March 31, 1993 UNITED STATES COURT OF APPEALS FOR THE FIRST CIRCUIT
No. 92-1343
ROBERT E. CAMERON,
Plaintiff, Appellee,
v.
HENRY TOMES, ET AL.,
Defendants, Appellants.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MASSACHUSETTS
[Hon. Robert E. Keeton, U.S. District Judge]
Before
Selya, Circuit Judge,
Coffin, Senior Circuit Judge,
and Boudin, Circuit Judge.
Elisabeth J. Medvedow, Assistant Attorney General, Commonwealth
of Massachusetts, with whom Scott Harshbarger, Attorney General,
Commonwealth of Massachusetts, was on brief for appellant. David M. Rocchio with whom Robert D. Keefe, Mark G. Matuschak,
and Hale and Dorr were on brief for appellee.
March 31, 1993
BOUDIN, Circuit Judge. This case was brought by Robert
Cameron, who is currently detained in the Massachusetts
Treatment Center for the Sexually Dangerous ("the Treatment
Center"). The defendants, whom we refer to as "the state,"
are officials who are responsible for the Treatment Center.
In substance, Cameron complains that his conditions of
confinement violate the Due Process Clause of the Fourteenth
Amendment and his asserted constitutional "right to
treatment."
After a bench trial the district court granted
injunctive relief and the state appealed. We modify the
injunction in accordance with this opinion and, with certain
clarifications, otherwise affirm most of the relief ordered
by the district court. Our decision is based upon the
district court's findings but rests upon somewhat different
legal grounds.
I. THE FACTS AND PRIOR PROCEEDINGS
On December 13, 1978, Cameron was convicted in Vermont
of aggravated assault with a deadly weapon and sexual
assault--apparently attempted rape--and sentenced to a term
of six to twenty years. He was then extradited to
Massachusetts and convicted on September 12, 1979, for
assault with intent to rape, kidnapping, and other crimes,
and sentenced to a term of ten to twenty years, commencing
after the Vermont sentence. On being paroled by Vermont on
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July 12, 1982, Cameron began serving his Massachusetts
sentence, which at the time of trial was set to expire in the
year 2002.1
After serving several years in a Massachusetts prison,
Cameron on November 14, 1985, was adjudged by the
Massachusetts Superior Court to be a sexually dangerous
person under M.G.L. c. 123A, and committed to the Treatment
Center for a period of one day to life. The occasion for the
commitment is not described. The Treatment Center, one of
several facilities located at MCI Bridgewater, has a
checkered history, much of it embroiled in litigation, e.g.,
Langton v. Johnston, 928 F.2d 1206 (1st Cir. 1991), and
M.G.L. c. 123A itself has an uncertain future.2 Most of the
Treatment Center's inhabitants have underlying criminal
convictions, and it is administered jointly by the
Departments of Mental Health and Corrections to address both
the medical and security aims of the Center. Cameron's stay
1The district court opinion recites that the Massachusetts sentence ended in February 1992; but the parties advise us that Cameron's release date at the time of trial was 2002. Cameron's brief says that this period may be shortened by good time credits and possible parole.
2The statute is one of the so-called sexual psychopath laws enacted in the 1940s in a number of states. See C.
Tenney, Sex, Sanity and Stupidity in Massachusetts, 42 B.U.L.
Rev. 1 (1962). In 1990, the Massachusetts legislature curtailed new admissions into the Treatment Center. See
Langton, 928 F.2d at 1209.
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at the Treatment Center appears to have been even more
unhappy than normal.
Although the parties agree on little else, it appears
that Cameron who is 50 years old and a Vietnam veteran
suffers from severe psychological disorders. In the words of
the district court, "Cameron suffers from a borderline or
mixed personality disorder and post-traumatic stress
disorder. There is also no dispute that as a result . . . he
may often act in a paranoid and confrontational manner."
Cameron v. Tomes, 783 F. Supp. 1511, 1517 (D. Mass. 1992).
