An ABC of complementary medicine: a new dawnBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7211.0 (Published 11 September 1999) Cite this as: BMJ 1999;319:0
All rapid responses
I thank Ms Connor for her "rapid response" to my letter. My
reading of the law is also that there is no current legal impediment to
sale of human skeletons per se. Indeed I made this very point clear in my
covering email to the editor. There are nevertheless legal concerns - to
which I referred, for instance, re import from abroad.
My approach to HMIA, for remarks on the opinions which Ms Connor
attributes to him, was met with a polite but firm refusal to comment.
Ms Connor alludes to a "partial knowledge of the European Convention
on Human Rights and Biomedicine." I presume that she is raising the issue
of European Treaty Series (ETS) 164, and in particular Chapter VII
Prohibition of financial gain and disposal of part of a human body,
Article 21, "The human body and its parts shall not, as such, give rise to
financial gain." The BMJ supplement continues to carry adverts for human
skeletons, eg "Full articulated real human skeleton. Whole skeleton in
vgc with good dentition. No longer available in the UK and cost thousands
of pounds in the US. Serious offers only please...". I commend Ms Connor
for highlighting the European Convention on Human Rights and Biomedicine,
a document which certainly seems relevant, in light of concern over
profiteering in human body parts. That the UK has not signed up to the
convention, does not preclude its articles having some merit.
It may be dangerous to claim justification for a particular course of
action by observing that others do likewise - Ms Connor quotes HMIA as
saying that "...many UK companies sell skulls, and [that] no attempt has
yet been made to stop them". A telephone and internet search for Companies
selling human skulls in the UK, reveals a paucity of stock, and that it is
a seller's market. This strengthens the case that the market is ripe for
Ms Connor admits that the origin of skeletons advertised in the BMJ
is frequently unknown. To use this absence of information as a
justification to continue to advertise human parts (or at least refusal to
stop it 'on speculative grounds') seems ludicrous. A study of the
department of Anatomy at the University of Vienna was instigated 'to
search, identify and exclude any anatomical preparations of doubtful
origin' - such specimens were found, removed from collections to be buried
in a grave of honour supplied by the City of Vienna. The report
concluded: '...the lack of interest of the medical establishment in the
use of bodily remains of human beings needs to be put up for discussion'.
The origin of skeletal parts is not a trivial concern.
I have (even) less knowledge of ethics than law, but I find the
arguments of Ms Connor unconvincing. I suggest, tentatively, that the
Ethics Committee re-examine this issue, and that the BMJ close this
potential avenue for the unregulated marketing of human material.
One last point: the lack of a direct profit motive should not absolve
the BMJ of responsibility for its advertising content.
1 Connor J. 2003. Re: a skeleton in the closet.
http://bmj.com/cgi/eletters/319/7211/0#38081, 17 October 2003
2 Huntley JS. 2003. A skeleton in the closet.
http://bmj.com/cgi/eletters/319/7211/0#37289, 1 October 2003
4 BMJ supplement p.112, 11 October 2003
5 Angetter DC. 2000. Anatomical science at University of Vienna 1938-45.
Competing interests: No competing interests
Mr Huntley is concerned about the legality and ethics of selling
skeletons for research purposes and suggests that BMJ Careers should no
longer accept ads for their sale. We had similar concerns in 2002 after a
reader made a similar complaint and compared BMJ unfavourably with GMC
News which had stopped accepting such ads. We decided to take the advice
of HM Inspectorate of Anatomy.
HMIA stressed that it has no remit for bodies originating or
skeletised outside the UK and its representative advised us that as most
skeletons in medical use originated in Asia pre 1985, they were beyond the
brief of the organisation. He was surprised at the suggestion that sale
of skeletons might be illegal and guessed that it had probably been
sparked by a partial knowledge of the European Convention on Human Rights
and Biomedicine. He emphasised though that the Convention is not yet part
of UK law and as yet cannot be said to restrict our activities. He pointed
out that many UK companies sell skulls and that no attempt has yet been
made to stop them.
We were reassured we hadn’t been publishing illegal ads. We worried
still that we hadn’t addressed the ethical issues and so referred
discussion to BMJs Ethics Committee.
The Committee thought about both the legality and ethics of sale and
ultimately advised that it would be ethical to advertise skeletons for
medical use providing they had not been wrongfully obtained. We recognise
that advertisers can prove very little about the origin of the skeletons
that they sell but have decided to continue to accept their ads rather
than refuse them on speculative grounds.
One last point: the ads in the Noticeboard section are carried free
of charge to the advertiser: BMJ does not profit from the ads in any way.
