612 F.

2d 754

INMATES OF the ALLEGHENY COUNTY JAIL, Thomas

Price Bey,
Arthur Goslee, Harry Smith, Robert Maloney, and
Calvin Milligan on their own behalf and
on behalf of all others
similarly situated, Appellants,
v.
Robert PIERCE, Chairman, Allegheny County Board of Prison
Inspectors and all other members of the Board; James
Jennings, Warden of Allegheny County Jail; and James
Flaherty, Robert Pierce and Thomas Foerster, Commissioners
for Allegheny County; John P. Lynch, Controller for
Allegheny County; Eugene Coon, Sheriff for Allegheny
County;
The Honorable Henry Ellenbogen, The Honorable John W.
O'Brien, The Honorable Samuel Strauss, and The Honorable
Patrick R. Tamila, Judges of the Court of Common Pleas of
Allegheny County; Peter Flaherty, Mayor of the City of
Pittsburgh.
No. 78-2621.

United States Court of Appeals,

Third Circuit.
Argued Sept. 4, 1979.
Decided Dec. 28, 1979.

Jere Krakoff (argued), Mark B. Greenblatt, Jon Pushinsky, Neighborhood

Legal Services Association, Pittsburgh, Pa., for appellants.
Alexander J. Jaffurs, County Sol., Dennis R. Biondo (argued), Asst.
County Sol., Pittsburgh, Pa., for appellees.
Before ALDISERT, ROSENN and GARTH, Circuit Judges.

OPINION OF THE COURT

ROSENN, Circuit Judge.

We are faced on this appeal with a challenge to certain conditions of

confinement for pretrial detainees incarcerated in the Allegheny County Jail.
On June 2, 1976, inmates of the jail ("Inmates") filed a class action against the
Allegheny County Board of Prison Inspectors ("Board") and other county
officials under 42 U.S.C. 1983 seeking a declaratory judgment that the
conditions violate the constitutional rights of the inmates.

On January 4, 1978, the district court issued the first of its two opinions.
Owens-FI v. Robinson, 442 F.Supp. 1368 (W.D.Pa. 1978). Although it found
that many of the challenged conditions did violate the constitutional rights of
the inmates, it held against them on the issues of contact visits, methadone
treatment, and psychiatric care. These findings were incorporated in the court's
final opinion and order of October 11, 1978. 457 F.Supp. 984. The Inmates
appealed. We affirm on the issues of contact visits and drug detoxification, and
remand on the issue of psychiatric care.

I.
3

The Allegheny County Jail is used primarily as a detention facility for persons
awaiting trial. In addition to pretrial detainees, other inmates are also housed at
the jail. These include: inmates who have been convicted but are awaiting
sentencing; inmates who have been committed to the jail for misdemeanors for
relatively short sentences; inmates on a work-release program; federal prisoners
awaiting trial or sentencing; and state and federal prisoners from other
institutions held in the jail while testifying in pending state and federal cases.
The average daily population is approximately 430 inmates with an average
length of confinement of about three weeks. Many inmates, however, are
confined for substantially longer periods of time.

The Inmates' action against the Board sought broad scale relief from allegedly
unconstitutional conditions at the jail. The district court found that many of the
challenged conditions did indeed fall below the constitutional minimum and
granted substantial relief.

Although not dispositive of the appeal before us, it is instructive to briefly

summarize the conditions found to exist by the district court. Living facilities
were unhealthy and unsafe. The plumbing system was antiquated and in

disrepair. As a result, leaks and overflows frequently occurred in the cells. The
cells lacked adequate lighting; the efforts of inmate-electricians seeking to
remedy that defect caused exposed electrical wires which presented fire and
shock hazards. Prisoners were required to sleep on canvas cots, many of which
were discolored by blood, vomit, feces, and urine. Vermin abounded. Cell
temperatures fluctuated between extreme cold in the winter and extreme heat in
the summer. The shortage of guards reduced supervision of the inmates and
permitted hoarding and vandalism of necessary supplies. This in turn
contributed significantly to chronic shortages of necessary items such as
blankets and bath towels.
6

Inmates with a wide spectrum of emotional and mental problems, ranging from
simple "acting-out" behavior to drug withdrawal, delirium tremens, epileptic
seizures, and mental instability, were confined in the "restraint room." Clothed
in hospital gowns or left naked, there they were bound to canvas cots with a
hole cut in the middle. A tub was placed underneath the hole to collect the
body wastes of the occupant.

