HEOC - Performance Enhancing Drugs and Risk Decision Making

Running head: PROSPECT THEORY AND DRUG USE IN SPORT
Performance enhancing drug use in professional sport is a risk

decision: A qualitative analysis of Prospect Theory

Helen L OConnor
Supervisor: Dr J eremy Adams
London Metropolitan University

Prospect theory and PEDs 1
Abstract
Current anti-doping legislation in competitive sports is advocated for reasons of fair-play and
concern for the health of athletes. Conceptualising performance enhancing drug use as a risk decision,
the present study examined how models of decision-making might be applied to understanding doping
in sport. Prospect Theory (Kahneman & Tversky, 1979) suggests that the way in which individuals
respond to risk decisions is likely to be influenced by a number of cognitive biases, including whether
the messages they receive about that decision are framed as a gain or a loss, and how they evaluate
that loss relative to a reference point, or point of view. Recent research has also emphasised the
importance of considering motivational and cultural constructs to account for the way in which
individuals evaluate the value of risk decisions. Qualitative data was collected fromsemi-structured
interviews conducted with 7 professional athletes (M=31.00, SD=11.05) to provide insight into the
factors that might explain an athletes decision to use performance enhancing drugs despite the risks
associated with use. Three major themes emerged from the data: goals, normalisation and affect. The
findings are discussed and recommendations are made for future decision-making research on risk
behaviours within sport. Anti-doping authorities should ensure that the effects of message framing are
built into future drug-compliance programmes.
Introduction
Performance enhancing drug use is assumed to be a serious problemacross many sports, a
concern which cumulated in the formation of the World Anti-Doping Agency (WADA) in November
1999. Despite international recognition of this problem, and although athletes across many, if not
most, sports have tested positive for a broad range of banned substances, accurate data on the
prevalence of doping is difficult to obtain for three reasons. First, despite advanced drug-testing
procedures, it is not financially feasible to screen all athletes. Second, it is difficult to obtain reliable
estimates of self-reported use fromathletes because doping in sport is essentially an underground
activity. Lastly, testing is not always accurate or reliable, and testing procedures are often one step
behind users and manufacturers in detecting new drugs and other techniques (Strelan & Boeckmann,
2006). Nevertheless, several surveys have revealed statistics which suggest that the use of
performance enhancing drugs has increased substantially over the past 50 years, perhaps
unsurprisingly considering the evolution of modern medicine in this period (Waddington, 2000). For
instance, in 1989, an Australian Senate Committee Report heard evidence that approximately 70% of
Australian athletes who had competed internationally had taken drugs (Australian Senate Committee,
1989). A similar enquiry by the UK Sports Council (1995) reported that, of the 448 British Olympic
athletes interviewed, 48% considered that drug use was a problemin their sport, a figure that
increased to 86% in track and field events. Moreover, it is evident that the use of performance-
enhancing drugs has spread fromathletics, weightlifting and cycling, the three sports in which drugs
appear to have been most frequently used in the 1960s, to almost all other sports (Mottram, 2005;
Waddington, 2005). There is also a growing body of evidence that performance-enhancing drugs are
being used at lower levels of competition, and by younger athletes (e.g., Buzzini, 2007; Donati, 2004)
and that use of anabolic steroids in particular is increasing in recreational fitness populations (Simon,
Striegel, Aust, Dietz, & Ulrich, 2006). Whilst the prevalence of drug use is likely to vary considerably
fromone sport to another it is clear that doping is widespread, and, in some sports, many athletes are
likely to be using performance-enhancing drugs (Hoberman, Wilson, & Derse, 2001).
The two main arguments for banning performance-enhancing substances in competitive sport
are that, first, it is widely considered that the enhancements to physical performance that these
substances offer is contrary to one of the virtues of sport: fair play (World Anti-Doping Agency
[WADA], 2002). Athletic competitions, it is argued, are designed to demonstrate the best performer
on a level playing-field reflecting natural capacities. It is, therefore, unfair if a particular resource,
such as performance enhancing drugs, is available to some competitors but not others (Sabini &
Monterosso, 2005). A second argument is the very real concern that many substances can be
detrimental to athletes health. For example, anabolic steroids can affect cardiovascular and mental
health (Gruber & Pope, 2000; Haller & Benowitz, 2000; Parssinen & Seppala, 2002); erythropoietin
(EPO) can lead to depression and increase the risk of heart attacks (Singbartl, 1994; Sullivan,
Martinez, Gennis, & Gallagher, 1998); and users of human growth hormone (HGH) can experience
hypertension, cardiac disease and overgrowth of hands, feet, and face (McHugh, Park, Sonksen, &
Holt, 2005). These are just some of the known risks: future generations of performance-enhancing
substances, or combinations thereof, might cause other physical or psychological damage.

Prevention Measures
In response to the continuing problem of performance-enhancing drug use in professional
sport, anti-doping policy has been based almost exclusively on what might be described as a punitive,
or law-and-order, approach (Waddington, 2000). Considerable resources have been directed towards
developing and implementing drug-testing programs both during and out of competition, with severe
penalties for those who test positive: usually a two-year ban for the first, and a lifetime ban for the
second offence (WADA, 2003). The WADA list of banned substances includes those which are
known to improve performance, and others, known as masking agents, which can be used to prevent
the detection of certain drugs in the blood or urine. The WADA prohibited substance list for 2008
includes over 200 specific substances (WADA, 2008d)., and every year, the number of banned
substances is likely to increase (Honour, 2004). Although biotechnological advancements often leave
sporting bodies one step behind athletes in identifying new substances that become available. the
WADA also maintains a strict monitoring programme in order to determine patterns of misuse for
currently non-prohibited substances (WADA, 2008b). Testing outside of competition for most
Olympic sports is conducted by the WADA, and an athlete can be required to be tested at any time or
place, and without notice. In-competition testing is the responsibility of the various International
Sports Federations for each summer, winter and paralympic sport. In recent years, other sporting
organisations, such as the World Association of Kickboxing Organisations (2006) and the World
Triathlon Corporation (2005), have adopted anti-doping guidelines and penalties in accordance with
the WADA code and banned substance list.
Measuring the effectiveness of testing programmes and the associated penalties is not
straightforward. Blanket testing is not carried out across all athletes in all sports and, more often than
not, randomsamples of athletes are tested, or the top performers in a particular competition are
singled out for screening. Ivan Waddington (2000) has criticised current mechanisms for measuring
the effectiveness of WADA policies (i.e., trends in the number of positive test results), arguing that
they are a, in fact, a poor index of the extent of drug use by athletes. Estimating that the number of
positive tests reported by WADA average one and a half percent of all tests undertaken in the past
five years, Waddington cautions against taking this as an indication that current screening
programmes are effectively tackling the problemof drug use in sport. Specifically, he points to
empirical findings which suggest that the breadth of drug use in sport is increasing, and that this trend
is diffusing to the lower levels of competition, as well as to adolescent athletes, and that use is
increasing in recreational fitness sports (e.g., Buzzini, 2007; Donati, 2004; Simon et al., 2006).
As well as directing considerable resources towards testing programmes and the development
of more sophisticated detection procedures (the WADA budget for 2008 is $27m(WADA, 2008a)),
the WADA anti-doping programme also incorporates some educational tools. In many instances,
education programmes merely provide factual information about the health risks and other
consequences of using performance-enhancing drugs, and ensure that athletes are aware of the latest
banned substances and testing requirements. The WADA also recommends educational programmes
which emphasise the other argument against doping: that it is unsportsmanlike. Such educational
programmes are specifically designed to promote appropriate moral reasoning, by developing
attitudes and social values that will encourage athletes to choose not to use performance-enhancers,
because they view such behaviour as the right thing to do (Donovan, Egger, Kapernick, & Mendoza,
2002). In most cases these programmes are directed at children and adolescents, such as the WADA
Values Based preventative educational programme, aimed at secondary school-aged children
(WADA, 2008c). Unfortunately there has been no research to date which has examined the
effectiveness of these programmes (Strelan & Boeckmann, 2006), potentially because the audience
for such programmes has been young athletes who are yet to enter the higher levels of sport
competition. But such programmes are, by nature of their target audiences, unable to address the
increase in potentially harmful drug use amongst non-elite athletes and recreational fitness
populations.
The main efforts by policy makers and sporting organisations to deter the use of banned and
potentially dangerous drugs within professional sport have focused on testing and penalties. This is
supplemented by some educational programmes emphasising the health risks and the moral aspect of
cheating. How, or whether, these measures are effective is difficult to evaluate, but evidence would
suggest that the use of performance enhancing drugs is still widespread. There is currently little
evidence in the sports medicine and sports science literature, either theoretical or empirical, on what
factors influence performance enhancing supplement use by sportspeople. The theoretical work is
limited to examinations of the relationship between attitude and behaviour for prohibited substance
use (Mazanov, Petroczi, Bingham, & Holloway, 2008). To gain a deeper insight into the decisions of
athletes who use illicit substances and escape detection, or the rationale behind the decisions of those
athletes who refrain fromusing, it might be possible to draw upon findings fromresearch based upon
two theoretical models of decision-making under risk: deterrence theory (Paternoster, 1987) and
prospect theory (Kahneman & Tversky, 1979).

