Baseball Men - The Skeptic

Our exclusive ‘Baseball Men’ interview series continues with Dr. Norman Fost, a steroids expert and medical ethicist at the University of Wisconsin

Peter Handrinos is a frequent contributor to Scout.com and author of the upcoming ‘The Best New York Sports Arguments:  The 100 Most Controversial, Debatable Questions for Die-Hard Fans’.

The following introduction has been altered from its original posting, which mischaracterized several of Dr. Fost’s views on the subject of steroids. The author regrets his initial errors.

Slowly and surely, the mainstream media has formed a familiar consensus on the subject of steroids.

Experts have repeatedly claimed that the drugs are physically harmful to users while being destructive to sports integrity. Time and time again we’ve been told that the various revelations and investigations of the last few years have soured the fans’ perceptions and the game’s historical record, all while sending a uniquely destructive message to impressionable kids.

All that has been part of the conventional wisdom on steroids, but Dr. Norman Fost has never been a part of it. In fact, he’s done his very best to present several alternative arguments.

Dr. Fost’s skeptical views, as passionately-held as they may be, would be relatively easy to dismiss if he didn’t possess such impeccable professional credentials. A 1960 graduate of Yale Medical School, he served a residency at Johns Hopkins Hospital before moving on to the University of Wisconsin Hospital, where he’s served as a tenured professor in pediatrics and the history of medicine for more than 20 years. He currently serves as the Chairman of UW’s Hospital Ethics Committee and has been a past Chairman of the American Academy of Pediatrics’ Committee on Bioethics.

Recently, one of the nation’s leading ethics authorities discussed his skeptical take on steroids and sports:

Do steroids help athletes perform better?

There’s no question that they improve performance in some athletes in some settings. As far back as World War II, steroids were known to enhance protein synthesis in certain tissues of the body and help injured muscles and wounds heal more quickly. There are good studies showing that weight lifters can improve their strength and performance by using anabolic steroids.

One theory about how they work is that they allow more vigorous weight training. Without them, weight lifters suffer micro-tears in their muscles and need to take time off to heal. Otherwise, they’ll be sore and, eventually, injured. Steroids allows you to train harder and, thereby increase muscle size and strength, and in time, to performance. I’m not aware of controlled studies that prove you hit more home runs, or throw harder or more often, but I don’t think there is much doubt that some baseball players have improved their performance by adding steroids to a rigorous weight training program. 

Some people may think you can just take a pill and suddenly hit more home runs. It’s not like that. The best power hitters work very hard and steroids probably allow them to work a little harder before stopping for recovery.

As you know, a lot of media stories have emphasized the physical harm associated with steroids. What’s your view?

There are two problems with the media accounts.

First, playing the sport causes far more permanent disabilities than those associated with steroid use. In football, far more players have died or become seriously disabled from playing the sport than for reasons related to steroids. I would guess more people have died playing baseball, versus taking steroids - namely, one [the Indians’ Ray Chapman in 1920]. I’m not aware of any major league baseball player whose death can be clearly attributed to steroids.

Good ethics start with good facts, and press accounts have been wildly exaggerated. The majority of reporters have been repeating the same claims about risks without checking the sources. This litany of claims - that steroids cause cancer, heart attacks, strokes, and other serious medical problems in baseball players - isn't supported by any reliable medical evidence.

When steroid users like Lyle Alzado [of the NFL] or Ken Caminiti have died, the media has simply assumed that the steroids played some significant part, but there isn’t a shred of evidence that either one was a 'steroid-related death', as Alzado’s cancer was described in the front page of the New York Times. The young man in Texas, [Taylor] Hooton, was a very sad case, but reportedly had other risk factors for his suicide, such as depression and was reportedly using Lexapro, an anti-depressant medication called an SSRI, which have been shown to be associated with suicidality. 

One of the problems with the prohibition policy is that everything is driven underground, so we can’t do the kind of well designed studies that could produce reliable information. I don’t belittle the non-life threatening risk associated with steroids, in everything from male pattern baldness, infertility (usually reversible), voice changes, mood changes, and acne. All those things are real. I do object to the claims about the life-threatening effects from steroid usage in the ways professional athletes use them.