Psychological treatment is available at the Treatment Center-
-indeed, its availability is provided for under a consent
judgment entered many years ago3--but Cameron found what was
offered unsuitable until 1989 when he established a working
relationship with a therapist.
In the meantime, Cameron brought the present suit in
1986 challenging his conditions of confinement. Counsel was
assigned, his claims evolved, and in December 1991 and
January 1992, the district court conducted a six-day bench
trial in the case. In his opinion issued on February 14,
1992, the district judge declared that Cameron had a
3Regulations adopted pursuant to the decree provide that "[e]very patient shall be offered treatment to effect his early return to public society. Such treatment shall consist of medical, psychiatric [and other services] . . . Such treatment shall be administered . . . in the least restrictive conditions which are consistent with [the patient's] security needs." Langton, 928 F.2d at 1211.
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"constitutional right to minimally adequate treatment [for
his mental disorders] based upon the exercise of professional
judgment." 783 F. Supp. at 1516. The court rejected a
motion to dismiss by the state, which had argued that no such
constitutional right existed. Id. It also rejected the
state's res judicata defense, id. at 1516-17, based on the
Langton case where a different district judge had found that
the Treatment Center was in general compliance with the
consent decree. See Langton, 928 F.2d at 1208-16.
The district court then ruled that, on a number of
issues, those in charge of the Treatment Center had made
judgments about Cameron and enforced policies against him
without, or contrary to, the advice of the medical
professionals involved in his treatment. 783 F. Supp. at
1518-25. The district court made specific findings relating
to Cameron's access to outside medical care, the use of
shackles and an armed guard in transporting him, his housing
in the facility, physical searches of him, and similar
matters. The court then granted injunctive relief on ten
different matters. Id. at 1526-27.
First, and most broadly, the court ordered the pertinent
administrative board within the Treatment Center to conduct
an immediate review of his current sexual dangerousness,
appropriate treatment and conditions, and his request to
participate in what is called the community access program.
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783 F. Supp. at 1526. This injunctive provision ended by
stating: "All final decisions on Cameron's long-term
treatment, including his participation in the community
access program, must be made by a qualified professional, or
with due respect and regard for the judgment of a qualified
professional." Id.
Several other decree provisions are similarly qualified.
The court suspended the use of shackles and an armed guard in
transporting Cameron for outside medical care unless and
until "a qualified decision maker determines through the
exercise of professional judgment that such restraints are
professionally acceptable, based on a weighing of [the
state's] needs along with Cameron's treatment needs." 783 F.
Supp. at 1526. Prohibited, under a similar condition, were
subjecting Cameron to a restrictive internal movement policy,
to an intrusive search procedure previously used and so-
called "oral cavity searches," and to the "current
disciplinary system" of the Treatment Center. Id. at 1526-
27.
Finally, without any qualification as to professional
judgment, the court ordered that Cameron be allowed medical
treatment at Veterans Administration facilities for specific
medical conditions, that he be allowed housing in the maximum
privilege unit of the Treatment Center without consenting to
share a room, and that a handicapped accessible room be
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immediately made available to him. 783 F. Supp. at 1526.
This last direction, as well as several of the others, was
related to physical disabilities suffered by Cameron,
including the amputation of a leg due to infection while
Cameron was in the care of the state.
II. DISCUSSION
Res Judicata. The state's threshold objection to the
suit is that Cameron's claims are encompassed by prior
litigation and are therefore barred as res judicata.
Emphasizing the "claim preclusion" branch of res judicata,
the state's brief says that one of the consolidated district
court cases embraced by Langton--Bruder v. Johnston--was a
class action suit concerning the right to treatment for all
persons confined at the Treatment Center as of 1987.
Cameron, says the state, was a member of the class and the
state prevailed in that case on the ground that treatment was
adequately provided.
We agree with the district court that the state has made
no showing that Cameron's claim is barred by res judicata.
Cases on res judicata, ample in many areas, are fairly sparse
where preclusion of distinctive individual claims is urged
based upon an earlier class action judgment. But in Cooper
v. Federal Reserve Bank of Richmond, 467 U.S. 880 (1984), the
Supreme Court confirmed what common sense would suggest: a
class action judgment--there, in a discrimination case--binds
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the class members as to matters actually litigated but does
not resolve any claim based on individual circumstances that
was not addressed in the class action. Id. at 880-82.
