Are students who study with teachers who do not include beta blockers as a possible solution to severe performance anxiety at a disadvantage? Do teachers who recommend beta blockers to students make a poor ethical decision: one that could even pose severe legal consequences? There is no doubt that educators are faced with an increasingly litigious society, and having the knowledge regarding specific legal issues has become extremely important.
Symptoms Presented Due to Anxiety or Nervousness
Most musicians and/or teachers have some understanding of the symptoms associated with performance anxiety. However, a more thorough comprhension of its causes and related symptoms will better equip these individuals to manage stress. For different individuals the root causes of performance anxiety are not necessarily the same, and therefore, care should be taken to first ascertain the primary cause. One of the most common physical responses to stressful performance situations is the increase of adrenalin (epinephrine) in the body. Receptors throughout the body respond to adrenalin in differing ways, which are often classified into five broad types: (1) peripheral excitatory action in blood vessels, salivary and sweat glands; (2) peripheral inhibitory action in the wall of the gut, bronchial tree, and in blood vessels supplying the skeletal muscle; (3) cardiac excitatory action; (4) metabolic actions in the liver and muscle; and (5) central nervous system excitatory action including increased respiration, wakefulness, and reduction in appetite.1 In short, many parts of the body react to adrenalin: from sweaty palms and shaking fingers to a queasy stomach and increased pulse rate. Adrenalin is an aid for quick action by large muscle groups, but can be a detriment to smaller muscle groups such as those in the fingers or lips. Hence many performers complain that their bodies do not react in the same way under the stress of performance as in times of practice.
Some symptoms of performance anxiety are best described as emotional or psychological. Increased moodiness, apprehension, and depression may be present during the on-going stresses of meeting performance standards. Also, musicians may find difficulty with concentration and focus during concerts or auditions. While increased adrenalin may exacerbate these symptoms, chemical imbalances in the body or psychological issues could also account for these symptoms. As a consequence no single medical or psychiatric solution is possible as a simple recommendation for symptoms associated with performance anxiety. The musician with severe performance anxiety may need counsel from multiple professionals to identify the root cause or causes of the debilitating symptoms.
An Increasing Acceptance and Prevalence
Utilizing beta blockers to alleviate performance anxiety has become widely accepted by many performers. These drugs were invented by Sir James W. Black in 1964. Three years later, in 1967, Propranolol became the first beta blocker to be approved by the Food and Drug Administration (FDA) for specific medical purposes.2 More than a decade later, in 1979, Thomas and Charles Brantigan published the first medical research in America supporting the effects of beta blockers for relieving stage fright.3 Although beta blockers were never approved for the treatment of anxiety, physicians are allowed to prescribe non-FDA approved medications if there is medical research that supports a benefit. Effectively, the drug was introduced to musicians in the late 1970s, and the use of beta blockers to treat performance anxiety has been increasing since as evidenced by numerous publications.
In 1982, Tom Hall of the Chicago Symphony published a significant article titled "A Cure for Stage Fright?" in Senza Sordino, the official publication of the International Conference of Symphony and Opera Musicians (ICSOM). This article introduced beta blockers to a community of musicians who eventually adopted these drugs, but it also discussed the potential dangers:
As with any drug, indiscriminate use is risky and undesirable. There is also an ethical issue. Might not the use of potent prescription drugs by a performer at an audition give him an unfair edge over the competition just as it might to the athlete or race horse? Does an audition by a candidate who uses Propranolol reveal with greater or lesser accuracy how he will play on the job? Must orchestras be prepared to administer blood and urine tests to audition applicants?4
ICSOM responded in the February, 1985 edition of Senza Sordino:
The July 1982 issue of Senza Sordino presented news of a study of the use of beta-blocking drugs like propranolol (Inderal) to alleviate the symptoms of stage fright. The use of these drugs for this purpose has been widely reported and was explored by medical conferences. . . , where concern was expressed over their indiscriminate use. Lew Waldeck of the American Federation of Musicians Symphony Department also expresses concern, reporting that Inderal is apparently being sold on the streets around performance centers in some cities and that some conservatory dispensaries are distributing beta-blockers to students requesting medication for stress.