Perceptual Deterrence Theory
Criminologists have long considered the relationship between the threat of formal legal
sanctions and crime. Perceptual deterrence theory (Paternoster, 1987) was originally formulated to
explain the role that legal sanctions play in regulating behaviour, particularly criminal acts. The
theory is based upon the rational choice model of human behaviour, Homo Economicus, which
proposes that an individuals behaviour is determined by a conscious cost-benefit analysis of the
likely consequences of that behaviour (Cornish & Clarke, 1986). Specifically, rational choice models
propose that individuals attempt to maximise their returns, making their decisions based on two
factors: the utility of the various outcomes and their respective probability. Utility, in this sense, refers
to whatever end a person would like to achieve, whether internal goods (e.g., happiness) or external
goods (e.g., money) (Broome, 1995), and individuals are assumed to be able to rationally compute the
probability of the various outcomes. Proponents of perceptual deterrence theory suggest that
deterrence is a psychological process, dependent upon an individuals subjective assessments of the
utility of the various benefits and costs associated with committing a particular criminal act.
According to the theory, if individuals perceive that punishment for a criminal act is both highly
certain and severe, and that this outweighs the benefits of the act, they are more likely to avoid that
act. Conversely, if benefits are perceived to outweigh the costs, the crime is more likely to be carried
out (Paternoster, 1987).
Deterrence theory research has traditionally concentrated on street crime populations,
particularly with respect to drugs (Lenton, 2005; Marlowe, Festinger, Foltz, Lee, & Patapis, 2005).
The theory has also been applied to understand decision-making across a range of other criminal
behaviours including tax evasion (Varma & Doob, 1998), domestic violence (Williams, 2005), and
driving offences (Pogarsky & Piquero, 2003; South, 1998). Since most deterrence research concerns
crime policy, the costs associated with offending have been mainly conceptualised in legal terms, or
formal sanctions, such as fines or prison sentences. The effects of informal and social sanctions are,
however, also recognised by the theory. These might include how an individuals peers react to his or
her criminal behaviour with disapproval, or disciplinary measures, such as job loss.
The equivalent of legal sanctions in the sporting context is drug-testing and the associated
penalties for positive test results, although decision-making theories have received little attention
regarding the problem of illicit substance use in sport. In fact, the only specific application of
deterrence theory in this context to date is the Drugs in Sport Deterrence Model (DSDM) proposed by
Strelan and Boekchmann (2003). This model contains three components: costs, benefits, and
situational factors. Costs, naturally, include legal sanctions (such as fines and suspensions), but also
include social sanctions (such as disapproval, ostracism, and material loss resulting froma withdrawal
of sponsorship or funding); self-imposed sanctions (such as guilt and reduced self-esteem); and health
costs which relate to the negative side-effects of performance-enhancing drugs. The benefits in the
DSDM include external goods, or material gains (such as prize money, sponsorship and
endorsements); social gains (such as fame, status and approval fromimportant others); and
internalised benefits, such as satisfaction at doing ones best (Strelan & Boeckmann, 2003).
Recognising that a cost-benefit analysis might be influenced by other factors, Strelan and Boekmann
(2003) include five contextual variables in their model, which they suggest are likely to affect
athletes subjective assessment of the costs and benefits of performance-enhancing drug use. These
are: prevalence perceptions; perceptions of ones competitiveness; professional status; perception of
authority legitimacy; and type of drug. Whilst providing some rationale for their inclusion, the authors
do not expand much upon these factors, which do warrant a closer evaluation.
With respect to prevalence perceptions, there is evidence that athletes who perceive
prohibited substance use as a problem in their sport might be more likely to use legal supplements as
an additional method of performance enhancement (next to methods like training and nutrition) to
overcome an assumed gap in competitive advantage (Goldberg et al., 2000; Sobal & Marquart, 1994).
Whilst limited to very few studies, a common-sense interpretation of these findings would suggest
that perceived prevalence of banned substances in a particular sport would also increase the likelihood
of an athlete choosing to use banned substances themselves, as a strategy to narrow the competitive
advantage (Breivik, 1992).
Strelan and Boekmanns (2003) second factor, perception of competitiveness, can perhaps
best be described in terms of the development in the structure of sporting competition in the past 50
years. Waddington (2005) has suggested that these developments, which include the politicisation of
sport and substantial increases in the rewards associated with sporting success, have had the
consequence of increasing the competitiveness of sport. According to Waddington, one result of this
has been the downgrading, in relative terms, of the traditional, or amateur, values associated with
taking part, and greatly increasing the value attached to winning. The fact that professional sport is
played for higher stakes is an important consideration when examining the context of the increasing
use of drugs in sport, particularly froma deterrence perspective. The rewards of success at an elite
level are great, both financially and in terms of personal glory and there is, consequently, greater
pressure for athletes to train longer and harder to maintain a constant improvement of sport
performance. Athletes are now encouraged to seek every possible way to improve their performance,
including a scientific approach to nutrition and training methods, seeking every biomechanical and
psychological advantage (Petrczi & Aidman, 2008). It is perhaps inevitable that some athletes will
seek an advantage through drugs.
Similarly, and perhaps unsurprisingly considering the increase in the competitive nature of
sport, professional status is a further variable cited by Strelan and Boekmann (2003) as potentially
contributing to an athletes perception of the costs and benefits associated with performance-
enhancing drugs. Skill, or competitive, level has been shown to influence a number of outcomes and
abilities relating to athletes, such as pain perception (Paparizos, Tripp, Sullivan, & Rubenstein, 2005),
imagery ability (Gregg & Hall, 2006), goal-setting (McPherson & Kernodle, 2007), aggression
(Rascle, Coulomb-Cabagno, & Delsarte, 2005), and coping with anxiety and stress. Whilst such
findings are typically measured in terms of age, this is, more often than not, a reflection of higher
competitive level and professionalism and almost all top level competitors are full time and, even if
not paid, are to all purposes professional (Waddington, 2005). There is also some limited evidence
that athletes are more likely to use performance-enhancing drugs towards the end of their careers
(Hughes & Coakley, 2001) or for rehabilitation purposes (Strelan & Boeckmann, 2006). It could be
argued that these athletes believe that the use of a banned harmful substance is a viable response to a
career-threatening situation such as a performance decline or injury.
Perception of authority legitimacy is, potentially, one of the more complicated situational
factors proposed in the DSDM. Fuller and LaFountain (1987) have suggested that some athletes are
able to rationalise the use of performance enhancing drugs as a victimless crime (p. 974). There is
also a moral argument that the WADA rules which dictate that professional athletes must
communicate their whereabouts at all times to the testing authorities, and be available with no notice
for randomtests, is an infringement of privacy (Waddington, 2005). Discrepancies between some
sports regarding acceptable and banned substances might create a situation whereby athletes doubt the
rationale behind banning a substance in one sport that is allowed in another. Moreover, the likelihood
that many athletes who use banned substances escape detection is likely to affect the perceived
effectiveness, and therefore legitimacy of testing programmes. How athletes perceive the legitimacy
or effectiveness of testing controls has not been examined in detail, and warrants further study.
The final situational variable in the DSDM, and the one which would appear to be the most
obvious, is the type of drug. This point is illustrated in Robert Goldmans (1992) survey of 198 world-
class athletes. When asked whether they would take an imaginary undetectable banned drug that
would guarantee them victory, but kill themwithin five years, more than half the athletes in the study
said that they would. Intuitively it would seemlikely that if an athlete believes there is no test for a
particular substance, they are more likely to consider using it, because the threat of legal sanctions
becomes irrelevant in the decision-making process. Even when the threat of legal sanctions is
removed fromthe costs of the decision, Goldmans finding raises an important question about why an
athletes motivation to win might override any consideration of a life-threatening health-risk, even to
the extent that social and self-imposed sanctions, are not taken into consideration. On a practical level,
even for athletes for whomthe health risks are likely to be a potential deterrent, the long-termside-
effects for more recently developed substances and procedures are not yet fully known. In such cases
there is potentially little information that can be provided regarding the health risks.
The DSDM (Strelan & Boeckmann, 2003) has received little empirical attention. One
potential explanation for this is that a large proportion of the research examining deterrence theory has
provided evidence that perceptions of the severity or certainty of legal sanctions often have very little
influence upon the decision to commit a criminal act (Krebs, Costelloe, & J enks, 2003). In most cases,
only when both the likelihood of detection and the severity of sanctions reach extreme (and often
unfeasible to implement) levels, do they have any effect. One reason for the failure of deterrence
theory to predict individual decision-making and, therefore, behaviour, is the variations observed in
how people compute the utility of various outcomes, which often does not equate to the actual
probabilities of those outcomes (Kahneman & Tversky, 1979). Whilst deterrence theory specifically
addresses criminal behaviour, expected utility theory (Von Neumann & Morgenstern, 1947), on which
deterrence theory is based, has also revealed similar findings. Of particular interest are the findings
fromthe health literature, which demonstrate that individuals are likely to vary widely when
calculating the utility of logically equivalent health outcomes. For example, Pinto-Prades and
Abellan-Perpian (2005) found that the utility of a hypothetical medical procedure varied between
0.48 and 0.80, depending on how the probabilities were described. Specifically, individuals accepted a
lower risk of death when success and failure probabilities of a medical procedure were given out of a
higher denominator (i.e., X out of 1000 will die, as opposed to Y out of 100), despite the percentages
being identical. Such findings demonstrate that individuals are not rational decision makers, which
has significant implications for the design of practical interventions.
Examining the DSDM in a sample of 116 elite footballers, Strelan and Boekmann (2006)
provided participants with two hypothetical scenarios. In the first scenario, they were told that,
following a serious and career-threatening injury, they had the option to take human growth hormone
(HGH) which would dramatically improve their chances of recovery, but were not given any
information regarding whether this could be detected. The second scenario was identical, but athletes
were told that there was no current test for HGH. In both scenarios athletes were asked to indicate the
probability that they would use HGH, as well as the certainty and severity of each of the legal, social,
moral, and health threats, as described in the DSDM. Supporting previous findings from the
deterrence literature, drug testing had little influence on athletes imagined drug use decision.
Moreover, after the athletes were informed that they could not be caught for using HGH, their mean
rating of decision to use increased from23.88 to 36.58, a difference which was significant. This
finding would suggest that knowledge of the absence of legal sanctions impacts on athletes
hypothetical decisions to use a particular substance, and supports Strelan and Boekmanns inclusion
of type of drug as a situational variable in the DSDM. Specifically, when athletes considered each of
the deterrents together, they were most likely to be deterred by their moral beliefs (i.e., the guilt they
anticipate they would experience as a consequence of engaging in an act that is contrary to an
internalised code), and their fear of the negative side effects. Strelan and Boekmanns findings reflect
what has been found in deterrence studies relating to other types of criminal behaviour: that moral
beliefs are the best predictor of an individuals decision to break a law, and that formal sanctions work
most effectively in conjunction with informal sanctions, such as the perceived threat of social
disapproval and moral commitment, to inhibit illegal behaviour (Bachman, Paternoster, & Ward,
1992; Grasmick & Bursik, 1990; Nagin & Pogarsky, 2003).
The emphasis on drug testing assumes that individuals respond primarily to the instrumental
characteristics of a banned drug-use decision, and ignores the potential of other factors for deterring
use (Strelan & Boeckmann, 2006). However, the increasing pattern of drug use in professional sport
would suggest that, when evaluating the risks involved in a decision to use a banned, harmful
substance, athletes are motivated or influenced by other factors, besides the traditional deterrents or
the information provided in educational programmes. Strelan and Boekmanns DSDM provides a
framework and starting point for understanding the factors that influence a decision to commit the act
of illegal, and potentially harmful, drug use in competitive sports. Nevertheless, the key assumption of
deterrence theory, that individuals are assumed to be rational, and are capable of weighing the
possible risks and rewards associated with every possible options, choosing that with the highest
expected utility, makes it much easier to practice deterrence froma theoretical standpoint. Rational
choice models have often failed to successfully predict the actions of individuals in real-world settings
and fail to provide an adequate description of how people make choices in many circumstances.
Humans rarely, if ever, have all the information necessary to make a decision. Even if they did, they
would lack the ability to combine and weigh the information accurately, as described by deterrence
theory (Starmer, 2000). What is clear is that some athletes are prepared to take the greatest risks with
respect to their health and, potentially, their careers (Goldman & Klatz, 1992; Strelan & Boeckmann,
2006). It might, therefore, make more sense to consider alternative models, which are able to account
for decisions which depart fromthe usual rationality model. One such theory is Prospect Theory
(Kahneman & Tversky, 1979).

