To some, like former US Presidential candidate John McCain, it's "human cockfighting." To others, it's the pinnacle of athletic expression, requiring mastery of both form and self. There is no question that mixed martial arts, or MMA, is a divisive topic.
In a statement released earlier this month, the Canadian Medical Association (CMA) reaffirmed its opposition to the sanctioning of MMA bouts in Canada. The organization has publicly espoused this view since at least 2010, when CMA members voted overwhelmingly to campaign for a ban on MMA contests. At a news briefing subsequent to that vote, CMA President Dr Anne Doig stated that, "Canada's physicians oppose any activity that would directly lead to the maiming and injury of Canadians."
The timing of the CMA release is relevant, since Parliamentarians are presently considering Bill S-209, which would essentially remove the present Criminal Code prohibition on MMA. While several provinces have allowed MMA bouts within their borders, the sport is still disallowed in PEI, Saskatchewan, Newfoundland and Labrador, Yukon, Nunavut, and most parts of New Brunswick. Bill S-209 likely opens the door to the sport in those hold-out regions.
This development presents for me personally what I expected would be a curious quandary. On one hand, I am an epidemiologist who is actively engaged in public health activities in Canada, professionally and emotionally committed to supporting actions, institutions and legislations that demonstrably protect Canadians' health. On the other hand, I'm a lifelong student of a variety of martial arts, and a vocal fan of the sport of MMA. Yet I unerringly find myself siding against the CMA position, despite their seemingly evidence-based stance. I do so for three reasons: the CMA position is premature, not applied evenly to a host of comparable activities, and philosophically problematic.
Several experts have already decried the CMA's position, mostly citing the peculiarity in focusing on one sport over another. Many, such as Dr Johnny Benjamin, accurately point out that mainstream sports, like ice hockey and football, render their own array of serious health outcomes to participants, yet do not suffer the enmity of the CMA.
Indeed, Dr Anne Doig's blanket opposition to "any activity that would directly lead to the maiming and injury of Canadians" would necessarily include in her folio of disavowed pursuits such common actions as the operation of any motorized vehicle, weight-lifting, stair-climbing, scuba diving, and even typing on a computer, if one were to take the argument to its absurd extreme and include eye strain and carpal tunnel syndrome as direct injuries.
But to argue thus would be to miss the CMA's more subtle point, that MMA, and combat sports in general, have as their stated objective the intentional and targeted injury of a human being. The same cannot be said of the activities listed above. On this point, medical associations worldwide have been surprisingly consistent. In 1983, the Journal of the American Medical Association (JAMA), one of the world's leading medical journals, called for a universal ban on boxing, going so far as to label the sport "an obscenity." In the past ten years, the British, Canadian, and Australian Medical Associations have all recommended that boxing be banned, particularly for young people. And in 1983, revised in 2005, the World Medical Association issued a formal statement calling for the global banning of boxing as a sanctioned sport, based on the observation that boxing is, "a contest in which the winner seems to be the one who produces more brain damage on his opponent than he himself sustains."
While variations of striking and combat sports have been with us since the ascent of our species, the modern sport of boxing is over a century old. MMA, on the other hand, is a sport invented by accident about 20 years ago, in the wake of the original Ultimate Fighting Championship (UFC) tournament meant to determine which traditional martial art is superior.
Because of that tournament, martial artists learned to blend previously distinct fighting traditions into a more comprehensive and competitive whole. Thus, as a more complete combat sport, MMA practitioners utilize boxing skills in coordination with other fighting styles, including, but not limited to, wrestling, jiu-jitsu, and kickboxing. It is therefore not surprising that national medical associations would employ the philosophical template used to justify an opposition to boxing to similarly oppose MMA.
But MMA is simply too new to have produced sufficient epidemiological data needed to draw meaningful injury rate comparisons with other sports. Reliance is therefore made on boxing injury statistics to make a case against MMA. However, at least one study suggests that the overall risk of injury resulting from boxing appears to be comparable to that in other "collision" sports, such as football, ice hockey, wrestling, and soccer. From a strictly evidence-based standpoint, then, it does not seem rational for a medical association to target combat sports to a greater degree than other sports.
Moreover, given that the evidence-based arguments arise solely from using boxing statistics to estimate the likely medical impact of MMA, we should consider the many ways in which the two sports differ. I will draw attention to just three. First, the point of boxing is for one competitor to out-strike the other, most commonly by targeting the head. In MMA, that is a fraction of the intent. It is equally likely for one MMA fighter to place the other in sufficient discomfort that the latter surrenders, or "taps out." This does not necessarily include trauma to the brain.
Second, boxing matches are quite a bit longer than MMA bouts. During that time, a boxer who is knocked down and senseless is permitted time to stand and regain his composure. In an MMA bout, that same fighter would likely be quickly finished and the bout ended. The boxing scenario presents repeated opportunity for continued brain trauma, while the MMA scenario does not.
Third, boxers employ significantly larger gloves than do MMA fighters. This allows the latter to inflict greater damage with fewer strikes. While this may seem counterintuitive, I believe that this in fact makes MMA safer than boxing. Fewer strikes leading to an earlier end to the fight means a lesser chance of long term brain trauma.
As well, the sensation of greater hand protection may lead to a boxer firing shots more frequently and with a greater tendency to strike the hard portions of the skull. In recognition of this phenomenon, this year the International Boxing Association banned the wearing of protective headgear by competitors in elite amateur bouts. Their rationale, based admittedly on limited data, is that the feeling of being protected actually encourages overuse of the head and hands as weapons, thus resulting in an increased risk of trauma.
None of this, though, discounts the philosophical basis of the CMA's objection to MMA: that the proximal objective of the sport is to cause bodily harm to a human being. Even if the eventual epidemiological data improbably shows MMA to be safer than, say, skipping rope, the CMA's underlying philosophy is a defensible one.
However, one needs to ask if intent is indeed a rational philosophical basis on which to build a medical opposition to any activity. From a constructive social perspective, one may decry the existence of a desire to cause harm. But I would argue that it is not the role of a national medical association to pass judgement upon motivation or intent. Why, then, does the CMA not oppose its members serving as military doctors, since all military activities are ultimately geared toward the destruction of human life?
Rather, to apply the considerable heft of a powerful, professional lobbying group against a popular activity with a growing fan base that cuts across many levels of society would require, to my mind, convincing data beyond all else, divorced from any consideration of participants' intent. Such data would concern injury rates, degrees of severity, hospitalization rates, and factors predictive and associated with deleterious health outcomes. Frankly, those data do not yet exist. When they eventually do, and if they prove damning to MMA, the role of the CMA should be to consider options beyond just an outright ban.
The nature of MMA as a brand new sport, for which rules, judging standards, permitted techniques, approved equipment, and even permitted participants, are still evolving daily, presents an unusual opportunity for medical bodies to participate in that evolution. The Unified Rules of MMA are barely over a decade old and are known to be imperfect. Medical bodies should be studying the sport and making recommendations to alter its rules, equipment and nature in order to make it safer, and not simply acting in a reactionary manner to seek to ban it outright.
