|||SUPREME COURT OF THE UNITED STATES
429 U.S. 97, 97 S. Ct. 285, 50 L. Ed. 2d 251
|||November 30, 1976
|||ESTELLE, CORRECTIONS DIRECTOR, ET AL.
|||CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT
|||Bert W. Pluymen, Assistant Attorney General of Texas, argued the cause
for petitioners pro hac vice. With him on the brief were John L. Hill,
Attorney General, David M. Kendall, First Assistant Attorney General,
and Joe B. Dibrell, Jr., Assistant Attorney General.
|||Daniel K. Hedges, by appointment of the Court, 425 U.s. 932, argued
the cause and filed a brief for respondent pro hac vice.
|||Burger, Brennan, Stewart, White, Marshall, Blackmun, Powell, Rehnquist,
|||The opinion of the court was delivered by: Marshall
|||Respondent state inmate brought this civil rights action under 42 U.S.C.
§ 1983 against petitioners, the state corrections department medical director
and two correctional officials, claiming that he was subjected to cruel
and unusual punishment in violation of the Eighth Amendment for inadequate
treatment of a back injury assertedly sustained while he was engaged in
prison work. The District Court dismissed the complaint for failure to
state a claim upon which relief could be granted. The Court of Appeals
held that the alleged insufficiency of the medical treatment required
reinstatement of the complaint. Held: Deliberate indifference by prison
personnel to a prisoner's serious illness or injury constitutes cruel
and unusual punishment contravening the Eighth Amendment. Here, however,
respondent's claims against Gray do not suggest such indifference, the
allegations revealing that Gray and other medical personnel saw respondent
on 17 occasions during a 3-month span and treated his injury and other
problems. The failure to perform an X-ray or to use additional diagnostic
techniques does not constitute cruel and unusual punishment but is at
most medical malpractice recognizable in the state courts. The question
whether respondent has stated a constitutional claim against the other
petitioners, the Director of the Department of Corrections and the warden
of the prison, was not separately evaluated by the Court of Appeals and
should be considered on remand. Pp. 101-108.
|||516 F.2d 937, reversed and remanded.
|||MARSHALL, J., delivered the opinion of the Court, in which BURGER, C.J.,
and BRENNAN, STEWART, WHITE, POWELL, and REHNQUIST, JJ., joined. BLACKMUN,
J., concurred in the judgment. STEVENS, J., filed a Dissenting opinion,
post, p. 108.
|||MR. JUSTICE MARSHALL delivered the opinion of the Court.
|||Respondent J. W. Gamble, an inmate of the Texas Department of Corrections,
was injured on November 9, 1973, while performing a prison work assignment.
On February 11, 1974, he instituted this civil rights action under 42
U.S.C. § 1983, *fn1
complaining of the treatment he received after the injury. Named as defendants
were the petitioners, W. J. Estelle, Jr., Director of the Department of
Corrections, H. H. Husbands, warden of the prison, and Dr. Ralph Gray,
medical director of the Department and chief medical officer of the prison
hospital. The District Court, sua sponte, dismissed the complaint for
failure to state a claim upon which relief could be granted. *fn2
The Court of Appeals reversed and remanded with instructions to reinstate
the complaint. 516 F.2d 937 (CA5 1975). We granted certiorari, 424 U.S.
|||Because the complaint was dismissed for failure to state a claim, we
must take as true its handwritten, pro se allegations. Cooper v. Pate,
378 U.S. 546 (1964). According to the complaint, Gamble was injured on
November 9, 1973, when a bale of cotton *fn3
fell on him while he was unloading a truck. He continued to work but after
four hours he became stiff and was granted a pass to the unit hospital.
At the hospital a medical assistant, "Captain" Blunt, checked
him for a hernia and sent him back to his cell. Within two hours the pain
became so intense that Gamble returned to the hospital where he was given
pain pills by an inmate nurse and then was examined by a doctor. The following
day, Gamble saw a Dr. Astone who diagnosed the injury as a lower back
strain, prescribed Zactirin (a pain reliever) and Robaxin (a muscle relaxant),
placed respondent on "cell-pass, cell-feed" status for two days,
allowing him to remain in his cell at all times except for showers. On
November 12, Gamble again saw Dr. Astone who continued the medication
and cell-pass, cell-feed for another seven days. He also ordered that
respondent be moved from 1n upper to a lower bunk for one week, but the
prison authorities did not comply with that directive.The following week,
Gamble returned to Dr. Astone. The doctor continued the muscle relaxant
but prescribed a new pain reliever, Febridyne, and placed respondent on
cell-pass for seven days, permitting him to remain in his cell except
for meals and showers. On November 26, respondent again saw Dr. Astone,
who put respondent back on the original pain reliever for five days and
continued the cell-pass for another week.
|||On December 3, despite Gamble's statement that his back hurt as much
as it had the first day, Dr. Astone took him off cell-pass, thereby certifying
him to be capable of light work. At the same time, Dr. Astone prescribed
Febridyne for seven days. Gamble then went to a Major Muddox and told
him that he was in too much pain to work. Muddox had respondent moved
to "administrative segregation." *fn5
On December 5, Gamble was taken before the prison disciplinary committee,
apparently because of his refusal to work. When the committee heard his
complaint of back pain and high blood pressure, it directed that he be
seen by another doctor.