Prospect Theory
Developed by two psychologists, prospect theory (Kahneman & Tversky, 1979) recognises
that certain cognitive pressures might have an effect on an individuals choices, taking into account
the misperceptions and biases that affect decision-making, and which allow for departures from
rational-choice models of behaviour. Unlike rational choice models (such as deterrence theory), which
are concerned with how risk decisions should be made (a prescriptive approach), prospect theory
concerns itself with how these decisions are actually made (a descriptive approach). Prospect theory
differs fromexpected utility models in three other important respects. First, it replaces the notion of
utility, usually defined in terms of net wealth, with value, defined in terms of gains and losses. These
gains and losses are evaluated around a subjective reference point, or point of view. Much of the
research in this field assumes that, for most individuals, the reference point for any decision is their
current situation, or the status quo. The preference for the status quo is a cognitive bias which causes a
preference for neutrality, and gains and losses are evaluated with respect to maintaining it (Kahneman
& Tversky, 2000). This bias aside, the reference point can also be variable and moveable and can
include other, non-status quo, points of view, although this is not always emphasised in the literature
(Heath, Larrick, & Wu, 1999). Second, unlike rational choice models, which assume that equivalent
formulations of a choice problemshould give rise to the same preferences, prospect theory predicts
that an individuals decision will systematically differ, depending on how the potential outcomes of
that decision are framed, or labelled, as gains or losses, relative to the reference point. Specifically,
prospect theory proposes that, depending how an outcome is framed, individuals will have a
preference for risk-adverse choices for relative gains, and risk-seeking choices for relative losses
(Plous, 1993).
Framing refers to the wording or other means of presenting logically equivalent information
and a framing effect (Tversky & Kahneman, 1981) arises when alternative framing of logically
equivalent information produces different decisions. Evidence to date suggests that framing effects are
a common phenomenon affecting both hypothetical and real decisions (Edwards, Elwyn, Covey,
Matthews, & Pill, 2001). This effect was illustrated in Tversky and Kahnemans (1981) well-known
Asian disease problem. Given a hypothetical situation in which the US was preparing for the outbreak
of a disease expected to kill 600 people, one group of participants were asked to chose between two
programs to combat the disease: programme A, in which 200 people will be saved, or programme B,
in which there is a one in three probability that 600 people will be saved, and a two in three
probability that no people will be saved. Using the same hypothetical scenario, a second group of
participants were provided with different options: programme A, in which 400 people will die, and
programme B in which there is a one in three probability that nobody will die, and a two in three
probability that 600 people will die. Despite the choices being identical in terms of real value, 72% of
participants in the first group preferred programme A, whilst only 22% of the second group chose this
programme. Tversky and Kahneman claim that prospect theory can predict these choices, by nature of
the way in which the solutions were framed as a gain or a loss. The majority choice in the first group
was risk averse: the prospect of saving 200 lives with certainty was more promising than the
probability of a one in three chance of saving 600 lives. For the second group, the certain death of 400
people was less acceptable than the two in three chance that 600 people would die.
The Asian disease problemalso illustrates a third difference between the two theories, in
terms of how they handle the probabilities attached to particular outcomes. Classical utility theories
assume that rational decision makers value a 50% chance of winning as exactly that. In contrast,
prospect theory treats preferences as a function of decision weights, and recognises that these weights
can be distorted, and do not always correspond to probabilities. Specifically, prospect theory
postulates that decision weights tend to overweight small probabilities and underweight moderate and
high probabilities (Plous, 1993).
Prospect theory is able to account for decisions (such as the Asian disease problem) which
depart fromthe rational-choice model, and provides a description for how individual decisions are
determined by the way in which the value of various outcomes are framed as a gain or a loss, rather
than the actual probability of any particular outcome. The theory represents a great improvement over
classical utility theory, and many violations of utility theory are explicitly predicted by it (Plous,
1993). Prospect theory has been applied to study and predict individual decision-making behaviour in
a variety of fields including economics (Benartzi & Thaler, 1995), consumer behaviour (List, 2004)
and political science (J . S. Levy, 1996). Supporting prospect theorys assumption that people have a
tendency to be risk-averse for gains and risk-seeking for losses, a number of these studies have
reported the tendency for negative information to have a greater influence on decisions and judgments
than positive information (Kahneman & Tversky, 1984; Skowronski & Carlston, 1989). As a
consequence of this, prospect theory has also been applied to behavioural decision-making in the
health domain (J . E. Smith & von Winterfeldt, 2004), a primary focus being the effects of message
framing. More specifically, research in this field seeks to understand how the efficacy of public health
campaigns can be improved by presenting information about the risks associated with various
behaviours, or the benefits of protective measures, to account for this bias (Schwartz, Goldberg, &
Hazen, 2008). For example, a recommendation to use dental floss on a regular basis can be stated in
terms of potential loss: If you do not floss regularly, you will increase your chances of tooth decay.
This same recommendation can also be stated in terms of a potential gain: If you floss regularly, you
will increase your chances of having healthy teeth and gums. There is a relatively large body of
literature which examines the effects of similar message framing across a range of risk reduction
measures including cancer screening (Turvey & Fishkin, 2003), vaccination (Abhyankar, O'Connor,
& Lawton, 2008), HIV-prevention, and smoking cessation (Toll et al., 2008). A large proportion of
these studies report findings that are consistent with the predictions of prospect theory. For example,
Abhyankar and his colleagues (2008) examined the efficacy of loss- or gain-framed messages on
parents intentions to obtain the MMR vaccine for their child. Participants received either a negative
message (emphasising the health risks and the anticipated anxiety of the parent) or a positive message
(emphasising the benefits of vaccination, and the peace of mind brought about by this choice). In
accordance with prospect theory, participants who had been exposed to the loss-framed message
reported stronger intentions to vaccinate, although, without a follow-up study, it remains unclear
whether the loss-framed message resulted in more actual vaccinations in this group.
In simple terms, therefore, an individuals evaluation of a particular risk decision can differ
depending on how the outcome is framed as a gain or a loss. The messages he or she receives from
policy makers and other providers of information can play an important part in creating this frame.
However, in prospect theory, an individuals reference point, or point of view, will also determine
how particular outcomes are subjectively perceived to be a gain or a loss relative to it. Because the
reference point is not necessarily the status quo, understanding the processes by which an individual
selects a particular reference point fromwhich to evaluate the value of various outcomes is, therefore,
an important factor in explaining risk behaviour. Very little is known about how an individual locates
the reference point for a particular decision, although recent research has begun to address this gap in
the prospect theory literature (Schwartz, Goldberg et al., 2008; Schwartz, Hazen, Leifer, &
Heckerling, 2008; Van Osch, van den Hout, & Stiggelbout, 2006).
Van Osch and her colleagues (2006) sought to examine the psychological processes which
might determine the selection of a reference point by combining quantitative and qualitative data. The
researchers used a life-year gamble protocol, instructing participants to choose between alternatives
across different hypothetical life-expectancy scenarios (e.g., a gamble between a 50% chance of living
in good health for 50 years, and a 50% chance of dying within one week, or a 100% chance of living
in good health for 25 years). Qualitative data was provided by instructing participants to think-aloud
during their evaluation of the different gambles, in order to assess which outcome in the gamble
served as the reference point. The qualitative findings fromthis study reveal some potentially useful
information regarding how individuals frame a risk decision with respect to their life-expectancy. In
particular, participants goals (e.g., career, retirement, or child-related) appeared to be an important
feature which caused the reference point to shift for different life-duration gambles. The authors
suggested that goals influenced the shift in outcomes that served as a reference point, and that the
outcomes closest to a goal-realising period most likely served as the reference point. More
specifically, to live for the period in which goal realisation is possible (e.g., I wont
consider my life a success if I cannot start a family; I could not do that if I only live until I am 39)
appeared to underlie the motivational processes of the individual, with goals being more frequently
mentioned for proximal than for distal life years. Another observation fromthis study was that some
participants were not attracted to the entire life-expectancy in the longer-duration gambles because
they anticipated disease at an advanced age. In other words, for some participants the longer life
expectancy was framed as a loss, meaning that general quality of life, as well as specific goals, was a
factor that influenced the decision for certain gamble scenarios.
The importance of goals is accepted in many accounts of human motivation and behaviour
across a variety of disciplines (Deci, 1992; Locke & Latham, 1996). Despite the wide use of
motivational concepts (such as goals) in other areas of psychology, the dominant tradition in decision-
making theory has emphasised value (or utility) as a basis for choice, with an emphasis on cognitive
processes. Nevertheless, some research based on prospect theory has examined the function of goals
in decision-making outcomes. For example, Levin and his colleagues (1998) distinguish between
three different types of decision frames: risky choice frames, attribute frames and goal frames, which
they propose will result in different decisions. Similarly, Heath and his colleagues (1999)
demonstrated that the goal itself might serve as a reference point by altering the (loss or gain) value of
outcomes as described by prospect theory. The authors attempt to explain motivational phenomena
like effort, persistence, and performance, by focusing not on the value of external rewards but on the
psychological effects of what they termmere goals (p. 80). Specifically, mere goals exclude
situations that can be examined with straightforward economic calculations (as are typical in the
decision-making literature), and include only those which are fundamentally psychological.
According to Heath et al., the reasoning behind this focus is to study the cognitive relevance of goals
without the confounding influence of economic gains. The authors also criticise the majority of
decision research for failing to explore non status quo reference points. In contrast, the goal literature
has shown the importance of changing and moveable goals (i.e., as non status quo reference points),
which will potentially change how outcomes are valued in human decision-making. Even the founders
of prospect theory, Kahneman and Tverskey (1979), have argued that, for some situations, an
individuals aspiration level might determine if outcomes are framed as gains or losses, and there is
some evidence that individuals are likely to accept more risk to achieve their aspiration level
(Verhoef, De Haan, & Van Daal, 1994).
Reflecting on findings such as these, Krantz and Kunreuther (2007) have suggested that the
cognitive aspects of decision-making theories and the motivational aspects of goal-setting approaches
can be combined, such that particular goals can be viewed as ways of increasing the utility of
outcomes. Moreoerver, Krantz and Kunreuther propose that this relationship will be more apparent for
proximal goals as opposed to distal goals. This would be consistent with evidence that setting goals in
the relatively near future might enhance expectations of future success (Bandura, 1986; Locke &
Latham, 1996, 2002).

