By Giulia Sesa & Silvia Camporesi
UEFA Euro 2020. Denmark v. Finland. Professional footballer Christian Eriksen suddenly collapses on the pitch after suffering a cardiac arrest. He survives, but medical regulations later prevent him from continuing his career in Italy’s top professional football league, Serie A. Eriksen’s case raises a difficult question: when athletes are excluded from sport because of a medical condition, are they being protected or discriminated against? And under what circumstances, if any, can such restrictions be ethically justified?
This question is not limited to cardiac conditions. Athletes living with HIV have long faced scrutiny and restrictions in sport. More recently, the 2026 Position Statement of the Association of Ringside Physicians recommended indefinite disqualification from combat sports for athletes with active HIV infection, regardless of current or previous antiretroviral therapy. Eating disorders and relative energy deficiency in sport raise similar questions, with the International Federation of Sport Climbing (now World Climbing) becoming the first international sport federation to adopt a traffic-light system to guide decisions regarding athletes’ eligibility to train and compete.
We often hear of ‘discrimination’ as something inherently wrong and ‘protection’ as something inherently good. But is really the case?
Sport places considerable value on inclusion. The fourth Fundamental Principle of Olympism states that “every individual must have the possibility of practising sport, without discrimination of any kind”. Additionally, athletes often have strong interests in participating, competing, pursuing their careers, and making decisions about their own bodies, including the level of risk they are willing to accept. At the same time, healthcare professionals, sport federations, and public authorities may have responsibilities to protect athletes and others from harm that may arise from participation or competition in sport.
Navigating these competing considerations is not always straightforward. In our paper, we explore when participation restrictions in sport may be ethically justifiable and when they may constitute unjustifiable discrimination. Drawing on four principles from public health ethics, namely proportionality, autonomy, minimization of harm, and the need for evidence, we analyze three fictional cases involving sport participation restrictions.
Consider cardiac conditions, where the primary concern is the athlete’s own physical health. Participation decisions should generally be made on a case-by-case basis through a shared decision-making process. This process should take account of the athlete’s health status, their values and preferences, the pressures that may influence those preferences, the athlete’s vulnerability to such pressures, the characteristics of the sport, and the availability of risk-mitigation measures and ongoing health status monitoring. Claims about protection cannot justify a blanket exclusion. Where restrictions are imposed solely on the basis of a diagnosis, without an individualized assessment of risk and circumstances, they may constitute wrongful discrimination.
Similar considerations apply in the context of eating disorders. There may be circumstances in which temporary exclusion is justified. For example, this may be the case where an athlete presents measurable and clinically significant health risks or complications, such as cardiac compromise, and where a multidisciplinary team, working with the athlete and their support network, determines that temporarily stepping away from sport is the most supportive course of action. However, exclusion based solely on an eating disorder diagnosis, rather than an individualized assessment of the athlete’s circumstances and level of risk, fails to recognize that sport may play different roles in different cases, either supporting recovery and well-being or contributing to further health deterioration. Consequently, blanket exclusions may constitute ethically unjustified discrimination.
HIV presents a different set of considerations because the potential interests of others may also be relevant. We argue that temporary suspension may be justified until an athlete achieves an undetectable viral load. Once an undetectable viral load has been achieved, and provided that effective treatment, ongoing monitoring, and appropriate risk-mitigation measures are maintained, continued exclusion from sport would be difficult to justify and may constitute wrongful discrimination.
We conclude that restrictions on or exclusions from sport participation may be ethically justifiable when they respond to a sufficiently established risk to the athlete, others, or both; are supported by appropriate evidence; are proportionate to the level of risk; respect the athlete’s values and preferences; and are introduced only after less restrictive alternatives and feasible risk-mitigation strategies have been considered. Other factors also matter. These include the interaction between the risks associated with the sport and those associated with the health condition, the pressures influencing an athlete’s decision-making, the athlete’s vulnerability to those pressures, whether the restriction is temporary or permanent, and the consequences of both participation and exclusion. In all cases, decisions about sport participation should be transparently justified and communicated, while remaining open to review as evidence and circumstances evolve.
Exclusion does not automatically mean wrongful discrimination. Likewise, describing a restriction as ‘protective’ does not necessarily make it ethically justified. In this context, as in many others, it is important to be wary of simplistic labels applied to complex problems, which instead require a nuanced and context-sensitive ethical evaluation.
Paper authors: Giulia Sesa, Pascal Borry, Sigmund Loland, Silvia Camporesi
Affiliations:
Giulia Sesa: Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven; Department of Sport and Social Sciences, Norwegian School of Sports Sciences.
Pascal Borry: Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven.
Sigmund Loland: Department of Sport and Social Sciences, Norwegian School of Sports Sciences; Department of Sport Science and Physical Education, University of Agder.
Silvia Camporesi: Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven.
Competing interests: None to declare
Social media accounts of post authors:
Giulia Sesa: https://www.linkedin.com/in/giulia-sesa-62a125237/
Silvia Camporesi: https://www.linkedin.com/in/120382/; profsilviacamporesi (IG)