|||On December 6, respondent saw petitioner Gray, who performed a urinalysis,
blood test, and blood pressure measurement. Dr. Gray prescribed the drug
Ser-Ap-Es for the high blood pressure and more Febridyne for the back
pain. The following week respondent again saw Dr. Gray, who continued
the Ser-Ap-Es for an additional 30 days. The prescription was not filled
for four days, however, because the staff lost it. Respondent went to
the unit hospital twice more in December; both times he was seen by Captain
Blunt, who prescribed Tiognolos (described as a muscle relaxant). For
all of December, respondent remained in administrative segregation.
|||In early January, Gamble was told on two occasions that he would be
sent to the "farm" if he did not return to work. He refused,
nonetheless, claiming to be in too much pain. On January 7, 1974, he requested
to go on sick call for his back pain and migraine headaches. After an
initial refusal, he saw Captain Blunt who prescribed sodium salicylate
(a pain reliever) for seven days and Ser-Ap-Es for 30 days. Respondent
returned to Captain Blunt on January 17 and January 25, and received renewals
of the pain reliever prescription both times. Throughout the month, respondent
was kept in administrative segregation.
|||On January 31, Gamble was brought before the prison disciplinary committee
for his refusal to work in early January. He told the committee that he
could not work because of his severe back pain and his high blood pressure.
Captain Blunt testified that Gamble was in "first class" medical
condition. The committee, with no further medical examination or testimony,
placed respondent in solitary confinement.
|||Four days later, on February 4, at 8 a.m., respondent asked to see a
doctor for chest pains and "blank outs." It was not until 7:30
that night that a medical assistant examined him and ordered him hospitalized.
The following day a Dr. Heaton performed an electrocardiogram; one day
later respondent was placed on Quinidine for treatment of irregular cardiac
rhythm and moved to administrative segregation. On February 7, respondent
again experienced pain in his chest, left arm, and back and asked to see
a doctor. The guards refused. He asked again the next day. The guards
again refused. Finally, on February 9, he was allowed to see Dr. Heaton,
who ordered the Quinidine continued for three more days. On February 11,
he swore out his complaint.
|||The gravamen of respondent's § 1983 complaint is that petitioners have
subjected him to cruel and unusual punishment in violation of the Eighth
Amendment, made applicable to the States by the Fourteenth. *fn6
See Robinson v. California, 370 U.S. 660 (1962). We therefore base our
evaluation of respondent's complaint on those Amendments and our decisions
|||The history of the constitutional prohibition of "cruel and unusual
punishments" has been recounted at length in prior opinions of the
Court and need not be repeated here. See, e.g., Gregg v. Georgia, 428
U.S. 153, 169-173 (1976) (joint opinion of STEWART, POWELL, and STEVENS,
JJ. (hereinafter joint opinion)); see also Granucci, Nor Cruel and Unusual
Punishment Inflicted: The Original Meaning, 57 Calif. L. Rev. 839 (1969).
It suffices to note that the primary concern of the drafters was to proscribe
"torture" and other "barbar" methods of punishment.
Id., at 842. Accordingly, this Court first applied the Eighth Amendment
by comparing challenged methods of execution to concededly inhuman techniques
of punishment. See Wilkerson v. Utah, 99 U.S. 130, 136 (1879) ("t
is safe to affirm that punishments of torture... and all others in the
same line of unnecessary cruelty, are forbidden by that amendment...");
In re Kemmler, 136 U.S. 436, 447 (1890) ("Punishments are cruel when
they involve torture or a lingering death...").
|||Our more recent cases, however, have held that the Amendment proscribes
more than physically barbarous punishments. See, e.g., Gregg v. Georgia,
(supra) , at 171 (joint opinion); Trop v. Dulles, 356 U.S. 86, 100-101
(1958); Weems v. United States, 217 U.S. 349, 373 (1910). The Amendment
embodies "broad and idealistic concepts of dignity, civilized standards,
humanity, and decency...," Jackson v. Bishop, 404 F.2d 571, 579 (CA8
1968), against which we must evaluate penal measures. Thus, we have held
repugnant to the Eighth Amendment punishments which are incompatible with
"the evolving standards of decency that mark the progress of a maturing
society," Trop v. Dulles, (supra) , at 101; see also Gregg v. Georgia,supra,
at 172-173 (joint opinion); Weems v. United States, (supra) , at 378,
or which "involve the unnecessary and wanton infliction of pain,"
Gregg v. Georgia, (supra) , at 173 (joint opinion); see also Louisiana
ex rel. Francis v. Resweber, 329 U.S. 459, 463 (1947); Wilkerson v. Utah,
(supra) , at 136. *fn7
|||These elementary principles establish the government's obligation to
provide medical care for those whom it is punishing by incarceration.
