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Dynamic Chiropractic – October 7, 1996, Vol. 14, Issue 21

The Patient's Role in Managed Care

By Arnold Cianciulli, BS,DC,MS,FICC,FACC
The respect for liberty and the desire for each person to determine their own actions/thoughts make up the central fabric of America. Free will is the core of liberty. Opposed to this perspective is the philosophy of determinism, which states that every act and decision is inevitably the result of our environment and is independent of human will. Hence, liberty vs. determinism is what I see in today's health care reform.

Core Concepts

  1. My body, including my mind, belongs to me 100 percent. No person, no employer, no government owns me.


  2. Health care benefits of which 85 percent come from the employer, are not given to me as a gift from a benevolent employer, but are offered in place of more money in my paycheck. Hence, health benefits are not to be confused with a gift from Santa Claus, but rather, they represent the employee's hard earned benefits to which they have a marketplace right.


  3. When an employee seeks the care of a chiropractic physician, a nurse, midwife, etc., this employee is not adding more financial burden to the package of benefits, rather, the employee wants to assert their own will and freely select a type of treatment for their health complaint that the employer may have determined to be excluded. For example, if the benefits include the delivery of babies, why should an employer determine that the pregnant woman must only use the services of an MD and not a nurse midwife? This determination violates the employee's personal beliefs and treats the employee as a piece of inanimate property. Classically, if a patient does not want drugs, surgery etc., and is of sound mind, to force drugs into this person would be assault and battery for which the offender is legally liable.


If I want chiropractic treatment, which is free from drugs/surgery for a covered problem within the benefits package which I have earned in the marketplace, how can an employer strip me of my personal liberty to choose what I want?

I believe it is time for all chiropractic organizations to study this denial of personal liberty in the workplace. It is time to call together some very dedicated lawyers to study this covert denial of one's personal liberty. This is not an argument against those of us who wish to use allopathic services, rather it is my desire to awaken my chiropractic colleagues to a miscarriage of basic liberty. While health freedom is not spelled out in the Constitution as Benjamin Rush, MD wished for, neither is the marketplace allowed to use child labor, polluted work places, subminimum wages etc. It is overdue for the chiropractic profession to study this humanitarian issue.

The citizens of America value their freedoms when it comes to religion, politics, and free speech. If a person can execute a living will which expresses their desires for a dignified death, certainly we can expect no less free will for the living. As long as Wall Street can run unchecked and downsize people's rights, it will be difficult for the chiropractic profession to grow in its service to America. Profits for American business are wonderful, but not at the expense of an employee's liberty to select what they feel is best for their own bodies.

Managed Care

While managed care is applauded for its cost containment, we must be careful to not focus exclusively on expenditures. How can we ensure quality of care when a person's right to select their health care service is denied? As the shift from patient-centered care to population based care occurs within managed care, health care professionals are asked to reduce our attention to individual patients and to think more globally. We are asked to maximize care within budgetary constraints. How do we trade off our fiduciary responsibilities to an individual patient when they are in clinical need? An ethical dilemma for some doctors who are given financial incentives to care less for the patient, and increase their financial pools. Do we minimize the patient and maximize profits for managed care plans? No matter how one approaches this issue, we in chiropractic need to discuss this from our own historical perspective and with ethical awareness.


The research community knows that the correct practice of all health care professionals is imperfect. With iatrogenic disease growing more each year, the need for chiropractic care grows, but we need evidence for our clinical practice. Also, we must realize that the efficacy of a procedure performed under an ideally controlled environment may not predict the effectiveness of procedures done under usual-life circumstances. Therefore, we as clinicians must weigh the benefits versus the risks of a procedure and in our case, we must remind the health care economists to include the costs of hospitalizations, recurrent surgeries, and other costly heroic procedures which directly result from iatrogenesis. As of now, economists compare chiropractic to allopathic costs, without adding the costs of adverse drug reactions and other medical misadventures to the real cost of a patient's care.

Today's research is for a better tomorrow: a tomorrow with a healthier lifestyle, a cleaner environment, and an increased quality of life. Let us help the people of America gain their fundamental rights to the choice of health care they desire. We must fight corporate determinism.

Arnold Cianciulli, BS, DC, MS
Bayonne, New Jersey

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