Director of BMJ Careers
Competing interests: No competing interests
A skeleton in the closet
There are considerable legal and ethical difficulties in the
regulation of uses of human tissues, not least of which pertain to the
inadequacies of the Human Tissue Act 1961 and the Human Anatomy Act 1984,
which are the subject of current legislative review for a new Human Tissue
Bill[1,2,3,4]. It is surprising that the BMJ supplement still carries
adverts for human skeletons[5,6]. This is especially so, given the concern
it shows over its advertising policies, which come under the remit of
its ethics committee[8,9].
In the 1800s, the body-snatchers (and the murderers Burke and Hare)
identified the medical fraternity as a ready market for human anatomy
specimens. Until the 1980s, the export of human skeletons from India,
for educative purposes, supplied a substantive market in the UK. The
preparation of human skeletons, though laborious, is not prohibitively
costly or technically difficult. Anatomical knowledge, though its
importance has been downplayed in current undergraduate curricula,
remains useful in clinical practice, especially surgery. It is
unsurprising then that the UK has a market for skeletons for private
study. This market is potentially lucrative, and open to abusive
Bone, in contrast to other human tissues, has not traditionally
provoked outrage from the public when displayed - skeletons are common
exhibits in museums and schools. It is unclear how organisations and
private individuals in possession of skeletal parts that antedate current
legislature should proceed. However, in light of the ethical and possible
legal concerns, it is suggested that the BMJ close this potential avenue
for the unregulated marketing of human material.
JS Huntley Lecturer in Orthopaedics & Trauma, Musculoskeletal
Research Unit, Medical School, Teviot Place, Edinburgh EH8 9AG
1 Department of Health. 2002. Human bodies, human choices. The law on
human organs and tissue in England and Wales. A summary consultation
2 Metters JS. 2003. The Isaacs report. DOH
3 Department of Health. 2003a. The import and export of human body
parts and tissue for non-therapeutic uses - A code of practice. DOH
4 Department of Health. 2003b. Isaacs report response. DOH
5 BMJ supplement. 2 August 2003 p.104
6 BMJ supplement. 12 April 2003 p. 111
7 Smith R. 1999. BMJ advertising policy [rapid response].
8 McCall Smith A, Tonks A, Smith R. 2000. An ethics committee for the
BMJ. BMJ 321:7210
9 Tonks A, McCall Smith A, Smith R. 2001. The BMJ's ethics committee
is open for business. BMJ 322:1263-4
10 Lee K, McDonald SW. 2002. Not modern-day body-snatching: the
response of the public. Scott Med J 47:66-70
11 Edwards JJ, Edwards MJ. 1957. The maceration and articulation of
bones. Chapter 9, pp.122-8, in Medical Museum Technology. Oxford
12 Reidenberg JS, Laitman JT. 2002. The new face of gross anatomy.
Anat Rec 269(2):81-8
13 Ellis H. 2002. Medico-legal litigation and its links with surgical
anatomy. Surgery 20(8):i-ii
Competing interests: No competing interests
First may I congratulate the Editor and Staff of the e-BMJ on this
excellent medium for debate and discussion on medical matters, all things
'medicine' and their importance in public perception. It transcends the
usual restricted and myopic visual field of opinion one observes in many
similar publications. When one seeks to monopolise the views of any aspect
of reality, from medicine to metaphysics, one does great injustice to the
Dr. Leibovici, your conviction that the BMJ should 'step back from
complementary medicine' (CM), and your contention that CM 'can be viewed
from within a few frames' suggests you wear glasses - are they bifocals?
It is my contention that the BMJ has at last paved the way for open,
and long-awaited, discussions on medical matters. Complementary medical
matters are merely matters which include forms of medicine which, if used
in collusion, may complement each other. WM and homeopathy can be
complementary if used in concert by colluding practitioners, as could
homepathy and TCM-acupuncture & moxibustion. Hijacking the term to
describe some kind of 'conglomeration of all things non-Western
medical'(WM) or non 'orthodox' to use an even sillier expression, serves
only those who try to protect their ill-conceived status as 'medical
practitioners' whilst exluding all other practitioners of the multivarious
forms of medicine one tends to see described as 'alternative' or
I direct a 'complementary therapy centre' thus accepting therapies
which complement my own speciality, Traditional Chinese Medicine (TCM) -
acupuncture & moxibustion, which would include WM if proffered.