An inmate must rely on prison authorities to treat his medical needs;
if the authorities fail to do so, those needs will not be met. In the
worst cases, such a failure may actually produce physical "torture
or a lingering death," In re Kemmler, (supra) , the evils of most
immediate concern to the drafters of the Amendment. In less serious cases,
denial of medical care may result in pain and suffering which no one suggests
would serve any penological purpose. Cf. Gregg v. Georgia, (supra) , at
182-183 (joint opinion). The infliction of such unnecessary suffering
is inconsistent with contemporary standards of decency as manifested in
modern legislation *fn8
codifying the commonlaw view that "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." *fn9
|||We therefore conclude that deliberate indifference to serious medical
needs of prisoners constitutes the "unnecessary and wanton infliction
of pain," Gregg v. Georgia, (supra) , at 173 (joint opinion), proscribed
by the Eighth Amendment. This is true whether the indifference is manifested
by prison doctors in their response to the prisoner's needs *fn10
or by prison guards in intentionally denying or delaying access to medical
or intentionally interfering with the treatment once prescribed. *fn12
Regardess of how evidenced, deliberate indifference to a prisoner's serious
illness or injury states a cause of action under § 1983.
|||This Conclusion does not mean, however, that every claim by a prisoner
that he has not received adequate medical treatment states a violation
of the Eighth Amendment. An accident, although it may produce added anguish,
is not on that basis alone to be characterized as wanton infliction of
unnecessary pain. In Louisiana ex rel. Francis v. Resweber, 329 U.S. 459
(1947), for example, the Court concluded that it was not unconstitutional
to force a prisoner to undergo a second effort to electrocute him after
a mechanical malfunction had thwarted the first attempt. Writing for the
plurality, Mr. Justice Reed reasoned that the second execution would not
violate the Eighth Amendment because the first attempt was an "unforeseeable
accident." Id., at 464. Mr. Justice Frankfurter's concurrence, based
solely on the Due Process Clause of the Fourteenth Amendment, concluded
that since the first attempt had failed because of "an innocent misadventure,"
id., at 470, the second would not be "'repugnant to the conscience
of mankind,'" id., at 471, quoting Palko v. Connecticut, 302 U.S.
319, 323 (1937). *fn13
|||Similarly, in the medical context, an inadvertent failure to provide
adequate medical care cannot be said to constitute "an unnecessary
and wanton infliction of pain" or to be "repugnant to the conscience
of mankind." Thus, a complaint that a physician has been negligent
in diagnosing or treating a medical condition does not state a valid claim
of medical mistreatment under the Eighth Amendment. Medical malpractice
does not become a constitutional violation merely because the victim is
a prisoner. In order to state a cognizable claim, a prisoner must allege
acts or omissions sufficiently harmful to evidence deliberate indifference
to serious medical needs. It is only such indifference that can offend
"evolving standards of decency" in violation of the Eighth Amendment.
|||Against this backdrop, we now consider whether respondent's complaint
states a cognizable § 1983 claim. The handwritten pro se document is to
be liberally construed. As the Court unanimously held in Haines v. Kerner,
404 U.S. 519 (1972), a pro se complaint, "however inartfully pleaded,"
must be held to "less stringent standards than formal pleadings drafted
by lawyers" and can only be dismissed for failure to state a claim
if it appears "'beyond doubt that the plaintiff can prove no set
of facts in support of his claim which would entitle him to relief.'"
Id., at 520-521, quoting Conley v. Gibson, 355 U.S. 41, 45-46 (1957).
|||Even applying these liberal standards, however, Gamble's claims against
Dr. Gray, both in his capacity as treating physician and as medical director
of the Corrections Department, are not cognizable under § 1983. Gamble
was seen by medical personnel on 17 occasions spanning a three-month period:
by Dr. Astone five times; by Dr. Gray twice; by Dr. Heaton three times;
by an unidentified doctor and inmate nurse on the day of the injury; and
by medical assistant Blunt six times. They treated his back injury, high
blood pressure, and heart problems. Gamble has disclaimed any objection
to the treatment provided for his high blood pressure and his heart problem;
his complaint is "based solely on the lack of diagnosis and inadequate
treatment of his back injury." Response to Pet. for Cert. 4; see
also Brief for Respondent 19. The doctors diagnosed his injury as a lower
back strain and treated it with bed rest, muscle relaxants, and pain relievers.
Respondent contends that more should have been done by way of diagnosis
and treatment, and suggests a number of options that were not pursued.
Id., at 17, 19. The Court of Appeals agreed, stating: "Certainly
an X-ray of [Gamble's] lower back might have been in order and other tests
conducted that would have led to appropriate diagnosis and treatment for
the daily pain and suffering he was experiencing." 516 F.2d, at 941.
