Blood Doping

What Are the Risk and Benefit of Erythropoietin (EPO)?

Lance cheated. Deep in our hearts we knew it, but until the words came out of his mouth, there was a glimmer of hope that he still could be our hero. Now he has fallen, admitting that he blood doped, used steroids and erythropoietin (EPO), and exhibited disdain to those around him, both friend and foe. The problem, however, is that sports are always filled with cheating, and the public accepts some acts of dishonesty as part of the game. The distinction between what is ethically acceptable and what is not continues to be a blurred line.

Muscle cells are factories that take the raw materials, oxygen and glucose, and turn them into energy. Training increases the ability of the body to deliver oxygen to the cells and increases muscle size. More efficiency and more power yield better athletic performance. Increasing the number of red blood cells in the body increases the ability to deliver oxygen to tissues and that's where blood doping and EPO come in.

EPO and Blood Doping

EPO is a naturally occurring hormone in the body that stimulates the bone marrow to produce more red cells. Medically, it is given to patients with anemia of chronic disease whose bone marrow is suppressed to help them have more energy and increase daily function. But, inject it into an elite athlete and the extra oxygen increases their aerobic capacity. If the cell factory runs out of oxygen, it turns to anaerobic metabolism, whose waste products shut down the ability to perform. The risk of increasing the number of red cells? Too many red cells can cause blood to sludge and clot in arteries and veins, causing bad things like stroke and heart attack.

Blood doping has the same end result as using EPO. In effect, the athlete donates a unit (about a pint) or two of blood to himself. The blood can be stored for a month or two while the body replenishes it and just before competition, the saved blood is transfused back into the athlete, increasing the red blood cell count and the oxygen delivery capacity. The risk? The same as using EPO – blood clots and potential death.

Blood doping and EPO use are illegal acts...cheating. But if money is no object, the same end result can be achieved quite legally. Runners who train at altitude, about 6,000 feet above sea level, can see an increase in their erythropoietin level. This is the body adapting to low oxygen concentrations. But intense training at altitude is difficult and performance increases, but not to a great extent. However, if an athlete could sleep at altitude and train at sea level, the effect on performance could be much more dramatic. Thus came the development of hypoxic tents (hypo=low + oxic= oxygen), in which an athlete could sleep and lounge for hours on end and then step outside and train at sea level. Erythropoietin increases in the body as do red blood cell counts and oxygen-carrying capacity. It's a perfectly legal strategy and accepted by WADA, the World Anti-Doping Agency, because of its safety record.


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Cheating in Sports: A Blurred Line

As research improves the capabilities of training to safely enhance performance, the line between cheating and legal means to gain an edge will continue to blur. Imagine being able to see a baseball or a tennis ball with vision better than 20/20. Will that extra split second help turn a ground out into a hit or a backhand in the net into a winner? Lasik surgery is an accepted procedure and unlikely to be considered an unethical performance enhancing operation. Oscar Pistorius, a double amputee, used Cheetah carbon fiber blades to run in the Olympics. His accomplishments were amazing as he overcame too many obstacles to count, not the least was making certain that the blades did not provide him a mechanical advantage over his non-amputee competitors. How long though before technology does create the advantage, and then what?

An Olympic gold, a Super Bowl championship, or a World Series ring demands years of sacrifice and training. The seduction of fame and riches often causes those with these aspirations to make unethical decisions. As much as the public adores a champion, it loathes somebody who cheats; but one person's cheater is another's crafty veteran. Throwing a spitball and not getting caught might get you into the baseball hall of fame, but as seen in the latest writers' vote, drugs are a nonstarter.

Repeated studies have asked athletes whether they would choose steroid use and die early or win an Olympic medal, and the temptation of gold wins every time. Lance cheated and then lied about cheating. Perhaps the world would have forgiven the drugs, but it won't forgive the lie.

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Medically reviewed by John A. Daller, MD American Board of Surgery with subspecialty certification in surgical critical care


"2016 List of Prohibited Substances and Methods." World Anti-Doping Agency. 2016.