Mandate or Guideline? Heat Illness and High School Sports Safety Policy

Timeline

1. Aug 2001Minnesota Vikings lineman Korey Stringer dies of heat stroke at training camp.
2. 2009An NATA inter-association task force issues preseason heat-acclimatization guidelines for secondary schools.
3. Aug 2010CDC estimates 9,237 time-loss heat illnesses a year among high school athletes, 2005–2009.
4. 2017The Korey Stringer Institute begins ranking state high school sports safety policies.
5. Apr 2019A study links state-mandated acclimatization guidelines to a 55% drop in preseason football heat illness.
6. 2024Researchers report 67 secondary school heat stroke deaths from 1982 to 2022, 63 in football.
7. Jun 2025Georgia tops the KSI evaluation at 93.7%; the median state scores 49.9%.
8. 2025Minnesota ranks near the bottom, scoring 3.75 of 20 on heat policy.

The ethical issues

• Whether known, preventable risks should be governed by mandates or recommendations.
• Unequal protection for athletes depending on their state and school resources.
• Coaches' competitive incentives versus athlete welfare.
• The role of outside rankings in pressuring governing bodies.
• Who bears the cost of athletic trainers, cooling tubs and monitoring equipment.

Stakeholders

Stakeholder	Interests & obligations
High school athletes	Safe practices and fast emergency care.
Parents and families	Confidence that schools protect their children.
Coaches	Preparing teams and competing, within clear rules.
State high school associations	Setting policy that member schools can follow and afford.
School districts	Managing budgets, liability and staffing.
Sports medicine researchers and advocates	Translating evidence into required practice.

The case

Every August, high school football teams across the United States begin preseason practice in the hottest weeks of the year. For most players it is the start of a season. For a small number it has been the end of a life. Exertional heat stroke, a dangerous rise in core body temperature during exercise, is one of the leading causes of sudden death in secondary school sport, and researchers describe it as largely survivable when treated quickly.^[3] The science of prevention is well established. What varies is whether the rules that put that science into practice are required or merely recommended, and that depends on which state an athlete happens to live in. This case asks who is responsible for protecting teenagers from a risk that is predictable and preventable.

Background

In 2010 the Centers for Disease Control and Prevention published the first national estimate of heat illness among high school athletes. Using data from a sample of 100 schools with certified athletic trainers, it estimated an average of 9,237 heat illnesses a year from 2005 to 2009 serious enough to keep an athlete out for at least a day.^[1] Football accounted for 70.7% of them, at a rate about ten times the average of eight other sports. Two-thirds occurred in August, and most football cases happened during preseason practice, often more than an hour after practice began.^[1] The CDC noted that its figures were an underestimate, because they excluded schools without athletic trainers and illnesses that did not cost a day of play. It stated plainly: “All heat illnesses in high school athletes are preventable.”^[1]

The deaths follow the same pattern. A study by researchers at the Korey Stringer Institute (KSI) reviewed exertional heat stroke deaths recorded by the National Center for Catastrophic Sport Injury Research from 1982 to 2022. It found 67 deaths in secondary school sport. Sixty-six were male, 63 were football players, three-quarters occurred in the southern region, and most occurred in August.^[3] The worst decade, 2002–2011, had 26 deaths. The most recent decade had 16, a 38% reduction from the peak but similar to the 1980s.^[3] The authors stress that rapid whole-body cold-water immersion, lowering body temperature within 30 minutes, makes heat stroke largely survivable.^[3]

The institute itself is named for Korey Stringer, a Minnesota Vikings lineman who died of heat stroke at the team’s training camp in 2001. His widow has since campaigned for policy changes for high school athletes, who she says “are often the ones forgotten when it comes to trainers and their health criteria.”^[7]

What happened

In 2009 a task force convened by the National Athletic Trainers’ Association (NATA) issued preseason heat-acclimatization guidelines for secondary schools. They phase athletes in over the first 14 days of preseason, limiting practice length, double sessions and protective equipment while bodies adapt.^[2][1] The guidelines were advice. Whether they applied in a given school depended on the state high school association or legislature.

