Ethical principles of complementary medicine application in health tourism

The subject of the research is the application of certain ethical principles in the implementation of complementary medicine in health tourism from the aspect of medical ethics and business ethics in tourism. The aim of the research is to identify the importance of applying certain ethical principles in the implementation of complementary medicine in health tourism. Bibliographic-speculative and descriptive analytical methods were used. The research showed that the application of all ethical principles contained in the Declaration of Helsinki, the International Medical Code of Ethics and the Global Code of Ethics for Tourism is significant and justified in implementing complementary medicine in health tourism, given the structure of beneficiary tourists and the range of services provided within health tourism. The potentials of complementary medicine in terms of its implementation in the corpus of health tourism are still underutilized in the Republic of Serbia, so they could be the subject of some future research in which the application of ethical principles contained in the mentioned documents would be an integral part of them.


Introduction
The modern mind man (homo sapiens recens) of unchanged qualities, potentials and possible realizations of his mental totality, has been present on our planet for five to seven thousand years. The adoption of this axiom is a fundamental starting point for understanding the past, and well-known civilizations, and man as the sole creator of all cognition. It is also a condition for us to understand not only ourselves as an inimitable specialty, but also ethics as a science and theory of morality.
The twentieth century brought contemporary views on the value of human life and established the aspirations of a third millennium man. Ethical teachings of the twentieth century based on new qualities have transformed and further transformed relationships in the community (Nenadović, 2007).
Health is one of the oldest, lasting and, in modern conditions, one of the strongest motives of tourist movements. Contemporary health tourism is a form of tourism undertaken for the purpose of maintaining, enhancing and restoring impaired physical and mental well-being through natural healing factors (mineral springs, climate, healthy drinking water, etc.), health services, sports and recreational and wellness facilities (Zeĉević, 2004). Bearing in mind the importance of health tourism, it is evident that the future development and diversification of Serbia's tourism offer should include this component. On the other hand, a question that remains to be considered concerns the direction, or component, of health tourism. The problem of health tourism development is complex and covers a wide range of possible services (Ţivanović & Krstić, 2018).
In the third millennium, with the tremendous advances in technological standards and research in the various sciences, especially medicine, which we are witnessing, people still give greater credibility to complementary than official medicine in terms of safety and costeffectiveness. It is evident that there is pronounced popularity and the need for the application of complementary medicine in the economically underdeveloped and developed part of the world (Oumeish, 1998). The application of complementary medicine, its techniques and procedures in countries in transition, must be subject to special quality control of the product, due to the lack of adequate quality standards and legislation in this field. Therapies applied in the field of complementary medicine should comply with the ethical principles of medical practice (Anderson et al., 1996).
The subject of this research is the application of certain ethical principles in the implementation of complementary medicine in health tourism from the aspect of medical ethics and business ethics in tourism. The aim of the research is to identify the importance of applying certain ethical principles in the implementation of complementary medicine in health tourism. A combination of different methods was used in the study . In the data collection stage, a bibliographic-speculative method based on reference sources and literature was used. In addition to the method mentioned above, the research is based on a descriptive analytical method.

Literature review
Contemporary ethics is most concerned with contemporary philosophy. The complexity of life in the current time, especially at the beginning of the 21st century, and the development of other disciplines that deal with the study of man and all his values closely link contemporary ethics with many sciences. The sciences with which contemporary ethics is most closely linked are on one side social, technical, natural, and esp ecially, medical sciences. The task of ethics as a philosophical science of morality is to penetrate into every moral action. By adopting ethical attitudes, the physician and the healthcare professional should further their ethical ideal in the context of the particularities of medical ethicsto preserve human lifeas a primary premise. Ethics should contribute to the understanding that ethical and moral values vary from civilization to civilization, but also during the same civilisation epoch. Ethics in practice proclaims and formulates publicly -codifies certain professional obligations and duties through written documents called codes. Codes of ethics for health care professionals, journalists, lawyers, bar associations, etc. are known. By codifying the social organization, professional associations and society as a whole put themselves in a position to regulate themselves. Violation of codified principles entails accountability within a professional organization, say, through a court of honor. Sanctions include reprimand, public stamping or exclusion from that branch organization. Sanctions, bans on practicing the profession, or bans on dealing with patients for doctors were also established. Finally, the moral rules and norms introduced into the codes are not permanent and unchanging, they change and evolve over time. Codified principles are of limited value, valid for the time for which they were enacted and socially regulated. Due to changing living conditions and social organization, there is a need to change previously adopted and codified ethical principles, which implies and justifies revisions of codes of ethics (Nenadović, 2007).