Some inmates were placed in solitary confinement for up to fourteen days

without a mattress, toilet articles, or a change of clothing. Other inmates were
confined in the nude in the isolation cell, an unfurnished, darkened, windowless
room for up to fourteen consecutive hours, without any blankets or sheets.

In short, conditions in the jail were shockingly substandard and, the district
court found, well below the minimum required by the Constitution.
Accordingly, the court entered an order providing relief. The Board does not
challenge these findings or the terms of the district court's order. In addition,
however, the district court denied the Inmates relief in three specific areas.
These denials form the basis of the Inmates' appeal presently before us.

Currently, jail policy precludes inmates and their visitors from physical contact,
restricting them instead to booths in which the inmate and visitor are separated
by a pane of glass and communication is by telephone.1 The district court
upheld this practice as a legitimate restriction in light of the security interests of
the jail.

10

The Inmates also challenge the method of drug detoxification at the jail.
Currently, any inmate who has been receiving methadone treatment from an
authorized treatment center in Allegheny County prior to his incarceration is
allowed to receive such treatment for six days following the date of
confinement, after which the treatment is terminated. The district court upheld

this practice as within the sound discretion of prison medical authorities.

11

Finally, the Inmates challenge the system of psychiatric care at the jail alleging
it to be constitutionally inadequate because of insufficient staffing. Although
the court ordered psychiatric training for all nurses at the jail and prohibited the
further use of restraint cots, it expressed no opinion as to the constitutional
sufficiency of the general level of psychiatric care.

II.
12

The Inmates' first contention on appeal is that the district court erred in ruling
that the prohibition of contact visits does not deprive the Inmates of their due
process rights under the fourteenth amendment. They argue that, under Bell v.
Wolfish, 441 U.S. 520, 99 S.Ct. 1861, 60 L.Ed.2d 447 (1979), the denial of
contact visits represents an "exaggerated response" to an asserted security
interest and therefore constitutes a denial of due process. We disagree.

13

In Bell v. Wolfish, the Supreme Court considered the standard to be applied in

evaluating conditions of pretrial detention. The Court held that "(i)n evaluating
the constitutionality of conditions or restrictions of pretrial detention that
implicate only the protection against deprivation of liberty without due process
of law we think the proper inquiry is whether those conditions amount to
punishment of the detainee." Bell v. Wolfish, supra, 441 U.S. at 535, 99 S.Ct.
at 1872.

14
Absent
a showing of an expressed intent to punish on the part of detention facility
officials, that determination generally will turn on "(w)hether an alternative purpose
to which (the restriction) may rationally be connected is assignable for it, and
whether it appears excessive in relation to the alternative purpose assigned (to it)." . .
. Thus, if a particular condition or restriction of pretrial detention is reasonably
related to a legitimate governmental objective, it does not, without more, amount to
"punishment". . . . Conversely if a restriction or condition is not reasonably related to
a legitimate goal if it is arbitrary or purposeless a court permissibly may infer that
the purpose of the governmental action is punishment that may not constitutionally
be inflicted upon detainees Qua detainees.
15

441 U.S. at 538-539, 99 S.Ct. at 1874. The Court admonished lower courts that
the government's interest in maintaining security and order and operating the
institutions in a manageable fashion is "peculiarly within the province and
professional expertise of corrections officials, and, in the absence of substantial
evidence in the record to indicate that the officials have exaggerated their
response to these considerations, courts should ordinarily defer to their expert

judgment in such matters." 441 U.S. at 540, 99 S.Ct. at 1875 n. 23.