Well, there does seem to be evidence of steroids’ harm to ball players, in that disabled list stays increased 31% from 1990 to 1998. Players like Caminiti, Jose Canseco, and Jason Giambi have all suffered severe injuries while they were taking them.

As to Caminiti, Canseco, and Giambi, anecdotes don’t tell me much. Some steroid users have had injuries and some haven’t. To attribute injuries to steroids, you’d have to do a more scientific study of users and non-users, and show that the incidence of injury was higher in one group. The fact that three famous steroid users had injuries doesn’t tell me very much.

I once told a reporter that there’s no evidence that steroids cause joint and knee problems, as he had implied in an article. He responded, ‘Come on Doctor, don’t you know that most weight lifters are on steroids, and most of them have chronic knee problems?’ I said, ‘Yes, I know that, but how many of the injuries are due to weight lifting and how many are due to steroids?’ He didn’t seem to understand that simple distinction.

As to your other point, yes, there do seem to be more injuries than decades ago. For example, when I was young, I could name the starting pitchers for the Dodgers, Giants and Yankees over a ten year period, because they basically stayed uninjured over that span. Today, there seem to be a lot more pitchers who are disabled early in their careers or burn out. 

Maybe it’s because they throw harder and don’t pace themselves, since they are not expected to pitch a complete game. Maybe it’s related to their training. I wonder if increased weight training isn’t causing more of wear-and-tear on muscle ligaments, with stretched and torn ligaments. I’d welcome more studies on the connection between weight training, in itself, and baseball injuries.

I suspect that steroids, in encouraging athletes to train harder and longer, may be associated with the greater injury totals, but the problem is [that] we just don’t know how much of the injury problem is due to steroids and how much to other factors.

You’ve come out for legalization of steroid usage for adults. What substances would you ban?

There ought to be a serious risk-to-benefit ratio, one with a substantial harm incidence with no compensating medical benefit. Ephedra, for example, has been alleged to cause 100 or more deaths. I’m not sure about the number - it’s hard to get a reliable number - but if that’s true, it would support the argument for a ban. That’s a substantial number, and the drug has no known medical benefit.

If it were the case that steroids caused a number of premature deaths, obviously, that would count against them. It’s a powerful argument, one that’s brought up by the steroid critics constantly, but, unfortunately, it’s not based on any reliable data at this point. I’d advocate better scientific studies to get the data. Jose Canseco claims that more than half of major league players use steroids. Can you name one who has had a heart attack or a stroke or liver cancer?

As you know, the issue isn’t just about medical science, but about ethics, and I wonder if you’d speak to some of the most popular arguments against steroids. For instance, it’s been said that ‘ball players are basically being forced to use steroids in order to keep up with the competition’.

The problem with that is, no one is forced to use steroids, any more than any one is forced to play professional sports. If you don't want to play, don't play. It's an offer, not a threat. It's an opportunity, not a requirement. No one's forcing you to do it, so everyone I know takes the risk voluntarily.

Another argument - ‘We have to protect athletes from their own competitive instincts’.

I don’t know if you can really protect people from themselves. It’s a basic tenet of American liberty that you don’t interfere with people who want to take risks if they are not exposing others to risks.

That’s to say - we allow people to do far more dangerous things than play football or baseball while using steroids. We allow people to bungee-jump, to ski on advanced slopes, to cliff dive. To eat marbled meat or ice cream pie every day if they want. I don’t think we want to go down a path in which we restrict and even criminalize behaviors just because they have health risks. And steroids are so low on the list of drugs or diets that cause serious harm I don’t understand why we would start there.

‘We might not know if steroids are terrible, but we should always err on side of athlete safety’.

As a physician, I wouldn’t prescribe enhancing drugs that might be dangerous, just so a patient can become a better athlete. However, forbidding the players from taking them? That’s something different. Playing professional sports involves substantial risks of harm with a high incidence of permanent disability, and I haven’t heard anyone say that we should prohibit players from volunteering to play football.

I guess one of the reasons I don’t really respect football is the fact that it’s based on crippling violence. Baseball has always had far more respect for its athletes’ health and well-being.

I don’t see Major League Baseball showing much concern about substances or behaviors that cause much more harm than steroids, such as alcohol and chewing tobacco. If the purported goal is to protect the athletes from harming themselves, why are the penalties for tobacco and alcohol use not as harsh as those for steroids? In the case of alcohol, they not only don’t discourage its use to the same degree as steroids, they promote it to the fans.

