CorrectCare

30 Years After Estelle v. Gamble: A Legal Retrospective

By William J. Rold, JD, CCHP-A

“It is but just that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself.” — Spicer v. Williamson¹

As we focus on Estelle v. Gamble,² 30 years after the U.S. Supreme Court held that prisoners had a constitutional right to health care, it is important to remember how we got there. To do so, we return to rural North Carolina in 1926.

The Wounding of Peter Camel
Duplin County Sheriff Williamson’s deputy wounded Peter Camel when he returned Mr. Camel’s fire while arresting him for armed robbery 80 years ago. The local doctor told the sheriff that Mr. Camel’s injuries required hospitalization and surgery beyond his skills. The sheriff took Mr. Camel to Dr. Spicer, a surgeon in the next county. According to the decision, Sheriff Williamson said to Dr. Spicer about Mr. Camel: “He is a human being. He is in my charge .... [D]o the best you can to save him.”

After successful surgery, Dr. Spicer sent Sheriff Williamson a bill, which the sheriff presented for payment to the Duplin County Board of Commissioners. The board refused payment, saying that it had not authorized the sheriff to remove the prisoner for care in another county or to incur these expenses. Dr. Spicer sued the sheriff, who impleaded the Board of Commissioners as a third party defendant, arguing that the bill was Duplin County’s responsibility.

These three parties (each with its own attorney) took this dispute to the North Carolina Supreme Court, resulting in the language quoted above. This early decision made three points: (1) it was Sheriff Williamson’s duty to arrange for Mr. Camel’s medical care; (2) Dr. Spicer was entitled to be paid; and (3) the public (i.e., the county) had to pay.

This decision set the stage (and the often highly charged philosophical debate) for everything that has followed: the scope of the duty (Sheriff Williamson took rather extraordinary measures at that time); the “deservingness” of the patient (Mr. Camel had shot a deputy and was facing the death penalty); and the power of the courts (forcing Duplin County to pay after the board had voted no).

Spicer v. Williamson resonated in other early cases. The Supreme Court of Indiana wrote: “We cannot believe that the law intended, where a man was in jail and in need of medical services ... that the county would not be liable for the services thus rendered by a physician under the employ of the jailer having the prisoner in charge.”³

Fifty years later, these decisions on the common law duties of sheriffs would converge with the obligation of government under the Eighth Amendment to the U.S. Constitution, as expressed in Estelle v. Gamble.

The Eighth Amendment
The antecedents of the law’s prohibition of excessive punishment date from the time of the Magna Carta, signed by King John at the point of a sword.⁴ Under the rule of Edward I, however, misdemeanors were still punishable by whipping, by mutilation or by removal of a hand or an ear; felonies, by decapitation. Punishment for treason was particularly harsh, and included hanging, castration and disembowelment.⁵

In light of this history, the drafters of the American Bill of Rights sought in 1791 to prohibit “cruel and unusual punishment.” Early applications of the Eighth Amendment interpreted it to forbid torture or wanton infliction of suffering, but the courts rarely interfered with prison administration. In 1871, for example, the Virginia Supreme Court of Appeals wrote: “[the prisoner] is for the time being a slave, in a condition of penal servitude to the State, and subject to such laws and regulations as the State may choose to prescribe.”⁶

The Eighth Amendment would lay largely dormant for a century. Indeed, as late as 1963, the Supreme Court of Delaware upheld the use of lashes as punishment, since they were not at the time of William and Mary considered to be “unnecessarily cruel and bordering on outright torture.”⁷

Historically, the correctional system in the United States has been protected from public scrutiny. Prisons were built far from population centers, and courts adopted a “hands off” doctrine regarding their administration.⁸ Early cases in the 1970s, however, revealed horrendous medical conditions in which inmates were used without supervision to perform medical care on their fellows, including pulling teeth, suturing and surgery. Dramatic instances were illustrated in which prisoners died, neglected, covered in maggots and lying in their own filth.⁹

J.W. Gamble and the Prison Farm
J.W. Gamble was working on a Texas prison farm when a bail of hay fell and injured his back. Mr. Gamble sued the chief prison doctor, the warden and W.J. Estelle, director of the state department of corrections, for lack of adequate medical treatment, for denying him a work excuse and for punishing him for refusing to work when medically unfit. The U.S. District Court dismissed the case for failure to state a claim under the Eighth Amendment, and the case came before the Supreme Court.

By this time, the Supreme Court had before it the common law precedents from Spicer and other state courts, statutory authority in 22 states for the same proposition, development of parallel Eighth Amendment jurisprudence by the lower federal courts and the standards of numerous organizations, including the U.S. Department of Justice, the National Sheriffs’ Association and the United Nations.

It also had its own precedents under the Eighth Amendment that prohibited “torture or a lingering death”¹⁰ and the “unnecessary and wanton infliction of pain,”¹¹ and that recognized the “evolving standards of decency that mark the progress of a maturing society.”¹²

It found that denial of medical care to the incarcerated, could, at worst, result in a “lingering death” and, in less serious cases, cause “pain and suffering which no one suggests would serve any penological purpose.”