The June 22, 1984 issue of the Medical Letter on Drugs and Therapeutics notes that propanolol "is usually well tolerated but is potentially dangerous in patients with heart disease or asthma, since even low doses can cause bradycardia, congestive failure, or life threatening bronchospasm. Fatigue, depression, nightmares, and impaired sexual function are fairly common adverse effects of continued use."
Dr. Frank Wilson, in a paper entitled "Inderal for Stage Fright?", further notes that Inderal can lower blood pressure to levels that cause fainting, can complicate the management of diabetes, can alter the body's reaction to agents used for general anesthesia, and has caused fatalities in individuals who have suddenly discontinued its use.
If you have never used it, don't take Inderal or any pill offered to you by a non-physician as an aid for dealing with nervousness. If you have Inderal, don't give it to anyone else to use. Whether you use it or not, urge your colleagues, students, and friends to observe these admonitions.5
The first scientific study regarding the use of beta blockers by professional musicians was undertaken by ICSOM soon thereafter, and found that 27% took beta blockers. From this group of users, only 19% took them on a daily basis for heart conditions; however, 70% reported occasional use without a doctor's prescription, and 72% used them for auditions.6
Several informal articles and interviews have demonstrated an increased use and acceptance of beta blockers for performance anxiety over time. According to an unscientific survey undertaken by the beta blocker study committee of FLUTE Internet mailing list in 1997, 52% of professionals used beta blockers for performance anxiety.7 In a 2006 interview for National Public Radio, the principal oboist of a major symphony orchestra stated the following about classical musicians, "If you were to do some kind of drug test, I would imagine that at least 90 percent of them are [using beta blockers for performance anxiety]."8 While there have been no recent scientific studies of the usage, most if not all musicians regularly performing symphonic music—particularly those currently undertaking auditions—are aware of the high prevalence of musicians using beta blockers for performance anxiety.
Applied instructors are often asked to assist students with strategies for stress management. Reputable teachers will undoubtedly propose many possible solutions before recommending any medication. This same principal—pursuing all possible non-medical solutions before considering beta blockers—is also found in many texts about topics such as professional success in music and maintaining performance health. However, most, if not all, of these books do not delve into the legality and ethics of using beta blockers. This may be largely due to the fact that these drugs have become accepted by many musicians as being appropriate given the physical and mental challenges they face. Additionally, these writings were undertaken—as we shall see—before beta blockers were classified as performance enhancers in other areas of society. In Beyond Talent: Creating a Successful Career in Music, Angela Myles Beeching states that, although "Inderal is commonly prescribed to musicians for performance anxiety," "Beta-blockers may be psychologically addicting, have various side effects, and possible drug interactions with anything else you may be taking. . . . Some musicians only rely on beta-blockers for special occasions, for important auditions or particularly stressful performance. The problem is you need to know how your body will react beforehand."9
Stuart Edward Dunkel's The Audition Process: Anxiety Management and Coping Strategies, included in the series Juilliard Performing Guides, addresses many possible solutions for anxiety, including diet and relaxation techniques. Regarding Propranolol, the author acknowledges "The 'underground musician's drug' is in widespread use today."10 Interestingly, he not only cites beta blockers but also includes the possible benefits of using the following other anxiety-reducing drugs: Tricyclic Antidepressants, Alprazolam, and Monoamine Oxidase Inhibitors. Dunkel also provides the "dosages recommended by investigators" and writes the following:
The use of drugs in controlling the symptoms of fear felt at an audition should be thought out carefully. . . . [O]ne should use caution by understanding the side effects of a given drug and by realizing that an addiction to drugs may occur and that this may therefore not be the ideal approach to a problem of stagefright [sic.].11
As one would expect in an academic text (a treatise published by one of the leading institutions of music), one is cautioned about the use of drugs. Nonetheless, there is also an acknowledgement of the challenges found in the music industry: at the time of writing, the authors had undertaken over 40 auditions without securing a permanent major symphony position. These challenges, and the availability of medication, can lead to a "win at all cost" mentality.
