Eric Fruchart

Patricia Rulence-Pâques

Cantisano Nicole
email: nicole.cantisano@univ-tlse2.fr

Eric Fruchart
email: eric.fruchart@univ-perp.fr

Rulence-Pâques Patricia

Mapping different ethical positions regarding a coach's decision to select or not an injured

Keywords: injury, judgment, coach, selection, ethics in sport injury, judgment, coach, selection, ethics in sport

Mapping ethical positions with regard to a coach's decision to select (or not) an injured athlete

Eric Fruchart, Patricia Rulence-Pâques, Nicole Cantisano

approach, the athlete decides for him/herself; the medical staff's role is to explain the 2 available options and then accept the athlete's decision. In a shared approach, the athlete and 3 medical professionals share information and decide together.

4

However, the literature on sports ethics has focused mainly on decision-making by 5 health professionals 5,7 and not on decision-making by coaches. This is surprising, given that 6 the decision to select an injured athlete or not ultimately rests with the coach. 8 It is important 7 to study ethical aspects of decisions taken by a coach's because he/she is viewed as a major 8 influence on the development of the athlete' values. 9 Testoni, Hornik, Klossner et al. 5 9 emphasized the need for larger, quantitative studies of health ethics in sport, in order to better 10 understand the decision-making processes for the various stakeholders in sport.

11

Health ethical issues in decision making involve the deliberation about ethical 12 principles. In general, they are based on autonomy, justice, beneficence, and non-13 maleficence. 10 Autonomy refers to the possibility of a person to take an informed or 14 uncoerced decision. Justice guides us to fairness and respect for laws and one's rights. The 15 principle of beneficence refers to "do good" and promotes the interest of the individual. The 16 principle of non-maleficence guides us to "do no harm" when our actions can affect others. 17 To select (or not) an injured athlete reflects the conflict between beneficence and non-18 maleficence principles. 10 Athletes make sacrifices for the team and for achieving the sporting 19 objective, such as playing when in pain. 11 Some sportspeople are strongly influenced by 20 comments from their teammates, medical staff and coach. Moreover, athletes often are very 21 keen to play, and believe strongly that they are best placed to know whether or not they can -22 even if this goes against medical advice. 12 Injury depends on the context. In professional 23 sport, the level of pressure to compete is very high. This competitive aspect might be what 24 makes a coach's decision ethically questionable. A coach's ability to make difficult ethical 25 decisions is often tested when he/she is faced with considerable pressure in the workplace. 13 Furthermore, the decision-making process is likely to differ from one individual to another 2 one as a function of personal and contextual variables. 14 For example, Bredemeier and 3 Shields 15 emphasized the effect of direct involvement in sport on moral judgment.

4

From a cognitive perspective, moral judgment can be considered as a judgment on the 5 acceptability or legitimacy (with reference to ethics) of a particular decision. 16 However, the 6 role of information integration in moral judgment has not been extensively studied 17 -even 7 though the integration of multiple determinants is known to have an impact. [START_REF] Colby | A longitudinal study of moral judgment[END_REF] To address 8 these issues, we sought to apply information integration theory in the field of ethics 2 to 9 highlight the mental process of judgment, i.e., the manner in which the participants (amateur 10 and professional athletes, amateur and professional coaches, physiotherapists, and non-11 athletes) integrate different information cues and then judge whether a coach's decision to 12 select (or not) an injured athlete is acceptable. Anderson's framework 2 assumes that all ethical 13 perceptions, thoughts and actions are goal-oriented and depend on the integration of different 14 items of information. This framework adds value because it focuses on the processes through which information cues of various types may be integrated into a judgment. 16 Anderson's framework has been implemented in many aspects of moral psychology: 2 17 (i) parents' acceptance of their child's vaccination against malaria (a study in Togo), 19 (ii) 18 Colombian citizens' views on everyday corruption, 20 and (iii) people's views on the 19 acceptability of surrogate pregnancy. 21 The framework has also been applied to bioethical 20 issues. [START_REF] Mullet | Functional measurement in the field of empirical 11 bioethics[END_REF] In the context of sports, Anderson's framework has been used to map moral positions 21 regarding violence on the field 23,24 and to map ethical positions regarding how non-athletes, 22 amateur athletes and professional athletes combined different informational cues when 23 judging the acceptability of nutritional supplements in sport. 25 In these studies, the link 24 between the participants' respective roles in sport and the ethical positions was not clear, and 25 merits an in-depth assessment. We reasoned that just as information cues influenced the judgment of whether it is acceptable to select (or not) an injured athlete. We considered four 3 information cues that are frequently cited in the literature on competitive sport or ethical 4 issues in sport. 26,27 They are related to the ethical principles and values of the various 5 stakeholders in the sports community (teammates, medical staff, coaches, and the athlete 6 him/herself) within a particular context (an important competition).

7

The first information cue was the athlete's degree of indispensability, as judged by 8 his/her teammates. Team sport players are influenced by their teammates. Indeed, teammates 9 contribute to the enjoyment of sport through the recognition of accomplishments, 10 companionship, and esteem. For instance, it is known that approval from teammates 11 influences global self-worth, the appropriate expression of emotions, and motivation to 12 perform pro-social behaviours. 28 The establishment of friendships appears to be a prime 13 reason for participation in sports. [START_REF] Weiss | Motivational orientations and sport behavior[END_REF] Competition between teammates for a key position in the 14 team can prompt athletes to feel that they must compete at all costs. Ogien 26 has written of 15 "submission in superior loyalties"; the athletes justify their decisions in terms of the 16 responsibility they have in carrying out a mission that is valued socially by the coach and the 17 team. Indeed, some athletes appear to be highly influenced by comments made by their that even in substantially lower-stake sports, coaches would be more likely to allow an athlete 3 who had sustained a concussion to continue playing if the game was considered to be 4 important (e.g. a European cup match).