A 2019 study led by Zachary Kerr of the University of North Carolina tested whether making the guidelines mandatory made a difference. Using high school injury surveillance data from 2005 to 2017, it compared states with and without mandated guidelines and found that heat-illness rates during preseason football practice were 55% lower where the guidelines were required.^[2] Kerr said the findings “highlight the potential benefits of state high school associations mandating injury prevention guidelines.”^[2]

Since 2017 the KSI has graded every state’s high school sports safety policies, drawing on association bylaws and state laws covering heat acclimatization, emergency action plans, athletic trainers, coaching education and other areas.^[6][4] Its 2025–26 evaluation ranked Georgia first at 93.67%, followed by Florida at 93.0% and New Jersey at 85.0%. At the bottom were Montana, Minnesota, Wyoming and Maine, which scored 30.0%.^[4] The median state score was 49.9%.^[6] A KSI official credited Georgia’s research on heat-illness prevention, saying “we’ve really adopted their model, especially environmental monitoring.”^[6]

The rules and governance

There is no single national rulebook for high school sport. Each state’s association, usually advised by a sports medicine committee, sets the rules its member schools must follow, and some legislatures add requirements in state law.^[7][6] The National Federation of State High School Associations (NFHS) provides guidance and model policies but does not impose them.

That structure creates the central gap. In Minnesota, where Korey Stringer played, KSI scored the state 3.75 out of 20 for heat policy, citing practices such as allowing two-a-day sessions at the start of the season.^[7] A co-chair of the state league’s sports medicine advisory committee said Minnesota does have a heat acclimatization protocol and that the league emails schools on hot days reminding them to check temperatures. Many protocols, however, are strongly encouraged rather than required, leaving the decision to individual schools.^[7]

State associations have pushed back against the rankings. Responding to an early KSI ranking, then NFHS executive director Bob Gardner said the institute had “proclaimed itself as judge and jury” and that a review of association websites was “an incomplete measurement” of the work states do for schools ranging from 50 students to 5,000.^[5] He argued that research data and funds for prevention programs “would be much more useful than giving grades.”^[5]

Aftermath

The rankings have become a lever for change. KSI’s chief executive said the institute has helped change 476 policies nationwide.^[7] The researchers behind the death-trend study conclude that continued deaths show schools still need “basic tools and policies to save lives,” including cold-water immersion and on-site medical staff.^[3] The gap between best-ranked and worst-ranked states remains wide, and so does the difference in protection a teenager receives depending on where they play.

The core dilemma

Should state associations require heat-safety measures that evidence shows save lives, even when doing so imposes costs and limits local discretion? Or should they set guidelines and trust schools and coaches to adapt them to local conditions and resources?

Competing values

The first value is the duty of care owed to minors in a supervised, compulsory-feeling setting. Teenagers cannot easily refuse a coach’s practice plan. The second is non-maleficence: the harm is severe, and the means to prevent it are known. Against these stand local autonomy, the real cost of athletic trainers and equipment for poorer schools, and the competitive culture of preseason football. Distributive justice cuts across all of them. The same athlete is better protected in Georgia than in Maine.

Strongest arguments

For mandates: The 2019 study is evidence that requirements, not recommendations, change outcomes.^[2] Voluntary guidance tends to be adopted unevenly, and the schools least likely to adopt it may be those with the fewest medical staff. When the CDC calls every heat illness preventable, an optional policy leaves avoidable harm in place.^[1]

For flexibility: Associations govern thousands of very different schools. A mandate that a small rural school cannot staff or fund may exist only on paper. Rankings based on written policy may not capture what schools actually do, as the NFHS argued.^[5] Resources for prevention may help more than grades.