Under Cooper, we think that res judicata plainly does
not apply in this instance. The several law suits and years
of proceedings embraced by Langton require pages to describe,
but the suits were concerned with fairly general issues
(e.g., physical plant, sequestration, equality of treatment)
and with specific claims of individuals other than Cameron.4
The closest that that litigation came to this case was (1)
endorsement of a general requirement of treatment set forth
in state regulations, (2) rejection of a charge that the
authorized absence program was underutilized, and (3)
rejection of a general attack on the "double bunking"
requirement. These claims dealt with the general condition
of inhabitants of the Treatment Center. If Langton has
anything else in common with this case, the state has not
mentioned it.
This case, by contrast, rests primarily on Cameron's
claims that his unusual situation requires special
accommodations: specifically, that his physical disability
affects his need for outside medical visits, freer movement
4A detailed history of the litigation and the issues decided is contained in the thorough, 171-page, unpublished decision of Judge Mazzone, which this court in Langton
affirmed on all issues apart from attorney's fees.
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within the Treatment Center, and separate bunking
arrangements adapted to his handicap, and that his mental
condition (what lay people would probably call paranoia)
makes ordinary physical searches, disciplinary arrangements
and other constraints unsuitable, indeed psychologically
dangerous, for him. There is no suggestion by the state that
these issues peculiar to Cameron were actually litigated in
the Langton case.
Thus, the state's claim reduces itself to the argument
that Cameron had to litigate those issues in the earlier
cases or forever hold his peace. To describe this claim is
to refute it: class action institutional litigation often
addresses general circumstances, not the distinctive plight
of someone claiming special needs or status. To the extent
individual concerns were addressed in Langton, Cameron is not
even mentioned in the district court decision. Nor could
earlier cases deal with later occurring events that are a
part of Cameron's present case. In theory, claim preclusion
is possible where an earlier class action claim is
essentially the same as a later action for individual relief,
and issue preclusion is possible where a fact resolved in the
class action proves important in the later action. See
Cooper, 467 U.S. at 880-82. No such overlap has been shown
here.
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The Merits. The district court in this case premised
its decision on what it deemed to be two established
constitutional rights possessed by those at the Treatment
Center: "a constitutional right to minimally adequate
treatment [for mental disorders] based upon the exercise of
professional judgment," 783 F. Supp. at 1516, and a right to
be free from "[b]odily restraints" except "when and to the
extent professional judgment deems this necessary . . . ."
Id. at 1520. It is not entirely clear whose professional
judgment--medical or administrative--the district court had
in mind; but the implication of its discussion is that the
administrators of the facility are bound to listen to the
judgment of the medical professionals and to heed it unless
they offer good reason for refusing to do so. Id. at 1519-
20.
Both sides on this appeal seek a decision on the
constitutional "right to treatment," the state urging that
none exists and Cameron supporting the district court. In
our view, a decision on the abstract issue of "a right to
treatment" is not necessary for a disposition of this case;
and the concept has only a remote connection to the actual
relief sought. We address this point briefly, against the
background of prior "right to treatment" law, before
considering Cameron's own situation and the proper touchstone
for appraising his claims.
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It is settled that those who are confined by the state,
for whatever reason, are entitled under the Constitution to
food, clothing, medical care, and reasonable efforts to
secure physical safety. Beyond such obvious essentials,
however, guidance from the Supreme Court is largely confined
to one cautiously phrased decision. In Youngberg v. Romeo,
457 U.S. 307 (1982), a mother, unable to care for her
retarded child, placed him in a state institution. Then,
discovering that he was sometimes physically restrained by
"soft" shackles and taught little in "basic self-care
skills," she sued. The Supreme Court held that under those
circumstances the child was constitutionally entitled to be
free from any but necessary restraints and had a right to
basic self-care training to secure safety and mobility. As
for deciding when and how much, the Court said that judges
should not dictate the choice among acceptable alternatives
and that a "presumption" of correctness must be attached to
"professional judgment." Id. at 321-23.