The hypocrisy of a steroids ban is even more obvious, in sports like football and hockey, where there is an even higher risk of permanent disability.

Another argument against legalizing steroids is in ‘the yuck factor’-  it’s simply offensive to have star players inject themselves with syringes in bathroom stalls and come out on the field as these over-inflated muscle men.

A couple of things.

I think, first, you can’t elevate repugnance - the yuck factor - to a moral principle. That’s not a reason for prohibiting something. Many people felt yucky about integrating schools and drinking fountains or having homosexuals teach in schools or having female airplane pilots. Different people can feel yucky about all sorts of things in life for different reasons - that’s not, in itself, a sufficient basis for prohibiting them or regulating them.

Second, part of that repugnance, to the extent that it exists at all, is manufactured by the the relentless, one-sided reporting in the press, and more recently, in Congressional hearings that were carefully staged to humiliate certain players.

Is the public really repelled by steroid use? Major League attendance has been booming during the so-called steroid era. Suspected steroid users are huge box office draws. The notion that fans wouldn’t come to see stars hitting home runs isn’t plausible. Fans didn’t stop coming to see [Mark McGwire] after he admitted taking andro [in 1998] and they didn’t stop coming to see [Barry] Bonds after he admitted taking steroids inadvertently [in 2004].

There isn’t any evidence that the public’s trust and love and affection for baseball has been lessened in recent years, despite the media’s best efforts to hype the steroids situation. People love [the game] for the same reasons they’ve always loved it, steroid scandals or not. And it’s not just chicks who love the long ball.

The President, speaking in the State of the Union address, commented on the situation, as you know. He said that the chemicals ‘send the wrong message - that there are shortcuts to accomplishment, that performance is more important than character.’

I’m not sure the President is in any place to talk about sending the wrong message. He found 15 seconds to talk about steroids in the State of the Union address, but not one second to talk about tobacco and alcohol, which are proven to kill hundreds of thousands of Americans, year-in and year-out . . . The administration has no serious initiatives on any of that.

This is called hypocrisy. You have 400,000 deaths a year due to tobacco - 400,000 a year! You have tens of thousands of alcohol-related deaths, a substance heavily promoted by Major League Baseball. And you have virtually no deaths linked to steroids - maybe one, maybe two. The President and Congress and the press have virtually nothing to say about tobacco and alcohol, but lots to say about steroids. You can’t take it seriously in terms of relevance to kids’ health.  

Why not make the situation better through a ban?

Because you’re not going to make it any better. It’s hard to reduce to zero [steroid] deaths - it’s somewhere close to zero already - but it’s relatively easy to reduce thousands of the 400,000 tobacco-related deaths. There’s only so much air time, and I’d recommend politicians talk about the things that really do affect kids’ values and kids’ health.

As you know, I’m in favor of a complete prohibition on steroid use by kids. There are adverse health effects there that don’t apply to adults, and kids can’t make informed choices. However, if baseball’s worried about sending a message to kids, I’m 100 times more concerned about a place called Miller Park, where they sell beer in industrial quantities. The League takes little notice of it, nor do they have penalties for players who abuse alcohol comparable to the penalties for steroid use.  

But you have to admit worry about a ‘something for nothing’ message with steroids. One of the reasons ball players are admired is because they have to work so hard for so long at the craft of the game. Steroids take away from that.

Well, there’s still no ‘something for nothing’. Athletes reach the highest level, because of physical and psychological qualities that allow them to perform under pressure. That is, Michael Jordan and Larry Bird became superstars because they worked harder than many others, and had extraordinary ability to concentrate and relax in pressure situations. I don’t know how drugs affect that. I wouldn’t imagine that they affect it at all.

Barry Bonds does not hit home runs because he uses steroids. He hits home runs because he’s a marvelous athlete with unbelievable hand-eye coordination and an extraordinary work ethic. He was a Hall of Fame player long before he allegedly started using steroids. Steroids may have increased his numbers over the last few years, but they didn’t make him a Hall of Fame player.

As you know, fan polls indicate strong public disapproval on the steroid issue. How would you explain that?

