Editor’s note: With Chris Froome’s case raising questions about the enforceability of anti-doping rules, and risky practices increasingly occurring at lower levels of the sport, Dr. John McGowan asks if it is time take a radically different approach to drug use in cycling. Dr. McGowan is a clinical psychologist, a lecturer at Canterbury Christ Church University (UK), and has worked in mental health and with substance abuse services for a number of years in the UK National Health Service. He has contributed to various publications including The Guardian and written about the bio-ethics of PEDs and doping in other outlets such as The Science of Sport.

So, the Froome verdict is in. After frenetic last-minute maneuvering from the Union Cycliste Internationale (UCI), World Anti-Doping Agency (WADA), and Amaury Sports Organization (ASO) he will, after all, ride the 2018 Tour de France. Have many minds been changed by the ruling? Perhaps not, and although exonerated, many believe Froome is still riding under a Salbutamol cloud.

Though cycling can contend that it takes performance-enhancing drugs (PEDs) more seriously than many sports, there are clearly gray areas around medicines such as Salbutamol. WADA has essentially admitted it is struggling to draw the line between acceptable therapy and performance-enhancing doping. Perhaps this shouldn’t surprise us as such matters are wide open to disagreement. If Twitter is any guide, many committed anti-doping advocates are arguing that the whole anti-doping system is busted — stacked in favor of those with the resources to defend themselves. So are WADA’s rules working? Do they protect fairness and athlete safety? And, if not, do we have an alternative way forward? By coincidence, the UCI has recently proposed some rule changes relating to cortisol levels which suggest an intriguingly different direction for future drug policy (more of which below).

Is the system broken? While WADA has been understandably keen to defend their processes, it’s clear that these are not happy times for anti-doping. The Court of Arbitration for Sport (CAS) has overturned bans on athletes identified in exposés of a Russian-sponsored doping program. What’s more, many of their compatriots competed in the Winter Olympics, despite the exclusion of Russia as a participating nation. The International Olympic Committee and WADA continue to deal with new allegations of lapses in oversight and compromised laboratories. In cycling, the UCI has also become increasingly concerned about the use of non-prohibited substances such as Tramadol. Perhaps more worrying though are events away from cycling’s elite ranks. Recently 20 riders were suspended for EPO use and other doping issues following races in South America. In Italy, prosecutors are pursuing criminal charges following the alleged PED-related death of young rider Linas Rumsas. There are also suggestions of organized doping within Rumsas’ amateur team, Altopack-Eppela.

The ongoing investigation into Altopack-Eppela, in particular, seems like a return to the doping badlands of the 1990s and suggests that current rules may be failing athletes rather than simply disappointing fans. Human Growth Hormone, micro-dosing of EPO, and drug-related deaths are supposed to behind us in the wake of 1998 (Festina), or possibly 2006 (Puerto), or maybe 2012 (Lance Armstrong’s final fall). The men’s and women’s World Tours, the sport’s premier showcases, now have biological passports for every competitor. There is also movement monitoring to enforce WADA rules. Yet it would appear that below the very top level, things are less heavily policed.

One obvious response to recent events is to beef-up rule enforcement throughout the sport. We could have biological passports for every rider in every UCI-registered team: at the Continental and ProContinental levels, rather than just at the top. We could demand greater transparency around blood and power data. WADA is also trying to develop education programs and to encourage changes in behavior.

While such answers may seem obvious, they might not always deliver the benefits we expect. There are clearly questions as to how practical all of these efforts might be and, more than that, worries about the invasions of personal liberty resulting from a massive increase in whereabouts monitoring. Obviously, the Froome case raises questions about the enforceability of the rules as they stand, though such issues arose after the biological passport case from 2015 (dropped by WADA and the UCI in the face of an appeal from Kreuziger’s team). In that sense, the world after the Froome decision really doesn’t look so different from the world before it. Also given the sheer number of PED cases across the board it’s getting harder and harder to argue that the rules are working. In light of the cases at the sub-elite levels of cycling though, it’s particularly unclear if ever more elaborate anti-doping initiatives will actually make sports any safer.