As stated earlier, the FDA approved beta blockers for certain conditions in 1967. Currently, clinical treatments supported by the FDA include cardiac arrhythmia, glaucoma, hypertension, migraine prophylaxis, and myocardial infarction.12 While the FDA does not approve other treatments, doctors may prescribe medications for other purposes if there is medical evidence to support their effectiveness. However, drug manufacturers may not advertise these drugs for that purpose. When medication is prescribed in this manner, the medication is being prescribed off-label (for a use other than it was intended). Lawyers.com provides more specific information on the legality of off-label uses for medications:
The FDA does not regulate the practice of medicine. After the FDA has approved a drug, a doctor is free to decide how to use it. It is legal for a doctor to prescribe an off-label use of an approved drug to treat a patient's condition. However, in doing so, a doctor is necessarily deviating from the standard of care.
Standard of care refers to the treatment that experts agree is appropriate for a particular medical condition. Doctors are legally obligated to provide their patients with the appropriate standard of care. If the patient experiences a bad reaction to the drug, the doctor may be liable for deviating from the standard of care for the patient's medical condition.13
Specifically, beta blockers are not approved by the FDA for anxiolytic treatment (the treatment of anxiety). Hence, several important questions arise: Is performance anxiety a medical condition, and if so, when is this the case? If performance anxiety is considered a medical condition, what medications are considered safe and appropriate for treatment?
Music is not a sport; however, legal and ethical precedents in athletics do inform discussions of beta blockers for musicians. First, because there are often more financial resources available in athletics than in music—symphonic music in particular—conditions exist where legal challenges are undertaken in sports while similar issues in music performances persist without legal intervention. Additionally, musicians face many challenges similar to athletes. Not only do both musicians and athletes need to be successful in competition (either in an athletic event or audition), but performance anxiety also hinders athletes in specific sports such as shooting, golf, and archery. The increased knowledge of human anatomy and metabolism, a wider range of drugs, and application of medical expertise to sports has changed all sporting events in the past century. The pressure to succeed in both music and sports may attract individuals to gain any advantage possible, including the use of Performance Enhancing Drugs (PEDs).
The World Anti-Doping Agency was established in 1999 with the charge to provide "scientific research, education, development of anti-doping capacities, and monitoring of the World Anti Doping Code." Included in this code is its "Fundamental Rationale":
Anti-doping programs seek to preserve what is intrinsically valuable about sport. This intrinsic value is often referred to as "the spirit of sport," it is the essence of Olympism; it is how we play true. The spirit of sport is the celebration of the human spirit, body and mind, and is characterized by the following values:
Ethics, fair play and honesty
Excellence in performance
Character and education
Fun and joy
Dedication and commitment
Respect for rules and laws
Respect for self and other Participants
Community and solidarity
Doping is fundamentally contrary to the spirit of sport.14
A musician's workday extends far beyond auditions; however, ICSOM adopted its "Code of Ethical Audition Practices" in December of 1984. This code does state that "auditions be conducted in accordance with guidelines ensuring competition that is fair to all who audition while providing the best results for orchestras seeking musicians."15 While the code states that a "joint committee of representatives of ICSOM, and the AFM Symphonic Services Division shall be established to oversee and review this code periodically," there is currently no policy regarding drug use at auditions.
Senator George J. Mitchell articulated several of the dangers that arise when performance-enhancing substances (including PEDs) are not monitored in a highly competitive field. The issue of integrity has not been widely examined by musicians because many publications in respected journals have supported beta blockers for performance anxiety, and again, the financial stakes are not the same as in athletics. Unlike in music, baseball's views on the drug culture have changed from the time decades ago, when there was no testing:
The illegal use of performance enhancing substances poses a serious threat to the integrity of the game. Widespread use by players of such substances unfairly disadvantages the honest athletes who refuse to use them and raises questions about the validity of baseball records.16
No similar change in professional music is yet evident, and this may in part be the result of music being an art for which statistics are not so easily generated. Comparisons are difficult to make. For instance, there is no "music hall of fame" in which the achievement for the best bassoon solo in the opening of Stravinsky's Le Sacre du Printemps or the loudest high c trumpeted in Strauss's Also Sprach Zarathustra is enshrined. However, the critical issue is that the unmonitored use of beta blockers for performance anxiety in conjunction with increasing expectations and competitiveness in the field are encouraging—or even forcing—more and more musicians (both professionals and students) to consume unnecessary medications that could have a harmful effect. In this regard, a significant parallel can be made between Senator Mitchell's report on performance enhancing substances in athletics and beta blockers in music:
The illegal use of these substances to improve athletic performance also carries with it potentially serious negative side effects on the human body. Steroid users place themselves at risk for psychiatric problems, cardiovascular and liver damage, drastic changes to their reproductive systems, musculoskeletal injury, and other problems. Users of human growth hormone risk cancer, harm to their reproductive health, cardiac and thyroid problems, and overgrowth of bone and connective tissue.
