SIOUX FALLS, S.D. — Sanford Health, which is financially backing a team of mixed martial arts fighters, might also use them as research subjects.

The potentially unusual relationship between Sanford and team of fighters it sponsors raises a number of ethical concerns about who holds the power when a health care organization has an existing financial relationship with its research subjects, said a bioethics expert.

"One of the big concerns that you have about this arrangement is the question of whether or not the subjects are freely consenting to enroll in a trial if the trial is being conducted by their employers, people who are paying their salaries," said Dr. Carl Elliot, professor of bioethics at the Center for Bioethics at the University of Minnesota.

At the moment, there is no connection between the Sanford-sponsored team and the organization's current and planned MMA research, which is centered on evaluating concussions among local fighters and has been underway since 2017, said Thayne Munce, researcher on Sanford's MMA concussion study at the Sanford Sports Institute.

Munce said he wasn't part of the planning for sponsorship of an MMA team, which was announced to the public in late September.

But there could be some collaboration in the future between the team and Sanford researchers, he said, although nothing has been formalized.

"I think you can think of it as a broader partnership," Munce said. "The MMA team was done in its own track. ... It certainly presents a potential opportunity to do research with fighters who may be on that team. How we do that logistically is going to be somewhat challenging."

Future research on fighters in the Florida-based team would likely depend on Sanford working in conjunction with NeuroSport, a brain health group that will be co-located with the team.

"We've had some preliminary discussion with them about potentially collaborating," Munce said. "They're on site, so anything that would be done directly with fighters would most likely be done by that group. But again, it's really early on to be able to speculate with that."

'Mixed martial arts is not badminton'

Sanford's potential dual relationship with MMA fighters calls to mind the case of Ellen Roche, Elliot said.

Roche was a lab technician at Johns Hopkins University who, along with other employees at the university, was recruited as a subject for an asthma study in 2001. The testing killed her. The university accepted full responsibility for her death and the matter sparked a re-examination of ethical standards for research on subjects who may only be volunteering under duress.

"The obvious question was, 'Why were you recruiting research subjects from your own employees, and was that consent free?'" Elliot said.

To Elliot, Sanford's sponsorship of an team of combat sports fighters, an activity where injury is virtually unavoidable, seems inconsistent with the larger mission of a health care company.

"Mixed martial arts is not badminton. You're not just investing in a sport where you're taking care of your own players. You're helping them beat their opponents senseless, which seems a little contrary to the mission of medicine," he said. "It just seems a very odd, questionable thing for a medical organization to get involved in."

Research all local . . . for now

Sanford Health is doing groundbreaking research on developing a concussion protocol for mixed martial arts matches, a battery of tests determine how possible concussions from fights and training have affected fighters, and should potentially keep them out of further fights for a period of time.

The sport currently puts injured fighters on ice for a set period of time, say a 7-day break, but Sanford is hoping to build a more sophisticated approach.

"What we're interested in, and what one of the gaps in the sports, is when it's safe for fighters to return to competition," he said.

Sanford's current research works with local fighters as subjects, independent of the newly sponsored Sanford MMA team, Munce said. Some of the current team members may have participated in the study in the past but do not at this time, he said.

Importance of consent

The MMA concussion research, like all Sanford research, is reviewed by what's known as an IRB, and Institutional Review Board, an in-house panel that ensures research is conducted correctly and within proper ethical guidelines.

Sanford Health is getting ready to launch a second MMA study, and is seeking approval from the IRB. Again, the study will recruit local fighters for its subjects and not target Sanford's MMA team, Munce said.

"We'll have a conflict-of-interest statement just informing future participants that Sanford does have this relationship with an MMA team and the outcomes of the study could influence that, or there could be some benefit to that," he said.

The conflict-of-interest statement should provide needed clarity for potential research recruits, as part of the study's consent process. And while Sanford isn't targeting members of the MMA team it sponsors for the current planned research, if it did so in the future, the IRB would be looped into the connection, Munce said.

"We're not targeting athletes who are on the Sanford MMA team for the research. Down the road, if we did do that, we would have to address that, we would have to make sure the IRB is aware of that," he said. "Part of that is covered in this statement, and they would have free will to choose to participate or not, and that's something that is consistent with every research study that we do."