The Failure of Informed Consent and the Football Brain Trauma Debate

The new football season looms before us. Olympic memories linger, but the countdown to football dominates sports radio and ESPN. Fans and media cannot wait for the game and the carnage. But before we jump in to enjoy the sport, let’s remember the shadow that hangs over every football player and game as well as our support of it.

Football can kill the soul of players.

Junior Seau, a NFL icon, shot himself in the chest in May. He joins three former professional football players who committed suicide in the last two years. Several were diagnosed after the fact with mental illness caused by brain damage related from repetitive head trauma. Seau’s brain has also been diagnosed as suffering from CSE a progressive disease resulting from repeated head trauma. It contributed to his erratic behavior and suicide.

Football kills the soul by destroying brain functioning. The brain suffers from the generation of webs of plaque in the brain that destroy neural communication and processing. These plaque entanglements seem to be caused by repetitive head injuries, mainly traumatic concussions. Repetitive impact alone may also do as much damage in creating the nodes of tau proteins that anchor these tangles. The tangles lock up neurons and disrupt the brain’s neural ability to communicate and sustain a bioelectrical balance.

In July 2012 over 3000 former players consolidated their law suit claiming the NFL “deliberately and fraudulently” withheld and discouraged knowledge about the damage football was doing to the brains of football players. The law suit reflects accumulating knowledge about the cognitive impacts of injury as well as a widespread and belated recognition that while football is a violent and dangerous game, its damage lay far deeper and more sinister than destroyed knees, brutalized ACLs, wrecked shoulders and crippled players late middle age.

I have written about this often. I talked of Achilles Revenge where athletes choose to risk their health for glory and wealth in exchange for physical pain. The brain trauma goes beyond physical pain. The neural damage undermines judgment and manufactures erratic emotional responses. Players can suffer from dementia, chronic traumatic encephalopathy. CTE induces depression, loss of memory, unpredictable emotional swings and aberrant decision-making. Player’s emotional and judgmental resources erode. The more we know the more we understand the issues may be underreported.

This erosion of judgment, emotional stability and resilience combines with the normal physical pain and status loss retired players face. The loss of their locker room camaraderie and support compounds this isolation. Roman Oben a 12-year veteran puts it this way, “they spend the rest of their lives being shadows of who they were at 25.”

The result?

The rash of suicides by retired football players augments the compelling evidence that a significant percentage of football players may struggle with declining cognitive limits and depression in rates beyond the regular population. After Jay Easterling killed himself with a handgun, his wife Mary Ann commented, “He felt like his brain was falling off…He was losing control. He couldn’t remember things from five minutes ago.” Earlier Dave Duerson had shot himself in the chest to preserve his brain for further study.

No other sport spawns this level of suicide. Sometimes suicide can be contagious as a way out of the emotional and spiritual pain of watching your personality slip away and losing control of all you value. No one knows how many ex-players struggle with mental illness induced by the brain trauma. No one knows the causal pathways. No one knows much about it because the NFL worked hard to discredit any research in this area.

The country will not outlaw football. Many present and former players resent efforts to mitigate the violence and long-term harm. They represent the classic commitment psychology of someone who has invested in the trauma and identity of the sport. They experience this as a form of initiation for them and the sport. If they did it, so should the young players. A number of players and commentators have already attacked the new NFL contract that places strict limits upon the level of contact in camp to protect the long-term welfare of players. They bitterly complain that drawing down the level of violence limits the ability of young players to demonstrate their toughness and beat out veterans. Others just say, “I’d do it all again.” So the players’ law suit focuses upon informing players and not regulating the game.

This solution flows from the  free choice defense. The players and league want to ensure that the new draftees have adequate information about the threats. The players can make “informed” choice.

Let’s look at what this informed consent might look like. We have to ask a person to make a decision to risk potential loss of their personality when they are 22 years old. We need to remember that human begins tend to overestimate catastrophic consequences but underestimate small losses. People also tend to be over optimistic in their own projections about how they will avoid statistical dangers to themselves. The informed negotiation leading to the brain trauma deal might look like this:

Drafted Player (DP)

“I have a chance to live my dream. I got drafted! This is incredible.”

Advisor/Agent (AA)

“Fantastic. Now we can negotiate with the teams to get you're a contract that matches your slot.”

RP    “How soon can we start?”

AA   “I meet with the team in two days, but before I begin we need to talk about something that a recent settlement with the league mandates.”