'Alternative' medicine, perhaps a more accurate term, still implies there
is an 'orthodoxy' and then the 'others', yet anyone who has spent time in
the Far East would know that TCM techniques have been in existence for
several thousand years, unbroken, and retain much of the original flavour
for which Westerners are now flocking as their Oriental counterparts have
done for millenia as WM fails to meet many medical needs. TCM is therefore
perhaps more 'orthodox' to the masses than WM, and at the very least
I suspect that you are one who believes there is an 'orthodoxy' and
'the others' despite perhaps several billion persons around the world from
China, Korea, Japan and India to the UK, France, Germany and the USA
availing themselves of many of 'the other' brands of medicine you so
readily consign to the 'rear step'. Your 'orthodoxy' is little more than a
political structure that came about when surgeons, apothecaries, nurses,
midwives and physical therapists fought for their rightful place alongside
each other in recent times and the latter three were cleverly denied equal
status despite their essential role in 'medical' healing. TCM also has its
complexity of modalities from acupuncture & moxibustion specialists
and herbal specialists, to physical therapists (Tai Chi, Qi Gong, Tui Na
etc. specialists) but these appear to have found equal status, as opposed
to partial subservience, the reasonable way.
Despite the political format achieved this past couple of centuries,
WM is still only able to provide about 20% of 'scientifically validated'
intervention for the public whose medical system it dominates with full
government approval. If it were a public utility and only 20% of its
services were guaranteed to work it would have been privatised long ago or
have gone out of business. Who in their right mind continues to buy goods
that are prone to fail 4 out of 5 times ( except our governments?!).
Were the BMJ to 'step back from CM' as you suggest you may as well
close down as the remaining dialogue between 'the converted' is not true
dialogue in the public interest. If one debates HEATING one doesn't just
accept the input of the Gas Board, its executives and employees - even if
it had achieved political and legal status as 'all knowing' - because the
public recognise that the Electricity industry has a voice, and Nuclear
power, and the Coal industry (despite politically-driven crises), and
physicists, chemists, CONSUMERS and so on...
Recent figures for public 'consumption' of Complementary and
Alternative Medicines (CAM) is something in the order of 60% of all
consultations being with CAM practitioners in the USA and 30 to 40% in the
UK. Surely you recognise the importance of this public demand for CAM
intervention. Your 'second frame' belies this obvious phenomenon and you
try to convince the reader that the public is fooled by its subjective
experiences of the tremendous benefits provided by CAM intervention. After
all, placebo is said to benefit as many as 30% of people - thats' 10% more
than WM can scientifically allude to providing - and if CAM were purely a
placebo (as some biased commentators attempt to dismiss CAM successes
through) then the public demand its effects.
When you try to fit any form of medicine to your intangible
concept 'the whole of the physical world' you miss the point - there is no
model that apllies to the 'whole physical world'. As Heisenberg said, once
you try to pin down reality, you lose the plot. When you 'fix' your plot,
reality passes you by.
Fortumately for the public, the BMJ has caught up with reality. Just
as sanitation and environmental changes, employment regulations, social
justice, education and human rights have improved health and welfare for
millions this century alongside innovations in all kinds of medicine, the
BMJ appears to be leading the field in availing the wider audience, from
'professional' to 'consumer', of it's expertise and this will lead to
added health benefits for all.
Let the beauty and power of the magic of medicine once again be
available to all; and let us see 'scientific method' placed in its
rightful position - just another tool from which one more perspective of
reality is developed.
I would be interested in your references for the following rather
strange statements and generalisations you made:-
1. 'After each unsuccessful trial of acupuncture there comes a flurry
of letters telling that the study failed because the traditional method
was not used; or rather the traditional method was used; needles were
inserted too deep; or not deep enough; or twirled once too many'.
2. 'Scientific medicine, one of the kernels of medicine as we
('orthodoxy') practice it'
3. 'Complementary or alternative medicine is defined as practices
that do not fit into its boundaries (scientific medicine) but are rather
based on rules of anthropocentric magic'
4. 'The deep model of alternative medicine is anthropocentric magic'
5. 'practitioners of alternative medicine are explaining to our
patients a set of magical rules to control the physical world, having the
human as the fulcrum'
6. 'A substance that causes complaints similar to these observed in a
patient will cure him if diluted to an infinitestimal concentration. We
will adjust your Qi force. these are phenomena that work only on the
living man, and not on any other component of the physical world'
7. 'All of these practices (CAMs) work in mild to moderate
complaints, but none in severe situations - again a strange unprecendented
8. 'Charlatans are not uncommon among the practitioners of
alternative medicine (I know this is not politically correct: but is it
true? Or maybe it is true just for Israel)'
9. 'But the core of medicine stood the test again and again in the
last century. For the first time in thousands of years we have a system
10. 'There is only one medicine'
11. 'Everything else is not medicine and should not be reviewed in a
I have a few quotes for you, WITH references...