Polls, as you know, are driven by the information available to those polled, and the information out there isn’t very good. When you tell people there are weapons of mass destruction in Iraq, 50% of the people will believe it. Even when you find out that they don’t exist, 40% still believe it!

Similarly, when the press tells the American people, over and over and over again, that steroids cause heart disease, cancer, and strokes and constitute a serious example of unfairness in sports, what are they going to believe? Of course the polls will reflect what they read and hear - there has been virtually no one telling them anything to the contrary.

Do you believe steroids undermine the continuity of baseball history?

There are all sorts of reasons why Bonds’ home runs aren’t really comparable to [Roger] Maris’ home runs, and why Maris’ home runs weren’t comparable to Babe Ruth. So many things have changed, including the height of the pitching pound, the ball park dimensions, the number of games, nutrition, videotape, computers - and they’re accepted in the course of things.

I’m told the average number of home runs rose 50% when the Indians moved from old Municipal Stadium to Jacobs Fields [in 1994]. Why wasn’t there a hue and a cry to add asterisks to those records? Because you’d have to put asterisks on everything - because nothing is truly comparable. Steroids undoubtedly have affected the number of home runs, but so have many other factors. The records would not be comparable even if there had been no steroids.

Here’s another argument - ‘baseball should be based on natural ability and hard work, but steroids are unnatural’.

This one escapes me completely.

All sports are unnatural, to the extent that they're all made-up games. It's impossible to imagine modern sports without unnatural enhancements, be they shoes and equipment to hundreds of legal dietary supplements and drugs. No one plays in a natural state without any unnatural assists. 

There are plenty of things that are enhancing, and they aren’t necessarily immoral because they’re enhancing. The claim that doctors shouldn’t give people enhancing therapies is not sustainable. Pediatricians give vaccines to children to enhance their immune system. Other physicians try to enhance the “normal” life span in other ways.

Gaining an advantage in sports would be unfair if it's unequally available, and the fact is that steroids have been ubiquitously available despite being illegal. The fairness argument doesn’t require prohibition. It could just as logically lead to legalization.

There are many things in sports that are unfair, but they aren't prohibited for the fact that they're not available to all. To take a simple example, the University of Wisconsin's offensive linemen sometimes have an advantage of 50 pounds per person over their opponents. Plenty of other Division I-A schools have bigger budgets and training facilities and physicians and so on, in order to recruit superior athletes.

In baseball, Bud Selig says he wants to ban steroids because they're anathema to fair competition. This is a sport where the New York Yankees, with a $200 million payroll, compete against teams with $40 million payrolls. That’s manifestly unfair and not only is little done to correct the imbalance; they just agreed to retrench on the luxury tax.

There's hypocrisy there on several levels. It calls to mind an incident from the 1988 Olympics. Ben Johnson, everyone remembers, had his gold medal taken away due to steroid use. On the same day, [gold medal-winning American swimmer] Janet Evans held a press conference in which she bragged about her access to a special, greasy type of swimsuit and said she was quite sure that it gave her an advantage in her race.

Johnson’s use of steroids was considered a great moral scandal, but Evans ended up as America's sweetheart. She had American ingenuity in action, and the fact she kept it secret was even better. The hypocrisy was so thick; it amazed me that none of the thousand reporters on hand picked up on it, then or since.

Do you see Major League Baseball’s tough new testing regime reducing steroid use in the game?

Well, it will almost definitely reduce usage for steroids that are testable. It will almost definitely divert users to steroids that aren’t testable, or non-steroid enhancers like human growth hormone. When you have a sport offering tens of millions of dollars to its stars, I think athletes will do whatever’s necessary to succeed at that level, and I suspect many players have already found something that isn’t detectable by the current testing.

In the long term, history indicates that the users and the chemists stay ahead of the testers, with more and more new substances. To me, that’s all the better reason to keep steroids legal and above ground, with effective lab testing for efficacy and safety. Driving something underground makes it almost impossible to regulate.

As you know, your skeptical views are in the minority. Do you think that will ever change?

National Public Radio once called me ‘the loneliest man in America’ (laughs), but the most prestigious medical journal in England recently had an entire issue dedicated to sports and drugs, and several of the authors agreed with my views. That was encouraging. I do think views can change.

The complete Table of Contents for the ‘Baseball Men’ interview series can be found here.