16

The Inmates argue that there is very little likelihood that additional contraband
will find its way into the jail if contact visits are allowed and that contraband
will be introduced into the jail in any case. They urge that a plan recommended
by the court adviser 2 which would have allowed contact visits in certain
instances, is a reasonable alternative to the absolute prohibition presently
imposed and would provide adequate protection for security interests at the jail.
Under that plan inmates would not be eligible for contact visits until after
having spent 45 days in confinement. The Inmates argue that this plan would
protect security interests in a number of ways. First, it would limit the number
of contact visits to a manageable level and thus eliminate the need to make
major structural changes in the jail. Second, the waiting period would give the
jail administration sufficient time to observe the various inmates and identify
which of them would pose security risks if permitted to have contact visits. It
also would afford the institution sufficient time to set up a visitor list for
eligible inmates and determine which visitors might pose security problems.

17

The Inmates' arguments, however, are unpersuasive. Even though the chances
of additional contraband being introduced into the jail by virtue of contact visits
may well be small, prohibition of such visits is, nevertheless, not unreasonable.
In Bell v. Wolfish the Court upheld body cavity inspection of inmates
conducted after contact visits. The Court noted that, although

18 has been only one instance where an . . . inmate was discovered attempting to
there
smuggle contraband into the institution on his person (this), may be more a
testament to the effectiveness of . . . (the body cavity search) as a deterrent than to
any lack of interest on the part of the inmates to secrete and import such items when
the opportunity arises.
19

Bell v. Wolfish, supra, 441 U.S. at 559, 99 S.Ct. at 1884-1885.

20

The rationale applied in Wolfish is applicable here, particularly because the

procedure the Court upheld was directed at detecting contraband that the
prisoners might attempt to smuggle in after contact visits. Testimony in this
case, by both the present and past wardens of the jail indicates that preventing
the introduction of contraband into the jail is the primary reason for the ban on
contact visits. The district court chose to credit that testimony and we cannot
say that its decision was clearly erroneous. The court found that "(a)llowing
contact visits would present a security problem at the jail." Thus, even though
the chance of additional contraband reaching the jail as a result of contact visits
may be remote, jail officials may reasonably act to remove even that remote

possibility.
21

Similarly, the existence of other less restrictive alternatives is also not

dispositive. As the Court indicated in Wolfish, unless the decision of prison
authorities has a punitive purpose or is unreasonable or exaggerated in relation
to an otherwise legitimate purpose, it is entitled to deference.

22

There is no indication in the record that the prohibition was adopted for
purposes of punishment. The Inmates, however, further argue that the
prohibition of contact visits encroaches upon a fundamental zone of privacy,
the family relationship, and therefore, is deserving of heightened scrutiny even
under Bell v. Wolfish. However, assuming a fundamental right is implicated by
the prohibition of contact visits, we believe that prohibition to be a permissible
restriction in the context of this case.

23

As the Court noted in Wolfish, "even when an institutional restriction infringes

a specific constitutional guarantee . . . the practice must be evaluated in the
light of the central objective of prison administration, safeguarding institutional
security." Bell v. Wolfish, supra, 441 U.S. at 547, 99 S.Ct. at 1878. See Jones
v. North Carolina Prisoners' Labor Union, 433 U.S. 119, 129, 97 S.Ct. 2532, 53
L.Ed.2d 629 (1977). As we noted above, the prohibition of contact visits is a
reasonable response to legitimate concerns of prison security. An inmate is not
precluded from visiting with members of his family and others, but only from
physical contact with those individuals.3 Thus the restriction is specifically
tailored to meet the perceived security problem. Further, the district court noted
that, were contact visits to be allowed, other costly and extensive security
measures would be required to prevent the entry of contraband. Where contact
visits are allowed such measures include: installation of metal detectors,
fluoroscopes, strip search rooms, and the testing of urine samples for drugs.
The court found that requiring these in the antiquated facilities of the
Allegheny County jail "would place an undue burden on the administration." In
such circumstances, a ban on contact visits represents a reasonable choice by
prison officials between alternative methods of protecting the legitimate
security interests of the jail.4 Thus, we affirm the holding of the court
permitting the jail officials to prohibit contact visits.