But the question whether an X-ray - or additional diagnostic techniques
or forms of treatment - is indicated is a classic example of a matter
for medical judgment. A medical decision not to order an X-ray, or like
measures, does not represent cruel and unusual punishment. At most it
is medical malpractice, and as such the proper forum is the state court
under the Texas Tort Claims Act. *fn15
The Court of Appeals was in error in holding that the alleged insufficiency
of the medical treatment required reversal and remand. That portion of
the judgment of the District Court should have been affirmed. *fn16
|||The Court of Appeals focused primarily on the alleged actions of the
doctors, and did not separately consider whether the allegations against
the Director of the Department of Corrections, Estelle, and the warden
of the prison, Husbands, stated a cause of action. Although we reverse
the judgment as to the medical director, we remand the case to the Court
of Appeals to allow it an opportunity to consider, in conformity with
this opinion, whether a cause of action has been stated against the other
|||It is so ordered.
|||JUSTICE BLACKMUN concurs in the judgment of the Court.
|||JUSTICE STEVENS, Dissenting.
|||Most of what is said in the Court's opinion is entirely consistent with
the way the lower federal courts have been processing claims that the
medical treatment of prison inmates is so inadequate as to constitute
the cruel and unusual punishment prohibited by the Eighth Amendment. I
have no serious disagreement with the way this area of the law has developed
thus far, or with the probable impact of this opinion. Nevertheless, there
are three reasons why I am unable to join it. First, insofar as the opinion
orders the dismissal of the complaint against the chief medical officer
of the prison, it is not faithful to the rule normally applied in construing
the allegations in a pleading prepared by an uncounseled inmate. Second,
it does not adequately explain why the Court granted certiorari in this
case. Third, it describes the State's duty to provide adequate medical
care to prisoners in ambiguous terms which incorrectly relate to the subjective
motivation of persons accused of violating the Eighth Amendment rather
than to the standard of care required by the Constitution.
|||The complaint represents a crude attempt to challenge the system of
administering medical care in the prison where Gamble is confined. Fairly
construed, the complaint alleges that he received a serious disabling
back injury in November 1973, that the responsible prison authorities
were indifferent to his medical needs, and that as a result of that indifference
he has been mistreated and his condition has worsened.
|||The indifference is allegedly manifested, not merely by the failure
or refusal to diagnose and treat his injury properly, but also by the
conduct of the prison staff. Gamble was placed in solitary confinement
for prolonged periods as punishment for refusing to perform assigned work
which he was physically unable to perform. *fn1
The only medical evidence presented to the disciplinary committee was
the statement of a medical assistant that he was in first-class condition,
when in fact he was suffering not only from the back sprain but from high
blood pressure. Prison guards refused to permit him to sleep in the bunk
that a doctor had assigned. On at least one occasion a medical prescription
was not filled for four days because it was lost by staff personnel. When
he suffered chest pains and blackouts while in solitary, he was forced
to wait 12 hours to see a doctor because clearance had to be obtained
from the warden. His complaint also draws into question the character
of the attention he received from the doctors and the inmate nurse in
response to his 17 attempts to obtain proper diagnosis and treatment for
his condition. However, apart from the medical director who saw him twice,
he has not sued any of the individuals who saw him on these occasions.
In short, he complains that the system as a whole is inadequate.
|||On the basis of Gamble's handwritten complaint it is impossible to assess
the quality of the medical attention he received. As the Court points
out, even if what he alleges is true, the doctors may be guilty of nothing
more than negligence or malpractice. On the other hand, it is surely not
inconceivable that an overworked, undermanned medical staff in a crowded
is following the expedient course of routinely prescribing nothing more
than pain killers when a thorough diagnosis would disclose an obvious
need for remedial treatment. *fn3
Three fine Judges sitting on the United States Court of Appeals for the
Fifth Circuit *fn4
thought that enough had been alleged to require some inquiry into the
actual facts. If this Court meant what it said in Haines v. Kerner, 404
U.S. 519, these Judges were clearly right. *fn5
|||The Haines test is not whether the facts alleged in the complaint would
entitle the plaintiff to relief. Rather, it is whether the Court can say
with assurance on the basis of the complaint that, beyond any doubt, no
set of facts could be proved that would entitle the plaintiff to relief.
reasons for the Haines test are manifest. A pro se complaint provides
an unsatisfactory foundation for deciding the merits of important questions
because typically it is inartfully drawn, unclear, and equivocal, and
because thorough pleadings, affidavits, and possibly an evidentiary hearing
will usually bring out facts which simplify or make unnecessary the decision
of questions presented by the naked complaint. *fn7
|||Admittedly, it is tempting to eliminate the meritless complaint at the
pleading stage. Unfortunately, this "is another instance of judicial
haste which in the long run makes waste," Dioguardi v. Durning, 139
F.2d 774, 775 (CA2 1944) (Clark, J.), cited with approval in Haines v.
Kerner, (supra) , at 521. In the instant case, if the District Court had
resisted the temptation of premature dismissal, the case might long since
have ended with the filing of medical records or affidavits demonstrating
adequate treatment. Likewise, if the decision of the Fifth Circuit reinstating
the complaint had been allowed to stand and the case had run its normal
course, the litigation probably would have come to an end without the
need for review by this Court. Even if the Fifth Circuit had wrongly decided
the pleading issue, no great harm would have been done by requiring the
State to produce its medical records and move for summary judgment. Instead,
the case has been prolonged by two stages of appellate review, and is
still not over: The case against two of the defendants may still proceed,
and even the claims against the prison doctors have not been disposed
of with finality. *fn8
|||The principal beneficiaries of today's decision will not be federal
Judges, very little of whose time will be saved, but rather the "writ-writers"
within the prison walls, whose semiprofessional services will be in greater
demand. I have no doubt about the ability of such a semiprofessional to
embellish this pleading with conclusory allegations which could be made
in all good faith and which would foreclose a dismissal without any response
from the State. It is unfortunate that today's decision will increase
prisoners' dependence on those writ-writers. See Cruz v. Beto, 405 U.S.