Health tourism is a journey aimed at obtaining health care. As a promising new branch of the tourism industry, health tourism allows users to solve their health problems when traveling on vacation and enjoying the beauty of a tourist destination. In the past, tourists mostly "stayed" in nature and were passively subjected to natural elements. Today, tourists literally "consume" nature and have very active influence on all the natural elements of the resort. Almost all types of tourism, especially mass tourism, strongly influence the change and degradation of natural resources. Therefore, it is necessary for the further development of tourism activities to be carried out on the principles of sustainable development (Gligorijević, 2013). "Tourism development has an impact on creating different positive and negative environmental effects. Tourism brings foreign exchange flow that strengthens economic development and improves the national economy. However, tourism also brings all those negative consequences, that can affect sustainable local community growth, unless its development is being taken care of. In this way, the tourism can develop significant consequences, some being devastating for surroundings and the environment it is operating in. The cause of this are uncontrolled negative effects on the elements of na tural living environment, such as air, water, soil, flora and fauna" (Trišić et al., 2018(Trišić et al., , pp. 1599(Trišić et al., -1600. Today, scientific medicine, based on the knowledge of the advanced sciences and traditional -alternative medicine, is equally persistent. Treatment and treatment methods and procedures that do not belong to scientific or official medicine, and are not taught at colleges and medical schools, are classified as traditional medicine. "The various types of complementary, alternative, unconventional, and integrative medicine in the Old World include the historical, cultural, social, traditional, and philosophical aspects of different civilizations that predominated, mainly in Asian, African, Far Eastern, Middle Eastern, and Arab countries. Most of these types of medicine are still in use today. Many understand that taking into account not only individually physiological and biological conditions, but including psychological, social, ecological and even parallel spiritual dimensions, may reveal the underlying contributing factors to the disease" (Oumeish, 1998(Oumeish, , p. 1373. Traditional medicine has a significant place and a number of countries have made significant strides in trying to define the legal framework, as well as experience in the field of regulation of this supplementary or alternative medical branch (World Health Organization, 2005).
Integrative medicine is a new direction in medicine that was created in response to t he limitations, primarily of official, allopathic medicine, but also of some branches of complementary and alternative medicine. Integrative medicine involves the use of the best possible treatments and procedures of scientific, allopathic medicine combined with the best complementary and alternative medicine (CAM) methods based on the individual needs of the patient. It integrates, or connects, both medical systems, adapting them to the individual, and using the safest, least invasive and cost-effective approach, integrating them into a holistic understanding of the individual. In its definition of health, the World Health Organization (WHO) emphasized that "health is a multidimensional phenomenon of dynamic equilibrium in which the relationship between an individual and his or her environment, both social and physical, must be understood as integral (holistic)" (World Health Organization, 2002). The basic meaning of an integral (holistic) approach to the advancement of human health is to use the best methods and procedures of official (so-called western, official) and traditional (alternative, complementary) medicine in order to assist the client in the best possible way. Alternative Health Promotion Technologies is a term that refers to the health technologies of traditional, complementary and alternative medicine. By this name, according to prof. Stambolovic, emphasis is given to the theoretical uniqueness of health technologies, which, in their therapeutic effect, are oriented primarily to strengthen the body's self-renewing potential (Stambolović, 1986). The demands and needs of healthcare users worldwide, as well as WHO recommendations, point to different alternative medicine technologies as a significant health care resource (Jović & Stambolović, 2013). Therefore, the need to integrate these health technologies into official health care systems becomes a legitimate issue for national health policy (Sokolov Milovanĉević et al., 2019). There is still a discrepancy between experiential and statistically documented evidence of the efficacy and effectiveness of alternative medical treatments. This is understand able in some ways, given the paradigmatic differences between alternative and biomedicine, as well as the lack of, or very scarce, funds to fund scientific research on alternative medicine and the holistic model of health and disease (Sharma, 1992).
