Steps Followed, Outcome Wrong: Tua Tagovailoa and the NFL Concussion Protocol

Timeline

1. 25 Sep 2022Tagovailoa stumbles after a hit against Buffalo, is evaluated for concussion, and returns after halftime.
2. 29 Sep 2022Against Cincinnati, Tagovailoa shows a fencing response and is taken to hospital with a concussion.
3. 1 Oct 2022The NFLPA dismisses the unaffiliated neurotrauma consultant involved; the NFL says it did not support the move.
4. 8 Oct 2022Joint review finds the protocol steps were followed; 'ataxia' is added as a no-go symptom.
5. 25 Dec 2022Tagovailoa suffers another concussion against Green Bay and misses the rest of the season.
6. Jul 2024After starting every game in 2023, Tagovailoa signs a four-year, $212.4 million extension.
7. 12 Sep 2024Tagovailoa suffers another concussion against Buffalo and is placed on injured reserve.

The ethical issues

• Team physicians' dual loyalty to player and club.
• Checklist compliance versus the purpose of a safety rule.
• Player autonomy and the desire to keep playing.
• Accountability when a rule's loophole causes harm.
• Who bears risk when diagnosis is uncertain.

Stakeholders

Stakeholder	Interests & obligations
Tua Tagovailoa	His health, career and right to make choices about his body.
Other NFL players	A protocol that protects them consistently.
Miami Dolphins	Winning and player availability.
Team physicians and independent consultants	Professional judgment and independence.
NFL	Player safety and the sport's reputation.
NFLPA	Holding management to health standards.

The case

In a September 2022 game against the Buffalo Bills, Miami Dolphins quarterback Tua Tagovailoa fell back and hit his head on the turf. When he stood up he shook his head and stumbled.^[4] He was taken to the locker room for a concussion check, cleared, and returned after halftime.^[3] Four days later, in Cincinnati, he was slammed to the ground, his arms and fingers locked in a “fencing response,” and he was carried off on a stretcher and taken to hospital with a concussion.^[4][3] A joint review by the league and the players’ union concluded that every step of the concussion protocol had been followed, yet “the outcome in this case was not what was intended.”^[1] The case asks what a safety rule is for, and who should decide when a player is fit to return.

Background

The NFL-NFLPA Concussion Evaluation and Management Protocol was formalized in 2013. Over time it added athletic-trainer spotters in the booth and unaffiliated neurotrauma consultants (UNCs), independent doctors approved and paid for by both the league and the union.^[1] The protocol was designed so that “competitive decisions never usurp quality care.”^[1]

At the start of the 2022 season, a player who showed one of four “no-go” signs (loss of consciousness, gross motor instability, confusion or amnesia) could not return. But there was an exception. If the player passed the concussion exam and the team doctor believed the instability had an orthopedic cause, he could re-enter the game.^[2] NFLPA president JC Tretter wrote that this “loophole” remained because of past cases in which a player’s stumble was judged to come from a leg injury rather than a head injury.^[2]

What happened

After the Buffalo game, head coach Mike McDaniel said Tagovailoa had hurt his lower back on an earlier play and that the back injury caused the stumble.^[3] The NFLPA opened an investigation.^[3] Four days later Tagovailoa played on a Thursday night against Cincinnati and suffered the concussion that put him in hospital.^[4]

On 1 October the NFLPA dismissed the UNC who had taken part in the Buffalo evaluation, citing his failure to understand his role and his hostility during the investigation. An NFL spokesperson said: “We never supported terminating him.”^[3]

The joint review interviewed the team’s medical staff, the head athletic trainer, the booth spotter, the UNC and Tagovailoa.^[1] It found that the club staff and the UNC watched the video and examined Tagovailoa in the locker room before the team physician cleared him after consulting the UNC. They concluded his instability was not neurologically caused and came from his back. But the physician and UNC “did not conduct an analysis” of his back during the concussion exam. Instead they relied on an earlier exam by other staff.^[3] The review noted that Tagovailoa “did not report or exhibit any signs or symptoms of concussion” during the locker-room exam, the rest of the game, or the following week.^[3]

The rules and governance

The collective bargaining agreement limits such reviews to whether each step of the protocol was carried out.^[1] On that test the staff complied. Tretter’s response was blunt: “Our union does not care about checklists; our concern is for player care.” He argued the exception was meant to apply only if the doctor was certain the symptom came from another injury.^[2]

From 9 October 2022, “ataxia” replaced gross motor instability as a no-go symptom. Ataxia is defined as “abnormality of balance/stability, motor coordination or dysfunctional speech caused by a neurological issue.” A player diagnosed with it by any club or neutral physician cannot return.^[1][3] NFL chief medical officer Dr. Allen Sills said that under the new rule Tagovailoa would not have returned against Buffalo. He also explained the conservative approach: “if we are going to be wrong, we would rather hold someone out who doesn’t have a brain injury.”^[4] Sills defended the staff involved as acting with “absolute integrity.”^[3]