5

The third information cue was the sports medicine professional's opinion. The latter's 6 decisions can directly affect sportspeople's lives. 33 Injuries are part of sport, and sports 7 medicine professionals are often the first people to deal with the athlete immediately after an 8 injury. Athletes should expect sports medicine professionals to (i) provide them with a correct 9 diagnosis and appropriate treatment, and (ii) take the right decision in order to make sporting 10 competitions as safe as possible for the athlete's health. The athlete assumes that the team's 11 medical staff is knowledgeable about the injury and that it is the staff's job to suggest the right 12 treatment. However, ethical conflict of interest among medical staff in the care of concussed 13 athletes is an increasingly studied topic. 27 Sports medicine professionals may be pressured by 14 coaches and athletes to allow injured athletes to return to competition before they are fit from 15 a medical standpoint. 34

16

The fourth information cue was the injured athlete's attitude. Athletes invest a great deal of time in the achievement of optimal performance, and their self-worth is often linked to 18 this performance. Hence, athletes often perceive an injury as an emotionally traumatic event 35 19 and may adopt perseverant attitudes when managing injuries (e.g. the idea of "playing through 20 the pain" as part of the "fighting spirit"). 36

21

The objectives of the present study were to map individuals' ethical positions 22 regarding whether or not the selection of an injured athlete for a competition would judge to 23 be acceptable. We wanted to discover how people cognitively combine information cues to 24 form an overall ethical judgment. 2 Our primary hypothesis was that study participants would would reveal inter-individual differences in ethical positions. [23][24][25] The second hypothesis was 2 based on Fruchart and Rulence-Pâques's findings 25 ; the participants' ethical positions would 3 vary according to their role in sport. This role corresponds to the individual's type of 4 participation in sport, i.e. as a function of the team's level of competition for the athlete or 5 coach or the type of involvement for sports physiotherapists and non-athletes. We reasoned 6 that the type of participation might affect an individual's moral judgment because 7 professional athletes/coaches, amateur athletes/coaches, physiotherapists and non-athletes are 8 likely to have different goals, values, and principles. 37 We hypothesized that non-athletes 9 would consider that selecting an injured athlete is never acceptable, and that physiotherapists 10 (i.e. medical professionals whose duty is to protect the athlete's health) would also consider 11 that selecting an injured athlete is never acceptable. Given that professional athletes are highly 12 involved in sport, we further hypothesized that they might be more likely than amateur 13 athletes and non-athletes to consider that selecting an injured athlete is acceptable. Lastly, we 14 hypothesized that because coaches are motivated by winning the match or competition, they 15 would sometimes consider that selecting an injured athlete is acceptable. They trained at least twice a week. The 45 male non-athletes played handball from time to 2 time as a leisure activity, and so were nevertheless able to reply to the study questionnaire.

3 Lastly, we enrolled 8 male professional handball coaches (coaching at a national level) and 17 4 male amateur handball coaches (coaching at district and league levels). We contacted 5 potentially eligible participants at universities and sports centers, explained the study, and 6 invited them to participate. If a participant agreed, we arranged where and when to administer 7 the questionnaire. Similarly, the study's objectives and procedures were explained to 30 In accordance with Anderson's methodology 38 , the material consisted of two sets of 16 12 cards. Each card contained a scenario, a question, and a rating scale. In the first set, the coach 13 decided to select an injured athlete, and in the second set, the coach decided not to select an 14 injured athlete. The stories were composed according to a four within-subject factor design: expected of each participant. In particular, the experimenter told the participant that he was 15 going to read a certain number of stories in which a coach decides whether to select an injured 16 athlete or not, and that he would then indicate the extent to which the coach's decision was 17 justified. The participant was instructed to identify with the athlete in each scenario and to 18 express an opinion about the acceptability of the coach's decision. In the familiarization 19 phase, each participant was presented with 4 of the 16 scenarios, so as to familiarize himself 20 with the task, the procedure, and the test materials. 38 The four scenarios were chosen so that For each rating, the point checked by the participant on the response scale was 9 converted into a numerical value from 0 to 10, where 0 was the left anchor. These numerical 10 values were then fed into graphical and statistical analyses, using the same approach as in 11 other studies of ethical positions in sport. [24][25] Given that we expected to see marked inter-12 participant differences in the responses, we performed a cluster analysis on the whole set of 13 raw data. To improve stability in the cluster solution; we performed a hierarchical cluster 14 analysis and then a non-hierarchical cluster analysis (K-means) in a two-step process. 39 After 15 the clusters had been defined, a separate repeated-measure analysis of variance (ANOVA) 16 was conducted on the data from each cluster, with the information cues as the independent variables, and the judgment of acceptability as the dependent variable. Chi-squared tests were 18 used to determine whether a cluster was associated with a particular participant role.

19

Results

20

The hierarchical cluster analysis produced a four-cluster solution (K = 4). In order to 21 compare each cluster with the others, we performed an ANOVA with all four clusters .013, η² p = .05; and the coach's decision, F(3,215) = 160.28, p < .001, η² p = .69. These 2 findings confirmed the tenability of the four-cluster solution.

3 Tukey's test revealed a significant difference between cluster 3 (M = 5.12; SD = 0.11) 4 and cluster 1 (M = 5.61; SD = 0.05), cluster 2 (M = 5.63; SD = 0.07), and cluster 4 (M = 5.83; 5 SD = 0.20). There were no significant differences between clusters 1, 2 and 4. The overall 6 estimated mean based on 16 scenarios for each cluster is shown in the top section in Table 1.

7

Table 1 shows the means for each factor for each cluster too. The ethical acceptability 8 of deciding not to select an injured athlete was similar in all four clusters (cluster 1: M = 8.05; 9 SD = 0.07; cluster 2: M = 6.55; SD = 0.10; cluster 3: M = 5.83; SD = 0.14; cluster 4: M = 5.92; 10 SD = 0.25). In contrast, the four clusters differed with regard to the degree of acceptability of 11 selecting an injured athlete. Tukey's test revealed a significant difference between cluster 1 12 (M = 3.16; SD = 0.09) and the three other clusters (cluster 2 (M = 4.71; SD = 0.10), cluster 3 13 (M = 4.39; SD = 0.11), and cluster 4 (M = 5.74; SD = 0.20)), and a significant difference 14 between cluster 4 and the three other clusters. The difference between cluster 2 and cluster 3 15 was not significant.

16

Figure 1 shows the four clusters for when the coach decided to select an injury athlete.

17

The mean ratings are given on the y-axis, and two levels of the medical staff's opinion are The first cluster (N = 90) could be described as "Selection is almost never acceptable" 21 (top panels in Figure 1), since the mean response was always close to the lower hand of the ANOVA of the data from cluster 1 highlighted the large effect sizes of the medical staff's 2 opinion and the athlete's opinion (Table 2).