Application of Prospect Theory to Drug Use in Sport
Prospect theory is, in many situations, able to account for decisions that depart fromclassical
rational choice models of risky decision-making. The observation that goals or aspirations can serve
to influence the perceived utility of outcomes, by serving as the reference point, or point of view, for a
particular decision, suggests that the theory is likely to hold promise in an application to drug-use in
sport. Athletes who choose to use performance-enhancing drugs are prepared to take risks: with their
health, and with detection and the associated penalties (potentially a lifetime ban fromtheir sport). If
some athletes are prepared to use banned and harmful performance-enhancing drugs to guarantee a
win or to prolong their career it would appear that, within a prospect theory framework, those athletes
have a reference point that is framed, at least in part, by sport career goals and aspirations. This is an
important consideration which has implications for the success of measures to prevent or reduce the
use of drugs in sport, particularly in how anti-doping messages to athletes are framed, and in whether
athletes require specifically designed messages at particular points in their careers.
There is no debate that goals are an important aspect of motivation and success within elite
sport (Ames & Roberts, 1992; Gould, Dieffenbach, & Moffett, 2002; Jackson & Roberts, 1992;
Munroe-Chandler, Hall, & Weinberg, 2004). To understand how the reference point, as framed by
particular goals, might influence an athlete in making a risky choice, such as using performance-
enhancing drugs, it is important to explore how some particular goals and their timeframes might
establish a reference point fromwhich this decision is yes. Within the health literature, an example
of a goal related to life-expectancy might often be I want to live to see my children grow up, which
creates a particular timeframe within which different life expectancy gamble outcomes will be framed
as a gain or a loss. However, elite athletes often have a narrow and specific set of goals pertaining to
their sport, the achievement of which typically involves the sacrifice of education, employment and
family or social goals (Hughes & Coakley, 2001). Likewise, the age at which a sportspersons career
is likely to end is far younger than for most other occupations (Van Raalte & Andersen, 2007), and
there is, consequently, a relatively small window of opportunity for themto achieve their sport-related
goals. Whilst for younger athletes some goals (such as to compete in an Olympic Games) represent
more distal timeframes, for the older athlete, this becomes a proximal goal, with, perhaps, one
remaining attempt. Sensitivity to the goal-realising period, as observed in Osch et al.s study (2006) is
therefore of interest with respect to elite athletes reference points regarding their decision to dope,
particularly considering the evidence that men and women participating in sport are more likely to
abuse drugs towards the end of their career (Hughes & Coakley, 2001).
Whilst an athletes goals are likely to be an important factor when evaluating the risk of a
decision to use performance-enhancing drugs, another potentially relevant, although under-
researched, finding fromthe sociocultural literature is that different cultural groups are likely to vary
in the way that they frame and respond to risk (Bunton, Nettleton, & Burrows, 1995; Collard,
Kempson, & Whyley, 2001). Whilst this evidence is derived fromsmall gender, race and socio-
economic groups, and predominantly focuses on financial risk, it also has implications for
understanding the importance of the wider frame of the sporting culture to which an athlete belongs.
Whether or not the general public condemn certain behaviours of athletes, such as concealed doping,
it has also been suggested that such behaviour might be viewed as a cultural normwithin sport.
Membership of this cultural group might, at least in part, serve to influence an athletes reference
point for both the moral and the health risks of using performance enhancing drugs. For instance, in
an early study which examined the attitudes of 50 athletes regarding performance enhancing drugs,
Fuller and La Fountain (1987) reported that some athletes rationalised doping as part of a "code of
commitment to sport." (p. 974). Froma cultural perspective, Hughes and his colleagues (2001) refer
to such behaviour as positive deviance and hypothesise that many forms of deviance in sport are not
caused by a disregard or rejection of social values or norms; instead they are the result of an
unquestioned commitment to a value systemframed by what they refer to as the sport ethic. This is
similar to the construct of athletic identity, or the extent to which an individual relates to and focuses
their self-identity on the role of an athlete (Brewer, Van Raalte, & Linder, 1993; Brown & Hartley,
1998; Grove, Lavallee, & Gordon, 1997).
Hughes and Coakley (2001) identified four common beliefs which they suggest are the most
commonly accepted factors defining what it means to identify oneself as an athlete: making sacrifices
for the game; striving for distinction; accepting risks and playing through pain; and refusing to accept
limits (pp. 362-363). Commitment to these beliefs has been linked to positive behaviours and
outcomes, such as improved performance (Lufi, Porat, & Tenenbaum, 1986), focus on sport goals
(Horton & Mack, 2000) and fostering motivation and discipline (Miller & Kerr, 2002). However,
over-commitment to the sport ethic can result in other, more problematic behaviours, such as over-
training, disordered eating and illicit use of performance-enhancers, the legitimacy of which is often
reinforced by those within the culture of sport. Studies which have examined attitudes of individuals
within the wider sporting culture have provided evidence that, at least at the elite level, coaches and
members of the medical profession are often supportive of the use of banned substances (Laure, 1997;
Millar, 1994). This point has been emphasised theoretically by Cialdini (2007), who advocates
research which distinguishes between injunctive norms (i.e., what most others say should be done)
and descriptive norms (i.e., what most others actually do), proposing that the latter appear to have
more influence than the former.
Speaking of risk cultures, writers such as Scott Lash (2000) have emphasised the
importance of considering how group membership influences the way in which individuals structure
their response to different types of risk. Lash also acknowledges an absence of empirical research
which explores this dimension of risk. Similarly, in sport, risk research has been limited to the
identification of risk- or sensation-seeking personality traits, with an emphasis on why some
individuals engage in high-risk sports (Diehm& Armatas, 2004; Franques et al., 2003; Rowland,
Franken, & Harrison, 1986; Yiannakis, 1976). To date, there has been little research which
investigates other types of risks some athletes take, such as performance-enhancing drug-use.