Youngberg left in limbo a prior line of lower court
cases and academic literature that had sought to shape a
broad constitutional "right to treatment," including
treatment of the psychological ills of confined persons.5
5See Stefan, Leaving Civil Rights to the "Experts": From
Deference to Abdication Under the Professional Judgment
Standard, 102 Yale L.J. 639, 686-90 (1992). Treatment, in
any curative sense, was not even an issue in Youngberg since
the retardation was not curable. The Court expressly
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Since Youngberg, a few circuits have ventured into this
constitutional territory, returning with different answers.6
We ourselves may have seemed to send mixed signals. In Doe
v. Gaughan, 808 F.2d 871 (1st Cir. 1986), this court, under
the caption "constitutional right to treatment," agreed that
Youngberg extended beyond the retarded to protect similar
interests of those mentally ill persons civilly committed to
a different Bridgewater facility. Id. at 884. In Langton,
four years later, this court explicitly refused to decide
whether there was a "constitutional right to treatment" at
the Treatment Center, remarking that "the trial judge's
skirting of the constitutional thicket was appropriate" as
such issues should be decided only when necessary. 928 F.2d
at 1217. One reason why it was unnecessary in Langton was
that the consent decree "set a higher standard than the
declined to devise any general rights to ameliorative programs beyond basic self-help training to assure safety and mobility, saying "we need go no further in this case." 457 U.S. at 319.
6Compare, e.g., Ohlinger v. Watson, 652 F.2d 775 (1980),
with Bailey v. Gardebring, 940 F.2d 1150 (8th Cir. 1991),
cert. denied, 112 S. Ct. 1516 (1992). See generally, Woe v.
Cuomo, 729 F.2d 96, 105 (2d Cir. 1984) ("The Supreme Court
has not directly addressed the question whether a constitutional right to treatment exists . . . .").
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Constitution" in affording treatment for those in the
Treatment Center. Id.7
Although the parties seek to litigate the abstract issue
of a right to treatment, we prefer to plow a furrow no wider
than the case demands. Cameron's claims for the most part
are not really "right to treatment" claims at all: he is
receiving substantial psychological treatment for his
condition, and most of the arguments he is making concern
housing, mobility, transportation, and security. Further,
under existing state law, there is already a regulation-based
right to treatment at the Treatment Center that equals or
exceeds anything that the Supreme Court would likely impose
under the Due Process Clause. See Langton, 928 F.2d at 1217.
It is also unclear whether, if the Supreme Court did provide
a general "right to treatment" for civilly committed persons,
it would apply that right to those held as well under
criminal sentence. Youngberg, 457 U.S. at 321-22.8 At the
7In Cortes-Quinones v. Jimenez-Nettleship, 842 F.2d 556
(1st Cir.), cert. denied, 488 U.S. 823 (1988), and Torraco v.
Maloney, 923 F.2d 231 (1st Cir. 1991), this court addressed
claims that authorities had not taken the precaution against suicide of individual prisoners. While both decisions spoke of the state's obligation to provide for medical needs, the context was very far removed from any generalized right to treatment for psychological conditions.
8Whatever other significance it may have, we think that Cameron's criminal sentence does refute any claim that he is entitled under the Constitution to minimum physical restraint based on the judgment of his doctors. Quite unlike the child in Youngberg, Cameron is under criminal sentence of
imprisonment for serious and violent crimes. To that extent,
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very least, the Court's approach in Youngberg suggests hewing
to the case-by-case approach.
Taking that approach here, we think the touchstone for
Cameron's claims is the Due Process Clause of the Fourteenth
Amendment, requiring conditions that do not fall below the
minimum standards of civilized decency. See generally Rochin
v. California, 342 U.S. 165 (1952). Under this rubric,
context works in Cameron's favor. While his prison sentence
will expire in 2002 or even earlier, his confinement in the
Treatment Center is from one day to life and will never end
unless his condition improves and he is found to be no longer
sexually dangerous. Thus, Cameron's best argument is that
the state's ordinary procedures and constraints are
affirmatively and needlessly worsening his mental condition,
so that he may well be confined long after his sentence has
expired. This is a claim with some bite, no matter how much
latitude states ordinarily have to run their institutions.