Aftermath

Tagovailoa returned in late October 2022.^[2] On Christmas Day he suffered another concussion against Green Bay and missed the rest of the season, including a playoff game.^[5] In 2023 he started every game for the first time and led the league in passing yards. In July 2024 he signed a four-year, $212.4 million extension.^[5] On 12 September 2024 he suffered another concussion after a head-first collision against Buffalo and was placed on injured reserve so he could progress through the protocol and see outside neurologists.^[5] NFL.com reported he had no plans to retire.^[6]

The core dilemma

When diagnosis is uncertain, should a safety rule err toward keeping a player in the game, trusting doctors’ judgment, or toward holding him out, even if he may be healthy? And who should decide: club doctors, independent consultants, the player, or a fixed rule?

Competing values

Player health stands against competitive availability. Professional medical discretion stands against bright-line rules. Player autonomy stands against protective paternalism.

Strongest arguments

For bright-line rules: Discretion created the loophole that let a player with a no-go symptom return.^[2] Team doctors work for clubs, creating a conflict of interest. A fixed rule protects every player equally.^[1][4]

For medical judgment: Doctors examine the player in front of them. A rigid rule may keep healthy players out for orthopedic problems.^[4] The review found no concussion signs in the locker room or the week after.^[3]

Applying the frameworks

Ethics of care

Care ethics centers the player as a patient in a relationship of trust. Tretter’s insistence that medical staff “serve us; not the game, not the owners and not the business” expresses this view.^[2] Care asks what attentive treatment required on that day.

Utilitarianism

A utilitarian would weigh the harm of a missed brain injury against the cost of holding out uninjured players. Sills’s reasoning, accepting more false alarms to avoid missed injuries, reflects such a weighing, given how serious brain injuries can be.^[4]

Kantian ethics

A Kantian lens asks whether players are treated as ends in themselves rather than as means to win. It also respects a player’s rational autonomy. That raises a question: how far should a player’s own wish to play carry when his judgment may itself be impaired?

Walk it through: the Simple Decision Model

1. What are the facts? Tagovailoa stumbled after a head impact, was cleared on a back-injury explanation without a back exam, and was concussed four days later; a review found the steps were followed.^[1][3]
2. Who are the stakeholders? Tagovailoa, other players, the Dolphins, the doctors and the UNC, the NFL and the NFLPA.
3. What are the options? Keep the exception; tighten it to require certainty; or remove it, as the ataxia rule largely did.
4. Which values are in conflict? Health against availability; discretion against bright-line rules; autonomy against protection.
5. What do the frameworks suggest? Care and utilitarian views both support erring on the side of caution; Kantian thinking adds respect for the player’s informed choice.
6. What would you decide and why? Draft the rule you would apply to a player who stumbles but passes a concussion exam.

What’s settled and what’s contested

Settled: The sequence of injuries, the review findings and the protocol change.^[1][3][5]

Contested: Whether anyone was at fault when the steps were followed; whether the UNC’s dismissal was fair; and how much say players should have over their own return to play.^[3][2]

Why this case matters

The case continues the story of the NFL concussion settlement and connects to the league’s Guardian Cap mandate. It shows how a safety system can comply with its own procedures and still fail its purpose.

Key terms

Duty of care

The responsibility of coaches, organizations and institutions to protect the health, safety and well-being of those in their charge. It is not a license for total control.

Principal–agent problem

When those acting on others’ behalf (agents such as executives, officials or agents) have interests that diverge from the people they serve.

Codes and guardrails

Written rules of conduct, backed by real consequences, that turn values into expected behavior. Without enforcement they are decoration.

Consent and autonomy

Whether people have agreed freely and with full information, and whether their right to make their own choices is respected.

Paternalism (hard and soft)

Restricting someone’s choices for their own good. Hard paternalism overrides competent, informed adults; soft paternalism steps in when information or autonomy is compromised.

Institutional accountability

Structures that make a sport organization explain its decisions and face consequences: clear authority, transparency, appeals, independent oversight and enforcement.

Definitions from the Ethics Cases glossary.

Discussion questions

1. If every step was followed, was anyone at fault?
2. Should players ever be allowed to return after showing a no-go symptom?
3. Is it right for a union to dismiss an independent doctor?
4. How much weight should a player's own wish to play carry?
5. Does a conservative rule unfairly keep healthy players out?

Sources

1. Joint NFL - NFLPA Statement on Review of Tua Tagovailoa Concussion Protocol — NFLPA
2. Concussion Protocols: Where We Stand Now — NFLPA (JC Tretter)
3. NFL, NFLPA agree to modify concussion protocols following completion of Tua Tagovailoa investigation — NFL.com
4. NFL-NFLPA agree to a change in concussion protocols — CNN
5. Dolphins placing QB Tua Tagovailoa (concussion) on injured reserve — NFL.com
6. Dolphins QB Tua Tagovailoa has no plans to retire after suffering latest concussion — NFL.com