Aims
Research on the use of performance enhancing drug use in sport has focused primarily on
athletes attitudes to drug use and there has been limited in-depth qualitative research on athletes
motivations to dope (or not), or their decision-making process (Donovan et al., 2002). Prospect theory
is a promising source of psychological principles that explain decision-making in terms of how the
value of a given outcome is altered by the presence of a reference point such as a goal. Addressing the
lack of research which examines how the presence of particular goals can affect human decision-
making, Krantz and Kunreuther (2007) have recommended the use of qualitative methods.
Specifically, they argue that these methods can reveal more about goals, aspirations and their
perceived relationship to a decision outcome, by uncovering an individuals conscious and
unconscious cognitions and emotions. A number of recent studies in the sport literature have also
advocated the use of qualitative approaches in the investigation of psychological qualities and
processes used by athletes and other sports professionals (S. L. Cresswell & Eklund, 2007; Dionigi,
2006; J ones, Hanton, & Connaughton, 2007). Qualitative methods are useful within sport psychology,
stemming, in part, fromthe fact that the population fromwhich samples can be drawn is relatively
small, but also because of the need to develop models for the behaviour or personality of athletes that
often can not be explained by traditional models and theories. Moreover, qualitative methods have
previously been applied specifically to examine performance-enhancing substance use in athletes,
with a focus on prevalence (Curry & Wagman, 1999) and attitudes (Diacin, Parks, & Allison, 2003;
Fuller & LaFountain, 1987).
Qualitative research with elite athletes has typically used both focus group and individual
interview methods for data-collection. Whilst focus groups are a viable means of collecting data, they
are not without limitations, including issues associated with group dynamics, and the fact that some
participants might be reluctant to state their views in such a public form, particularly for an
underground activity, such as drug-use. The focus group also limits the number of questions that can
be asked and it has been suggested that the focus interview can provide false or extreme views (Patton
1990). Consequently, this study will use individual, semi-structured interviews. This methodology
provides the opportunity to probe athletes responses and establish more detailed information
regarding the unique experiences and understandings of each athlete. The qualitative approach will
also enable purposeful sampling of athletes identified to be of particular interest to the research topic
(i.e., athletes who have competed at a professional level in sports where doping tests are conducted).
Recognising that individual decision-making for risky behaviours can not, in many situations,
be adequately explained by rational-choice models, the present study represents an attempt to explore
doping in sport using Kahneman and Tverskys prospect theory (1979). Prospect theory has, to date,
not been applied to this particular type of risk decision, and the present study is specifically informed
by prior research which has examined the motivational mechanisms underlying the reference point, or
point of view, fromwhich the value of risk decisions are evaluated (Van Osch et al., 2006). The
purpose of the present study is to collect qualitative data which might provide more insight into the
reference point for a decision to use, or not use, performance enhancing drugs. There are three
specific aims: first, to generate data fromwhich a greater understanding of how an athletes goals and
aspirations might contribute to a decision to use performance enhancing drugs; second, the study will
explore how the timeframes for achieving these goals might also influence a decision; lastly, this
methodology will also provide an opportunity to explore the influence of the wider cultural
framework of sport.
Method
Ethical approval was granted for this study in accordance with the requirements of London
Metropolitan Universitys Ethical Committee (see Appendix 1), and adheres to British Psychology
Society (2004) guidelines for psychological research with adult populations.

Approach
Thematic analysis was selected for the present study because it does not require the detailed
theoretical and technological knowledge of alternative approaches such as grounded theory and
discourse analysis. It is, consequently, a more accessible formof analysis for those inexperienced in
qualitative research (Braun & Clarke, 2006). Furthermore, thematic analysis has been recommended
for under-researched topics, or when working with participants whose views on the topic are not
known (Braun & Clarke), both of which apply to the topic of present study. Thematic analysis is a
method for identifying, analysing and reporting patterns within a data set in rich detail (C. Smith,
1992), whilst allowing the researcher to interpret various aspects of the research topic. This method
also acknowledges the active role the researcher plays in identifying patterns and themes, and
selecting those which are of interest (Boyatzis, 1998). In this context, thematic analysis is used as an
essentialist, or realist, method, which allows the researcher to theorise the motivations, experience,
and meaning of participants in a straightforward way (Boyatzis).

Participants
A priori power analysis is not required for qualitative designs, but, whilst qualitative
investigations (particularly in the sport psychology domain) typically employ small samples, sample
size still is an important consideration in this method of research. Samples should not be too large
that it is difficult to extract thick, rich data, nor too small that it is difficult to achieve data saturation,
theoretical saturation, or informational redundancy (Sandelowski, 1995). Consequently some
methodologists have provided guidelines for selecting samples in qualitative studies, including those
that employ individual interviews (J . W. Cresswell, 2007; Guest, Bunce, & J ohnson, 2006;
Onwuegbuzie & Collins, 2007). Following these recommendations, a total of eight adult athletes were
recruited to participate in the study. One participant decided to withdraw fromthe study after the
interview, and so the final sample included seven male participants ranging in age from20 to 50 years
(M=31.00, SD=11.05).
Consistent with qualitative methodologies, purposive sampling was used to select study
participants, a method that is particularly useful when the population for study is highly individual,
such as elite athletes (P. Levy & Lemeshow, 1991). The research question required that the sample
consisted of participants for whomboth the benefits and costs of taking performance enhancing drugs
were relevant. Thus, to ensure that the sample was relevant to the research questions, participants
were drawn fromsports, and competitive levels, in which drug-tests (and the associated penalties for
positive results) take place. The criteria for inclusion in the study were: (a) participants should have
had at least 3 years experience in national or international competition; (b) participants were drawn
fromcompetitive sports in which athletes have previously tested positive for performance enhancing
drugs in the past, and in which testing is carried out; and (c) participants should be adults (classified
as any age above 18 years). To maximise sample sizes, despite the sensitive and potentially
contentious nature of the subject-matter, it was emphasised to potential participants that strict
confidentiality and data-protection measures would be taken. To provide an incentive to participants,
the researcher offered to provide a free introductory workshop about mental skills training in sport at
the athletes club.
The final sample represented 5 individual sports (kickboxing, karate, powerlifting, triathlon
and cycling) and two teamsports (basketball and football). Two athletes had retired fromsport and 5e
were still competing. Four athletes had or were competing at international level, and 3 at national
level. The mean number of years competing across all athletes was 7.14 (SD=2.45).

Instruments
Following the recommendations of Foddy (1999) a semi-structured interview guide was
prepared in advance of conducting interviews. The interview guide comprised 4 sections (see
Appendix 2). First, some introductory comments and general questions including demographic
information, as a way of building rapport with respondents. Second, the main descriptive questions
which guided the content of the interview. These were designed to seek the respondents perspectives,
experiences and opinions, whilst also avoiding jargon and emotionally-laden words (e.g., The
number of positive doping tests across many sports suggests some athletes do dope. Why do you think
that is?). In order to gather information relating to particular issues identified in prior research, some
questions were designed to provide facts that the interviewee did not have to hand, but without
leading themtowards a particular answer (e.g., There is some evidence that performance enhancing
drugs are more likely to be used by some age-groups of athletes than others. Why do you think this
is?). Floating prompts were a third part of the interview guide, used to encourage detailed
description, clarify meaning, or elaborate upon certain issues. Finally, concluding comments enabled
clarification of the issues discussed, and allowed the respondent to raise additional issues that they did
not feel had been adequately covered previously.