III.
24

The Inmates' next claim is that the district court erred in its finding that the
system of methadone treatment at the jail does not constitute a denial of due
process. Inmates of the jail who have been receiving methadone treatment prior
to incarceration from an approved clinic in Allegheny County5 are given

methadone treatment through their sixth day of confinement, after which

treatment is terminated.6
25

The testimony of the medical experts conflicted; one testified that seven days of
methadone treatment would be sufficient and another advocated administering
decreasing methadone dosages over a twenty-one day period. Both the prior
and present jail physicians approved of the jail's program of treatment. The
district court concluded that the appropriate form of treatment involved a
"discrete medical judgment" and it found no abuse of discretion of the jail
physicians regarding the choice of treatment. On this record, we perceive no
"deliberate indifference" to the inmates' serious medical needs in disregard of
the standard enunciated in Estelle v. Gamble, 429 U.S. 97, 105-06, 97 S.Ct.
285, 50 L.Ed.2d 251 (1976).

26

The Inmates, however, argue that our opinion in Norris v. Frame, 585 F.2d
1183 (3d Cir. 1978), requires that we vacate the district court's holding and
remand for further fact finding. In Norris, we held that because Pennsylvania
has by regulation provided specific procedures for termination of methadone
treatment, Id. at 1189 n.17, a pretrial detainee who has been receiving such
treatment in an approved program prior to incarceration, has a due process
liberty interest in the continuation of such treatment. We held that when prison
officials seek to terminate that treatment other than in accordance with the
procedures required by that regulation they must "demonstrate . . . a legitimate
security concern, or a genuine fear of substantial administrative disruption." Id.
at 1185.

27

Our opinion in Norris, however, must be read in light of the Supreme Court's
opinion in Bell v. Wolfish, supra. There the Supreme Court set forth the
standard to be used in evaluating the constitutionality of conditions of pretrial
confinement. The governing inquiry, as we noted above, is whether the
particular condition or restriction has a punitive purpose. "Absent a showing of
an expressed intent to punish on the part of detention facility officials," we
must determine "(w)hether an alternative purpose to which (the restriction) may
rationally be connected is assignable for it, and whether it appears excessive in
relation to the alternative purpose assigned (to it)." Bell v. Wolfish, supra, 441
U.S. at 538, 99 S.Ct. at 1873-1874.

28

In this case, there is nothing in either the district court's opinion or the record of
the testimony presented at trial which indicates a punitive purpose on the part
of jail authorities. The district court itself held that, given the circumstances,
the methadone treatment provided at the jail constituted a reasonable medical
decision. We believe the record supports the court's conclusion.

29

There also appears to be a permissible purpose in curtailing the methadone

treatment. Jail authorities may reasonably act so as to exclude contraband from
the jail environment. See Bell v. Wolfish, supra. Thus, they may prohibit
contact visits, regulate the material received by inmates from outside the jail, or
institute strip searches of inmates after contact visits with non-inmates. Such
measures have been held to be reasonably related to the legitimate concerns of
institutional security. This type of concern is also evinced in the testimony of
the jail wardens. It appears to us that such a legitimate security interest is also
present in the jail's restriction of methadone treatment. Drug use in jails or
prison facilities is certainly of the utmost concern to jail and prison authorities.
That is true whether the drug is heroin, marijuana, or methadone. The potential
for jail or prison disruption caused by the presence of drugs is well-known.
Thus, jail authorities have a legitimate security concern in limiting exposure of
inmates to drugs, even those administered on a controlled basis, to as short a
period of time as is medically reasonable. We therefore perceive no error in the
district court's approval of the methadone detoxification program.

IV.
30

The Inmates' final contention is that the relief granted by the district court, fails
to raise the level of psychiatric care at the jail to the constitutionally required
minimum.

31

Expert testimony at trial indicated that, of an average daily population at the

jail of approximately 430 inmates, between 60 and 80 could reasonably be
expected to have "easily identifiable and fairly serious mental health problems."
Notwithstanding, there are no psychiatric care professionals on the staff of the
jail. The medical staff consists of one part-time physician and five registered
nurses. Although the doctor is on call twenty-four hours a day he spends
approximately two hours a day at the jail. Of this, generally less than fifteen
minutes per day is spent in the jail hospital which includes the restraint ward.
Testimony indicated that the doctor spends approximately 35 seconds with each
patient in restraint in reaching his decision as to the need for continued restraint.
No nurses are stationed in the jail hospital. A nurse will visit the hospital twice
every shift for fifteen or twenty minutes in order to dispense medication.