DP    “Got it. What’s up?”

AA   “Well, I need to alert you to the fact that football can be dangerous to your health. Here is a list of the dangers. I also have a video you can watch.”

DP    “Come on man. Of course I know that. I have three surgeries to prove it. This is news?  Football is a violent and dangerous game, I know that.”

AA   “Well I need you to read this disclaimer and check the part of about brain trauma, dementia and compromised judgment.”

DP    “Yeah, I’ll read it, but I know this stuff. I’m not afraid of this. My bonus will cover it all. Besides, this stuff is a hundred years in the future.”

AA   “Well actually, it’s about 20 to 30 years in the future, but you are right, most of these injuries start to impact you in your late forties. Sadly Chris Henry suffered it when he was 26. I also want to remind you that we may need to set aside some funds for this just in case from your signing bonus or your first year.”

DP    “Look, this is stupid. I am 23. I will be fine and besides I owe it to my mom and friends to take care of them. I promised my mom a new house, and I want her out of where she lives. Man, I suffered for this, and I want my return. She deserves this. I can take care of the stuff later. I’ve got a lot of money. Right now, just get the money so I can take care of my family.”

AA   “I just want to be clear. Football is dangerous and brutal and violent. We both know that.  Well, the court settlement does give you the option of talking to some guys, watching videos or going to a panel to talk about how to think about these injuries and prepare for it.”

DP   “I know what I’m getting into. I have the scars on my knee and shoulder to prove it. Besides I’m a lineman, and I’ve never had a concussion so I’m not that worried about it.”

AA   “Well some doctors think it’s not about concussions, but it about repetition. A number of players have had serious brain issues without any real concussions.”

DP   “Ok, OK. I’ll think about it. But I’ll take the risk. This is my one shot, my one chance. Football is what got me here. I owe it to myself and to my family. Besides I’ve read the interviews. Most of the guys say they’d do it all again even if they have sore knees.”

AA   “Well, OK. But remember you have been duly notified as required by the terms of the court settlement.”

DP    “By the way, what do the guys who have suffered brain damage say about how they are handling it.”

AA   “Well it’s kind of hard to figure out.”

DP    “What?”

AA  “Well. You know for some of the guys. Well, you know. Well, it’s like this.”

DP    “What are you getting to? Come on, spit it out.”

AA   “Well. A lot of them are not compos mentis.”

DP    “Come on. I’ve got a degree, but I did not take French.”

AA   “Well they aren’t really all the able to talk about how they are doing. You see, well. You see. Well a couple are living with tubes in their throats and respirators. Some of them are not all that stable or coherent all the time.”

DP    “This is getting a little weird.”

AA   “Look I’m trying to help. Think of it this way. You get wealth, privilege, fun and status for awhile.”

DP    “Yeah. I know. That’s the whole point of this.”

AA   “Well the other side is. You potentially give them your soul.”

DP    “This is a little metaphysical man, are you sure you are OK?”

AA   “I just want you to know. Their wives do most of the talking.”

DP    “Well I read about some other guys who were big names like Seau and Easterboork who were struggling with this. What did they say?”

AA   “Well, they can’t say much. They committed suicide.”

DRP   “Your’e shitten me, man. Look man, this is getting us nowhere. What do you expect me to do, go manage a car rental office?    ---         This won’t happen to me. Let’s make this happen.”

So much for informed consent changing decisions of players.

Every one of us entering a career embarks on a path that will change us. We seldom know what our future self will look like when we enter a job world. Sometimes we discover that our path is destroying what we value in ourselves, and we change jobs or change careers. Sometimes ten years down the road we look in the mirror and no longer recognize the person we have become. 

Throughout our life we negotiate over the person we are and the person we are becoming. None of us really knows how we will end up, but we do know that the person we become will be is shaped by the work we do. No different with football, but the impact can be  a little more severe.

No person easily or rationally risks his or her personality and capacity to be a human decision maker. The core of our humanity lies in our ability to feel, think and shape our life; it depends upon our brain working. The stealthy soul death brought on the brain trauma induced by impacts condemn players to a living death, far beyond their imagination.

Expecting informed individual choice option to address the brain damage threat is an illusion. It makes as much sense as the older argument that coal miners made a free choice to enter the mines and accept black lung disease compared to unemployment. The solutions remain similar. The sport and unions need to continue aggressive and continued research and interventions to minimize the long-term damage. The other path should involve joint contributions to a fund to support later life victims of the brain damage and soul loss that no one should have to bargain away.