WHO estimates that between 65 and 80% of the world's population uses alternative medicine as the primary form of health care (World Health Organization, 2002). More than half of the population in Germany and America use some form of traditional treatment, and in the UK 64% of government offices provide this type of healthcare. In Australia, 80% of physicians recommend acupuncture and meditation to their patients, and one quarter of physicians have received training in one or more alternative treatment techniques. Switzerland became the first country in Europe in 2009 to guarantee the right to complementary medical treatment under the Constitution, meaning that complementary medicine technologies are included in the basic package of healthcare services and funded by health care funds (Rist & Schwabl, 2009;Studeli, 2009). All medical systems that view man as energy, which is an indivisible part of everything else that exists, are called by one name holistic medical systems. At the heart of holistic therapeutic approaches is faith in man and counts on the wisdom of a body capable of self-healing. "The physician cures, but it is nature that heals " is an old Latin saying. It is believed that every person has self-healing power that needs to be released, or directed towards healing, balance in the body in case of various health disorders (Bašić & Jović, 2011).
Alternative medicine is not a substitute for official medicine, but provides additional health and healing options. By embracing the principle of wholeness, alternative medicine understands people as individuals and views human suffering as an expression of personal and family history. Accordingly, assistance and support are also individualized. Human suffering cannot be understood by isolated observation of organs and symptoms, which is led by the partialization of official medicine. The full meaning of certain health diso rders becomes clear only by inclusion in the whole, both the organism itself and its context (environment, family, social network, living conditions, etc.). A holistic approach starts from the basic idea that the body, mind and spirit form an indivisible whole and that the individual is firmly connected to the environment, family, society and the world in which he or she lives. Holistic attitudes in healing are based on the assumption that the state of health is a reflection of the dynamic balance of body-mind-spirit, and that no segment is viewed as an isolated entity. It should be borne in mind that submission to any holistic method entails a change in lifestyle, including most commonly a change in eating habits, as well as how the client thinks about himself and the environment that surrounds him. In order to choose the conventional or alternative method of health or healing promotion that best suits us, we need to know beforehand what the basic features and approaches that these methods entail (Hellinger & Hevel, 2010).
In the Republic of Serbia, the Law on Health Care defines health care as an organized and comprehensive activity of a society with the primary goal of achieving the highest level of protection of the health of citizens and families. Health care, within the meaning of this Law, includes the implementation of measures for preserving and improving the health of citizens, preventing, suppressing and early detection of diseases, injuries and other health disorders and timely and effective treatment and rehabilitation. Human rights and values in health care imply that every citizen has the right to exercise health care while respecting the highest possible standard of human rights and values, that is, has the right to physical and psychological integrity and to the safety of his personality, as well as respect for his moral, cultural, religious and philosophical beliefs. Given that the goal of health care is to "achieve the highest level of protection of the health of citizens and the family", attempts to combine the knowledge and experience of so-called official and traditional (complementary) medicine in this interest are given their full meaning and importance (National Assembly of the Republic of Serbia, 2019).
The Code of Ethics is a set of formal and informal principles, schemes, regulations and good practices in business conduct. Business ethics defines desirable rules of business conduct that are the framework for action that is allowed or not allowed, but also indicates the basic rules of moral action of the person (Ristić, 2004). Corporate Social Responsibility means acting through the offering of socially beneficial services with a minimum d etrimental effect whose consequences are economically acceptable over a long period of time. The significant link between business ethics and socially responsible business that characterizes the global world market is an essential component of the tourism economy. "In today's fast-changing tourism market, the only opportunity to compete for a tourist destination is through the offering of a sustainable tourism product. Sustainable development goes hand in hand with the concept of socially responsible business" (Golja & Kristinić Niţić, 2010). Articles 3, 4 and 5 of the Global Code of Ethics for Tourism deal with Corporate Social Responsibility: Tourism, a factor of sustainable development; Tourism, a beneficiary of the cultural wealth of mankind and a factor in promotion and Tourism, a work that benefits host states and associations. Article 5 states that the tourism business should be an integral component of the "local economic and social fabric". The last point discusse s the need to explore the impact of tourism development projects on the environment and nature by professionals in this field, who, with the greatest possible transparency and objectivity, should provide, information on their future programs and their foreseeable consequences. Tourism professionals should foster dialogue about the content of their future programs with the population involved (Buzar, 2015).