32

Some assistance is provided to the jail physician by the psychiatrists of the

Allegheny County Behavior Clinic. The Clinic is under the jurisdiction of the
Allegheny County Court of Common Pleas and is responsible for evaluating all
persons charged with homicide, sex offenses, and certain other crimes
regardless of whether they are incarcerated. The Clinic, however, has no formal
responsibility for psychiatric diagnosis and treatment of inmates of the jail.

Nevertheless, when requested by the jail physician, a Behavior Clinic

psychiatrist will see patients at the jail and recommend medication. The
decision whether to actually prescribe and administer the medicine remains
with the jail physician, however. This is because the Clinic is primarily
diagnostic and is not involved in treatment. Even then, testimony indicates the
psychiatrist will generally see a patient only one time, although where deemed
necessary more visits will be made. From the record it appears that the
diagnosis offered by the Clinic is conclusory and without the sort of full
explanation that would normally be offered if the case had been referred by
another physician. The record also indicates that restraint and administration of
psychotropic medication remain the primary methods of treatment for
psychiatric disturbances at the jail. Expert testimony indicates that without the
close supervision that is lacking at the jail, administration of such drugs is
likely to be either ineffective or dangerous.
33

The district court's order does provide some relief: the court forbade the further
use of restraint cots, limited the use of restraints in general, and ordered that all
nurses at the jail receive psychiatric training. The court, however, expressed no
finding as to the adequacy of psychiatric care at the jail.

34

Although negligence in the administration of medical treatment to prisoners is

not itself actionable under the Constitution, failure to provide adequate
treatment is a violation of the eighth amendment when it results from
"deliberate indifference to a prisoner's serious illness or injury." Estelle v.
Gamble, 429 U.S. 97, 105, 97 S.Ct. 285, 291, 50 L.Ed.2d 251 (1976). Because
the case before us involves pretrial detainees, rather than convicted prisoners,
our analysis must proceed under the Due Process Clause of the fourteenth
amendment rather than the eighth amendment. See Bell v. Wolfish, supra, 441
U.S. at 535, 99 S.Ct. 1861. Nevertheless, "(i)t would be anomalous to afford a
pretrial detainee less constitutional protection than one who has been
convicted." Hampton v. Holmesburg Prison Officials, 546 F.2d 1077, 1079-80
(3d Cir. 1976). Thus, at a minimum the "deliberate indifference" standard of
Estelle v. Gamble, must be met. As we noted in West v. Keve, 571 F.2d 158
(3d Cir. 1978), the Estelle test is two-pronged. "It requires deliberate
indifference on the part of prison officials and it requires the prisoner's medical
needs to be serious." Id. at 161.

35

Appropriately, this test affords considerable latitude to prison medical

authorities in the diagnosis and treatment of the medical problems of inmate
patients. Courts will "disavow any attempt to second-guess the propriety or
adequacy of a particular course of treatment . . . (which) remains a question of
sound professional judgment." Bowring v. Godwin, 551 F.2d 44, 48 (4th Cir.

1977). Implicit in this deference to prison medical authorities is the assumption

that such an informed judgment has, in fact, been made. When, however, prison
authorities prevent an inmate from receiving recommended treatment for
serious medical needs or deny access to a physician capable of evaluating the
need for such treatment, the constitutional standard of Estelle has been violated.
West v. Keve, supra, 571 F.2d at 162.
36

Systemic deficiencies in staffing which effectively deny inmates access to

qualified medical personnel for diagnosis and treatment of serious health
problems have been held to violate constitutional requirements. In Gates v.
Collier, 349 F.Supp. 881 (N.D.Miss.1972), Aff'd, 501 F.2d 1291 (5th Cir.
1974), for instance, the court found that "(t)he medical staff and available
facilities (at the Mississippi State Penitentiary) fail to provide adequate medical
(treatment) for the inmate population." 349 F.Supp. at 888. As a result the
court ordered the hiring of additional medical staff, both physicians and nurses,
to bring the level of medical care up to the constitutional minimum.