The odds are that individual players will not build up a fund. Mary Ann Easterling, whose husband committed suicide, summed it up, "I'd also like to see the NFL take care of the players that do have symptoms or could possibly have symptoms."

The league and union need to do this. It is the least they can do for the sentence that some players will consign themselves to.

Achilles Revenge II: Brain Trauma and the Footballs

The accumulating evidence on head injuries and long term brain damage poses an immense problem for  American and European footballs. The problem arises because the contact initiated and the impact on the brain seems so woven into the pattern of the sport. Imagine soccer without headers (it is possible but won't happen: imagine football without head contact; impossible), but something must be done.

The awful injuries pose the question: should we change the sports to protect safety. The problem deepens because these are injuries that pose serious problems down the line; they are not immediate like ACLs or torn labra, but accumulate insidiously in increasing brain damage. Even concussions, where the sports are focussing, are only symptomatic of the long term costs.

For instance look at the pictures of two brains--a healthy brain and the poisoned brain of a 26 year old NFL wide receiver  Chris Henry. He had no history of concussions but after months of increasingly erratic behavior, he died attempting to jump on a moving truck driven by his fiance. Henry's brain  is shot through with the poisoned proteins. The  repetitive impact and the additive effect of  toxic proteins generated by the trauma was destroying his brain. The proteins like tau proteins create brain tangles and inefficiencies and degradation of connections. People suffer impaired cognitive reasoning long before dementia, alzheimers or Lou Gehrig's sets in.


Everyone focuses upon concussions because they seem immediate and can sort of be diagnosed and have some protocols for recovery. But as ventilator ridden Steve Smith writes from on a computer using eye movement:     "I have hit people 40 to 50 times every week in practice, not to mention 50 to 70 times on game day 16 days a year, not to mention camp every year." In a computer generated voice, Smith asks, "When is enough enough? You have the old-school owners that say, 'That's how you make them tough.' I'd love to see them get out there and hit heads with guys that are bigger than them."

Two answers are given for not changing. First, "this is the game" and "the game entails physical risk, that is what makes it the game and demands courage and skill of players." Soccer depends for some of its critical moves and scoring upon heading. Football grows from the organized directed violence of bodies upon bodies which require heads to be involved. Second, players now know the risk and play with informed consent; players accept the risk and get amply rewarded for playing.

Both answers are illusions. Games evolve and change all the time. I can quote you writers who declared the end of football and baseball, for that matter, when players were forced to wear protective helmets. The forward pass has been modified and formations have been outlawed in American football from the beginning when the killing machine single wing was outlawed. Soccer spends immense effort policing actions that can bring injury to its players. So rules to protect players from injuries make perfect sense to protect the integrity of the game; eliminate temptations to unfair play to "take players out;" and to protect the investment of coaches and teams in players. Even NASCAR which so depends upon crashes as an intrinsic aspect of its appeal constantly jiggers rules to keep even playing fields and build in protections for drivers.

Second, the informed consent argument makes little sense for three reasons. First, most elite players begin playing at very early ages, long before anything resembling real consent is possible. They are driven as much by parents as their own joy at the game. Later accolades, status and team loyalty motivate  them. None of this supports free informed consent for 12-20 year olds. The brain damage begins as early as high school age. Second, many of the players in both footballs come from poor or disadvantaged backgrounds. This is their way out, either to college or a lucrative career. They have few options except to stay in dangerous dead end worlds, so "informed" consent for 16 year olds trying to get out and often carrying the hopes of their family fails. Third, humans regularly as a species underestimate  future losses relative to immediate gains. The idea of a header or tackle leading to irreparable brain impairment in your fifties, is just too far away for the vast majority of folks, let alone athletes, to plan around. It seems a reasonable risk to a 19 year old or a 26 year old player seeking to build a nest egg or help companions win.

Not only does informed consent fail as an answer, but the nature of the injuries are not just physical. This is not about arthritis and limited mobility, this means the personality of the player changes or is destroyed. We are talking not about injuries but destroying the personality of the person who is asked to make the choice, not a knee, leg or shoulder injury. Too much is at stake, the very assumption of informed consent--having a whole and reasoned personality--is destroyed by the additive trauma of CTE.

New protocols on concussions are not enough. We need to change the games.