Anthony Wade had suicide on the brain. While incarcerated and awaiting trial for second degree murder, Wade attempted suicide by overdosing on Thorazine, a drug he had been prescribed to combat voices in his head. He was then prescribed a liquid medication and was diagnosed as being severely depressed. In one of his last interviews before beginning his prison sentence, Wade told officials that he had a suicide plan but refused to share the details. After returning from a psychiatric hospital, Wade began therapy along with his 25-60 year sentence in state prison.
Wade met with defendant psychiatrist Dr. Mehra. Mehra recommended that Wade be prescribed Sinequan, an antidepressant with sedating properties. Wade also met with defendant Dr. Cabrera. Cabrera, who Wade saw monthly, determined that Wade's condition was becoming severe and prescribed more anti-depressants.
Defendant Dr. Rodriguez, who met with Wade in between visits with defendant Cabrera, noted that Wade was not suicidal. Due to a scheduling error, Wade met with psychologist James Little, whose notes indicated that Wade was very angry about being incarcerated and that he wanted to kill himself.
Within weeks, Wade was dead, having overdosed on his antidepressant medication.
Wade's representatives sued the doctors for civil damages. The issue was whether or not the defendants had exhibited deliberate indifference to Wade's medical needs by providing inadequate care and prescribing medication in tablet rather than liquid form.
Holding: Plaintiff failed to state a claim against Mehra but had stated one for deliberate indifference by Cabrera and Rodriguez. To prove deliberate indifference, the plaintiff had to show that Wade's Eighth Amendment right to be free from cruel and unusual punishment had been infringed because he had not been given necessary medical treatment.
Medical malpractice does not become a constitutional violation merely because the victim is a prisoner, the court stated. The plaintiff had to show that the defendants acted or failed to act despite knowledge of a substantial risk of serious harm. The court one judge dissenting, noted that Mehra's negligence in failing to take extra precautions did not comprise an Eighth Amendment violation. Cabrera and Rodriguez, however, were well aware of Wade's plans to commit suicide and their continued course of treatment constituted deliberate indifference to the risk of death.
| Robert Miller, M.D. Professor of Psychiatry University of Denver |
Dr. Miller comments: Williams raises several issues unique to psychiatrists who work in jails and prisons. The first is the conditions under which correctional psychiatrists work. The second is that, in addition to medical malpractice, they can be sued for violating inmates' constitutional rights by showing deliberate indifference to their serious medical needs.
The first issue is more relevant to individual psychiatrists, since it makes little difference to them under which statutes they are sued. The most important question is whether correctional psychiatrists should be held to the same standards of practice as psychiatrists working in other areas of practice. Since psychiatry is considered to be a medical specialty, the law imposes a national standard of practice, thus holding all psychiatrists to the same standard. While there is no question that correctional psychiatrists differ by practicing in systems whose primary goal is not the provision of adequate medical care, the courts have not held that limitations in resources excuse psychiatrists from liability; nor should they.
The American Psychiatric Association's Task Force Report on Psychiatric Services in Jails and Prisons states that "The goal [of providing treatment to inmates] is to provide the same level of mental health services to inmates that are available in the community." In addition to practicing minimally adequate psychiatry (all that the courts require), correctional psychiatrists have a professional obligation to develop specific expertise in working with correctional patients and in correctional systems.
Disorders such as Antisocial Personality (and more importantly, psychopathy) adult Attention Deficit Hyperactivity Disorder, the paraphilias and gender identity disorders, are much more common in forensic populations, as are treatment-resistant and non-compliant patients. In addition, inmates are much more likely than are other types of patients to hoard medication, for suicide or for barter, even going so far as to regurgitate swallowed medications and store or sell them.
Psychiatrists also have a responsibility to act as advocates for humane treatment and adequate resources for mentally disordered inmates, although their status (the great majority are part-time) frequently diminishes their influence. The APA Task Force states that "Psychiatrists must define their professional responsibilities to include advocacy for improving mental health services. They should identify and report problems, first to correctional administrators, and then, if necessary, to other regulatory and advocacy bodies." Unfortunately, many full-time correctional mental health professionals become cynical, and are as much a part of the problem as are guards and wardens. Since correctional psychiatrists may be found responsible for providing inadequate resources, tort liability provides not only an incentive for psychiatrists, but a bargaining tool for negotiating with administration.
In a correctional setting, particular caution needs to be exercised around medication, even if it causes extra expense. Liquid medications are more expensive that pills, one reason why their use is discouraged in cost-conscious systems. But the choice of treatment here certainly deviates from psychiatric care. Deliberate indifference, however, which has been traditionally reserved for cases in which treatment has been denied entirely, rather than administered negligently. The frequency and substance of the psychiatric and psychological contacts, and the active treatment provided here, do not demonstrate systematic neglect traditionally associated with deliberate indifference.
| Robert Sherman, Esq. Greenberg Traurig LLP |
Attorney Sherman comments: An old expression among legal practitioners teaches that hard cases make bad law. Williams may be a prime example. Why? Let us first understand the right at stake.
This is not a medical malpractice claim where the standard for recovery is simple negligence, i.e., whether the practitioner deviated from accepted practice in the local community. Instead, the allegation here is of a civil rights violation—that the prison psychiatrists infringed upon a constitutionally protected right. (It is hard to know why a medical malpractice claim was not also alleged since the opinion is silent on the point. It may be that liability limitations under the law of Michigan foreclosed a claim or at least made such a claim economically impractical. Or, it could be that a settlement already had been reached on a malpractice count which made it no longer part of the case). To recover on a civil rights theory, a showing of mere negligence does not suffice. Instead, the plaintiff must prove that: a) he was deprived of a constitutionally protected right; and b) that the defendants acted with deliberate indifference to that right.
The first prong of that standard is not in dispute. It is well established in the law that even prisoners do not lose all constitutional rights by virtue of their confinement. Prisoners have a constitutionally protected right to receive necessary medical treatment. Here, the case turns on the application of the second prong of the test—whether Anthony Wade's suicide was the result of deliberate indifference by the psychiatrists. On its face, the answer seems self-evident. The psychiatrists had all examined Wade, had reviewed his records and had concluded, albeit wrongly, that he did not present an imminent danger of suicide. Indeed, they did not ignore his needs but maintained him on his medication for depression and added individual psychotherapy to his treatment regime. Those facts are hardly consistent with an attitude, to paraphrase the dissent, of "what the hell, we know he's suicidal, but we just don't give a damn." Even if there was indifference to his needs, at most it seems negligent, not deliberate.
Divorced from the cold legal standard, the facts do present a compelling indictment of the prison mental health system. At the end of the day, that appears to be what the majority simply could not ignore. In their view, even the most minimally competent psychiatric care would have prevented his suicide. The records accompanying Wade to state prison were replete with warnings about the level of dangerousness he presented to himself, He had tried to commit suicide before, had suicidal ideations, and even a suicide plan. This man was a serious risk—he was not getting better, but worse, in terms of coping with his long term confinement. Simple steps, like instituting a close watch on him and ensuring that he received his medication in liquid rather than pill form could have prevented this tragedy from occurring. The majority felt that to condone what they viewed as gross negligence would have sent an ugly message to prison officials regarding their responsibilities for those entrusted to their care. Yet what about the applicable legal standard? Deliberate now seems to include unintentional conduct. The majority found the facts hard to ignore. And hard cases make bad law.
