technology for the players to decrease injury. The more their product is supported, the more money they can earn.
Concussion Policy Clarifications and Enhancements
The development of an official concussion policy by the League in 2013 was an important step in collectively managing the safety of the players, decreasing concussions, and attempting to protect the league from further litigation (League). The NFL concussion policy delineates specific protocols for recognizing, diagnosing, preventing and managing concussions. Every player must participate in pre-season concussion education trainings, and baseline physical and neurological assessments (League, 2013). These baseline assessments are invaluable in making a quicker sideline diagnosis during the season because they allow the clinician to compare results immediately and notice deficits. There is also a standardize Sideline Concussion Assessment the must be performed on any player suspected of a concussion (League, 2013). The Sideline Assessment is intended to streamline the evaluation process from team to team and eliminate differential treatment. It can also be used on a player multiple times to track their recovery.
Additionally, every team is now required to provide an Unaffiliated Neurotrauma Consultant (UNC) (League, 2013). The UNC is expected to be involved with all sideline evaluations once a concussion is suspected. They are meant to offer an unbiased view in identifying a concussion. These supplementary medical staffers add an extra layer of protection to the gameday safety of a player and increase the transparency of evaluations so fewer concussions will be missed. The clarification that needs to be introduced into the Concussion Policy is to say that the UNC has the sole power to remove a player from the game when a concussion is suspected. Currently, the team doctor can overrule the UNC and remain the exclusive judge for this decision which leaves room for manipulation by the coaches and opens the league to liability.
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The last part of the Concussion Policy outlines a specific return to play protocol. Currently the five steps of the protocol are clearly outlined and meant to be completed in a progression (See Appendix D). However, the NFL needs to determine a specific timeline for this protocol to occur. Currently, there is nothing to stop a player from completing his steps in a day. The NFL needs to enforce a 24-hour wait in between each step of progression so that symptoms can be fully monitored. This timeline is adapted from the International Concussion Consensus Guidelines and utilized by medical professionals around the world (CDC, 2015). This means the full protocol will take almost a week to complete before clearance is attained. Adapting these guidelines will eliminate the risk of sustaining another concussion before the first has healed which may reduce the long-term health problems associated with repetitive head trauma.
Safer Rules and Regulations
The violent contact in the sport of football is so severe that the NFL is taking steps to help ensure the safety of its players. Along with stricter concussion management policies for practices and games, the NFL is making changes to the rules of the game itself to better protect their players (See Appendix E). In 2011, the NFL changed the kick-off rule by five yards “in hopes of reducing the speed of collisions” during kick-off (Ezell, 2013). Since then over 40 other rules have been put into effect to limit dangerous hits, especially to the head, but still allow Football to remain a competitive contact sport (League, 2015b). Some of these rules include, “The Defenseless Receiver”, “Peel Back Blocks”, “Chop Blocks”, and allowing “Medical Timeouts” (See Appendix E). The NFL implemented every one of these rules to make the game safer for the men playing it.
“Medical Timeouts” are a new regulation for the 2015/2016 season. The idea behind a “medical time-out” is that a third pair of eyes will now be on the players in addition to the officials on the field and their own medical staff. If both the team’s medical staff and the officials on the field miss a player looking disoriented and unstable then a “medical timeout” can be called by the ATC’s in the press box. The ability to stop the game is a good safety precaution, but the practicality of anyone actually doing it is yet to be seen.
Even with these new rule changes, concussions and injuries are still a risk of the game of football. However, there has been measured success since the limiting of helmet hits and head contact. In the 2014 Injury Data Report filed by the NFL the data revealed, “Concussions caused by helmet-to-helmet hits [were] down 43% from 2012-2014” (League, 2015a). Aside from the NFL removing contact completely from the game, which would forever change the sport, a next step for continued player safety could be for the NFL to add the verbiage “if the defender is going for the ball” to the “defenseless receiver” rule. It would free up the defender and still make plays on the ball without putting the receiver in danger.
The game of football is violent, and the injuries one can suffer playing it can be so absolute that careers can be ended in the blink of an eye. The NFL realizes that they need players to have a league. They are doing what they can to help maintain the safety of the players while performing on the field. One of the fears is that the NFL is becoming too soft with all the rule changes and not allowing defenders to get those “big hits” anymore. It is the responsibility of the league to protect the players no matter what the backlash is from the public. Although they weren’t for many years, the NFL is now consistently making rule changes to decrease the risk of concussions and injury for their players.