3

The second cluster (N = 60) was termed "Selection is sometimes acceptable, 4 depending on the medical staff's opinion" (upper middle panels in Figure 1). Overall, the 5 judgments were close to the middle of the response scale (M = 4.71; SD = 0.10). The 6 participants in this cluster based their judgment of acceptability principally on the medical 7 staff's opinion. The lines rise from left to right, indicating a strong effect of the medical 8 staff's opinion; the more favorable the medical staff's opinion, the more the selection of the 9 injured athlete is judged to be acceptable. The lines are the same in the left and right graphs, 10 indicating that the teammates' opinion had no effect. An ANOVA of the data from cluster 2 11 emphasized the large effect size of the medical staff's opinion (Table 2).

12

The third cluster (N = 49) was termed "Selection is sometimes acceptable, depending 13 on the athlete's and medical staff's opinions" (lower middle panels in Figure 1). Overall, the Hence, when the athlete was willing to play and the medical staff agreed, the participants 22 considered that it was acceptable to select him. An ANOVA of the data from cluster 3 showed 23 the large effect sizes of the athlete's opinion and the medical staff's opinion (Table 2).

24

The fourth cluster (N = 20) was termed "Selection is often acceptable, depending on 25 the athlete's opinion" (bottom panels in Figure 1). Overall, the mean response (M = 5.74; SD considered that the coach's decision is often acceptable if the athlete agrees. An ANOVA of 6 the data from cluster 4 showed a significant effect of the athlete's opinion (Table 2).

7

Table 3 shows each cluster's composition with regard to the participants' status. The 8 result of the 6 (Type of participant) × 4 (Cluster) Pearson's chi-squared test was significant, χ² 9 (15) = 39.89, p < .001. 10 Marascuilo's post-hoc multiple comparisons procedure was used to test the 11 significance of differences between pairs of groups within the cluster and to determine where 12 there were significant differences in the clusters' respective compositions (see Table 4). In the medicine staff's opinion, and the athlete's opinion) when judging the acceptability of a 5 decision to select (or not) an injured athlete. We expected an analysis of the integration 6 process to highlight different individual ethical positions. [23][24][25] This hypothesis was confirmed, 7 since our overall analysis of the raw data on selecting (or not) an injured athlete identified two 8 different moral positions (the first corresponding to cluster 3, and the second corresponding to 9 clusters 1, 2 and 4). The members of cluster 3 were more likely that members of clusters 1, 2 10 and 4 to consider that the coach's decision to select an injured athlete was acceptable. Our 11 second hypothesis was the ethical position would depend on the participant's role in sport.

12 This hypothesis was confirmed because the four clusters differed in their composition. Our 13 findings confirm that moral positions differ with regard to violence and doping in sport. [23][24][25] 14 Many factors are involved, and they are likely to contribute in a complex way to the final 15 ethical judgment. Our results indicate that moral judgment depends on the person's level of 16 involvement in sport. 15 Views on various ethical issues can be characterized by the manner in 17 which individuals with different roles in sport integrate various items of information when 18 judging the acceptability of an act.

19

This first analysis showed that the participants in the four clusters differed very little in 20 their ethical view of when a coach decides not to select an injured athlete; all the participants 21 judged that this decision is always acceptable, underlining the "wisdom" of the coach's 22 decision. All the participants endorsed a secure ethical position by considering that the 23 athlete's health is primordial and that not selecting an injured athlete is always acceptable. approved in the sports area. This is a classical approach to morality, referred to as 2 deontology. 40 People comply with principles, codes, and policies committed as a single group.

3 However, the members of the four clusters differed in their judgment of the acceptability of 4 selecting an injured athlete; three different ethical positions were identified in this respect, 5 corresponding to (i) cluster 1, (ii) clusters 2 and 3, and (iii) cluster 4.

6

Ethical position 1 (cluster 1) 7

In the first ethical position, the selection of an injured athlete was judged to be almost 8 never acceptable. Selecting an injured athlete was only acceptable when the medical staff's 9 opinion was favorable and the athlete wanted to play. The participants in cluster 1 considered 10 that the medical staff's opinion was essential; the members of this cluster placed great trust in 11 the medical staff. 7 However, the participants also considered the athlete's opinion, which 12 highlights their appreciation of the complexity of the coach's decision and the athlete's efforts 13 to stay in the team. This finding confirms that the coaches must take account of an injured 14 athlete's needs. 41,42 The members of cluster 1 judged that the coach's decision may be 15 acceptable when these two conditions (a favorable opinion from the medical staff, and the 16 athlete's willingness) are met. In all other conditions, selecting an injured athlete was not 17 acceptable. The ethical position adopted by the members of cluster 1 is in line with a shared 18 decision-making approach, 5 where the athlete and medical staff are at the heart of ethical 19 decision-making; they share information and decide together. The athlete may give the 20 medical staff information about his/her concerns, sporting objectives, feelings, and 21 discomfort. In exchange, the medical staff may explain the risk and benefits of continued 22 participation, and the available treatment options. 43

23

The professional athletes (54% of whom were in cluster 1) adopted this ethical 24 position, and considered that the selection of an injured athlete is almost never acceptable. In Professional athletes may consider that their body is their work tool -a tool that they must 3 take care of. Consequently, they often considered that it is not acceptable to play when 4 injured. Suffering an injury and being treated may be stressful -especially so for elite 5 athletes, who have more to lose. By developing an ethical position in line with a shared 6 decision-making approach, the professional athlete can seek to work with the medical staff 7 and make a mutually valid decision. 44 In high-level sport, the legal responsibility for deciding 8 to allow an injured athlete to play almost always lies with a sports medicine specialist. The 9 latter will advise the coach on the rate at which an injured athlete can be progressively 10 exposed to increasing levels of physical activity. 45

11

Ethical position 2 (clusters 2 and 3) 12

In the second ethical position, selecting an injured athlete was sometimes acceptable.