The court developed the standard “deliberate indifference to serious medical needs” to define the Eighth Amendment obligation to provide health care under the Constitution. It has remained largely unchanged for the last 30 years.

Interestingly, Mr. Gamble lost his case. In the three months after his injury, he was seen 17 times by various medical personnel. His complaints were grounded in malpractice, not deliberate indifference. This underscores that the standard of liability under the Eighth Amendment is relatively narrow. The amendment does not render prison officials or staff liable in federal cases for malpractice or accidents, nor does it resolve professional disputes about the best choice of treatment. It does, however, protect three basic rights.

Estelle’s Three Basic Rights
In the hundreds of cases following Estelle, three basic rights have emerged: the right to access to care, the right to care that is ordered and the right to a professional medical judgment.¹³ The failure of correctional officials to honor these rights has resulted in protracted litigation, the awarding of damages and attorneys’ fees, and injunctions regarding the delivery of health care services.

The right to access to care—emergency and routine, as well as specialists and hospitals when needed—is fundamental. When access is denied or delayed, the health staff does not know which patients need immediate attention and which need care that can wait. “A well-monitored and well-run access system is the best way to protect prisoners from unnecessary harm and suffering and, concomitantly, to protect prison officials from liability for denying access to needed medical care.”¹⁴

Generally, courts assume that care would not have been ordered if it were not needed. Thus, once a health care professional orders treatment for a serious condition, the courts will protect, as a matter of constitutional law, the patient’s right to receive that treatment without undue delay. The easiest way for an institution to lose a lawsuit is to fail to provide inmate-patients with the care that its own staff has ordered.

The adjudication of constitutional claims is not the business of second guessing health care professionals. In enforcing the right to a professional medical judgment, the courts will not determine which of two equally efficacious treatment modalities should be chosen. Rather, they seek to “ensure that decisions concerning the nature and timing of medical care are made by medical personnel, using equipment designed for medical use, in locations conducive to medical functions, and for reasons that are purely medical.”¹⁵

While the constitutional standard does not require that an express intent to inflict pain be shown (Wilson v . Seiter),¹⁶ it does include an inquiry into the defendants’ state of mind for a “subjective” showing of “deliberate indifference.” It is not enough that the defendant should have known or understood the danger to the inmate. The defendant must know of and disregard a substantial risk (Farmer v. Brennan).¹⁷ Such knowledge, however, can be inferred from the surrounding facts where the failure to respond to a clear risk is reckless.

‘Serious Medical Needs’
The Constitution requires that correctional officials provide medical care only for “serious medical needs.” Generally, a medical need is serious if it “has been diagnosed by a physician as mandating treatment or ... is so obvious that even a lay person would easily recognize the necessity for a doctor’s attention.”¹⁸ Conditions are also considered serious if they “cause pain, discomfort, or threat to good health” (Dean v. Coughlin).¹⁹ A condition need not be life-threatening to be deemed serious, and many treatment plans that are labeled “elective” nevertheless are deemed serious within the meaning of Estelle.

In general, courts consider three factors in determining whether correctional officials are being deliberately indifferent to serious medical needs: (1) amenability of the condition to treatment; (2) consequences to the patient if treatment does not occur; and (3) likelihood of a favorable outcome. Within this mix, the court also may consider the anticipated length of the patient’s incarceration. It is one thing to decline provision of dentures or an artificial limb to an inmate with a three-day jail sentence. It is quite another to withhold such adjuncts to a patient serving 20 years to life.²⁰

The Impact of Managed Care
Estelle was decided before the advent of modern notions of HMOs, managed care and “contracting out” for medical services. The impact of these developments would reach the Supreme Court in 1988. Again, North Carolina was center stage.

Quincy West was an inmate whose Achilles tendon was repaired by Dr. Atkins, an orthopedic surgeon under contract with the state department of corrections. Mr. West’s lawsuit claiming that Dr. Atkins’ care was so deficient as to constitute deliberate indifference was dismissed by the lower federal courts because Dr. Atkins was independent contractor, not a state employee.

West v. Atkins was of considerably greater moment than the Achilles tendon job that prompted the case or the quality of Dr. Atkins’ care: If corrections could avoid Estelle liability simply by “contracting out,” the body of law developed since Estelle was gravely at risk.

The Supreme Court ruled that Dr. Atkins could be sued under the Eighth Amendment.²¹ Two important principles emerge from West and its progeny. First, private contractors to state and local governments who provide services to prisoners are “state actors” for purposes of the Eighth Amendment. Second, the governments that hire them also remain liable for failing to provide constitutionally adequate care.

Conclusion
“No serious student of American correctional history can deny that litigation has provided the impetus for reform of medical practice in prisons and jails” (Nathan, 1985).²² As resources become increasingly scarce and government officials are constantly faced with doing more with less, it can be taken as some comfort that the courts remain steadfast as a last resort for a safety net for prisoner patients and for their providers.

— About the author: William J. Rold, JD, CCHP-A, is an attorney specializing in correctional health care law, policy and ethics, and is based in New York City; he represents the American Bar Association on the NCCHC board.

References

[This article first appeared in the Summer 2006 issue of CorrectCare.]