Research instruments and methods
Within the research, a combination of different methods was used. In the data collection stage, a bibliographic-speculative method based on reference sources and literature was used. In addition to the method mentioned above, the research is based on a descriptive analytical method. The first part of the paper presents a theoretical framework using a bibliographicspeculative method using a large number of literature sources of domestic and foreign literature, as well as internet sources. The research work involved different methods. Of the analytical, the method of analysis, abstraction and deduction was used.

Results and discussion
The ethical peculiarity of the practical application of medical knowledge and skills arose and developed at the same time as the emergence and development of h umane medicine. Modern medical ethics has imposed the principles, duties and moral obligations of the medical profession, and there is a need for uniformity in this field for all physicians in the world. The result is the formation of world organizations, such as the World Health Organization and the World Medical Association at the United Nations, the formulation of codes, declarations, resolutions and declarations binding on all countries, or doctors on all continents and all countries. Contemporary medical ethics implies continuous, further development in line with the development and achievements of scientific medicine and increasingly sophisticated medical technology, and the basic principle binding on the physician is: "My patient's interest will always remain my primary concern" (Nenadović, 2007). Deontology in medical practice implies all the obligations of professional persons arising from moral norms and commandments, which are related to the duties and rights of all pro fessions in medicine (physicians, dentists, pharmacists, healthcare professionals, administrative workers in medicine).
Establishing a positive feedback link between morality and law, reflected in the application of adequate legal norms, is the key to addressing potential medical and dental disorders in the application of complementary medicine. The diagnostic assessments referred to in paragraph 1 of this Article entail a set of methods and procedures of complementary medicine used to diagnose the disorder, which are not based on conventional biological mechanisms and cannot serve for the diagnosis of diseases in conventional medicine. The education of health professionals for performing methods and procedures of complementary medicine shall be conducted in accordance with the provisions of this Law related to continuing education. Article 218 states that "only those methods and procedures of complementary medicine are allowed which: 1) do not harm health; 2) do not discourage the patient from using conventional medicine methods and procedures; 3) are performed in accordance with recognized standards of complementary medicine.
Methods and procedures of complementary medicine may be performed in a health care institution or private practice, in accordance with this Law and regulations adopted for the implementation of the Law by a health worker, to whom the Minister has issued a permit to carry out certain methods and procedures of complementary medicine." The Minister, on the proposal of the Republican Expert Commission on Complementary Medicine, prescribes more detailed conditions and manner of performing methods and procedures of complementary medicine in a health institution, other legal entity, or private practice, as well as a program of professional training of health workers for performing methods and procedures of complementary medicine (National Assembly of the Republic of Seriba, 2019).
According to the current Rulebook on closer conditions, method s and procedures for performing methods and procedures of traditional medicine, adopted in 2018, the methods and procedures are classified into 13 groups of methods of prevention, diagnosis, treatment and rehabilitation:  Individual authors (Zeĉević, 2004) consider that there are three types of health tourism: healing (only healing and one form of recovery), curative (representing rehabilitation) and wellness (focused on what it means: in a healthy body a healthy mind, that is, a good state of mind and body) (Cohen & Bodeher, 2008). Wellness tourism is a new term that means the universal offering of conditions and procedures for achieving optimal physical and spiritu al well-being of individuals. The wellness offer can be realized without the use of natural healing elements and without the supervision of a doctor. Spa tourism is defined as a type of complex health and tourism activity that is carried out in natural spas, in which the treatment and rehabilitation of various diseases and illnesses, recovery and prevention of diseases with the professional application of natural healing elements and procedures of physical medicine and rehabilitation play a key role. A special category is also hospital or medical tourism, which are trips undertaken by individuals for the purpose of hospital treatment and performing certain medical procedures (for example, surgical, dental, etc.). Detailed concepts of wellness megatrends characteristic of wellness and spa philosophy can be found in the literature (Berg, 2008). These are health, long life, individuality, the predominance of women in the spa, modern spirituality and the movement for health. From the aspec t of spa innovation, an analysis of the five most important megaturist spa trends is necessary (Abram & Kosińska, 2016). These are: Mediterranean spa, spa, wellness, ethno spa, eco spa. In addition to the wellness phenomenon, innovations in spa tourism health services should concentrate on the application of modern medical technologies and therapeutic cosmetic treatments. Also, this innovative approach should be enriched with elements of culture, tradition and ethnomedicine in resorts, to a greater extent than previously with ecology (Berg, 2008).