Apart from the dangers posed to the major league player himself, however, his use of performance enhancing substances encourages young athletes to use those substances. Young Americans are placing themselves at risk of serious harm. Because adolescents are already subject to significant hormonal changes, the abuse of steroids and other performance enhancing substances can have more serious effects on them than they have on adults.17
Both professors and professional musicians serve as role models similar to professional athletes. If these professionals are consuming and/or recommending drugs (even with medical supervision—as was usually the case with steroids by baseball players), how long will it be before students believe they must take them to earn a successful grade on a jury or earn the chair they deserve in an ensemble when they know their classmates are doing so? How long will it be before secondary students feel compelled to take the medications before university auditions, solo and ensemble festival, all-state auditions? Other ethical issues arise as well. Different doctors exert their own ethical standards since beta blockers as an anxiolytic treatment are not FDA approved. If one doctor does not approve and prescribe this medication, will students and/or parents resort to shopping around for a doctor who will or even purchase the drugs without the care of a physician? As noted earlier, the 1987 study by ICSOM indicated that of the 27% of professional musicians that had taken beta blockers, 70% had done so without a prescription.
A recent article in the Strad titled "The Taboo Tablet" presented a few case studies of musicians using beta blockers:
My father was a professional trumpet player, and I had learnt [sic.] what a beta-blocker was by the age of ten—to me they were normal. Almost all the wind players I knew had taken them for auditions and for concerts in which they had a major solo. With little performance experience, I took 10mg of propranolol for my undergraduate auditions.18
In 1995, when I was 13-14, I was performing the Saint-Saëns Violin Concerto No. 3 quite regularly with orchestras around Canada, and I was fine. But when gearing up for performances of the Sibelius Violin Concerto I noticed that my bow arm would feel weak immediately after the initial adrenaline rush of being on stage. . . . I talked to a teacher about my symptoms after she had selected a challenging programme for me to perform. . . . She suggested I try a beta-blocker, and that suggestion saved my career.19
These and other statements illustrate that the use of these drugs extends to young musicians and that more and more of these young musicians may be compelled or forced to use beta blockers, as the expectation of perfection in live performance increases.
Beta Blockers and Academia
The American Association of University Professors (AAUP) provides some guidance about the ethical responsibility of the professors in the classroom:
As teachers, professors encourage the free pursuit of learning in their students. They hold before them the best scholarly and ethical standards of their discipline. Professors demonstrate respect for students as individuals and adhere to their proper roles as intellectual guides and counselors. Professors make every reasonable effort to foster honest academic conduct and to ensure that their evaluations of students reflect each student's true merit. They respect the confidential nature of the relationship between professor and student. They avoid any exploitation, harassment, or discriminatory treatment of students. They acknowledge significant academic or scholarly assistance from them. They protect their academic freedom.20
As practitioners, experts in the field, and educators, professors are called upon to present to their students all aspects of music making and study. Sharing knowledge, however, comes with ethical dilemmas. Are professors who make their students aware of the effectiveness of beta blockers in treating anxiolytic symptoms associated with performance anxiety merely informing them of a widely established medical tool in the field? Are professors who inform their students of the effectiveness beta blockers in alleviating the negative aspects of performance anxiety simply equipping their students with the knowledge of a widely accepted practice in the field—and one that will assist them in being competitive in a oversaturated job market? Are professors who either recommend beta blockers under supervised care or make students with anxiolytic symptoms aware of these drugs perpetuating an underground culture, subjecting their students to possibility of medical complications, and placing themselves and their institutions under legal jeopardy?
