Drug use is well recognised in sport but very difficult to quantify. The occasional positive test or even the large scale investigation of the Tour de France creates barely a ripple of disbelief.
We still delude ourselves about the purity of sport and the wonder of human performance.
But we cannot get away from the evidence, even if circumstantial that drugs help performance. The benefit is mostly through enabling athletes to train harder and recover more quickly and the drugs listed on the letter from Victor Conte cover a range of anabolic medications. Some of these are detectable. There is also guidance on how to avoid detection.
These revelations, together with evidence on celebrity medallists Marion Jones and Tim Montgomery, could, arguably, deter other athletes. Realistically, this is unlikely. If the champions use drugs, could there be a greater incentive or advertisement for drug use.
And the medical dimension: For the relatively few high profile athletes who are caught, it would be naive not to suspect others below the radar. Clearly there are biochemists, pharmacists, and doctors who supply, control and monitor the athletes. If a nation, government, or sporting body expects sporting excellence who could blame them.
It is a difficult position; huge expectation and knowing that drugs can help attain results. It is a particularly difficult position for a doctor involved with top level sport to know that drugs work, suspect some athletes of using drugs, and to consider the ethics in being asked to advise an athlete-patient under your care.
Domhnall MacAuley is Primary Care Editor, BMJ