In the context of the accelerated globalization of everyday cultural values, especially the rise of international trade and tourism, differences in people's cultures are becoming increasingly visible, as a potential source and cause of the unethical behavior of participants in these world events. The tendency to satisfy economic interests above cultural ones creates negative trends. Such bad influences can be minimized by strengthening cultural interests in behavioral models of both tourists and domicilians. One way of emphasizing the importance of an acceptable and conventional form of such communication and interaction is by codes of ethics, which are intended to remind, in a particular cultural form, the respect for true values in tourist movements (Trišić & Štetić, 2019). The tourism industry promotes codes of conduct as a set of expectations, behaviors and rules, written by large and significant market entities, with a particular focus on culture and the environment, through a form of sustainable development (Presbury & Edwards, 2010;Veljković & Ţivković, 2018). Codes for tourists are everyday cultural guides that emphasize the type of travel behavior. The basis of the tourist codes is the general culture, as well as the relation to natural resources, language, indigenous population, cultural heritage, acceptable behaviors and customs. Codes of ethics make full sense only if tourists are aware of their importance. The Code should remind tourists of an acceptable and cultured way of behaving in a tourist destination, so that its core values with all geographical, cultural and social characteristics can be experienced at the same time. Tourism ethics and appropriate cultural codes should be as universal as possible (Pokrajac & Štetić, 2017).
United Nations World Tourism Organisation (UNWTO) is the creator of the Global Code of Ethics for Tourism. "UNWTO The Global Code of Ethics for Tourism is a complete set of principles aimed at leading tourism development stakeholders. It is addressed to governments, the private sector, communities and tourists, with the goal of helping to maximize the benefits of tourism while reducing its potentially negative impact on the environment, cultural heritage and societies around the world. Although not legally binding, the Code has a mechanism for voluntary implementation through its recognition by the World Tourism Ethics Committee (WCTE), an independent and impartial body to which interested parties may submit questions regarding the implementation and interpretation of the document. The ten principles of the code cover the economic, social, cultural and environmental components of tourism" (MINT, 2014). These are: the contribution of tourism to mutual understanding and appreciation among people and societies, tourism as a means of individual and collective fulfillment, tourism as a factor of sustainable development, tourism as a beneficiary of the cultural heritage of humanity and a factor in its promotion, tourism as a useful activity for the countries of the community and the host, obligations of independent tourism professionals responsible for development, the right to tourism, freedom of movement, rights of employees and entrepreneurs in the tourism industry and implementation of the Global Code of Ethics for Tourism (UNWTO, 1999).
When it comes to health tourism, the ideal solution for the application of traditional-medical methods of diagnosis and treatment, as well as rehabilitation, are spa-climatic spas, which structurally represent the ideal combination of health resorts and tourist facilities. The structure of spa and climate resorts enables the functional fusion of two very powerful human activities of the third millenniumhealth and tourism. Ethics in practice proclaims and publicly formulatescodifies certain professional obligations and duties, through written documentscodes, which put social organizations, professional associations and society as a whole in a position to regulate themselves. The application of the ethical principles proclaimed by the International Medical Code of Ethics, as well as the Global Code of Ethics for Tourism, guarantees the safe and effective implementation of complementary medicine in health tourism. Modern medical ethics, based on four basic principles: the principle of respect for life, the principle of fairness (non -discrimination on any basis), the principle of charity (humanity) and the principle of respect for the patient's personality, is the starting point for the application of adequate ethical principles in incorporating complementary medicine into health tourism. The significant link between business ethics and socially responsible business characterizing the global marketplace that offers services that are useful to society and possible harms minimized, so that the long-term consequences of these harms are not unacceptable, is a respectable component of applying adequate ethical principles when incorporating complementary medicine into health tourism. The reconciliation of a strict medical ethical stance on the prohibition of experimentation under any human condition, and a reasoned scientific stance on the inevitability of biological experimentation as a basis for the advancement of medical science, was achieved in the Declaration of Helsinki, according to which biological experiment is allowed only by volunteers if it extends medical knowledge and realizes an immediate benefit to a sick person. The Declaration of Helsinki regulates the ethical principles of the human therap eutic experiment and they are much more lenient. The use of new therapeutic methods is forbidden if the same success can be achieved by existing ones.