37

In Newman v. Alabama, 349 F.Supp. 278 (M.D.Ala.1972), Aff'd, 503 F.2d

1320 (5th Cir. 1974), Cert. denied, 421 U.S. 948, 95 S.Ct. 1680, 44 L.Ed.2d
102 (1975), the court found that "gross understaffing" of medical facilities in
the Alabama prison system constituted a constitutional violation. As the Second
Circuit noted in Todaro v. Ward, 565 F.2d 48, 52 (2d Cir. 1977), "(w) hen
systematic deficiencies in staffing, facilities or procedures make unnecessary
suffering inevitable, a court will not hesitate to use its injunctive powers." See
Bishop v. Stoneman, 508 F.2d 1224 (2d Cir. 1974). Thus, where the size of the
medical staff at a prison in relation to the number of inmates having serious
health problems constitutes an effective denial of access to diagnosis and
treatment by qualified health care professionals, the "deliberate indifference"
standard of Estelle v. Gamble has been violated. In such circumstances, the
exercise of informed professional judgment as to the serious medical problems
of individual inmates is precluded by the patently inadequate size of the staff.

38

Although most challenges to prison medical treatment have focused on the

alleged deficiencies of medical treatment for physical ills, we perceive no
reason why psychological or psychiatric care should not be held to the same
standard. The leading case in this respect is Bowring v. Godwin, supra. There,
in holding that a convicted prisoner is entitled to psychological or psychiatric
care for serious mental or emotional illness, the court noted that it saw "no
underlying distinction between the right to medical care for physical ills and its
psychological or psychiatric counterpart." Bowring v. Godwin, supra, 551 F.2d
at 47. See Laaman v. Helgemoe, 437 F.Supp. 269 (D.N.H.1977). Further,
expert testimony received at trial in the instant case indicated that the failure to

provide necessary psychological or psychiatric treatment to inmates with

serious mental or emotional disturbances will result in the infliction of pain and
suffering just as real as would result from the failure to treat serious physical
ailments. Thus, the "deliberate indifference" standard of Estelle v. Gamble is
applicable in evaluating the constitutional adequacy of psychological or
psychiatric care provided at a jail or prison. The key factor in determining
whether a system for psychological or psychiatric care in a jail or prison is
constitutionally adequate7 is whether inmates with serious mental or emotional
illnesses or disturbances are provided reasonable access to medical personnel
qualified to diagnose and treat such illnesses or disturbances. We hold that,
when inmates with serious mental ills are effectively prevented from being
diagnosed and treated by qualified professionals, the system of care does not
meet the constitutional requirements set forth by Estelle v. Gamble, supra, and
thus violates the Due Process Clause.
39

The record before us indicates there are substantial deficiencies in the system of
psychiatric care at the Allegheny County Jail. Nevertheless, we are not
confident that the record accurately reflects existing conditions at the jail. As
indicated at oral argument, it does not contain the two reports of the advisor
appointed by the district court nor does it reflect the change in conditions
caused by the district court's order.8 Furthermore, the district court did not
make a specific finding as to the adequacy of the system for psychiatric care at
the jail. We, therefore, remand to the district court for its determination whether
the level of psychiatric care meets the constitutional minimum in light of the
standards which we have articulated.9 Should the district court determine that
the constitutional requirements have not been satisfied, it will then, of course,
order such relief as it finds is required.

V.
40

The judgment of the district court accordingly will be affirmed on the issue of
contact visitation and drug detoxification. The district court's judgment on the
issue of psychiatric care will be vacated and the case remanded for further
proceedings not inconsistent with this opinion.

41

Each side to bear its own costs.

42

ALDISERT, Circuit Judge, concurring and dissenting.