Further, the findings of the district court, which
control unless clearly erroneous, Fed. R. Civ. P. 52(a); Doe
v. Gaughan, 808 F.2d at 877, lend support to Cameron's
argument. The findings amount to a determination by the
district court that procedures that might ordinarily be
applied--such as certain of the searches and the internal
he lacks the same "liberty" interest as the child in Youngberg.
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movement controls--worsen Cameron's condition and may well be
unnecessary in this case. See 783 F. Supp. at 1523-25.9 On
both points, effect and necessity, the district court says
that this is the judgment of the medical professionals and
that no adequate response has been obtained from the
administrators. Id.
The state broadly disputes this version of events,
pointing to other evidence showing how much it has helped
Cameron and tried to accommodate his special needs. It does
not, however, make much effort in its brief to rebut specific
findings as to specific episodes. We think there is some
conflict in the evidence but also that the district judge's
findings are not clearly erroneous. It is true that these
findings were made in the framework of a legal analysis that
we do not adopt, but the findings fit well enough into a due
process framework and this court may affirm on any grounds
supported by evidence. See Doe v. Anrig, 728 F.2d 30, 32
(1st Cir. 1984).
9For example, the court invoked the testimony of Cameron's therapist that the shackling was "harmful to Cameron's mental health" and the court found it unnecessary based on "uncontroverted evidence." 783 F. Supp. at 1520. The court determined that the Treatment Center's internal movement policy, allowing free movement for only 10 minutes each hour, was unworkable for Cameron as an amputee, creating "undue pressure [that] . . . compromises his treatment." Id.
at 1522. A forcible search of Cameron while handcuffed, which the court found may well have been unnecessary, drove Cameron into moods of "helplessness, anger, despair and hopelessness . . . ." Id. at 1523.
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Relief Ordered by the District Court. The immediate
relief ordered by the district court is, with one or two
exceptions, fairly modest, primarily requiring further
consideration of Cameron's case and some interim measures.
Importantly, the court has ordered a general reappraisal of
Cameron's treatment and conditions, with decisions to be made
by the administrators "with due respect and regard for the
judgment of a qualified professional." 783 F. Supp. at 1526.
But given the district court's use in several contexts of the
"professional judgment" standard, a word is in order for the
guidance of the parties and for any future litigation that
may ensue.
In an institution like the Treatment Center, as in an
ordinary prison, security and administrative concerns may
clash with the welfare and comfort of individuals, as the
district court recognized. This was so in the facility at
issue in Youngberg, 457 U.S. at 320, and it is surely so in
the Treatment Center where most if not all those detained
have been convicted of crimes and many may be dangerous. Any
professional judgment that decides an issue involving
conditions of confinement must embrace security and
administration, and not merely medical judgments.
Thus when it comes to appraising the judgments of the
administrators, it does not follow that they are bound to do
what the doctors say is best for Cameron even if the doctors
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are unanimous. The administrators are responsible to the
state and to the public for making professional judgments of
their own, encompassing institutional concerns as well as
individual welfare. Nothing in the Constitution mechanically
gives controlling weight to one set of professional
judgments. Indeed, when it comes to constitutional rights,
none of the professionals has the last word. Professional
judgment, as the Supreme Court has explained, creates only a
"presumption" of correctness; welcome or not, the final
responsibility belongs to the courts. See Youngberg, 457
U.S. at 323.
With this clarification as to the role of "professional
judgment," we sustain the first injunctive relief provision
ordered by the district court directing the general
reappraisal of Cameron's personal dangerousness and of his
general conditions of confinement. Para. 1 (783 F. Supp. at
1526). The findings noted above and the evidence portrayed
in the district court's decision support this fairly modest
directive. In framing equitable relief, a district court has
substantial latitude, and we think its "remand" to the
Treatment Center administration is well within its authority.