Are we keeping athletes safe? These recent cases highlight two very important aspects of performance enhancement: the role of expert supervision, and more critically, an inherent lack of athlete safety. When the elite seek an advantage (legitimate or not), they may have the resources do so with specialist medical oversight. Wealthy sports teams have access to doctors, physiologists, and trainers. Those down the food chain, like Linas Rumsas, often don’t have anything like that level of support. It’s easy to assume that WADA rules are there to protect athletes in the lower or developing tiers of the sport. Do they though?

The reasoning behind the WADA code is clear. If doping is reduced at all levels of competition, this should level the playing field so that commitment and natural talent rise to the top. Fairness is really the primary focus. While safety is mentioned, the presumption is that prohibition will also automatically lead to better health and safety for the athletes. This is not always the case.

This is similar to the stance wider society take on recreational drugs. Prohibition is seen as the primary way to check harm. It’s is a complicated issue though, as prohibiting drugs or alcohol brings its own set of problems. Unregulated supply, dangerous administration (e.g. infected needles), and criminal involvement are all risks. As 1920s America showed, with a ban on alcohol, prohibition is not always the best way of protecting people from danger — especially when they continue out of habit, addiction, or social convention, to take whatever substance is banned. For these kinds of reasons some governments (for example The Netherlands and Canada’s liberal cannabis laws, or the Roosevelt administration’s repeal of Prohibition) judge that relaxing the rules around at least some substances can be for the public good.

A persistent criticism of the WADA ethos over the years has been along these lines. The problem is that forbidding some substances may actually make their use more rather than less risky. The incentives to dope are still there and internet sources have made many established (and new) performance-enhancing substances more available than ever. The web also makes it possible to share methods for using these substances without detection. In this context, the WADA Code risks pushing illicit substance use completely underground.

Whether you’re a Belgian kid dreaming of a World Tour contract or a Kenyan runner hoping for a better life on the U.S. marathon scene, rewards are large and safety measures can be minimal. If you’re an athlete seeking a performance enhancement, who do you ask for advice? If you’re self-medicating and have a dangerous reaction, where do you go for help? Consumers of PEDs might not have any idea as to the authenticity of the drugs they are taking or safety of the methods they are using to administer them. At the lower levels of sport, performance boosting efforts are limited — and made even more risky — by secrecy and lack of backup.

Tyler Hamilton’s “The Secret Race” provides a great example of such problems. Even high-level riders in the Armstrong-era were harmed, not so much by drugs, as by dodgy medics, questionable practices, and taking medicines without proper supervision. The testimony of former rider Jesus Manzano in the trial of Eufemiano Fuentes detailed the quite bizarre mix of drugs and transfusions administered to cyclists by the Spanish doctor. Manzano became seriously ill after a contaminated blood transfusion. The prohibition of substances can also lead to criminal supply chains which are completely unregulated, and which may also expose PED consumers to prosecution.

Are there alternatives to WADA? So if the WADA code isn’t properly addressing safety, could we take another route? Perhaps there are lessons to be learned from wider society here. Of course, many governments also make certain drugs taboo: but in national and regional health services, containment and treatment strategies are often very different. Rather than aiming punish people, services are often focused on harm minimization (sometimes called harm reduction).

Instead of prohibition (often complicated, expensive and difficult to achieve), harm minimization seeks to reduce the dangerous effects of substance use. Needle exchanges, aimed at bringing down infections among intravenous drug users, are a classic example. The primary aim is to reduce danger by tackling the spread of blood-borne diseases like HIV and Hepatitis C. Harm minimization can also involve helping people think about safer supplies and in some cases, it can even mean decriminalizing certain drugs, as the US did with alcohol in the 1930s.

Could such a strategy have something to offer sport? The UCI’s recent announcement that it is adopting cortisol measurement standards, suggests that cycling’s governors are ready to take some tentative steps in this direction. The proposal is to block riders from starting races if they show reduced cortisol levels and to enforce rest/recovery periods of eight days. This strategy was pioneered by the Mouvement Pour un Cyclisme Credible (MPCC), as low cortisol levels may compromise recovery from injury. While depleted cortisol can be the product of the use of the steroid cortisone, the primary aim of this measure seems to be safety rather than reducing PED use.