319, 327 n. 7 (REHNQUIST, J., Dissenting).
|||Like the District Court's decision to dismiss the complaint, this Court's
decision to hear this case, in violation of its normal practice of denying
interlocutory review, see R. Stern & E. Gressman, Supreme Court Practice
180 (4th ed. 1969), ill serves the interest of judicial economy.
|||Frankly, I was, and still am, puzzled by the Court's decision to grant
If the Court merely thought the Fifth Circuit misapplied Haines v. Kerner
by 6908able. On the other hand, if the Court thought that instead of a
pleading question, the case presented an important constitutional question
about the State's duty to provide medical care to prisoners, the crude
allegations of this complaint do not provide the kind of factual basis
Court normally requires as a predicate for the adjudication of a novel
and serious constitutional issue, see, e.g., Rescue Army v. Municipal
Court, 331 U.S. 549, 568-575; Ellis v. Dixon, 349 U.S. 458, 464; Wainwright
v. City of New Orleans, 392 U.S. 598 (Harlan, J., Concurring). *fn11
Moreover, as the Court notes, all the Courts of Appeals to consider the
question have reached substantially the same Conclusion that the Court
adopts. Ante, at 106 n. 14. Since the Court seldom takes a case merely
to reaffirm settled law, I fail to understand why it has chosen to make
this case an exception to its normal practice.
|||By its reference to the accidental character of the first unsuccessful
attempt to electrocute the prisoner in Louisiana ex rel. Francis v. Resweber,
329 U.S. 459, see ante, at 105, and by its repeated references to "deliberate
indifference" and the "intentional" denial of adequate
medical care, I believe the Court improperly attaches significance to
the subjective motivation of the defendant as a criterion for determining
whether cruel and unusual punishment has been inflicted. *fn12
Subjective motivation may well determine what, if any, remedy is appropriate
against a particular defendant. However, whether the constitutional standard
has been violated should turn on the character of the punishment rather
than the motivation of the individual who inflicted it. *fn13
Whether the conditions in Andersonville were the product of design, negligence,
or mere poverty, they were cruel and inhuman.
|||In sum, I remain convinced that the petition for certiorari should have
been denied. It having been granted, I would affirm the judgment of the
Court of Appeals.
42 U.S.C. § 1983 provides:
|||"Every person who, under color of any statute, ordinance, regulation,
custom, or usage, of any State or Territory, subjects, or causes to be
subjected, any citizen of the United States or other person within the
jurisdiction thereof to the deprivation of any rights, privileges, or
immunities, secured by the Constitution and laws, shall be liable to the
party injured in an action at law, suit in equity, or other proper proceeding
appears that the petitioner-defendants were not even aware of the suit
until it reached the Court of Appeals. Tr. of Oral Arg. 7, 13-15. This
probably resulted because the District Court dismissed the complaint simultaneously
with granting leave to file it in forma pauperis.
complaint states that the bale weighed "6.00 pound." The Court
of Appeals interpreted this to mean 600 pounds. 516 F.2d 937, 938 (CA5
names and descriptions of the drugs administered to respondent are taken
from his complaint. App. A-5 - A-11, and his brief, at 19-20.
are a number of terms in the complaint whose meaning is unclear and, with
no answer from the State, must remain so.For example, "administrative
segregation" is never defined. The Court of Appeals deemed it the
equivalent of solitary confinement. 516 F.2d, at 939. We note, however,
that Gamble stated he was in "administrative segregation" when
he was in the "32A-7 five building" and "32A20 five building,"
but when he was in "solitary confinement," he was in "3102
Eighth Amendment provides:
|||"Excessive bail shall not be required, nor excessive fines imposed,
nor cruel and unusual punishments inflicted."
|||At oral argument, counsel for respondent agreed that his only claim
was based on the Eighth Amendment. Tr. of Oral Arg. 42-43.
Amendment also proscribes punishments grossly disproportionate to the
severity of the crime, Gregg v. Georgia, 428 U.S. 153, 173 (1976) (joint
opinion); Weems v. United States, 217 U.S. 349, 367 (1910), and it imposes
substantive limits on what can be made criminal and punished, Robinson
v. California, 370 U.S. 660 (1962). Neither of these principles is involved
e.g., Ala. Code Tit. 45, § 125 (1958); Alaska Stat. § 33.30.050 (1975);
Ariz. Rev. Stat. Ann. § 31-201.01 (Supp. 1975); Conn. Gen. Stat. Ann.
