Opinion
2:06 pm
Thu April 10, 2014

Keep Your Head in the Game

IPFW Associate Professor and medical ethicist Abraham Schwab.
Credit Courtesy / Abraham Schwab

This Friday, the Indiana Pacers face the Miami Heat for the fourth time this season, a game that will likely determine home court advantage for the Eastern Conference Playoffs.

The Pacers won two of the first three meetings, due in no small part to the play of Roy Hibbert. Hibbert scored 21 points in their third meeting on March 26, and affected Chris Bosh’s attempt at a game-winning shot. Bosh’s attempt fell short and the Pacers won 84-83. But, after taking an elbow like this earlier in the fourth quarter, I wonder if Hibbert should have been benched for his own protection.

The Indiana Pacers are all too familiar with potential costs of the NBA’s concussion protocol. During game four of last season’s Knicks-Pacers playoff series, George Hill took an elbow from Tyson Chandler. He played on and had an outstanding game (26 points). The next day he complained of headaches, leading to the diagnosis of a concussion. He missed game five of the series, and the Pacers lost by 10.

As George Hill’s experience indicates, diagnosing concussions is difficult. In some cases, like Hill’s, symptoms do not arise for hours. In other cases, symptoms appear immediately, including loss of memory, delayed or incoherent speech, and disorientation. Look again to the video of Lebron James’ flagrant foul. Watching the game live, I was sure Hibbert had a concussion.

My son had a bike accident the week before Hibbert’s injury. He flew over the handlebars and landed face/head first on the asphalt. Hibbert rocks back and forth on the ground, exactly as my son had; Hibbert stands up and falls down again, exactly as my son had; Hibbert walks woozily to the bench, exactly as my son had walked unsteadily back to our house. And my son and Hibbert had no recollection of the event itself.
 

 

My son was diagnosed with a concussion and kept away from physical exertion for most of two weeks. Hibbert was back in the game in two minutes.

If you read a summary of the NBA’s concussion policy, two key points stick out. First, the assessment is completed by the team’s own medical staff. Second, the assessment tool goes unmentioned.

The NBA’s concussion policy requires the medical staffs’ evaluative judgments. First, at the beginning of the season the medical staff evaluates a player to produce baseline scores. Second, when they suspect a player has a concussion, this same staff evaluates the player again. On March 26, and again this Friday, the Pacers will be playing for playoff seeding. The medical staff knows this and it will affect their judgment.

I don’t doubt the Pacers’ medical staff is well-intentioned. I don’t doubt that they want to limit or eliminate the risk to players’ health. But they have skin in the game. They want the team to win. And they want to keep their jobs. It’s easy to imagine a team “going in a different direction” if the staff diagnoses too many concussions. Again, it’s not about the medical staff’s choices. Research on conflicted interests is clear—individuals who are subject to conflicting interests make biased decisions whether they want to or not.

Such bias can be limited by the structure of the NBA’s assessment, but we don’t know what assessment is used. The NBA likely uses the Standardized Assessment of Concussion (SAC)—an assessment developed specifically for evaluating athletes on the sidelines. The SAC form limits the possibilities for bias, and when performed appropriately catches around 8 or 9 out of every 10 concussed individuals. Of course, the NBA may use a different, less reliable assessment tool. Some assessments, for example, rely on patient (or player) evaluation of symptoms—a strategy sure to produce less than honest answers.

"For my kids, I've got my own concussion protocol...if my children are even suspected of having a concussion, we'll just assume they have one."

The SAC misses as many as one in five concussions. Other assessments are even less reliable. For my kids, I’ve got my own concussion protocol. Because the assessments are imperfect and because the assessments will be run by individuals with conflicted interests and because the harms of a second successive concussion are quite high (including “Second Impact Syndrome” which can be, though rarely is, fatal), if my children are even suspected of having a concussion, we’ll just assume they have one. Indeed, the NBA suggests just such a strategy, whether or not they follow it themselves.

My approach is, of course, a conservative one that the NBA is unlikely to adopt. But there is one thing the NBA can do if they are serious about protecting player health: have the assessments run by individuals who have NO stake in the outcome. No team physicians and no one who’s paycheck comes directly from the NBA. Hire an outside firm to hire the physicians who run the tests. Sure it will cost more money, but it’s a question of value—what’s more important to the NBA: player health or making a little more money. 

 

Abraham Schwab is an associate professor of philosophy and medical ethicist at IPFW.

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