43

Because I find no error in the disposition by the trial court of the three basic
constitutional issues presented by this appeal contact visits, methadone

treatment, and psychiatric care I would affirm the judgment of the district court
in full. Accordingly, I join parts II and III of Judge Rosenn's opinion affirming
those portions of the district court's judgment which determine that the county
jail rules prohibiting contact visitations and administering methadone treatment
do not offend the fourteenth amendment. For the reasons that follow, however,
I dissent from the majority's reversal of that part of the judgment relating to
psychiatric care.
I.
44

In Estelle v. Gamble, 429 U.S. 97, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976), the
prisoner-plaintiff suffered a back injury during a prison work assignment when
a bale of cotton fell on him. He was initially examined and returned to work but
then was re-examined, prescribed a painkiller, and permitted to remain in his
cell. During a three month period he was seen by medical personnel on
seventeen occasions but, allegedly, was treated inadequately for his back injury,
high blood pressure, and heart problems. Presented with the opportunity for
deciding when faulty medical treatment of an inmate amounts to a
constitutional deprivation, the Court determined that the government has an
obligation to provide medical care for those it is punishing by incarceration,
that Denial of medical care causes pain and suffering inconsistent with
contemporary standards of decency, and then concluded that deliberate
indifference to serious medical needs of prisoners constitutes a violation of the
eighth amendment:

45
(D)eliberate
indifference to serious medical needs of prisoners constitutes the
"unnecessary and wanton infliction of pain" . . . proscribed by the Eighth
Amendment. This is true whether the indifference is manifested by prison doctors in
their response to the prisoner's needs or by prison guards in intentionally denying or
delaying access to medical care or intentionally interfering with the treatment once
proscribed. Regardless of how evidenced, deliberate indifference to a prisoner's
serious illness or injury states a cause of action under 1983.
46

429 U.S. at 104-05, 97 S.Ct. at 291 (citations and footnotes omitted). The
deliberate indifference standard, however, was clarified by the Court to include
only "wanton infliction of unnecessary pain" and not circumstances caused by
an accident or by inadvertent failure:

47
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.
48

429 U.S. at 106, 97 S.Ct. at 292. Subsequently, in Bell v. Wolfish, 441 U.S.
520, 535, 99 S.Ct. 1861, 60 L.Ed.2d 447 (1979), the Court specifically
instructed that the proper constitutional inquiry is whether conditions of pretrial
detention amount to punishment of the detainee.

49

It is against the standards announced in Estelle and Wolfish that we must

evaluate the claims that the psychiatric procedures offend the eighth and
fourteenth amendments. In my view, the legal precepts that control require us to
decide whether appellants met their burden of proof before the district court by
satisfying (1) the test of Estelle : whether there was "deliberate indifference to
serious medical needs" constituting "unnecessary and wanton infliction of
pain," and (2) the test of Wolfish : whether conditions or medical treatment
were designed "for the purpose of punishment," or if not expressly so designed,
were "not reasonably related to a legitimate goal," or were "arbitrary or
purposeless." 441 U.S. at 539, 99 S.Ct. at 1874.

II.
50

Applying these legal precepts to the facts adduced at trial on the adequacy of
psychiatric treatment, I concur in the result reached by the district court. I agree
with the majority that the district court made no findings Ipsissimis verbis as to
the adequacy of psychiatric care at the jail, but after examining a voluminous
record and a comprehensive opinion dealing with many phases of jail
conditions, supplemented by decrees which ordered sweeping reforms, I find
no fault in the district court's final resolution of the constitutional issues relating
to psychiatric care. By ordering special training for the nurses, the district court
implicitly considered it unnecessary to require the jail to install additional
professional staff or procedures in order to meet minimum constitutional
standards. Judge Cohill ordered:

51 A sufficient number of nurses who qualify as psychiatric nurses shall be

14.
employed so that there will be at least one psychiatric nurse on duty at the jail at all
times.
52

Appendix for Appellants at 76a.

53 The defendants shall, by January 1, 1979, arrange for a training program for
25.
present and future jail nurses in the area of psychiatric nursing. All present jail
nurses must enroll in the program as soon as it is established. All nurses employed

by the jail in the future shall, within six months of their date of employment,
complete said training course.
54

Id. at 96a-97a.