Historians of cycling’s anti-doping policies haven’t been off the mark by comparing this move to the 50% hematocrit rule which was implemented in 1997. Clearly, that policy was ineffective at dissuading use of EPO, and arguably led to further escalation of doping: it made the ‘cheater’ line crystal clear. However, there was a safety rationale. Perhaps it was a little unscientific, but it did come in in the aftermath of several young riders dying, allegedly as a result of thickened blood.

What’s stopping a different approach? With all of the problems currently plaguing anti-doping, can we say that the WADA Code is working effectively? Or are containment policies like the 50% rule and the proposed cortisol policy a credible way forward? The cortisol rule change perhaps provides a small taste of what a different type of drug regulation code might look like: one based on athlete protection rather than an idea of fair competition.

However, going further along this road would certainly require a shift in our current thinking. Harm minimization assumes that people you want to protect are going do things you don’t want them to and that you might not always be able to stop them. Public perception of harm minimization is dependent on whether a community believes that humans will always push the limits of what’s allowed. The question we have to answer is, are PEDs, in some form or another, inevitable in sport? As sporting fans can imagine, the issue of whether the existing WADA policy has actually failed in this regard has been the subject of heated debate. If you do believe that PED use is not going to go away, then focusing on the safety of what’s going on anyway makes lot more sense.

The WADA Code’s entrenched black and white concept of an ideal competitive landscape is perhaps an even bigger stumbling block to a different approach. In the WADA view, ‘clean’ athletes are rewarded and ‘dirty’ ones are punished. For many fans, accepting that athletes will take performance enhancers may conflict with a heartfelt desire for ‘fair’ competition. That sense of what is and isn’t fair hugely influences our perception of athletes. If anyone is seen as a victim in the WADA scenario it’s riders such as Christophe Bassons: denied his fair chance in competition by cycling’s EPO years. Can we ever see Linas Rumsas or even other riders who have lost careers as a result of drug-bans, in a similar light? Though PED users may be viewed as transgressors they are, for the most part, simply young people who have made risky, or sometimes tragic choices given the circumstances in which they have found themselves.

At present we condemn dopers because our concept of fairness is treated as absolute and clear, but the truth is that the world is far more complex than right or wrong. It’s worth bearing in mind that what is seen as ‘unfair’ competition is not set in stone. In the days of Harold “Chariots of Fire” Abrahams, simply having a coach was seen as cheating. It’s hard to see today’s athletes accepting that. Taking caffeine was, at one stage in sporting history, viewed as a somewhat nefarious practice. Now coffee and cycling are the best of friends. Other things are less accepted now than in the past. It’s not that long ago that the UK media treated Bradley Wiggins’ asthma treatments as a story of triumph over adversity. More recently his use of Triamcinolone (use it should be stressed that was within the rules) had him accused of taking unfair advantage. Now, just missing tests can be construed as a form of cheating, as with former women’s world champion Lizzie Deignan. All of this suggests that what is viewed as unfair is subjective and changes over time.

Even if we can agree on fair limits (and the Froome and Wiggins cases also suggest we really can’t) the idea that eliminating PEDs provides a ‘level playing field’ is also somewhat questionable. There are many, many other other inequalities in sports which contribute to the divide between fair and unfair — including access to playing field at all. For example, there are very few elite swimmers from Central Asia or sub-Saharan Africa. There is more to that than athletes simply not having the physical gifts of an Ian Thorpe or a Michael Phelps: people also need somewhere to swim. Expressing outrage over PED use, while ignoring other inequalities, highlights other unfairly weighted priorities.

The concept of fairness may not always be the clearest or most consistent idea, but it is something I understand. Since the time of the ancient Greeks, sport has always been a vehicle of our hope and passions. Sport has been idealized as the place where the best rise to the top because of skill, strength, and experience. But never forget that the ancient Greeks were also not above seeking an edge by any means available, and today is not so different. While we obviously have to have rules, are the ones we have fit for purpose?

Anti-doping’s inflexible and unwavering ideal of fairness may be compromising the well-being of competitors under its care. In the light of the Froome case, and of many other failures, could it be time to consider scrapping the WADA code altogether? Perhaps we should now look in a different direction, one where, rather than only upholding the image of sport, we aim to make athlete health our top priority.