We also conclude that, on the same basis and with the
same clarification as to the role of professional judgment,
the district court's findings, see 783 F. Supp. at 1522-24,
support several other conditioned decree provisions: that
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administrators consider requests by Cameron for treatment
outside the Treatment Center, para. 4 (id. at 1526); that the
ten-minute movement restriction and oral-cavity searches be
suspended as to Cameron unless and until a qualified
decision-maker concludes that they are appropriate for
Cameron; and that the "Extraction Team" searches of Cameron
be barred unless there is prior consultation with a Treatment
Center clinician. Paras. 5, 6 and 8 (id. at 1526).
On two other decree provisions, we believe modifications
are required. First, the district court ordered that an
armed guard and shackles no longer be used when transporting
Cameron outside the facility unless and until a qualified
decision-maker determines this to be necessary. Para. 3 (783
F. Supp. at 1526). In matters of security, as opposed to
administrative convenience, the administrators' discretion is
at its zenith and Cameron is still under criminal
sentence.10 An armed guard and shackles may seem needless
precautions for an amputee, but we think that the Treatment
Center should not be obliged to suspend its specific security
measures for outside visits while Cameron's case is being
reexamined. If the district court wishes to require this
10M.G.L. c. 123A, 6A, provides that, subject to exceptions entrusted to an administrative board, "any person committed as a sexually dangerous person . . . shall be held in secure custody." Discharge from the Treatment Center does not "terminate . . . any . . . unexpired sentence." Id. 9.
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armed-guard-and-shackles requirement to be re-examined on an
expedited basis, that is within its province.
Second, we similarly modify the district court's general
injunction preventing the Treatment Center "from enforcing
the current disciplinary system, run by Department of
Correction personnel, against Cameron" until a new system
suitable to his needs is constructed. Para. 7 (783 F. Supp.
at 1526). We have no problem with the decree's requirements
that the administrators consider whether changes are
warranted in the current system as applied to Cameron and
that medical judgments be weighed in this process. But we
think that a generally phrased suspension of "the current
disciplinary system" in the meantime cuts too broadly and may
raise security issues as well.
Finally, we sustain three unqualified decree provisions
made by the district court: that Cameron be allowed to
continue, as apparently he is at present, visits to Veterans
Administration facilities related to his amputation,
circulatory problems, and possible cancer; that the "consent"
to double bunking be waived as to Cameron, the "consent"
being largely symbolic; and that a handicapped accessible
room, including a hospital bed if necessary, be made
available to him. Paras. 2, 9, 10 (783 F. Supp. at 1526-27).
These specifics of relief lie largely within the judgment of
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the district court, and the state's brief makes no targeted
showing that these provisions are improper.
III. CONCLUSION
No one who reviews this record can dispute that Cameron
has done harm in the past, nor doubt that he has been
afflicted with serious mental illness. The findings of the
district court suggest that, without special attention to his
peculiar circumstances, further damage will be done to his
mental condition. We conclude that the state does have a Due
Process Clause obligation, to be balanced by it with
competing demands and interests, to seek to limit the extent
to which it worsens Cameron's condition and thereby extends
his detention indefinitely. Needless to say, there can be no
precision in such a Due Process Clause "standard" nor any way
to avoid further dispute about its application, if the
parties are bent on dispute.
The district judge, we think, had the right idea in
directing the Treatment Center to undertake a good faith
reappraisal of its policies as applied to Cameron. The more
swiftly the matter is returned to that forum, with that
perspective, the better off Cameron will be. As for the
state, it may regard the district judge's strictures on its
attitude as unfair and heedless of its past efforts for
Cameron. But the injunction, at least as we have adjusted it
and delimited its future effect, is not unduly burdensome.
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Like Cameron, the state has an evident interest in a
resolution that avoids further litigation.
The district court's injunction is modified as set forth
above and is otherwise affirmed, with the clarifications and
upon the grounds stated in this opinion. No costs or
attorneys' fees shall be awarded in connection with this
appeal.
It is so ordered.
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