55

The testimony concerning adequate psychiatric care was conflicting. Appellants

presented expert witnesses supporting the necessity for expanded services.
Appellees presented expert testimony to the contrary. Dr. Alphonse J. Cipriani
described how the jail physicians referred appropriate cases to a psychiatric
setting if the symptoms warranted:

56

Q. But in the case of men who have psychiatric disorders, specifically, (the
nurses) are not trained?

57

A. No. As I indicated before, we are into a philosophical question, I would

repeat for the Court, this is a County Jail with a medical infirmary, a medical
hospital, a medical restraining room. We are a County Jail.

58

I am not, and we are not a psychiatric hospital. We are not a psychiatric unit.
The patients, as I said before, get adequate care until final disposition is made.

59

Now if final disposition means within 24 hours I should have this patient in a
general hospital, that's where he or she goes. If it means that this patient should
be in a psychiatric setting immediately even before the psychiatric consultation
agrees, I told you, that is the way that patient would be handled, the
disposition.

60

But in terms of being a County Jail, they are getting good, adequate psychiatric
and general medical care for that period of time that they are there until the
Court decides the final disposition.

61

It is my opinion. That's what I have observed in three months.

62

Appendix for Appellees at 6b.

63

Testimony was also adduced that a jail physician is on call twenty-four hours a
day and is actually on the premises approximately two and one-half hours a
day, and that the services of the Allegheny County Behavior Clinic, an arm of
the court of common pleas, are available to the inmates. Five psychiatrists and
two psychologists from the clinic "have direct involvement in the Allegheny

County Jail." Appendix for Appellants at 369a. The director of the clinic
testified that the clinic acts as "psychiatric consultant to Dr. Smith, the jail
physician." Id. at 372a. Upon request of the jail physician, an inmate will be
examined by a Behavior Clinic psychiatrist, a diagnosis will be made, and
medication or other treatment will be recommended to the jail physician. Id. at
374a. These psychiatrists are available five days a week. Id. at 385a.
64

On this record I cannot conclude that appellants met either their burden under
Estelle of proving "deliberate indifference to serious medical needs" or the test
of Wolfish, that the professional psychiatric care was "(designed) for the
purpose of punishment," or if not expressly so designed, was "arbitrary or
purposeless." For their part, the majority conclude that they "are not confident
that the record accurately reflects existing conditions at the jail." Maj. Op., at
763. The function of an appellate court in the Anglo-American tradition,
however, is to review the judgment of the district court based on the record
before it. Having reviewed that record I would affirm the judgment of the
district court in all respects.

Inmates are allowed to have visitors three times per week for one hour

Arnold Pontesso was appointed by the district court as its advisor in this case.
He previously served as Director of Corrections for the State of Oklahoma as
well as Warden of the Federal Reformatory in El Reno, Oklahoma

We note that the restriction at issue here does not prevent visits from noninmates but only prohibits contact visits. See Valentine v. Englehart, 474
F.Supp. 294 (D.N.J., 1979) (court holds ban on visits by children
unconstitutional under Bell v. Wolfish.)

Although the issue was not before it in Wolfish, the Court implied that
prohibition of contact visits is a reasonable alternative to body cavity searches
in preventing contraband from entering a jail or prison. Bell v. Wolfish, 441
U.S. at 559-60, 99 S.Ct. 1861 n. 40

Currently, inmates who have been receiving methadone treatment from clinics
located outside Allegheny County receive no methadone treatment after
incarceration. The district court found this "uneven treatment" to constitute a
violation of the Equal Protection Clause. Nevertheless, the court apparently
ordered no relief in this regard and the parties do not raise the issue on appeal

The district court, however, found that the inmate can request other medication
to help ease the effects of his methadone or heroin withdrawal. Those

dispensed at the jail included the tranquilizer Sparine and such medicine as
Tylenol, Maalox, and Benadryl
7

We caution, however, that even though the System of care may itself be
constitutionally sufficient the refusal to make that system of care available to a
particular inmate may itself be unconstitutional. See Bowring v. Godwin,
supra. We are not faced with that issue here, however, and express no opinion
as to the relevant standards to be applied in making that determination

The Board, for instance, alleged at oral argument that the improved
recordkeeping required by the district court's order indicates that psychiatrists
from the Behavior Clinic now spend a substantial amount of time at the jail

The district court may receive whatever additional evidence it deems relevant
in making that determination