The Declaration of Helsinki elaborates on the following principles of a clinical experiment. Clinical experiments may only be performed by scientifically qualified persons, who have already demonstrated a high level of expertise and moral maturity, and if they have been repeated several times in animals or in experimental laboratories and guarantee the succe ss of its application to humans. A proportionate relationship between goal and risk is necessary when conducting a clinical experiment. It is unacceptable to allow a banal disease to be cured through experiment, without the risk being high, or even endangering the health or life of the patient. The Declaration of Helsinki gives the basic principles for biomedical research in general, and then the principles for diagnostic-therapeutic (clinical) and non-therapeutic (non-clinical) biomedical research. In addition to relying on the principles presented in the Declaration, guidelines for their application in biomedical research used to achieve standards in the implementation of complementary medicine methods in health tourism, as part of this research, must equally apply the International Medical Code of Ethics and the Global Code of Ethics for Tourism. Article 2 of the Global Code of Ethics for Tourism discusses the prospects for tourism development: Tourism, as a means of collective and personal fulfillment, says in point 4: "Travels for religious, health, educational and cultural purposes, or for exchange purposes for language learning, are particularly useful forms of tourism, which deserve to be encouraged." Article 6 of the Global Code of Ethics for Tourism, referring to the Obligations of Participants in Tourism Development, states in paragraph 2: "Depending on them, tourism professionals, in cooperation with public authorities, should show concern for the safety, accident prevention, health protection and food security of those seeking their services. They should also ensure that there are adequate insurance and assistance systems in place; should accept the reporting obligations laid down in national regulations and pay fair compensation in the event of non-compliance with their contractual obligations" (UNWTO, 1999).

Conclusion
Continuous improvement of the behavioral awareness of tourists within the framework of sustainable tourism development of health tourism is one of the tasks of planning tourism development of this form of tourism worldwide. In order to integrate this activity into the general health-tourism and social development, it is necessary to continuously inform and educate all tourist entities on the correct and ethically acceptable form of using resources in tourism. Given that health tourism resources, especially in the field of complementary medicine, are still insufficiently recognized and used by tourists, particular attention should be paid to tourism planning and commercialization of these tourism resources in accordance with generally accepted ethical principles of sustainable tourism development. By applying the process of health-tourist emancipation, it is necessary to minimize potential conflicts between the guest, the host and the environment in this interaction. One model of successfully overcoming these conflicts is the positive impact of adequate codes of ethics on the development of a health tourism behavior culture.
When it comes to research on the ethical principles of the application of complementary medicine in health tourism, we can conclude that the application of all the principles contained in the Declaration of Helsinki, the International Medical Code of Ethics and the Global Code of Ethics for Tourism, is very significant, given the structure of beneficiary tourists and the range of services provided within health tourism. Balneo-climatic spas are an ideal solution for the application of complementary -medical methods of diagnostics, treatment and rehabilitation, as well as for the application of complementary -medical methods within their rich wellness tourist offer. Establishing a positive feedback link between morality and law, reflected in the application of adequate legal norms, is the key t o addressing potential medical and dental disorders in the application of complementary medicine. Modern legal norms, in general, better, more justly and effectively regulate community relations than moral norms can. Compliance with the applicable legislat ion in the field of complementary medicine will greatly contribute to the adequate implementation of the ethical principles contained in the medical code of ethics relating to this field.