The New York Times cites at least one university music instructor who was terminated for informing students of the benefits beta blockers have in treating symptoms associated with performance anxiety. Ruth Ann McClain, who taught flute at Rhodes College in Memphis was released in 2003 for sharing what she termed as "feel[ing] normal for a performance," as a result of a medication prescribed under a doctor's supervision:
Ms. McClain, a grandmother who was then teaching flute at Rhodes College in Memphis, started recommending beta-blocking drugs like propranolol to adult students afflicted with performance anxiety. And last year she lost her job for doing so.
College officials, who declined to comment for this article, said at the time that recommending drugs fell outside the student-instructor relationship and charged that Ms. McClain asked a doctor for medication for her students. Ms. McClain, who taught at Rhodes for 11 years, says she merely recommended that they consult a physician about obtaining a prescription.21
While informative, the New York Times article omitted many important details. McClain was an adjunct instructor who was suspended mid-year and then did not have her contract renewed. She cites that these actions were taken after one student complained: a student who utilized beta blockers without incident in a senior recital but then had other disagreements regarding her coursework and assessment.22 Rhodes College is a private college with a Presbyterian heritage. Regardless of the religious or philosophical foundation of the institution, there is little doubt that a student, parent, and/or administrator may not share the same ethical views as an instructor. A recommendation viewed as beneficial by an instructor might be viewed as deleterious by others. The consequences of such a recommendation may be as severe as termination of an instructor's contract.
Both music instructors and sports coaches serve as mentors to the students and athletes under their supervision. The death of Earl "Hank" Gathers, an athlete who died while undertaking medically supervised treatment with beta blockers, illustrates how a university employee's judgments may be questioned through legal action. In this case, a $32.5 million wrongful death suit was filed against his coach and the doctors who treated him. Specifically, Paul Westhead, Gather's basketball coach at Loyola Marymount, was charged with asking doctors to change or reduce medication that controlled a dangerous heart rhythm before the athlete died on the court. Westhead stated the following in regard to the matter:
As his coach, I did my best for Hank Gathers. I was never part of the medical decisions concerning Hank. I did not decide what medication to prescribe or what dosage to take. I feel badly that my relationship with Hank and his family could be distorted with this legal action.23
A $1.5 million settlement was eventually reached out of court. The medication was Propranolol under a doctor's supervision. The question arises: does a music professor informing students of the possible benefits of taking the medication with a doctor's supervision place them and their institution under similar liabilities?
A Shifting Paradigm
Supporters of beta blockers often cite that beta blockers are not performance enhancers. For example, Eddie Silva, in a blog for the Saint Louis Symphony, stated the following regarding the New York Times article addressing the termination of Ruth Ann McClain: "The article makes comparisons to steroids in the sports world, which seems way off the mark. Beta blockers don't build muscle mass; they relieve anxiety. They are not performance enhancers."24 Ironically, beta blockers have indeed been classified as performance enhancers by numerous sports organizations, and examining these trends provides some insight into worldviews in a shifting paradigm.
One of the most influential events in the establishment of a standard list of performance enhancers internationally was the founding of the World Anti-Doping Agency (WADA) in 1999. Beta blockers were indeed listed on the World Anti-Doping Code as early as 2009. As a result, many sporting organizations have also outlawed the use of beta blockers. The International Olympic Committee (IOC), the Pro Golf Association (PGA), and the National Association for Stock Car Auto Racing (NASCAR) are among the organizations that list beta blockers as a banned substance in totality or for certain sports. The National Collegiate Athletic Association (NCAA) has outlawed beta blockers for competitive shooting, and since this organization follows other major athletic organizations, prohibitions in golf and other sports are sure to follow if they have not already been established.25
Beta Blockers are also considered a banned substance if and when these sports are held in the Olympics. The World Bridge Federation (overseeing the game of cards) has also banned beta blockers in competition. Effectively, beta blockers are now classified as a performance enhancing substance, joining anabolic agents (including anabolic steroids), peptide hormones, beta-2 agonists, hormone antagonists and modulators, diuretics and masking agents, enhancing of oxygen transfer (including blood doping), chemical and physical manipulation (including Intravenous Infusions), gene doping, stimulants, narcotics, cannabinoids, glucocorticosteroids, and alcohol.26 Most educators will not even know most of these substances, let alone recommend them. However, the fact that beta blockers are grouped with these drugs should raise concerns among educators. Beta blockers are banned in sports for providing basically the same benefits touted by musicians, and the drugs pose the same health risks to both musicians and athletes. Should not two employees of the same institution—a music professor and a university golf coach—abide by the same ethical standards?