"My doctor is nice; every time I see him I'm ashamed of what I think
of doctors in general" Mignon McLaughlin.
"I don't see why any man who believes in medicine would shy at the
faith cure" Finley Peter Dunne
"The principles of Washington's farewell address are still sources of
wisdom when cures for social ills are sought. The methods of Washington's
physicians, however, are no longer studied" Thurman Arnold
"The art of medicine consists of amusing the patient while nature
cures the disease" Voltaire
"One of the things an average doctor doesn't have time to do is catch
up on the things he didn't learn in school, and one of the things he
didn't learn in school is the nature of human society, its purpose, its
history, and its needs....If medicine is necessarily a mystery to the
average man, nearly everything else is necessarily a mystery to the
average doctor" Milton Mayer
"Wherever the art of medicine is loved, there is also love of
Competing interests: No competing interests
Complementary medicine can be viewed from within one of a few frames.
Two are relevant to the present discussion.
One contains (among others) the following assumptions:
· Medicine is a social construct.
· Complementary/alternative medicine is defined as practices outside this
construct (and please look at the Cochrane definition, which defines this
construct as the 'politically dominant health system of a particular
society or culture in a given historical period').
· Thus the boundaries of medicine are defined by questions similar to
these: What is acceptable? Is it in common use? How is it paid for? What
political structures support it? What social needs does it fulfil?
Articles or reviews that have as their main purpose to answer these
questions are an important service.
· We believe in empirical proof. We are lucky to live in a time when a
potent methodology was developed to search for empirical proof, the
epitome of it being the randomised, controlled, double blind study.
Systematic reviews help in assembling the evidence.
· Empirical testing the way we believe should be done is such a powerful
tool that we really do not care about the origin of the ideas we examine.
The opposite is true: practices or hypotheses from everywhere are welcomed
to be tested. This is the politically correct thing to do.
· When the boundaries are shifting (and they shift because of
social/political forces, by definition and belief) we will be able to use
our empirical methodology to test what should or should not be adapted
from the practices that are straddling the border now.
· As our mission is (and always was) mainly to alleviate suffering, we
should not be too squeamish about using anything that does it.
· A combination of old-time patriarchism and 'scientific' hubris created
in medicine a breed of hard-hearted and conceited bastards. A bit of
competition will do no harm.
The second frame contains the following assumptions:
· Medicine is a social construct. However the most powerful tool we have
acquired is 'scientific medicine' (from lack of a better term). It is such
an effective tool that it changed radically the practice of medicine (and
probably society as well, by changing life expectancy) in the last
· The core of scientific medicine is not empirical testing alone.
Empirical proof (elicited using the best methodology) is very important.
However standing alone it might (and has) failed us:
1. By definition it is not protected from a small chance of error.
2. Even using the best methodology, it is not protected from inadvertent
introduction of bias and from fraud.
3. For the last few thousand years, empirical testing was used. Sometimes
even with surprisingly correct methodology. In the Louvre one can see
Babylonian models of livers of sacrificial animals that were modelled
before major battles, and the prognostication was written on them before
combat. If you were to be presented with a set of one thousand
prognostications like these, all made before the battle and all of them
successful, would you believe in the method? Or would you rather look for
the hand of the priest? i.e., even the most ardent empiricist has hers/his
limits of credulity in empirical proofs.
· 'Scientific medicine' was successful because it combined empirical proof
with a deep model. We will accept empirical proof if it fits (even at the
far margins) the model of the physical world that we use. The model
applies to the whole of the physical world, including our bodies. This
model is frequently changing. By definition, a scientist is a person who
looks for explanations at the far fringes of hers/his deep model, and
brings these fringes to the centre. However there are hypotheses that
cannot be accommodated even at the fringes (livers of sacrificial beasts
will predict the future; a substance that causes complaints similar to
these observed in a patient will cure them if diluted to an infinitesimal
· Two examples of why we need the deep model:
1. It is the only way to use the failure of a trial or an experiment
to move on. Given the model, we expected success. Failure should prompt an
examination of the model; or a critical look at the experiment. After each
unsuccessful trial of acupuncture there comes a flurry of letters telling
that the study failed because the traditional method was not used; or
rather the traditional method was used; needles were inserted too deep; or
not deep enough; or twirled once too many: a blessing of explanations we
have no way to choose from, because we have no idea whatsoever how the
treatment is supposed to work. If we have no idea, we must try all the
alternatives (including some I would like to try).