Procedure
Potential participants were initially contacted through personal contacts of the researcher.
Attempts to contact a total of 25 athletes were made, of which 8 agreed to participate, and with whom
an interview time was arranged. One participant subsequently withdrew fromthe study. At the start of
the interview, participants signed a consent form(see Appendix 3) and received standardised
introductory comments concerning the rationale for the study, confidentiality, participants rights, and
the reasons for audio-recording the interviews. After collecting demographic information, a general
instruction was provided to encourage participants to draw upon all aspects of their experiences as an
athlete (i.e., their own experiences as well as observed examples). Using the interview schedule
prepared in advance, 8 semi-structured interviews were conducted and recorded, of which 6 were
conducted by telephone, and 2 in person. Clarification and elaboration probes were used to ensure an
accurate and in-depth understanding of what the participants were describing, and to create a
consistent level of depth across the interviews. Finally participants were asked to comment upon the
interview experience and any issues which might have been overlooked. Interviews ranged in length
from35 to 102 minutes (M=63.00, SD=22.17). After the interview was finished, participants were
also provided further information about the rationale for the study, which constituted the participant
debrief.

Analysis
The interviews were transcribed verbatimand the content analysed by the researcher and two
other postgraduate psychology students. Analysis involved a repeatedly moving back and forward
between the entire data set and the coded extracts of data that were being analysed. Whilst limited
space is provided in the present paper to discuss the process of analysis in detail, a more
comprehensive explanation of the 6-step process followed can be found in Braun and Clarke (2006).
Initially, each investigator read and re-read the transcripts, observing and looking for patterns
of meaning and issues of potential interest in the data, and noting themdown. Next, initial raw data
codes were collected, which represented the smallest meaningful pieces of interview text, using
quotes to represent a meaningful point or thought. The third stage involved collating codes into
potential themes, and gathering all data relevant to each potential theme. A theme was identified when
it was considered to represent a level of patterned response or meaning within the data set, even if it
was not directly related to the research question. In the next step of the process, themes were
reviewed, to see whether they worked in relation to the coded extracts and the entire data set,
generating a thematic map of the analysis. The coding and themes were consensually validated among
the three investigators during group meetings and no inconsistencies or differences arose. Ongoing
analysis of the data set was carried out to refine the specifics of each theme, generating clear
definitions and names for each theme. Finally, salient quotes were selected, which related back from
the analysis to the research aims and literature (Braun & Clarke, 2006).

Results
Fromthe semi-structured interviews, three main thematic discourses became evident,
reflecting a number of factors that participants considered to influence an individual athletes decision
to use, or not use, performance enhancing drugs. These were goals, normalisation and affect.

Goals
All participants cited sport-related goals and ambition to reach the highest level of
performance or accolade as being the most common factor likely to influence an athletes decision to
use illegal performance enhancers.

In my mind, the only reason someone would take something is to get that ultimate goal
and everything that goes with it.to achieve that highest point in their sport.

Its the only thing an athlete wants.to be the best at whatever sport they do. If they
arent the best then all that training and all that sacrifice you makethen its worth
nothing.

Athletes also related the decision to use performance enhancing drugs to a strategy to enable
an athlete to achieve more than they could with natural methods alone, in order to achieve the goals of
being at the top of their sport:

They probably think that, well either Ill just be second place for the rest of my life and
not get anywhere else, or I can just take the risk and be at the top. Thats because that
is their onlyambition. Once they get that gold, they know they can retire at the peak
of their career.

I dont think these people care about.having a heart attack or whateverthey want
to go out on a highespecially if they know they wont get that chance again. You
have the Olympics every four yearsyou might not get another chance.

Similarly, participants considered that an athlete might respond to a performance decline or
injury by taking performance enhancing drugs that would keep themin the game, doing what they
love.

They have probably worked hard their whole lifefor this opportunity. Maybe they
had an injury or a slump...that can happen to everyone.they panic and think they can
cheat their way out of doing it the hard way, the natural wayfor that final chance to
achieve something.

All participants agreed that older athletes were more likely to use performance enhancing
drugs, because of their shrinking window of opportunity to achieve anything in sport and as a way
of remaining within sport:

Some people are just too stubborn to let it go.nowadays youve got people breaking
in the scene when theyre like 16, playing at the highest level anda lot of the people
of the older generation feel they have to use an enhancer to keep themselves on that
high level with them, on a par with those fitter younger athletes.

Athletes have a small window of competition within their particular discipline. I can
see that people feel their advantage slipping away, that their time is running out.their
resilience is going, their stamina is dropping.so they would seek other things just to
stay in there just maybe one more year, just get another year out of it

You go fromplaying every single day and pushing yourself and competing every
single day to doing nothingits a massive adjustment, and youd be left with well
what do I do now? Ive done nothing else in my lifeA lot of athletes arent rocket
scientists but,..they run, they shoot, they jump, whatever they do, its not like theyre
in business, its not like they have anything else to go on to. So of course you want to
continue on that lifestyle, its probably all you know.

Reflecting upon their own attitude towards performance enhancing drugs, some athletes had
also considered how the health related side-effects might affect their quality, and length, of life after
they had retired fromsport. This was conceptualised with respect to other aspects of achievement or
non-sport goals.

I know I wont be competing beyond a certain age. There are other things I want to do,
like spend time with my kidsmaybe do a coaching qualification.I dont want to
drop dead of a heart attack when I amsupposed to be fit fromall my years of
training. Its not worth the risk.

Normalisation
At the start of each interview, participants were asked about their perceptions of
performance enhancing drug use, both in their own sport, and in the wider context of
professional sports. All participants considered that doping was a widespread problem, citing
various well-known examples in the public domain of athletes who had tested positive. They
also all believed that current prevention methods were unlikely to expose all of the athletes
who were using performance enhancers because its a game of cat and mouse, like computer
hacking. They cant keep up with all the new drugs and technology.
Whilst no athlete admitted to using performance enhancing drugs themselves (they
were not asked to reveal this), many were able to provide examples of athletes they had
trained with or competed against that evidently did dope, but avoided detection. When asked
why they thought these athletes were using drugs, most stated that it was the dramatic
changes in physical appearance between seasons that would be impossible with just diet or
training.
The most frequently cited categories across all interviews related to the normalisation
of illicit doping within sport, including issues relating to the increased financial rewards in
many sports, and the entertainment value of sport for the general public. Athletes also
discussed their opinion of how doping was encouraged behind the scenes by people
working with athletes.

YeahI know trainers and physios who put it out there as an option.and depending
on the situation, depending on the circumstancesan athlete might respond. If
somebody has been injured forthree or six months and the trainer suggests to them
that if they take this enhancement they could decrease their recovery time by a couple
of months they are more likely to, you know, to take it.

Trainers, and I know of some examples, can try and influence someone, saying, well
if you just take this everyone does it. And if that trainer or coach has taken
somebody to the top level before, then everyone respects them, and other athletes they
train think they have to follow his ways to have the same success.

I mean doctors aresupposed to keep people healthybut a doctor on a teamis going
to know who is taking what substance arent they? They know absolutely everything
about that athletes physical health, they have to. They might try to make sure doping
isnt taken to extremes, but they dont stop it happening. They know its going on.

It has an evolution of some sort hasnt it, because youre passing it on, somebodys
passing it on to somebody else and it has a way of, and this is how it filters into certain
sports, because somebodys recommended what someone else did to performed better.

The increased monetary gains that are offered within sport, and the additional benefit
that celebrity status gives athletes, were also cited by participants as factors which encourage
doping in sport.

I think its changed a lot for a lot of sports... I expect if you go back forty, thirty years
there were a lot more people that did things because they enjoyed it rather than for the
fame, and there certainly wasnt the kind of money that there is now...I mean, someone
can win the Olympics and theyre made for life.

There is too much money pumped into a lot of sports now and that temptation has got
in the way. Top athletes know that they can be another of these celebrity type people,
who get moneyprobably more than they did when they were competingdoing
stupid things unrelated to sport like appearing in TV shows and launching their own
clothes line or advertising pointless products.

With all the extra money and sponsorship and advertising you can getathletes in
some sports in particular only need to do sport for a few years, then they can retire.
They get to keep all that money whatever happens down the line, like testing positive.
They need to put restrictions on these sums of money becauseif they couldnt afford
to retire on their earnings they would probably think twice about what they were
doing.

Another factor that participants believed contributes to the normalisation of drug use
in sport is the effect of audience attitudes to doping, in particular their ambivalence towards
athletes who are caught, and their enjoyment of watching high-level performance however it
is achieved.

I dont think the public really care whether people are doping or not. They dont care if
athletes are cheating. Its a freak showthey like watching other people pushing
themselves to extreme limitsdoing things they could never do themselves.

I mean there are people that are going to want to see people run the 100 metres in
seven and a half seconds, there's people that are going to want to see himbe able to
jump eight metres in the long jump. Therell always be an audience for it.

People get bored when records arent broken all the timethe time or the length or the
height and world records seem to be more important however they are achieved.

When asked about how sport audiences react to athletes who are discovered to be
using performance enhancing drugs, participants suggest that sport audiences are not
bothered about cheating, they kind of forget about it and although they know it happens,
they dont seemto care.

People will always remember the person who stepped on the podium, even if they are
caught doping later and lose their medalbut they will never remember the person the
medal got passed on to because its not important after the eventeveryone just
moves onto watching the next Olympic Games or whatever.

You never know who got the gold medal retrospectively but you would still remember
the time someone broke a recordpeople talk about it for years afterwards, even if
that athlete had dopedand people still tune in or turn up to watch sporting events
despite all the scandals.