Performance Enhancers and Academics
Performance enhancers are not relegated to only music and sports. A parallel can also be made in academics. The abuse of medications prescribed for Attention Deficit Hyperactivity Disorder (ADHD) was recently documented in an article titled "Illicit Use of Prescription ADHD Medications on a College Campus: A Multimethodological Approach" published in the Journal of American College Health. In this study, nearly 2,000 undergraduates at a large, public, southeastern university were surveyed. Thirty-four percent of these students reported the illegal use of ADHD stimulants (the taking of these under-the-counter medications without the required medical supervision):
Most illegal users reported using ADHD stimulants primarily in periods of high academic stress and found them to reduce fatigue while increasing reading comprehension, interest, cognition, and memory. Furthermore, most had little information about the drug and found procurement to be both easy and stigma-free.27
As noted earlier, the prevalence of beta blockers in music performance demonstrates a general acceptance within the profession. Interestingly, students surveyed in the aforementioned study also demonstrated a "general lack of guilt or dissonance over taking illegal stimulants. Most viewed its use as not only physically and psychologically harmless, but also morally acceptable, because it was used for academic purposes and not for social entertainment."28 Just as beta blockers have been shown to alleviate the symptoms of performance anxiety, stimulants such as Adderall have been demonstrated as highly effective in increasing attention span, making academic study more interesting, improving cognitive abilities, and fighting fatigue.29
Certainly no reputable music performer or academician would recommend either beta blockers or Adderall without a doctor's supervision. However, many applied instructors recommend that their students see a physician for a beta blocker prescription for performance anxiety (but not for hypertension for which the drug is FDA approved). Could an academician who has a student doing poorly justify recommending that he or she seek a Ritalin prescription to improve academic performance? The use of stimulants as a study aid has begun to receive attention. The use of these drugs for cognitive enhancement is also not approved by the FDA, but there has been has been evidence that they are indeed effective. An important recent study published in 2008 and titled "Illicit Use of Prescription ADHD Medications on a College Campus: A Multimethodological Approach," in Journal of American College Health is among the first to expose the alarming prevalence of illegal use of drugs for cognitive improvement:
The biggest barrier to prevention efforts, however, may be the professed effectiveness of the drug itself. Almost all participants claimed that ADHD medications were highly effective in increasing their attention span, making work more interesting, improving their cognitive abilities, and fighting fatigue. With the multifaceted demands placed on college students (eg, grades, social life, finances) and the increasingly competitive workforce that awaits them after graduation, these students believe they have found the "magic bullet." "It works!" explained Lisa, a senior premed major. "Why wouldn't you use it if it works? The stuff is great. Great!" We are left to wonder, therefore, how to persuade students not to take stimulants that are so soundly praised for their effectiveness in a culture that increasingly justifies the means by the ends.30
Various medications have been proven to be effective in improving cognitive function, and more students are turning to them as a resource for improved academic performance. In effect, a "win at any cost" mindset can be seen in music, sports, and academics.
Educators must succeed in multiple roles, including serving as mentors, role models, and distributors of knowledge. In providing students with contemporary and accurate research, a music educator's responsibility includes referring students to information on performance anxiety and multiple approaches to mitigating stage fright. Students should be well informed of the risks and rewards of any method that reduces performance anxiety. However, caution is recommended to educators who consider recommending beta blockers or other medicines to students. Not only should direct recommendation (which is medical advice) be left to qualified physicians, but indirect recommendations may be just as problematic too. As mentors, applied faculty often provide their own life experiences as a means of instructing their students. However, educators who share personal experiences using beta blockers could be understood as directly recommending the drugs, and this warrants great caution.