2. A deep model is necessary to choose the hypotheses we are going to
test. Resources are limited. The moment we give up on the model, we should
test everything. How do you choose what to test? There are thousands of
practices, with a multitude of variations. It is quite easy to show that
if you were to use definitions of the 'social construct' to choose the
hypotheses to be tested rather then a deep model, you will reach
paradoxes and contradictions very soon.
· 'Scientific medicine', one of the kernels of medicine as we practice it,
is not a social construct. Thus complementary or alternative medicine is
defined as practices that do not fit into its boundaries, but are rather
based on rules of anthropocentric magic. The medical practices of Gil Blas
de Santillane and of his illustrious mentor are alternative medicine,
although they fitted so well in the politically dominant health system of
their particular society.
· Scientific medicine does not contradict compassionate and emphatic
practice of medicine. In contrary, the offer of partnership in the way to
health and well being should include the explicit science of medicine.
Shamanic, magic practices open to a few are in contradiction to that.
· I doubt the honesty of offering my patients treatments that are, to the
best of my knowledge, pure placebo: even if it will help them.
Why should I bother you with these platitudes? The BMJ is publishing
an ABC of Complementary Medicine. There is little doubt that the reviews
fit well into the first frame and not into the second. Of course reviews
do not reflect the views of the publication or its editorial policy. But
they do to some extent: The BMJ is ready to dedicate to it quite a lot of
space. It is an ABC, the grammar of it. To some extent the journal is
placed within the first frame.
What is so bad about it? I must admit that the first frame is much
more attractive, open minded, really cool. I am concerned mainly that by
embracing it we uphold some practices which, given an explicit choice, we
would rather not:
· The 'deep model' of alternative medicine is anthropocentric magic. This
is what the practitioners of alternative medicine are explaining to our
patients: a set of magical rules to control the physical world, having the
human as the fulcrum. Herbs are beneficial and can do no harm. A substance
that causes complaints similar to these observed in a patient will cure
him if diluted to an infinitesimal concentration. We will adjust your Qi
force. These are phenomena that work only on the living man, and not on
any other component of the physical world. I would guess none of you are
firm believers in magic. Honouring your patients, are you ready to offer
them these explanations?
· All of these practices work in mild to moderate complaints, but none in
severe situations - again a strange and unprecedented dichotomy.
· Using the 'social frame' for definitions, we are exposed to intense
manipulations. Manipulating the media and the political system can create
quite an impression about what belongs to the 'politically dominant health
system'. Lately we witness these manipulations time and again.
· Charlatans are not uncommon among the practitioners of alternative
medicine (I know this is not politically correct: but is it not true? Or
maybe it is true just for Israel).
· A lot of harm is done: by side-effects of medicines, by withholding
treatment from people who need it.
These mistakes are made in medicine as well. But the core of medicine
stood to the test again and again in the last century. For the first time
in thousands of years we have a system that works. Please ask yourselves
if by embracing the first frame (which I admit is attractive) we do not
undermine a good thing instead of finding ways to repair its faults.
I would of course prefer the BMJ to make a firm commitment to the second
frame: there is only one medicine; we base our decision whether to adopt a
practice on empirical evidence; on our deep model; and on our commitment
to the well-being of our patients. Everything else is not medicine and
should not be reviewed in a medical journal (the odds for such a
commitment are low, aren't they?) Can these guys at the BMJ be swayed?
Dr Leonard Leibovici
Department of Internal Medicine E
Rabin Medical Center, Beilinson Campus
Competing interests: No competing interests
The BMJ does have an elaborate policy on advertising, and I think
that it would be a good idea for us to publish it on our website.
We would not advertise tobacco products under any circumstances, but
we generally have a liberal policy on advertising. Readers must be able in
a glance to tell editorial from advertising material. Assuming that
condition is met, then we are willing to carry most (but not all)
advertising that is legal and decent--because we know that readers have
quite different expectations for editorial and advertising material. They
know the difference and discount substantially the claims of advertisers.
We might waste a lot of time and resources checking and vetoing
advertisements. Our energy is better spent improving the editorial
Competing interests: No competing interests
Is it not inconsistent of the BMJ to promote "Clinical
Evidence" from the BMJ Publishing Group, complete with
website,on p700 of BMJ 7211, 11th September 1999 and
then accept an advert for a "Diploma in Metaphysics"
where health practitioners can understand "the human
energy field", p9, BMJ Classified, 11th September,1999?
Does the BMJ have a policy with regard to accepting
advertising from any source?
Would advertising from the tobacco industry be
Charles G Kelly,
Consultant Clinical Oncologist,
Northern Centre for Cancer Treatment,
Newcastle General Hospital,
Newcastle upon Tyne NE4 6BE
Competing interests: No competing interests