§ 18-7 (1975); Ga. Code Ann. § 77-309 (e) (1973); Idaho Code § 20-209
(Supp. 1976); Ill. Ann. Stat. c. 38, § 103-2 (1970); Ind. Ann. Stat. §
11-1-1.1-30.5 (1973); Kan. Stat. Ann. § 75-5429 (Supp. 1975); Md. Ann.
Code Art. 27 § 698 (1976); Mass. Ann. Laws, c. 127, § 90A (1974); Mich.
Stat. Ann. § 14.84 (1969); Miss. Code Ann. § 47-1-57 (1972); Mo. Ann.
Stat. § 221.120 (1962); Neb. Rev. Stat. § 83-181 (1971); N.H. Rev. Stat.
Ann. § 619.9 (1974); N.M. Stat. Ann. § 42-2-4 (1972); Tenn. Code Ann.
§§ 41-318, 41-1115, 41-1226 (1975); Utah Code Ann. §§ 64-9-13, 64-9-19,
64-9-20, 64-9-53 (1968); Va. Code Ann. §§ 32-81, 32-82 (1973); W. Va.
Code Ann. § 25-1-16 (Supp. 1976); Wyo. Stat. Ann. § 18-299 (1959).
|||Many States have also adopted regulations which specify, in varying
degrees of detail, the standards of medical care to be provided to prisoners.
See Comment, The Rights of Prisoners to Medical Care and the Implications
for Drug-Dependent Prisoners and Pretrial Detainees, 42 U. Chi. L. Rev.
705, 708-709 (1975).
|||Model correctional legislation and proposed minimum standards are all
in accord. See American Law Institute, Model Penal Code §§ 303.4, 304.5
(1962); National Advisory Commission on Criminal Justice Standards and
Goals, Standards on Rights of Offenders, Standard 2.6 (1973); National
Council on Crime and Delinquency, Model Act for the Protection of Rights
of Prisoners, § 1(b) (1972); National Sheriffs' Association, Standards
for Inmates' Legal Rights, Right No. 3 (1974); Fourth United Nations Congress
on Prevention of Crime and Treatment of Offenders, Standard Minimum Rules
for the Treatment of Prisoners, Rules 22-26 (1955). The foregoing may
all be found in U.S. Dept. of Justice, Law Enforcement Assistance Administration,
Compendium of Model Correctional Legislation and Standards (2d ed. 1975).
v. Williamson, 191 N.C. 487, 490, 132 S.E. 291, 293 (1926).
See, e.g., Williams v. Vincent, 508 F.2d 541 (CA2 1974)(doctor's choosing
the "easier and less efficacious treatment" of throwing away
the prisoner's ear and stitching the stump may be attributable to "deliberate
indifference... rather than an exercise of professional judgment");
Thomas v. Pate, 493 F.2d 151, 158 (CA7), cert. denied sub nom. Thomas
v. Cannon, 419 U.S. 879 (1974) (injection of penicillin with knowledge
that prisoner was allergic, and refusal of doctor to treat allergic reaction);
Jones v. Lockhart, 484 F.2d 1192 (CA8 1973) (refusal of paramedic to provide
treatment); Martinez v. Mancusi, 443 F.2d 921 (CA2 1970), cert. denied,
401 U.S. 983 (1971) (prison physician refuses to administer the prescribed
pain killer and renders leg surgery unsuccessful by requiring prisoner
to stand despite contrary instructions of surgeon).
See, e.g., Westlake v. Lucas, 537 F.2d 857 (CA6 1976); Thomas v. Pate,
(supra) , at 158-159; Fitzke v. Shappel l, 468 F.2d 1072 (CA6 1972); Hutchens
v. Alabama, 466 F.2d 507 (CA5 1972); Riley v. Rhay, 407 F.2d 496 (CA9
1969); Edwards v. Duncan, 355 F.2d 993 (CA4 1966); Hughes v. Noble, 295
F.2d 495 (CA5 1961).
See, e.g., Wilbron v. Hutto, 509 F.2d 621, 622 (CA8 1975); Campbell v.
Beto, 460 F.2d 765 (CA5 1972); Martinez v. Mancusi, supra; Tolbert v.
Eyman, 434 F.2d 625 (CA9 1970); Edwards v. Duncan, supra.
He noted, however, that "a series of abortive attempts" or "a
single, cruelly willful attempt" would present a different case.
329 U.S., at 471.
The Courts of Appeals are in essential agreement with this standard. All
agree that mere allegations of malpractice do not state a claim, and,
while their terminology regarding what is sufficient varies, their results
are not inconsistent with the standard of deliberate indifference. See
Page v. Sharpe, 487 F.2d 567, 569 (CA1 1973); Williams v. Vincent, (supra)
, at 544 (uses the phrase "deliberate indifference"); Gittlemacker
v. Prasse, 428 F.2d 1, 6 (CA3 1970); Russell v. Sheffer, 528 F.2d 318
(CA4 1975); Newman v. Alabama, 503 F.2d 1320, 1330 n. 14 (CA5 1974), cert.
denied, 421 U.S. 948 (1975) ("callous indifference"); Westlake
v. Lucas, (supra) , at 860 ("deliberate indifference"); Thomas
v. Pate, (supra) , at 158; Wilbron v. Hutto, (supra) , at 622 ("deliberate
indifference"); Tolbert v. Eyman, (supra) , at 626; Dewell v. Lawson,
489 F.2d 877, 881-882 (CA10 1974).
Tex. Rev. Civ. Stat., Art. 6252-19, § 3 (Supp. 1976). Petitioners assured
the Court at argument that this statute can be used by prisoners to assert
malpractice claims. Tr. of Oral Arg. 6.