Paradigm shifts and increased litigation on America's university campuses signal that even greater care must be taken to introduce students to ethically and medically sensitive subject matter within a well-informed context: one that includes a broad sampling of literature representing diverse opinions. This kind of diligence will provide well-meaning instructors the greatest protection should they believe a student will benefit from the use of beta blockers. Perhaps exposing students to the prevalence of beta blockers within the context of a pedagogy course or even an ethics course in music provide the necessary safeguards. In these instances a broad context is given that includes both benefits and side effects of the drugs. This is preferable to presentation of the subject in the confines of an applied studio where mentioning beta blockers could be interpreted as endorsement of performance enhancement drugs. AAUP supports the academic freedom needed to address this difficult topic:
Teachers are entitled to freedom in the classroom in discussing their subject, but they should be careful not to introduce into their teaching controversial matter which has no relation to their subject. Limitations of academic freedom because of religious or other aims of the institution should be clearly stated in writing at the time of the appointment.31
Clearly, the subject of beta blockers for performance anxiety does have relation to the subject of music performance; however, knowing relevant policies established by one's institution is critical in making informed decisions. Unfortunately, not only do these policies change over time, but administrators and legal counsel are not likely to provide clarity regarding specific policies both because they do not want to limit academic freedom and these officials are not able to predict what kinds of legal challenges may arise. Moreover, the legality of medical use of drugs often rests in the interpretation of the law, and these issues can be challenged in court. As a result, applied faculty that endorse beta blockers or are interpreted as endorsing beta blockers may be doing so at their own risk.
Altman, Lawrence K. "Suit Calls Coach and Doctors Negligent in Gathers's Death." New York Times. Archived from the original on April 21, 1990. http://www.nytimes.com /1990/04/21/sports/suit-calls-coach-and-doctors-negligent-in-gathers-s-death.html?src=pm (accessed April 15, 2012).
American Association of University Professors. 1940 Statement of Principles on Academic Freedom and Tenure with 1970 Interpretive Comments. Washington: AAUP, 2006. http://www.aaup.org/AAUP/pubsres/policydocs/contents/1940statement.htm (accessed April 15, 2012).
American Association of University Professors. Statement on Professional Ethics. Washington: AAUP, 2009. http://www.aaup.org/AAUP/pubsres/policydocs/contents/statementonprofessionalethics.htm (accessed April 15, 2012).
Beeching, Angela Myles. Beyond Talent: Creating a Successful Career in Music. Oxford, NY: Oxford University Press, 2005.
Brantigan, Thomas A., Neil Joseph, Charles O. Brantigan. "The Effect of Beta Blockade on Stage Fright: A Controlled Study." Rocky Mountain Medical Journal 76, no. 5 (September-October 1979): 227‒33.
"Concern over Widespread Use of Beta-Blockers." Senza Sordino 23, no. 3 (February 1985): 2.
DeSantis, Alan D., Elizabeth M. Webb, and Seth M. Noar. "Illicit Use of Prescription ADHD Medications on a College Campus: A Multimethodological Approach." Journal of American College Health 57, no. 3 (2008): 315‒23.
Dunkel, Stuart Edward. The Audition Process: Anxiety Management and Coping Strategies. Stuyvesant, NY: Pendragon Press, 1989.
Goodman, Luis S. and Alfred Gilman. The Pharmacological Basis of Therapeuatics, 4th ed. London: The Macmillan Company, 1970.
Hall, Tom. "A Cure for Stage Fright?." Senza Sordino 20, no. 5 (July 1982): 1. http://www.icsom.org/archive/senza/allsenzas/senza205.pdf (accessed April 15, 2012).
Harby, Karla, Kathrin Kucharski, Sarah Tuck, and Julia Vasquez. "Beta Blockers and Performance Anxiety in Musicians: Frequently Asked Questions." A Report by the Beta Blocker Study Committee of Flute Talk.
Jaspers, Margaret. "Off-Label Use of Prescription Drugs." In Lawyers.com. http://consumer-law.lawyers.com/consumer-fraud/Off-Label-Use-of-Prescription-Drugs.html.
Mitchell, George J. Report to the Commissioner of Baseball of the Independent Investigation into the Illegal Use of Steroids and Other Performance Enhancing Substances by Players in Major League Baseball. New York: Office of the Commissioner of Baseball, 2007. http://files.mlb.com/mitchrpt.pdf (accessed April 15, 2012).
Nelson, Catherine. "The Taboo Tablet." The Strad 121, no. 1444 (August 2010): 24‒28.