Helmet Advancements
The NFL has made numerous changes since the beginning of football when it comes to the use and durability of its equipment. The role of protective gear and equipment in making football safer for the players follows a fine line. Manufacturers have used innovating methods over the years to produce smarter and up-to-date models. Helmets were brought to the game to prevent skull fractures and subdural hematomas in the 1900’s (League, 2012). They’ve evolved over the past century from leather to the first hard plastic design in 1939 to models now made to try and address the concussion risk (See Appendix F).
Many scientists and people who work with the National Operating Committee on Standards for Athletic Equipment (NOCSAE) have stated that there would never be a concussion proof helmet (Mihoces, 2014). They have taken steps to find out the types of forces and level of impact that can cause these injuries. NOCSAE is a non-profit based out of Kansas City, who sets the testing standard for helmets. Manufacturers have a licensing agreement with NOCSAE to certify helmets based on whether they meet the standard. Each year the NFL sends a number of helmets to NOCSAE to see if the equipment meets the standard. If the piece of equipment is passed and put into use by a NFL player, the equipment must be updated over a number of years. This ethical dilemma was addressed when the NFL became aware that most of its players were still wearing older model of helmets during the peak of a concussion era.
The NFL has added new ideas to address the dilemma of how to minimize the concussion risk for its players and still remain a contact sport. They’ve had numerous talks with helmet manufacturers and NOCSAE about adding impact sensors to its helmet so that it can be scientifically assessed about the types of hits players take game by game (Fairnaru, 2015). Although the NFL cannot prevent concussions from happening in the game of football, they have ultimately done a better job of policing the issue. The NFL most recently donated $30M to the National Institute of Health (NIH) in 2012 to focus on advancing science on medical understanding of brain injuries (League, 2012). Years ago, the NFL failed to address the concussion issue, today, they’ve made it aware that it is a topic that needs to be discussed, analyzed and addressed. Making its employees and affiliates aware that changes are being made each day for this issue, shows the league's expansion.
Conclusion
With the alarming amount of past NFL players committing suicide, the NFL has taken a more focused look into the head trauma during participation and how it is impacting each player. Football is a collision sport. A single play in football has been compared to driving a car at 35 miles per hour into a cement wall. On average, an NFL offense runs 80 plays a game. The impact of these plays is taking a concerning toll on the bodies of the players.
The NFL acknowledges the physical demands of football and has recently donated 30 million dollars to the National Institutes of Health to research sports injuries - including joint disease, chronic pain, and CTE (League, 2012). They started a youth safety initiative called the “Heads Up Program” in which the game of football is taught with better hitting techniques to protect the head. The NFL is holding clinics in which youth coaches can be taught by NFL players and coaches how to properly tackle and be tackled in order to lower the risk of injury. Along with the community outreach the NFL has changed the rules of the game to take away the “big hit” where a player cannot protect himself before contact.
NFL Commissioner Roger Goodell said in an on-air interview before the Superbowl in 2013, “Well that’s why we are investing in the research, so that we can answer the questions. What is the link? What is the cause of some of the injuries that our players are still dealing with? And we take those issues very seriously. We’re going to let the medical individuals make those points. We’re going to give them the money to advance that science. In the meantime, we need to do everything we can to advance the game and make sure it’s safe.”
Football is a contact sport and that is why society loves it so much, but with that comes risk of injury. The NFL is enhancing safety on the field by decreasing the repetitive head trauma that causes CTE through the development of a concussion management protocol, stricter return to play guidelines, and implementing new rules and regulation changes. In addition, by working closely with helmet manufacturers and donating money to fund research for technology advancements, the NFL is hoping to lessen impacts which lead to concussions. With these three areas of reform the NFL already shows from 2012 to 2014, a 36% decrease of concussions occurring in season games (League, 2015a). The NFL has a clear view of the seriousness of concussion and is doing everything in their power to ensure the safety of its players. Only time will tell if that foresight will last or if the vision of the league will become clouded after years and years of taking hits.
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