Applying the frameworks

Ethics of care

Care ethics focuses on the vulnerable person in the relationship. A teenager in preseason practice depends on adults to recognize danger and stop activity. On this view, the relationship itself creates obligations. Coaches and administrators should not wait for a mandate to adopt acclimatization, monitoring and cold-water immersion. A care perspective also asks whether athletes feel able to report symptoms without fear of losing their place.

Utilitarianism

A utilitarian weighs total harms and benefits. A 55% reduction in heat illness across a state’s football programs is a large benefit, and deaths prevented carry enormous weight.^[2] Against that are costs: equipment, staffing, and shorter or less intense early practices. A utilitarian would also ask whether money spent meeting a mandate might do more good elsewhere, but the low cost of cooling tubs relative to the harm avoided usually favors action.

Justice

Justice asks whether protection is distributed fairly. Under the current system, an athlete’s safety depends partly on the policies of their state and the budget of their school.^[4] A justice perspective might support minimum statewide standards plus funding for schools that cannot afford them, so that safety is not a privilege of wealth or geography.

Walk it through: the Simple Decision Model

1. What are the facts? Heat illness is common in preseason football, deaths cluster in August and the South, and mandated acclimatization is associated with large reductions.^[1][2][3] State policies vary widely.^[4]
2. Who are the stakeholders? Athletes, families, coaches, school districts, state associations, the NFHS and sports medicine advocates.
3. What are the options? Keep guidelines voluntary; mandate acclimatization only; mandate a full package including environmental monitoring, emergency plans and athletic trainers; or mandate and fund.
4. Which values are in conflict? Duty of care and non-maleficence against local autonomy, cost and competitive tradition, with fairness across states as a further concern.
5. What do the frameworks suggest? Care and utilitarian reasoning lean toward mandates; justice adds that mandates need resources to be real.
6. What would you decide and why? Decide as a state association board. Be ready to explain your answer to the family of an athlete harmed under your policy.

What’s settled and what’s contested

Settled: Heat illness in high school sport is concentrated in preseason football; exertional heat stroke is largely survivable with rapid cooling; mandated acclimatization guidelines are associated with fewer heat illnesses.^[1][2][3]

Contested: Whether policy rankings fairly measure state effort; how far associations should override local discretion; and who should pay for the staff and equipment that best practice requires.^[5][7]

Why this case matters

This case extends the questions raised by the college death of Jordan McNair at Maryland to the far larger and less resourced world of high school sport. It also connects to elite scheduling decisions in extreme heat, such as the 2025 Club World Cup. It shows how institutional accountability can depend on whether a rule says “must” or “should.”

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.

Non-maleficence

The duty to avoid causing harm, often paired with care ethics when setting safety rules.

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.

Distributive justice

Fairness in how scarce opportunities, resources, benefits and burdens are shared.

Institutional accountability

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

Codes and guardrails

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

Definitions from the Ethics Cases glossary.

Discussion questions

1. If a harm is known and preventable, is a recommendation ever enough?
2. Should a state association be held responsible for a death if its policy was optional?
3. Is it fair to rank states on written policies rather than outcomes?
4. How should poorer schools meet expensive safety standards?
5. What responsibility do coaches have when policy is silent?

Sources

1. Heat Illness Among High School Athletes — United States, 2005–2009 — CDC, Morbidity and Mortality Weekly Report
2. Mandatory preseason guidelines reduce heat illness among high school football players — UNC Injury Prevention Research Center
3. Fatal Exertional Heat Stroke Trends in Secondary School Sports From 1982 Through 2022 — Sports Health (via PubMed Central)
4. State High School Sports Safety Policies: 2025–2026 evaluation — Korey Stringer Institute, University of Connecticut
5. NFHS Responds to Korey Stringer Institute Ranking of High School Associations Regarding Managing Injury Risk — NFHS
6. Georgia ranks No. 1 in safety policies for high school athletes — Atlanta Journal-Constitution
7. Nearly 25 years after Korey Stringer's heat exhaustion death, how is Minnesota protecting high school athletes? — CBS Minnesota