Contrary to MR. JUSTICE STEVENS' assertion in Dissent, this case signals
no retreat from Haines v. Kerner, 404 U.S. 519 (1972). In contrast to
the general allegations in Haines, Gamble's complaint provides a detailed
factual accounting of the treatment he received. By his exhaustive description
he renders speculation unnecessary. It is apparent from his complaint
that he received extensive medical care and that the doctors were not
indifferent to his needs.
|||1 In his complaint, Gamble alleged that he had been placed in administrative
segregation and remained there through December and January. At the end
of January he was placed in solitary confinement. In an affidavit filed
in the Court of Appeals the following December, see n. 8, (infra), Gamble
alleged that with the exception of one day in which he was taken out of
solitary to be brought before the disciplinary committee, he had remained
in solitary up to the date of the affidavit.
|||2 According to a state legislative report quoted by the Court of Appeals,
the Texas Department of Corrections has had at various times one to three
doctors to care for 17,000 inmates with occasional part-time help. 516
F.2d 937, 940-941, n. 1 (1975).
|||3 This poorly drafted complaint attempts to describe conditions which
resemble those reported in other prison systems. For instance, a study
of the Pennsylvania prison system reported:
|||"When ill, the prisoner's point of contact with a prison's health
care program is the sick-call line. Access may be barred by a guard, who
refuses to give the convict a hospital pass out of whimsy or prejudice,
or in light of a history of undiagnosed complaints. At sick call the convict
commonly first sees a civilian paraprofessional or a nurse, who may treat
the case with a placebo without actual examination, history-taking or
recorded diagnosis. Even seeing the doctor at some prisons produces no
more than aspirin for symptoms, such as dizziness and fainting, which
have persisted for years." Health Law Project, University of Pennsylvania,
Health Care and Conditions in Pennsylvania's State Prisons, in American
Bar Association Commission on Correctional Facilities and Services, Medical
and Health Care in Jails, Prisons, and Other Correctional Facilities:
A Compilation of Standards and Materials 71, 81-82 (Aug. 1974).
|||A legislative report on California prisons found:
|||"By far, the area with the greatest problem at the hospital [at
one major prison], and perhaps at all the hospitals, was that of the abusive
doctor-patient relationship. Although the indifference of M.T.A.s [medical
technical assistants] toward medical complaints by inmates is not unique
at Folsom, and has been reported continuously elsewhere, the calloused
and frequently hostile attitude exhibited by the doctors is uniquely reprehensible....
|||"Typical complaints against [one doctor] were that he would...
not adequately diagnose or treat a patient who was a disciplinary problem
at the prison...." Assembly Select Committee on Prison Reform and
Rehabilitation, An Examination of California's Prison Hospitals, 60-61
|||These statements by responsible observers demonstrate that it is far
from fanciful to read a prisoner's complaint as alleging that only pro
forma treatment was provided.
|||4 The panel included Mr. Justice Clark, a retired member of this Court,
sitting by designation, and Circuit Judges Goldberg and Ainsworth.
|||5 In Haines a unanimous Supreme Court admonished the federal judiciary
to be especially solicitous of the problems of the uneducated inmate seeking
to litigate on his own behalf. The Court said:
|||"Whatever may be the limits on the scope of inquiry of courts into
the internal administration of prisons, allegations such as those asserted
by petitioner, however inartfully pleaded, are sufficient to call for
the opportunity to offer supporting evidence. We cannot say with assurance
that under the allegations of the pro se complaint, which we hold to less
stringent standards than formal pleadings drafted by lawyers, it appears
'beyond doubt that the plaintiff can prove no set of facts in support
of his claim which would entitle him to relief.' Conley v. Gibson, 355
U.S. 41, 45-46 (1957). See Dioguardi v. Durning, 139 F.2d 774 (CA2 1944)."