13

Clusters 2 and 3 made up this position but differed somewhat. In cluster 2, selecting an 14 injured athlete was sometimes acceptable but depended on the medical staff's opinion; the 15 more favorable this opinion, the more the selection was judged to be acceptable. These 16 participants considered that healthcare professionals were essential. Healthcare professionals 17 work with athletes to promote optimal health for participation in sport. The medical staff have 18 a key role in serving the athlete because the latter's health may be compromised for the good 19 of the team and/or the pursuit of glory and fame through winning. 46 The members of cluster 2 20 developed an ethical position in line with a paternalistic decision-making approach, 5 21 considering the medical staff is the main stakeholder considered when judging the 22 acceptability of selecting an injured athlete. A favorable medical opinion is essential for 23 ethical decision-making. The medical staff is best placed to assess the risks associated with 24 selecting an injured player, and so should make the decision. staff's opinion -a factor centered on the athlete's health. Amateur athletes appear to be more 3 sensitive to the athlete's health, and are not to be totally immersed in the performance issue 47 4 Alternatively, one can hypothesize that amateur athletes are less knowledgeable about sports 5 injuries and their consequences than professional athletes are. 48 This might explain why 6 amateur athletes consider that the medical staff's opinion is most important. Even though 7 amateur coaches receive a substantial amount of formal education on human physiology, their 8 judgments show that they considered the sports physician to be unambiguously responsible 9 for the coach's decision. 49

10

In cluster 3, selecting an injured athlete was sometimes acceptable but depended on 11 the opinions of the athlete and the medical staff; the more strongly an athlete wanted to 12 compete, the more the selection was judged to be acceptable. Likewise, the more the medical 13 staff's opinion was favorable, the more the selection was judged to be acceptable. The 14 members of cluster 3 adopted an ethical position close to a shared decision-making approach. 5 15 The athlete's and the medical staff's opinions were essential for ethical decision-making.

16

Hence, the medical staff and the athlete should discuss the most appropriate decision for a 17 given situation. 44

18

The participants in cluster 3 (containing 33% of the non-athletes, 24% of the amateur 19 athletes, 24% of the amateur coaches and 20% of the physiotherapists) considered that the 20 selection of an injured athlete depended on the athlete's and the medical staff's opinions -21 emphasizing the importance of collaboration between these two stakeholders on ethical 22 issues. Sports medicine staff should communicate and respond to whatever an athlete's injury 23 concerns, and can tell the athlete about the importance of managing an injury. The athlete 24 might maintain a positive attitude toward the treatment program, as he/she is willing to learn 25 and to do whatever is needed to recover as fully as possible. 50 The ethical decision-making According to this second ethical position (in clusters 2 and 3), the selection was 3 judged to be more acceptable when the team needed the athlete. Team sports involve social 4 support from other athletes. When injuries occur, athletes are afraid of being separated from 5 the team group. For example, Gould, Udry and Bridges 51 found that athletes prevented from 6 participating in their activity are more stressed because they lose contact with their team, 7 coach, and friends. Injured athletes report feeling isolated and lonely, 47 and are dissatisfied 8 with the social support they received when injured. Udry, Gould and Bridges 52 stated that 9 teammates have a greater effect than coaches or medical professionals on an injured athlete's 10 emotional state. Athletes who come back quickly after injury are more respected and more 11 admired than those who do not. 3

12

As mentioned above, this second ethical position encompasses clusters 2 and 3. This 13 might be considered to be surprising from an ethical standpoint. The members of clusters 2 14 and the members of cluster 3 did not have the same approach to ethical decision-making, and 15 respectively adopted positions in line with paternalistic decision-making and shared decision-16 making. Research on medical ethics has highlighted a move towards shared decision-making 17 model at the expense of paternalistic decision-making. 53 The second ethical position described 18 here shows that the shift from a shared decision-making model to a paternalistic model is not 19 so clear; the two models can be grouped together within the same ethical approach -showing 20 that a transition from the paternalistic model to the shared decision-making is now underway.

21

Ethical position 3 (cluster 4) 22

In the third ethical position, the coach's decision to select an injured athlete was 23 generally acceptable if the athlete agreed. Injuries are commonplace for athletes engaging in 24 competitive sport. Each competition must be won, and so the athletes follow their coach, who 25 has a leadership role. The third ethical position was adopted by the participants in cluster 4. They estimated that the athlete alone must decide whether or not he/she can perform when 2 injured; in ethical terms, this is aligned with an autonomous decision-making approach. 5 The 3 decision-making is unilateral, and the athlete makes an independent choice. 44

4

Cluster 4 (containing 32% of the professional athletes) often agreed with the coach's 5 decision and often considered that selecting an injured athlete is acceptable as long as he/she 6 agrees. Participating in competitions is the athletes' job, although an ethical dilemma arises 7 whenever an individual athlete's best medical interests conflicts with the performance 8 expectations of authority figures (e.g., coaches). 45 Although there are various types of 9 personal relationship in sport (athlete-athlete, athlete-team manager, athlete-team physician, 10 etc.), the coach-athlete relationship is unique and is crucial for athlete development. 54 In the 11 context of injury, in keeping with the principle of autonomy 11 , the healthcare professional 12 limits him/herself to explain diagnostic and treatment options and must approve the athlete's 13 decision. 55 The question is to what extent an athlete agrees to compete or to try to compete 14 after sustaining an acute or overuse injury. Athletes may adopt a flippant attitude towards pain 15 and/or may hide their pain from significant others, such as teammates and coaches. 12 16 "Playing" is important in maintaining an athlete's identity and sense of professional pride and 17 in avoiding the "injured role", which is negatively perceived within the sports environment. 56 18 Pain and frequent medical treatment are perceived to be normal in professional sport. 12

19

Athletes should be fully aware of the short-and long-term risks of playing when injured. That 20 raises the dichotomy between the beneficence and non-maleficence and the conflicts between 21 these two principles can lead athletes to risk situations. 10 They should be aware that injuries athletes because competitive performance is not important for the former group. 13 It is known 2 that individuals with different roles (amateur athletes, professional athletes, coaches, 3 physiologists, etc.) may have different objectives and principles. 37 Amateur athletes want to 4 have fun playing a sport rather than playing to win a championship all season. They are less 5 intensely engaged with the sport; their objectives are characterized by short-term goals, 6 enjoyment, and health-related outcomes. Côté and Gilbert 13 suggested that performance 7 coaching entails a more intensive commitment to a preparation program for competition. To 8 this end, the coaching program is highly specific.