Needleman, Katherine. Interview by Jamie Hammon. Intern Edition, NPR, Summer 2006. http://www.npr.org/about/nextgen/internedition/sum06/docs/transcripts/betablockers.pdf (accessed November 16, 2012).
International Conference of Symphony and Opera Musicians. Code of Ethical Audition Practices. http://www.icsom.org/handbook/handbook13d.html (accessed April 15, 2012).
Silva, Eddie. "Chemistry." STL Symphony Blog, St. Louis Symphony. October 19, 2004. http://www.stlsymphony.org/blog/2004/10/chemistry.html.
"The Use of Beta Blockers by ICSOM Musicians." Senza Sordino 25, no. 6 (August 1987): 4.
Tindall, Blair. "Better Playing Through Chemistry." The New York Times. Archived from the original on October 17, 2004.
"Beta Blocker." Wikipedia. http://en.wikipedia.org/wiki/Beta_blocker (accessed April 15, 2012).
World Anti-Doping Agency. World Anti-Doping Code. Montreal: World Anti-Doping Agency, 2009. http://www.wada-ama.org/Documents/World_Anti-Doping_Program/WADP-The-Code/WADA_Anti-Doping_CODE_2009_EN.pdf (accessed April 15, 2012).
World Anti-Doping Agency. The World Anti-Doping Code: The 2009 Prohibited List—International Standard. Montreal: World Anti-Doping Agency, 2008. http://www.wada-ama.org/rtecontent/document/2009_Prohibited_List_ENG_Final_20_Sept_08.pdf (accessed April 15, 2012).
World Anti-Doping Agency. The World Anti-Doping Code: The 2011 Prohibited List—International Standard. Montreal: World Anti-Doping Agency, 2010. http://www.wada-ama.org/Documents/World_Anti-Doping_Program/WADP-Prohibited-list/To_be_effective/WADA_Prohibited_List_2011_EN.pdf (accessed April 15, 2012).
Zycher, Benjamin and Joseph A. Dimasi. "The Truth about Drug Innovation: Thirty-Five Summary Case Histories on Private Sector Contributions to Pharmaceutical Science." Medical Progress Report (No. 6 June 2008). www.manhattan-institute.org/html/mpr_06.htm/ (accessed April 15, 2012).
1Goodman and Gilman, The Pharmacological Basis of Therapeuatics, 478.
2Zycher and Dimasi, "The Truth about Drug Innovation."
3Brantigan et al., "The Effect of Beta Blockade on Stage Fright," 227.
4Hall, "A Cure for Stage Fright?", 1.
5"Concern Over Widespread Use of Beta-Blockers," 2.
6"The Use of Beta Blockers by ICSOM Musicians," 4.
7Harby, Kucharski, Tuck, and Vasquez, "Beta Blockers and Performance Anxiety in Musicians."
8Needleman, interview by Jamie Hammon. See "An Interview with Thomas A. Brantigan: Beta Blockers and Musicians—A Thirty-Year Retrospective," in College Music Symposium Volume 51.
9Beeching, Beyond Talent, 225.
10Dunkel. The Audition Process, 122.
12Wikipedia, "Beta Blocker," http://en.wikipedia.org/wiki/Beta_blocker.
13Jaspers, "Off-Label Use of Prescription Drugs."
14World Anti-Doping Agency, World Anti-Doping Code, 14.
15International Conference of Symphony and Opera Musicians. Code of Ethical Audition Practices.
16Mitchell, Report to the Commissioner of Baseball, 8.
18Nelson, "The Taboo Tablet," 27.
20American Association of University Professors, Statement on Professional Ethics, 2009.
21Tindall, "Better Playing Through Chemistry."
22McClain, interview by the author, July 25, 2011.
23Lawrence K. Altman, "Suit Calls Coach and Doctors Negligent in Gathers's Death."
24Eddie Silva, "Chemistry."
25World Anti-Doping Agency, The World Anti-Doping Code (2009), 9.
26World Anti-Doping Agency, The World Anti-Doping Code (2011), 9.
27DeSantis, Webb, and Noar, "Illicit Use of Prescription ADHD Medications on a College Campus," 315.
31American Association of University Professors, 1940 Statement of Principles on Academic Freedom and Tenure with 1970 Interpretive Comments.