404 U.S., at 520-521.
|||Under that test the complaint should not have been dismissed without,
at the very minimum, requiring some response from the defendants. It appears
from the record that although the complaint was filed in February, instead
of causing it to be served on the defendants as required by Fed. Rule
Civ. Proc. 4, the Clerk of the District Court referred it to a magistrate
who decided in June that the case should be dismissed before any of the
normal procedures were even commenced. At least one Circuit has held that
dismissal without service on the defendants is improper, Nichols v. Schubert,
499 F.2d 946 (CA7 1974). The Court's Disposition of this case should not
be taken as an endorsement of this practice since the question was not
raised by the parties.
|||6 This is the test actually applied in Haines, for although the Court
ordered the complaint reinstated, it expressly "intimate no view
whatever on the merits of petitioner's allegations," 404 U.S., at
521. It is significant that the Court took this approach despite being
pressed by the State to decide the merits. As in this case, the State
argued forcefully that the facts alleged in the complaint did not amount
to a constitutional violation. (Only in one footnote in its 51-page brief
did the State discuss the pleading question, Brief for Respondents 22-23,
n. 20, in No. 70-5025, O.T. 1971.) Yet, this Court devoted not a single
word of its opinion to answering the argument that no constitutional violation
|||7 Thus, Haines teaches that the decision on the merits of the complaint
should normally be postponed until the facts have been ascertained. The
same approach was taken in Polk Co. v. Glover, 305 U.S. 5, in which the
Court reversed the dismissal of a complaint, without intimating any view
of the constitutional issues, on "he salutary principle that the
essential facts should be determined before passing upon grave constitutional
questions...." Id., at 10. See also Borden's Co. v. Baldwin, 293
U.S. 194, 213 (Cardozo and Stone, JJ., Concurring in result). This approach
potentially avoids the necessity of ever deciding the constitutional issue
since the facts as proved may remove any constitutional question. Alternatively,
a more concrete record will be available on which to decide the constitutional
issues. See generally Rescue Army v. Municipal Court, 331 U.S. 549, 574-575.
Even when constitutional principles are not involved, it is important
that "the conceptual legal theories be explored and assayed in the
light of actual facts, not as a pleader's supposition," so that courts
may avoid "elucidating legal responsibilities as to facts which may
never be." Shull v. Pilot Life Ins. Co., 313 F.2d 445, 447 (CA5 1963).
|||8 In an affidavit filed in the Court of Appeals, Gamble states that
he has been transferred to another prison, placed in solitary confinement,
and denied any medical care at all. These conditions allegedly were continuing
on December 3, 1974, the date of the affidavit. The Court of Appeals apparently
considered these allegations, as shown by a reference to "the fact
that has spent months in solitary confinement without medical care and
stands a good chance of remaining that way without intervention,"
516 F.2d, at 941. Presumably the Court's remand does not bar Gamble from
pursuing these charges, if necessary through filing a new complaint or
formal amendment of the present complaint. The original complaint also
alleged that prison officials failed to comply with a doctor's order to
move Gamble to a lower bunk, that they put him in solitary confinement
when he claimed to be physically unable to work, and that they refused
to allow him to see a doctor for two days while he was in solitary. Gamble's
medical condition is relevant to all these allegations. It is therefore
probable that the medical records will be produced and that testimony
will be elicited about Gamble's medical care. If the evidence should show
that he in fact sustained a serious injury and received only pro forma
care, he would surely be allowed to amend his pleading to reassert a claim
against one or more of the prison doctors.
|||9 "The only remarkable thing about this case is its presence in
this Court. For the case involves no more than the application of wellsettled
principles to a familiar situation, and has little significance except
for the respondent. Why certiorari was granted is a mystery to me - particularly
at a time when the Court is thought by many to be burdened by too heavy
a caseload." Butz v. Glover Livestock Comm'n Co., 411 U.S. 182, 189
(STEWART, J., Dissenting).
|||10 As this Court notes, ante, at 100 n. 5, even the meaning of some
of the terms used in the complaint is unclear.
|||11 If this was the reason for granting certiorari, the writ should have
been dismissed as improvidently granted when it became clear at oral argument
that the parties agreed on the constitutional standard and disagreed only
as to its application to the allegations of this particular complaint.
See Tr. of Oral Arg. 38, 48.
|||12 As the four Dissenting Justices in Resweber pointed out:
|||"The intent of the executioner cannot lessen the torture or excuse
the result. It was the statutory duty of the state officials to make sure
that there was no failure." 329 U.S., at 477 (Burton, J., joined
by Douglas, Murphy, and Rutledge, JJ.).
|||13 The Court indicates the Eighth Amendment is violated "by prison
guards in intentionally denying or delaying access to medical care or
intentionally interfering with the treatment once prescribed." Ante,
at 104-105. If this is meant to indicate that intent is a necessary part
of an Eighth Amendment violation, I disagree. If a State elects to impose
imprisonment as a punishment for crime, I believe it has an obligation
to provide the persons in its custody with a health care system which
meets minimal standards of adequacy. As a part of that basic obligation,
the State and its agents have an affirmative duty to provide reasonable
access to medical care, to provide competent, diligent medical personnel,
and to ensure that prescribed care is in fact delivered. For denial of
medical care is surely not part of the punishment which civilized nations
may impose for crime.
|||Of course, not every instance of improper health care violates the Eighth
Amendment. Like the rest of us, prisoners must take the risk that a competent,
diligent physician will make an error. Such an error may give rise to
a tort claim but not necessarily to a constitutional claim. But when the
State adds to this risk, as by providing a physician who does not meet
minimum standards of competence or diligence or who cannot give adequate
care because of an excessive caseload or inadequate facilities, then the
prisoner may suffer from a breach of the State's constitutional duty.
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