9

It is undeniable that a coach's decision concerning an athlete's health can be judged in 10 different ways. It is a complex decision. The injured athletes' participation in competition and 11 the circumstances in which coaches make these decisions require a more nuanced 12 appreciation. 58 What coaches consider may be affected by their experience. The decision-13 making process employed by coaches can be due to novice-expert differences and differences 14 in amateur-professional context. 59 Professional coaches may have easy access to sportspecific medical advice, while amateur coaches may not. Consequently, the most relevant 16 sources of information may be lacking and the priority may be to minimize lost training 17 time. 60 Compared to novice coaches, expert coaches may have stored decision-making 18 procedures from personal experience. 61 In addition to learning from experience, what coaches 19 consider is also affected by their education qualifications in injury care and management.

20

Least experienced coaches may consider less informational parameters than experienced 21 coaches whose decision-making may be regulated via a range of additional considerations. 58

22

Nevertheless, coaches have a major role in athletes' ethical development. 9 As noted by principles. Coaches must also be aware of and understand their legal responsibilities. It is also 7 essential for coaches to have the skills and knowledge needed to meet their obligations. 8 However, as long as athletes are informed of the risks and potential consequences of 9 competing when injured and wish to compete without being pressured to do so, no ethical 10 issues are raised.

11

We suggest that the coaches could be confronted with this type of ethical decision in 12 their education and training. Our questionnaire or other sports simulations could be used to 13 stimulate debate between coaches and prompt them to think about ethical dilemmas. We 14 recommend having clear rules for each roles (athletes, medical staff, and teammates) when an 15 athlete is injured because it is difficult to both protect the athlete's health and to seek to win 16 the competition. 17 Before making a decision, the coach should communicate with medical staff and the 18 injured athletes. It would be useful to establish a consensus between people who are directly 19 involved in the case. This approach helps to compare potentially conflicting positions and to 20 brainstorm possible alternatives. At this level, we suggest that all the involved individuals 21 should think about the potential consequences (on the athlete's health, on the teammates' 22 trust, on the team's performance, etc.) of selecting or not selecting an injured athlete. The present study had some weaknesses, which should be considered in future 2 research on sports ethics and health. Firstly, we did not take account of certain social factors 3 (families, agents, managers, fans, the media, etc.) that could be incorporated the acceptability 4 of a coach's decision. 3 Other informational cues could have been considered, such as the 5 uncertainty of the results, the impact on the sponsors, and so on. In our scientific approach, 6 however, only a small number of factors might impact the judgment. Including too many 7 factors in a questionnaire might lead to cognitive overload for the participants. 38 8 Secondly, we did not take account of the nature and severity of the injury. 8 The 9 acceptability of the coach's decision might differ as a function of these factors. Concussion or 10 a slight ankle sprain will be associated with different risks for the athlete's health if he/she 11 continues to compete. 34

12

A third (methodological) limitation relates to the fact that the ANOVA in each cluster 13 had the same threshold for statistical significance, even though the sample size in each cluster 14 differed. In fact, a different threshold should have been used in each cluster. However, we applied the statistical approach typically used in studies of Anderson's framework. [19][20][21][START_REF] Mullet | Functional measurement in the field of empirical 11 bioethics[END_REF] 16 Fourthly, our study scenarios focused on a rapid return to play; the athlete injured 17 him/herself on the day before the competition. However, the pain may last for longer. The 18 acceptability of a coach's decision may depend on the time since the injury and the time since 19 treatment was initiated (days, weeks, or months). 65 20 Fifthly, further ethical issues concerning the athlete's health could have been studied.

21

For instance, we consider that confidentiality may be an important ethical issue. 66 Athletes 22 rely on the medical staff's professionalism, and information about their health ought to remain 23 confidential. However, sports medicine professionals may be agents or employees of a club, 24 and may handle the information cues differently. Is violation of a professional duty of The objective of the present study was to map individuals' ethical positions according 3 to the acceptability of selecting or not an injured athlete. On one hand, the non-selection of an 4 injured athlete was unanimously approved. On the other hand, the selection of an injured 5 athlete led to three different ethical positions which differed in terms of the type of role in 6 sport. This study emphasizes that coaches play an important role in athletes' life for their 7 improvement. They need to be aware of the risks and consequences of their decision. For that, 8 they must take care of the athlete's health which needs collaboration with medical staff. This 9 study suggests to improve coach-medical staff-athlete communication. The mean acceptability ratings are given on the y-axis. The two levels of the medical staff's advice are given on the x-axis. MSU means "medical staff is unfavorable", and MSF means "medical staff is favorable". Each line corresponds to one level of the athlete's opinion: the dotted line corresponds to agreement to compete, and the solid lines corresponds to refusal to compete.

Each panel corresponds to one level of the teammates' opinion: in the left panels, the athlete is not indispensable for the team; in the right panels, the athlete is indispensable for the team.

  acceptability of nutritional supplement use, they might influence the 2

19

  The second information cue was the competition's importance. One of the prime 20 distinguishing factors within sport is competition. Sporting competition has generally been 21 portrayed as being inherently stressful. To be competitive, individuals have to focus on doing 22 their best relative to others in the same domain of achievement. Coaches are essential for the 23 athlete's performance -especially in high-level sport. 30 As part of the coach-athlete 24 relationship, coaches are responsible for producing successful sporting performances. 31 25 Coaches may have to make decisions about the importance of injuries, particularly during Bramley, Kroft, Polk et al.'s 32 study of a sample of hockey coaches found 2

8

  physiotherapists who agreed to participate and then filled out the study questionnaire. All the 9 study participants were unpaid volunteers living in France. 10 Material 11

  15 (a) the injured athlete's indispensability (indispensable or not), (b) the importance of the 16 competition (important or not), (c) the medicine professionals' opinion (selection or nonselection), and (d) the athlete's opinion (willing to compete or not

45

  ProcedureThe study procedure complied with French and European ethical standards, 6 institutional rules, and the 1964 Declaration of Helsinki and its later amendments. The study 7 was approved by the University of Perpignan's institutional review board (Perpignan, France) 8 and the clubs' officials and managers. The participants were given information about the 9 study's objectives and procedure, and gave their written consent. Participants were instructed 10 to read the scenarios (presented one at a time in random order) and to mark their responses on 11 the response scale immediately after reading the scenario. The participants filled out the study 12 questionnaire alone. This part of the study comprised a familiarization phase and an 13 experimental phase. In the familiarization phase, the experimenter explained what was 14

21

  the participants were exposed to the full range of stimuli. Participants were given an 22 opportunity to review their ratings and to modify them if they wished. Subsequently, 23 participants provided their finalized ratings. During the following experimental phase, all 16 24 scenarios were administered. Participants provided the ratings at their own pace but -in 25 contrast to the familiarization phase -were not allowed to review or modify their responses.