Affect
Participants described a number of feelings or emotions relating to decisions to use
performance enhancing drugs. The most common of which was the feel-good-factor or sense of
pride that comes fromknowing you had achieved everything naturally. Similarly many athletes
discussed how doping would only be cheating yourself, one describing this as leaving you feeling
empty and worthless.

I get a lot more satisfaction fromknowing Im doing all this naturally, by myself. I
wouldnt be able to cope with knowing I had achieved it by taking anything and if I
had won a title, the money.it wouldnt mean anything to me. All those good feeling
would be ruined.

I wanted to performnaturally and pure and have my conscience clearyoull know
that if you win a gold medal or you achieve something in the back of your mind will
taint what youve done.you cant feel good about yourself.

This was perceived to be of greater consequence than being condemned as a cheat by
other people.

I think if you get caught and everythings wiped clean then thats the worst thing that
can happenI would be devastatedworthless.whether people still look up to you
or not.I mean, if you do it for like, ten years, you build up all your records and then
all of a sudden they get wiped clean.even if for the first nine years you took nothing
and you got those records fair and square and all of a sudden theyre gone.

When asked about the feelings of athletes who do use performance enhancing drugs, participants
described how feelings of loss or disappointment in poor performance could lead an athlete to use
drugs:
Its a real downer. I mean, you remember what you used to be like and what you
could attain and you just dont bounce back so well. You feel depressed and like you
didnt try hard enough.

To work so hard to get to an Olympic Games and then mess up is devastatingBut
its all youve done, you think winning is the only thing that will make you happy and
it probably iseverything that makes you happy or sad is about sport.

Discussion
The objective of the present study was to examine how theories of decision-making are able
to provide a framework for understanding athletes use of performance enhancing drugs. Although
rational choice models of decision making have been applied to the issue of drug-use in sport (Strelan
& Boeckmann, 2003; Strelan & Boeckmann, 2006), this is the first study to apply prospect theory
(Kahneman & Tversky, 1979). Prospect theory is able to account for decisions that depart from
rational-choice models of behaviour, and acknowledges that individual decision-making is influenced
by a number of cognitive biases. These biases include how decisions differ depending on whether
identical outcomes are framed as gains or losses. Similarly, an individuals reference point will also
determine how particular outcomes are subjectively perceived to be a gain or a loss relative to it.
Whilst little is known about how an individual locates the reference point for a particular decision,
prior research in the health domain has provided some evidence that goals themselves can serve as a
reference point (Van Osch et al., 2006).
The qualitative findings fromthe present study provide information that, at least in part,
supports prior findings fromdecision-making research, with respect to the potential importance of an
individuals goals in shaping their attitude towards risk decisions. However, the themes which
emerged also provide further information that emphasise the importance of placing decision-making
processes within a wider cultural framework.

Goals
Goals were the most frequently occurring theme described by the athletes in the present study.
Specifically, some participants considered post-sport goals, such as health and longevity to be an
important consideration when evaluating the health risks of doping, but believed that other athletes
would be prepared to sacrifice longer termhealth benefits in order to achieve a more primary goal
within their sport, such as beating a personal best, or breaking a record. The study by Van Osch et al.
(Van Osch et al., 2006) provided preliminary findings that goals can serve as a reference point, which
might increase the utility of particular decision outcomes. It has subsequently been recommended that
the cognitive aspects of decision-making theories and the motivational aspects of goal-setting
approaches can be combined (Krantz & Kunreuther, 2007) to provide a more accurate account of
individual decision-making.
In the course of their career, athletes constantly set goals and make choices regarding the way
these goals can be achieved, and Petroczi and Aidman (2008) have advanced a model of goals within
sport, consisting of a cycle of choice goal to commitment execution feedback on goal attainment
goal evaluation/adjustment. The authors propose that this cycle has numerous exit points, each of
which provided an opportunity for behaviour change, which might or might not be related to the use
of prohibited methods, such as performance enhancing drug use. This model accounts for a
relationship between facilitating and inhibiting factors, such as subjective norms and personality
variables which are further influenced by situational factors. The combination of the factors might
influence intentions to use performance enhancing drugs. This would be consistent with recent
research examining whether risk appraisal or preference is independent of aspirations (Sokolowska,
2006) and which provides evidence that risk choices involve a balance between an individuals
disposition toward risk and the opportunities of the situation. Petroczi and Aidman emphasise that
these influences are likely to vary fromone stage of athlete development to the next, making some
athletes more vulnerable to engaging in doping practices than others at certain time periods. Whilst
the model suggests that deterrence strategies are likely to be more effective if they target the
influencing factors at the appropriate career stage, the authors do not identify which groups of athletes
are likely to be at most risk. To enable more effective interventions to prevent illicit drug use in sport
would require further research to identify the groups of athletes and their respective career stages who
are at most risk of engaging in doping practices.

Normalisation
In the present study, normalisation was described by athletes in terms of the sport
workplace, including how coaches, medical professionals, and even teammates, might encourage
athletes to use performance enhancing drugs as a viable method of improving performance. Some
athletes also described how the ambivalent attitude of sport audiences has also reduced the perception
of doping as a morally unacceptable behaviour. With respect to normalisation of risk, Helms (1984)
has described a "risky shift" phenomena (p. 23) which might explain this acceptance of doping within
sport. Helms describes risk as occurring within a cultural framework, in which groups of individuals,
in certain contexts, are willing to take risks as a group that they would not take as individuals. Helms
suggests that when a group verbalises its decision concerning a risky situation, the group's decision
tends to be riskier than the individuals would have recommended privately. Specifically, when an
individual realises that he or she is not riskier than the other members of their group, they will adjust
their risk-taking attitude upward. Group discussion allows members to rehearse their arguments
regarding the decision, and, moreover, familiarity with a hazard is likely to promote a higher level of
acceptable risk concerning the hazard or situation.
A similar explanation is offered by a sociological explanation of deviance. Petetti-Watel and
Moatti (2006) suggest that many people engaged in risk behaviours tend to deny the risky label, and
describe deliberate risk-taking as a formof positive deviance, which is related to a need to conformto
the dominant risk culture. Reflecting on social risk and the meaning of sport, Frey (1991) emphasised
that risk perceptions are based on cultural and social factors, noting that in some cultures, including
sport, risk is an integral part of the value structure, and valued positively, especially if success is the
outcome of the risky action taken. This description is similar to that proposed by Hughes and Coakley
(Hughes & Coakley, 2001) who suggest that athletes are likely to take a number of risks, including
performance enhancing drug use, as a result of a commitment to the value systems of what they term
the sport ethic. What this finding would support is the observations by Ivan Waddington (2005) that
the value systemof sport has shifted, such that the amateur moral principles of fair-play have been
superseded by values which place a higher emphasis on winning and professionalism. This shift in
values has in turn, potentially increased the value that is placed on risk.

Affect
In the present study, athletes identified feelings of regret, particularly with respect to retiring
fromsport without having achieved the maximumlevel of performance that had been aspired for.
This was given as one reason that might cause athletes to resort to performance enhancers to cope
with performance decrements brought about by age or injury, and to avoid such feelings of regret.
Conversely, some athletes discussed how, knowing that they had cheated by using performance
enhancing drugs, would diminish any sense of pride, whatever their achievements. Most models of
decision-making are consequentialist in nature: they assume that decision makers choose between
alternative courses of action based on a cognitive evaluation of the utility and likelihood of their
consequences. However, writers such as George Loewenstein (Loewenstein, Weber, Hsee, & Welch,
2001) argue that choice can be an emotional experience as much as an cognitive one. Lowenstein
proposes a risk-as-feeling hypothesis, suggesting that emotions such as dread, hope and anxiety can
influence a decision maker as much as the formal details of the decision. Furthermore, emotional
reactions to risky situations often diverge fromcognitive assessments of those risks, and when such
divergence occurs, emotional reactions can often drive behaviour. However, this does not necessarily
suggest that consequentialist models, such as prospect theory, are wrong, but might point to the fact
that the utility of a given outcome can also be determined by the immediate or expected emotional
reactions to that choice. Understanding how emotional processes can improve our understanding of
risk behaviour is a promising avenue of enquiry.

Limitations
The present study is the first to apply previous findings fromprospect theory research to the
issue of drug-use in sport, but it is acknowledged that this study has several limitations. First, given
the sensitive nature of the subject-matter, participants might have felt uncomfortable with some of the
questions raised in the semi-structured interviews, and consequently provided socially desirable
answers that did not fully reflect their genuine opinions or experience. The interview guide was
designed to eliminate this issue as much as possible by asking questions of a more general or
hypothetical nature, rather than probing the reasons why individual participants would or would not
use performance-enhancing drugs. Nevertheless, all participants were able to discuss other athletes
they had trained with or competed against who they believed had taken performance enhancing
substances, and there was no denial of the issue within professional sport.
A second limitation is the small sample size that was used to generate the themes. Although
the sample size followed recommendations for qualitative research, some of the individual interviews
were shorter in length than anticipated, and not all of the interviews provided as rich a description as
was hoped, due to the participants time constraints. It would be unwise to assume that the qualitative
data achieved theoretical saturation, and additional themes might have emerged given a slightly larger
sample. Similarly, whilst the sample was originally selected to represent a range of sports, this also
limits generalisation of the findings to particular sub-groups of athletes.
Finally, whilst the present study employed a qualitative approach to examine the
psychological processes involved in decision-making, it would also have benefited fromthe addition
of quantitative data. Within decision-making research, quantitative data is typically gathered by
providing participants with hypothetical gambles (e.g., monetary, life-expectancy) and probabilities
for various outcomes, and asking them to select their preferred outcome or decision. The study by
Van Osch et al. (2006) demonstrates a mixed-design that might be adapted for further research into
performance-enhancing drug use in sport, because of the inclusion of a think-aloud protocol that was
carried out whilst participants were also providing quantitative data in their selection of various life-
expectancy gambles.

