Having grown up around professional combat sports, both real – boxing – and simulated – wrestling – I've always had a high level of tolerance towards this colorful world, populated as it is with unusual characters, hangers-on, and the stories that could only exist around the ring. My wife would often question how a neurologist could come from such a background, or turn the other eye to such brutality. I've seen up-close the slow progressive decline of so many in the years and decades after the careers ended, leading from modestly slurred speech and stiff gait to a walker, a wheelchair, and then to a completely dependent state. As a youngster I'd often hear that that the old fighters had “Alzheimers,” but everyone in the business knew that this was somehow related to repeated head injuries.

Decades of desensitization to combat sports could not, however, prepare me for a recent accidental encounter with a mixed martial arts organization termed UFC, short for Ultimate Fighting Championship. To a howling crowd, increasingly bloodied barefoot combatants, clad in bathing suits and leather gloves, savagely pounded opponents' heads into a bloodied, lacerated state of unconsciousness. Between rounds, bikini clad women designated “Octagon babes” strut across the ring, holding signs indicating the number of the next round. When coma finally ensues from the beating, the announcers triumphantly cry out that the loser “was given a long nap.” The winner dances across the floor, waves to the crowd and opines on his next match while the loser is helped out of the ring, blood is cleared off the mat, and the ring is readied for the next fight.

And then a final affront. Between fights a message appears at the bottom of the screen – an advertisement for Shriners Hospitals. The announcer now breaks from his blow-by-blow description of the coma to ask for contributions to support the Shriner's mission of providing care for burn victims and children in need. One could not make this up – an outstanding, high-profile medical organization dedicated to patient care and research searching for dollars in the most inhumane venue imaginable. No Hollywood simulation could match the surreal violence of what had just transpired on prime-time network television.

Neurologists are well acquainted with the concerns raised about the effects of repeated concussions in sports as varied as football, hockey and soccer,1 and the increasing evidence that chronic traumatic encephalopathies mediated by propagating deposit of (tau) protein aggregates are responsible, at least for some cases.2 In many sports, concussions are side effects and not primary goals of competition, and in such situations measured changes in rules could be implemented to decrease the risk of brain injury without seriously compromising the essence of the sport or the fan experience. However, injury to the nervous system is such a fundamental goal of boxing, and certainly of the UFC, that a simple tweak of the rulebook to protect against brain damage is simply not possible.,

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Figure  . Ultimate Fighting Championship bout at the Metro Radio Arena in Newcastle, England, Saturday Jan. 19, 2008. (AP Photo/Jon Super)

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More than a decade ago, Senator John McCain courageously dubbed the UFC “human cockfighting” and demanded that it be banned in the US. Nothing happened. Rules were modified somewhat – eye gouging and groin punches were disallowed, but kicks and punches to the head remained centerpieces of the action. (Amazingly, “abusive language” in the ring is not permitted.3) The British Medical Association (BMA) is to be congratulated for taking a strong public stance against both mixed martial arts and boxing (both remain legal in the UK however),4 and other national medical associations have also expressed their opposition. Although the American Medical Association (AMA) has had a formal anti-boxing policy in place for three decades, remarkably in 2008 the AMA removed a key element of this policy supporting “model legislation seeking to curtail the utilization of boxing as a public spectacle to the extent feasible.”5 The decision was based on the conclusion that continued support for legislation to ban boxing was not feasible, a position that could be viewed as technically correct but morally suspect.

In the United States the UFC is carried (nonexclusively) by the Fox network, an organization that in its news division takes an openly conservative perspective and promotes itself as “pro-life” supporters of traditional family values. Of course, the Fox network is not alone in its culpability; one could argue that they are simply satisfying, consistent with their social perspective (violence yes, sex no), a clear public demand for this type of content. Indeed, the size of the audience is remarkable: Pay Per View UFC matches can generate a million or more subscribers at $60 per hit.

The medical, and especially the neurology, community has an obligation to do more. We need to spread the word that brain bashing is not a socially acceptable spectator sport, and partner with our national organizations to expand and improve the effectiveness of public awareness and other educational initiatives. We should forcefully counter articles in the medical literature taking the position that closer medical supervision could obviate the need for a ban, or even worse that consenting adults have the ethical right to maim each other if they choose to do so.6 We also need to pursue an agenda for more funding to understand, prevent, and treat concussive injuries; these represent millions of cases annually and also may affect 25% or more of returning US combatants from the Middle East; traumatic brain injury has been termed the “signature illness” of the Iraq war.7 And finally, we should avoid the temptation to align with groups whose purpose is anathema to our mission, no matter how great our financial need.


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  2. References
  • 1
    McAllister TW, Flashman la, Maerlender A, Greenwald RM, et al. Cognitive effects of one season of head impacts in a cohort of collegiate contact sports athletes. Neurology 2012; 78: 17771784.
  • 2
    Stern RA, Riley DO, Daneshvar DH, Nowinski CJ, et al. Long-term consequences of repetitive brain trauma: chronic traumatic encephalopathy. PM&R 2011; 3: 54605467.
  • 3
    Legislative Counsel Bureau – State of Nevada. Nevada State Athletic Commission Regulations: Chapter 467 - Unarmed Combat.
  • 4
    White C. Mixed Martial Arts and Boxing should be Banned, says BMA. BMJ 2007; 335: 469.
  • 5
    American Medical Association. 2008 Annual Meeting. Reports of the Council on Science and Public Health.
  • 6
    Sokol DK. Ethics Man: Boxing, mixed martial arts, and other risky sports: is the BMA confused? BMJ 2011; 343: d6937.
  • 7
    Institute of Medicine of the National Academies.Gulf War and Health Volume 7: Long-Term Consequences of Traumatic Brain Injury. Washington, DC: The National Academies Press, 2009.