1

  All evaluations (including those of the non-athletes who played for leisure) took place in 2 sports clubs. The participants worked individually in a quiet room, and took about 30 minutes 3 to complete the questionnaire. In each category of participant, half of the participants were 4 presented first with scenarios in which the coach decides to select the injured athlete and then 5 scenarios in which the coach decides not to select the injured athlete. The other half of the 6 participants were presented with the same sets of scenarios but in the opposite order.

22 simultaneously

 22 and then applied a post-hoc test. The four clusters differed significantly from 23 each other with regard to all the factors: teammates, F(3,215) = 7.63, p < .001, η² p = .10; the 24 importance of the competition, F(3,215) = 13.41, p < .001, η² p = .16; the medical staff's

  18given on the x-axis. Each line corresponds to a level of the athlete's opinion, and each panel 19 corresponds to a level of the teammates' opinion.

  20

  22 scale (M = 3.16, SD = 0.09). The members of this cluster based their judgment principally on 23 the medical staff's opinion and the athlete's opinion. Each line clearly rises from left to right, 24 showing that the medical staff's opinion influenced the participants' judgments. The lines are 25 separate, showing that the athlete's opinion also influenced the participants' judgments. An

  14 judgment was close to the middle of the response scale (M = 4.39; SD = 0.11), and the 15 members of this cluster considered principally the athlete's opinion and the medical staff's 16 opinion when judging the acceptability of selecting an injured athlete. The fact that the lines are far apart indicates a strong effect of the athlete's opinion; the more he/she wants to 18 compete, the more the selection is judged to be acceptable. Each line rises from left to right, 19 showing that the medical staff's opinion influenced the judgments of acceptability. The lines 20 are the same in the left and right graphs, indicating that the teammates' opinion had no effect.

  21

  19) was above the middle of the 0-10 scale. The two lines are almost the same in the left 2 and right graphs, indicating that the teammates' opinion had no effect. Furthermore, the lines 3 do not rise from left to right, indicating that the medical staff's opinion had no effect. The 4 lines are separate, indicating an effect of the athlete's opinion. The individuals in this cluster 5

2

  13comparison Cluster 1 vs Cluster 4, 54% of the professional athletes and 35% of amateur 14 coaches were in cluster 1, and 32% of professional athletes and 0% of amateur coach were in 15 cluster 4. In comparison Cluster 2 vs Cluster 4, Cluster 2 contained 41% of the amateur 16 coaches, 32% of the amateur athletes, and 11% of the professional athletes; Cluster 4 17 contained 0% of the amateur coaches, 3% of the amateur athletes, and 32% of the professional 18 athletes. In comparison Cluster 3 vs Cluster 4, Cluster 3 contained 34% of the non-athletes, 19 24% of the amateur athletes, 24% of the amateur coaches, 20% of the physiotherapists, and 20 3% of the professional athletes; Cluster 4 contained 11% of the non-athletes, 3% of amateur 21 athletes, 0% of the amateur coaches, 7% of the physiotherapists, and 32% of professional 22 athletes. 23 Discussion 24The objective of the present study was to map ethical positions according to whether 25 or not the selection of an injured athlete just before a competition was judged to be Our first hypothesis was that the participants would differ in how they integrated 3 several factors (the indispensability of an injured athlete, the importance of the competition, 4

  25various professional domains, professionals used a variety of tools to perform their work: for psychology researcher uses a computer, a radiologist uses an X-ray machine, etc.

  2

  43

  the ethical position 2 and thus primarily considered the medical 2

  2

22 may

 22 shorten their athletic career or may affect them after the end of their athletic career. 57 23 Practical Applications 24 A person's role in sport might explain the observed differences in ethical positions. 25 Non-athletes or amateur participants may not have the same ethical position as high-level

23

  Robbins and Rosenfeld 41 , sports coaches are often needed to provide basic support to injured 24 athletes in variety of situations and circumstances. Coaches are responsible for preventing or , and energy.62 Mohamadinejad and Mirsafian 63 classified a coach's duties 2 into seven major categories, which cover different types and various levels of recreational and 3 competitive sporting activities. If coaches want athletes to participate safely, they should be 4 aware of their responsibilities because an accident that injures an athlete may trigger civil 5 action against the coach. 64 Enabling athletes to compete when injured may violate ethical 6

23

  Therefore, effective respectful collaboration between stakeholders is required when faced 24 with an ethical dilemma.7 25Limitations and perspectivesPage 23 of 35 https://mc.manuscriptcentral.com/spo International Journal of Sports Science &

  I and Hogg JM. Coaches' decision policies about the participation of injured 2 athletes in competition. Sport Psychol 1999; 13: 42-56.

3 9 .

 9 Dhurup M and Mathaba RL. Beyond wining: Validation of unethical behaviours of amateur 4 sport coaches' scale as perceived through the lenses of athletes. AJPHERD 2015; 5 November: 293-309. 6 10. Devitt BM. (2016). Fundamental ethical principles in sports medicine. Clin Sports Med 7 2016; 35: 195-204. 8 11. Waddington I. Ethical problems in the medical management of sports injuries: a case 9 study of English professional football. In : Loland S, Skirstad, B and Waddington, I 10 (eds) Pain and injury in sport: a social and ethical analysis. London: Routledge, 2006, 11 pp.182-199. 12 12. Hammond L, Liley J, Pope GD et al. "We've just learnt to put up with it": an exploration 13 of attitudes and decision-making surrounding playing with injury in English 14 professional football. Qual Res Sport Exerc Health 2013; 6: 161-181. 15 13. Côté J and Gilbert W (2009). An integrative definition of coaching effectiveness and 16 expertise. Int J Sports Sci Coach 2009; 4: 307-323.