Recommendations
The findings fromthe present study reveal a number of factors that are likely to determine an
athletes decision to use performance enhancing drugs, and which, consequently, open up several new
areas of enquiry for future research. In particular, it is recommended that future studies investigate the
differences between attitudes towards (and prevalence of) doping across different time points in an
athletes career. It would be of further benefit to incorporate Petroczi and Aidmans (2008) life-cycle
model of drug use in sport in future research to examine the validity of this model, and to gain a
deeper understanding of how athletes goals change throughout their career. In more general terms, it
is also recommended that sport psychology research alters the way in which samples are categorised,
particularly when addressing age differences and motivational constructs. It might be more relevant to
examine differences categorised by career point, rather than age per se.
A further recommendation for future research is that the examination of risk within sport
avoids focusing exclusively on individual traits, such as sensation-seeking, with samples drawn from
those who participate in so-called extreme sports. The present study conceptualises doping as a risk
decision, both in terms of health risks, and in terms of the potential damage to career and reputation
that a positive test can cause and, consequently, theories of decision-making were used as the
framework for this study. Whilst it is of value to understand how individual differences might lead to
variations in the appraisal of a risk decision, such as performance enhancing drug use, research that
focuses solely on personality variables ignores the potential impact of other psychosocial factors, such
as motivation, goals, and culture. An examination of the social and cultural framework of sport might
offer a more useful window into understanding the complex forms of risk-decisions that athletes
make. Such an approach might reveal more about the real-life choices of athletes than offered solely
by personality or decision-making models previously applied to understanding risk appraisal.
Specifically, the notion of risk within sport should be treated as a broader construct than simply the
risks directly associated with the activity of a particular sport. It can be argued that all sports are
extreme, in terms of the physical and mental demands that they place on an athlete. Froma cultural
perspective, risk-taking has been identified as a common factor across all high-level athletes, related
to a commitment to the sport ethic (Hughes & Coakley, 2001). Further examination of how over-
commitment to the sport ethic might lead athletes to normalise performance-enhancing drug use
would be useful, but future studies should also examine whether athletes are similarly able to
rationalise other risk-behaviours such as disordered eating (Petrie, Greenleaf, Tenenbaum, & Eklund,
2007) and over-training syndrome (Tobar, 2005) that are also areas of concern within elite sport.
The present study also identifies a number of practical considerations that could be
incorporated into the drug-prevention programmes of organisations such as the WADA. In particular
how the effects of message framing (e.g., whether a particular outcome is described as a gain or a
loss) can alter how people respond to risk decisions. Within the WADA framework, the opportunity
for message framing is likely to occur within their education programmes, which are predominantly
directed towards younger athletes at the start of their sport careers. Currently these programmes
emphasise the health risks associated with performance enhancing drug use as well as the morally
unacceptable nature of using drugs to improve performance. However, there appears to be no detailed
explanation for why or how particular messages are selected, nor any evidence that these programmes
have been designed to account for the existing theoretical evidence on message framing.
The designers of drug-education programmes for athletes need to address a series of issues in
order to increase the likelihood that those programmes will be effective. Firstly, it is important to
select the appropriate target groups for different messages, which would most likely include athletes
at different stages in their careers (e.g., junior, mid-career, senior, veteran, or injured). Secondly,
given the influence of the cultural aspects of sport in normalising certain risk behaviours amongst
athletes, it is worth considering the most appropriate voice to deliver these messages to particular
groups of athletes. If drug-use in sport is, even in part, considered to be a legitimate behaviour to
improve performance, it is likely that messages delivered by those who operate outside of the sport
ethic (e.g., the medical profession, school-teachers) will have less of an impact than those delivered
by people who are within it (e.g., top athletes and coaches). Finally, the message, or combination of
messages that is likely to be the most effective should be considered, taking into account the effects of
message framing and the utility of emotions: for example ensuring that health-related messages
emphasise the appropriate losses or gains associated with drug use. Similar consideration should be
taken when constructing messages that seek to appeal to fair play (or condemn cheating), or describe
the potential loss of income or respect brought about by a positive dope test (British Medical
Association, 2002).
Whilst humans are not necessarily rational decision makers in terms of their ability to
calculate the probabilities of many real-life decisions involving risk, it would nevertheless make sense
to ensure that they were in possession of as many of the facts as possible in order to evaluate potential
outcomes. The professional athletes in the present study were able to cite a few well-known examples
of athletes who had failed drugs tests in the past, but were unable to recall what the specific penalty or
final outcome of any appeals process had been. Moreover, none were able to recall any instances of an
athlete being banned within their own sport at any level, despite regular drug-testing taking place.
Nevertheless, athletes across many sports do test positive on a regular basis. For the sports covered by
the WADA, annual doping statistics are published via their website, but the findings of the present
study would suggest that most athletes are unaware of the true figures. If it were possible to widen the
circulation of this data, with athlete names, type of sport, type of drug, whether they tested positive
within or outside of competition, as well as the penalties imposed and titles, records, or medals lost,
this might increase perception of the likelihood of being caught doping, as well as make the costs
associated with doping more salient, increasing the deterrent effect of those costs. Whilst this would
be a relatively inexpensive enhancement to anti-doping programmes, it is unlikely to be supported by
the various sporting organisations, who will seek to protect the reputation of their particular sport (and
in turn protecting their sponsorship deals and audiences) by keeping negative messages about drug-
use to a minimum.
Finally, given the support for the role of goals in influencing decision-making outcomes, it is
recommended that athletes of all ages are encouraged to build non-sport goals into their goal-setting
processes. Goal-setting is an integral part of professional sport, and is one of the factors that can
improve sport performance, but it is perhaps inevitable that commitment to these goals will ignore
other aspects of an athletes life, particularly post-retirement. Making goals, whether related to family,
health, education or employment, might contribute to their decision-making processes when
evaluating the costs and benefits of certain behaviours, including the use of performance-enhancing
drugs.

Conclusion
Current anti-doping legislation in competitive sports is advocated for reasons of fair-play and
concern for the health of athletes. With the inception of the World Anti Doping Agency (WADA),
anti-doping effort has been considerably intensified and resources invested in anti-doping are rising
steeply. However, despite the current measures to deter and detect doping, athletes continue to use
banned substances, and many are presumed to avoid apprehension (Hoberman et al., 2001),
suggesting that these measures are not working as effectively as intended. It is therefore important for
sporting organisations to identify other factors that could be addressed in order to reduce the
prevalence of illegal drug use in competitive sport.
Conceptualising performance enhancing drug use as a risk decision, both in terms of health
risks and the risk of being detected and punished with a ban fromsport, the present study examined
how models of decision-making, in particular prospect theory (Kahneman & Tversky, 1979), might be
applied to understanding doping in sport. Recent research has also emphasised the importance of
considering motivational and cultural constructs to account for the way in which individuals evaluate
the value of risk decisions. Using a semi-structured interview design, qualitative data was collected
that might provide further insight into the factors that contribute towards an athletes decision to use
performance enhancing drugs despite the risks associated with use. Three major themes emerged from
the data: goals, normalisation and affect.
Whilst there is a need for deterrence measures to control performance-enhancing drug use in
sport, the primary method for deterring athletes fromdoping (testing and penalties) is inherently
flawed because testing procedures are always likely to remain several steps behind the advancement
of new drugs and procedures. Likewise, logistical and financial constraints that prevent testing of
every athlete during their competition and training cycle are such that the achievement of zero drug
use among athletes based solely upon testing programmes is likely to be an unrealistic goal. It would
presumably be preferable to develop attitudinal change amongst athletes, to increase the number of
athletes who view the behaviour as immoral, irrespective of the health concerns or risk of detection
(Donovan et al., 2002). Whilst long-termattitudinal change will, inevitably take some time to evolve,
and its success challenged by the normalisation of drugs, and risk, within the culture of sport, the
findings fromthe present study point to some relatively simple solutions which can be implemented to
adapt anti-doping messages. In particular, and supplemented by further research, messages to
particular groups of athletes should be designed which account for the framing effects described by
prospect theory. Theories of decision-making also hold promise for understanding other forms of risks
that athletes take.
OConnor Page 33

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Appendices
1 Ethics Form (available on request)
2 Interview Schedule (available on request)
3 Participant Consent Form (available on request

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Running head: PROSPECT THEORY AND DRUG USE IN SPORT

Performance enhancing drug use in professional sport is a risk

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