  17

  14. Shields DL, LaVoi NM, Bredemeier BL et al. Predictors of poor sportspersonship in 18 youth sports: personal attitudes and social influences. J Sport Exerc Psychol 2007; 29: 19 747-62. 20 15. Bredemeier BJ and Shields DL. Divergence in moral reasoning about sport and life. 21 Sociol. Sport J, 1984; 1: 348-357.

22 16.

 22 Rest J. The major components of morality. In Kurtines W and Gewirtz J (Eds.) Morality, 23 moral behaviour, and moral development. New York, NY: Wiley, 2004, pp. 24-30. 24 17. Arnold JP. Sport, moral development, and the role of the teacher: Implications for 25 research and moral education. Quest, 2001; 53: 135-150.

F

7 43 .

 43 Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: 8 revisiting the shared treatment decision-making model. Soc Sci Med 1999; 49: 651-9 661. 10 44. Whitney SN, McGuire AL and McCullough LB. A typology of shared decision making, 11 informed consent, and simple consent. Ann Intern Med 2004; 140: 54-59. 12 45. Wilkerson G. Patient-centered care and conflict of interests in sports medicine athletic 13 training. Int J Athl Ther Train 2012; 17: 1-3.

14 46 .

 46 Peer Kimberly S. The changing context of sport and medicines social contract with 15 society: implications for sports medicine ethics. Int J Athl Ther Train 2017; 22: 5-10. 16 47. Cudmore M. Managing injured athletes -A psychological perspective for the strength & 17 conditioning coach. J Aus Strength Cond 2014; 22: 54-61. 18 48. Peer KS. The changing context of sport and medicines social contract with society: 19 Implications for sports medicine ethics. Int J Athl Ther Train 2017; 22: 5-10. 20 49. Caldwell R. The changing roles of personnel managers: Old ambiguities, new 21 uncertainties. J Manag Stud 2003; 40: 983-1004.

22 50.

 22 Robbins JE and Rosenfeld LB (2001). Athletes' perceptions of social support provided by 23 their head coach, assistant coach, and athletic trainer, pre-injury and during 24 rehabilitation. J Sport Behav 2001; 24: 277-297. 25 51. Gould D, Udry E and Bridges D. Stress encountered when rehabilitating from season Page 29 of 35 https://mc.manuscriptcentral.com/spo International Journal of Sports Science & injuries. Sport Psychol 1997; 11: 361-378. 2 52. Udry E, Gould D and Bridges D. People helping people? Examining the social ties of 3 athletes coping with burnout and injury stress. Int Rev Sport Exerc Psychol 1997; 19: WH V and Dvonch M. Informed consent in sports medicine. Clin Sports Med 6 2004; 23:183-193. 7 54. Prophet T, Singer J, Martin I et al. Getting to know your athletes: Strengthening the 8 coach-athlete dyad using an integrative personality framework. Int Sport Coach J 9 2017; 4: 291-304. 10 55. Meisel A and Kuczewski M. Legal and ethical myths about informed consent. Arch Intern 11 Med 1996; 156: 2521-2526. 12 56. Roderick M, Waddington I and Parker G. Playing hurt: managing injuries in English 13 professional football. Int Rev Sociol Sport 2000; 35: 165-180. 14 57. Ristolainen L, Kettunen JA, Kujala UM et al. Sport injuries as the main cause of sport 15 career termination among Finnish top-level athletes. Eur J Sport Sci 2012, 12: 274-16 282.

  17

  58. Vergeer I and Lyle J. Coaching experience: Examining its role in coaches' decision 18 making. Int J Sport Exerc Psychol 2009, 7: 431-449.

19 59 .

 59 Galanter CA and Patel VL. Medical decision making: A selective review for child 20 psychiatrists and psychologists. J Child Psychol Psychiatry 2005, 46: 675-689. 21 60. Vergeer I. Family physicians and sports injury care; Perceptions of coaches. Can Fam 22 Physician 1997, 43: 1755-1761.

23 61 .

 61 Abraham A, Collins D and Martindale R. The coaching schematic: Validation through 24 expert coach consensus. J Sports Sci 2006, 24: 549-564.

F

Figure 1 .

 1 Figure1. The combined effects of the teammates' opinion, the medical staff's opinion, the athlete's opinion and the coach's opinions on the acceptability of selecting an injured athlete, by cluster. Note. The Figure shows the four clusters related to judgements of acceptability of selecting an injury athlete. The mean acceptability ratings are given on the y-axis. The two levels of the medical staff's advice are given on the x-axis. MSU means "medical staff is unfavorable", and MSF means "medical staff is favorable". Each line corresponds to one level of the athlete's opinion: the dotted line corresponds to agreement to compete, and the solid lines corresponds to refusal to compete. Each panel corresponds to one level of the teammates' opinion: in the left panels, the athlete is not indispensable for the team; in the right panels, the athlete is indispensable for the team.

  /mc.manuscriptcentral.com/spo International Journal of Sports Science & Coaching

16 Method 17 Participants 18 We included 219 male adult participants, including 28 professional handball players

	19	(M age = 24.64; SD = 8.04), 91 amateur league handball players (M age = 23.83; SD = 9.00), 45
	20	non-athletes (M age = 33.82; SD = 8.85), 17 amateur handball coaches (M age = 26.23; SD =
	21	8.85), 8 handball professional coaches, (M age = 39.38; SD = 9.70), and 30 male
	22	physiotherapists working with sports teams (M age = 25.02; SD = 8.57). The 28 professional
	23	handball players came from five national-level teams. They trained 10 times a week, and were
	24	contacted by one of the investigators (himself a professional athlete). The 91 amateur
	25	sportspersons were all male handball players from seven teams at different competitive levels.

). There were 16 possible

	1	extent do you think that the coach's decision is acceptable?". Beneath each scenario was an
	2	11-point response scale ranging from "not at all acceptable" on the left and "completely
	3	acceptable" on the right.
		F
		o r
		P
		e e r
		R e v
	18	combinations (2 × 2 × 2 × 2) of these factors, i.e. 16 stories. The scenarios were built in order i e w
	19	to achieve ecological validity, i.e. each corresponded to a real sporting situation. A typical
	20	scenario was as follows: "Moulgloute is a professional cross-country skier. He competes in
	21	relay races with his teammates. Moulgloute's teammates do not consider him to be
	22	indispensable for the team. The day before an important race, Moulgloute hurts his ankle
	23	during a training session. After examining the ankle, the team's medical staff consider that
	24	Moulgloute will be able to compete the next day. Moulgloute tells his coach that he does not
	25	feel ready to compete. The coach selects Moulgloute for the race". The question was "To what

  Advances in sport psychology. Champaign, IL: Human Kinetics, 2002, pp.101-Cushion C. Coach behaviour. In: Lyle J and Cushion C (eds) Sports coaching: Kroshus E, Baugh CM, Daneshvar DH et al. Pressure on sports medicine clinicians to Unified social cognition. New York: Psychology Press, 2008. Robbins JE and Rosenfeld LB. Athletes' perceptions of social support provided by their 2 head coach, assistant coach, and athletic trainer, pre-injury and during rehabilitation. J

	1 (ed) 2 183. 1 41. 3 Sport Behav 2001; 24: 277-297.
	4 4	Professionalism and practice, London: Elsevier, 2010, pp.44-61 42. Udry E. The role of significant others: Social support during injuries. In: Crossman J (ed)
	5 5	31. Kristiansen E and Roberts GC. Young elite athletes and social support: Coping with Coping with sports injuries: Psychological strategies for rehabilitation. Oxford:
	6 6	competitive and organizational stress in "Olympic" competition. Scand. J. Med. Sci. Oxford University Press, 2001, 148-156.
	7	Sports 2010; 20: 686-695.
	8	32. Bramley H, Kroft C, Polk D et al. Do youth hockey coaches allow players with a known
	9	F concussion to participate in a game? Clin Pediatr 2012; 51: 283-287. F
	10	o r o r 33. Arvinen-Barrow M, Massey WV and Hemmings B. Role of sport medicine professionals o r
	11	P P in addressing psychosocial aspects of sport-injury rehabilitation: professional athletes' P
	12	e e r e e r views. J Athl Train 2014; 49: 764-772. e e r
	14 15 16 17 18	R e v i e w R e v i e w prematurely return collegiate athletes to play after concussion. J Athl Train 2015; 50: 944-951. R e v 35. Quinn A and Fallon B. Predictors of recovery time. J Sport Rehabil 2000; 9: 62-76. 36. Augutis M and Anderson CJ. Coping strategies recalled by young adults who sustained a spinal cord injury during adolescence. J Spinal Cord Med 2012; 50: 213-219. i e w
	19	37. Proios M, Doganis G, and Athanailidis I. Moral development and form of participation,
	20	type of sport, and sport experience. Percept Mot Skills, 2004; 99: 633-642
	21 38. Anderson, NH. 22 39. Hair JF, Black WC, Babin, BJ et al. Multivariate data analysis (7th ed.). Englewood
	23	Cliffs, NJ: Prentice-Hall, 2010.
	24	40. McDonald JE and Beck-Dudley CL (1994). Are deontology and teleology mutually

3 30. 13 34.

2

  Means and SDs for each factor in the four clusters

	THE ACCEPTABILITY OF SELECTING (OR NOT) AN INJURED ATHLETE THE ACCEPTABILITY OF SELECTING (OR NOT) AN INJURED ATHLETE	31 34
	1 Table 1 1 Table 4
		Cluster 1	Cluster 2	Cluster 3	Cluster 4
		M	SD	M	SD	M	SD	M	SD
		5.12 0.11 5.61 0.05 5.63 0.07 5.83 0.20
	Factor
	TEAMMATE
	Not indispensable	5.75 0.67 5.55 0.84 5.10 0.11 5.84 0.20
	o r F o r F F 5.45 0.54 5.70 0.78 5.11 0.11 5.81 0.20 IMPORTANCE OF COMPETITION Indispensable o r o r
	Low	P P 5.59 0.66 5.56 0.86 5.23 0.10 6.22 0.21 P P
	High MEDICAL STAFF	e e r e e r 5.62 0.53 5.69 0.69 4.99 0.12 5.43 0.24 e e r e e r
	Not in favor of selection In favor of selection	R e v R e v 5.21 0.05 5.51 0.07 5.04 0.11 6.19 0.22 5.99 0.08 5.75 0.09 5.18 0.11 5.47 0.24 R e v R e v
	ATHLETE Wants to compete	i e w i e w 5.46 0.05 5.52 0.08 4.82 0.11 5.49 0.21 i e w i e w
	Does not want to compete	5.75 0.07 5.74 0.07 5.39 0.12 6.17 0.20
	COACH
	In favor of selection	3.16 0.09 4.71 0.10 4.39 0.11 5.74 0.19
	Not in favor of selection	8.05 0.07 6.55 0.10 5.83 0.14 5.92 0.25
	3

2

  Marascuilo's post hoc multiple proportion comparisons for the participants, between the four We applied Marascuilo's post hoc procedure for multiple comparisons. This tested 22 the significance (p < .05) of pairwise differences within the cluster of groups. When the 23 comparison between two clusters was significant, the significant pairwise differences are 24 shown in Table4. 25 * indicates significant differences in the clusters.

	3 clusters.
	4
	Not Indispensable
	5
	6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Legend: Comparison Cluster 1 vs Cluster 2 Cluster 1 vs Cluster 3 Cluster 1 vs Cluster 4 Professional athletes vs amateur coaches Cluster 2 vs Cluster 3 Cluster 2 vs Cluster 4 Professional athletes vs amateur athletes Professional athletes vs physiotherapits F o r P e e r Professional athletes vs amateur coaches Cluster 3 vs Cluster 4 Professional athletes vs amateur athletes R e v χ² 8.98 10.17 12.34 14.40 4.12 22.90 23.56 13.05 36.00 23.86 46.00 Professional athletes vs non-athletes 22.99 Professional athletes vs amateur coaches 90.00 i e w	p .11 .07 .03* .01* .53 <.001* <.001* .02* <.001* <.001* <.001* <.001* <.001*

https://mc.manuscriptcentral.com/spo International Journal of Sports Science & Coaching

1 Table 3 2 Results of the Pearson's Chi-square test between the roles of participants and the four 3 clusters.