YOUNGBERG, SUPERINTENDENT, PENNHURST STATE SCHOOL AND HOSPITAL, ET AL. v. ROMEO, AN INCOMPETENT, BY HIS MOTHER AND NEXT FRIEND, ROMEO
No. 80-1429
Supreme Court of the United States
Argued January 11, 1982—Decided June 18, 1982
457 U.S. 307
David H. Allshouse, Deputy Attorney General of Pennsylvania, argued the cause for petitioners. With him on the briefs were Leroy S. Zimmerman, Attorney General, and Robert B. Hoffman and Allen C. Warshaw, Deputy Attorneys General.
Edmond A. Tiryak argued the cause for respondent. With him on the brief were Ralph J. Moore, Jr., and William F. Sheehan.*
*A brief for the State of Connecticut et al. as amici curiae urging reversal was filed by Carl R. Ajello, Attorney General of Connecticut, and Hugh Barber, Richard T. Couture, and Francis J. Mac Gregor, Assistant Attorneys General, Charles A. Graddick, Attorney General of Alabama, and R. Emmett Poundstone III, Assistant Attorney General, Robert K. Corbin, Attorney General of Arizona, and Anthony B. Ching, Assistant Attorney General, Steve Clark, Attorney General of Arkansas, and Robert R. Ross, Deputy Attorney General, Jim Smith, Attorney General of Florida, Linley E. Pearson, Attorney General of Indiana, Robert T. Stephan, Attorney General of Kansas, William J. Guste, Jr., Attorney General of Louisiana, James E. Tierney, Attorney General of Maine, Frank J. Kelley, Attorney General of Michigan, Paul L. Douglas, Attorney General of Nebraska, Gregory H. Smith, Attorney General of New Hampshire, James R. Zazzali, Attorney General of New Jersey, Robert O. Wefald, Attorney General of North Dakota, William J. Brown, Attorney General of Ohio, David B. Frohnmayer, Attorney General of Oregon, Dennis J. Roberts II, Attorney General of Rhode Island, Daniel R. McLeod, Attorney General of South Carolina, Marshall Coleman, Attorney General of Virginia, Kenneth O. Eikenberry, Attorney General of Washington, and Chauncey H. Browning, Jr., Attorney General of West Virginia.
Briefs of amici curiae urging affirmance were filed by Margaret F. Ewing, Paul R. Friedman, and Jane Bloom Yohalem for the American Orthopsychiatric Association et al.; and by Dan Stormer and Mary Burdick for Mental Health Advocacy Services et al.
H. Bartow Farr III filed a brief for the American Psychiatric Association as amicus curiae.
The question presented is whether respondent, involuntarily committed to a state institution for the mentally retarded, has substantive rights under the Due Process Clause of the Fourteenth Amendment to (i) safe conditions of confinement; (ii) freedom from bodily restraints; and (iii) training or “habilitation.”1 Respondent sued under
I
Respondent Nicholas Romeo is profoundly retarded. Although 33 years old, he has the mental capacity of an 18-month-old child, with an I. Q. between 8 and 10. He cannot talk and lacks the most basic self-care skills. Until he was 26, respondent lived with his parents in Philadelphia. But after the death of his father in May 1974, his mother was unable to care for him. Within two weeks of the father‘s death, respondent‘s mother sought his temporary admission to a nearby Pennsylvania hospital.
Shortly thereafter, she asked the Philadelphia County Court of Common Pleas to admit Romeo to a state facility on a permanent basis. Her petition to the court explained that she was unable to care for Romeo or control his violence.2 As part of the commitment process, Romeo was examined by a physician and a psychologist. They both certified that re-
At Pennhurst, Romeo was injured on numerous occasions, both by his own violence and by the reactions of other residents to him. Respondent‘s mother became concerned about these injuries. After objecting to respondent‘s treatment several times, she filed this complaint on November 4, 1976, in the United States District Court for the Eastern District of Pennsylvania as his next friend. The complaint alleged that “[d]uring the period July, 1974 to the present, plaintiff has suffered injuries on at least sixty-three occasions.” The complaint originally sought damages and injunctive relief from Pennhurst‘s director and two supervisors;3 it alleged that these officials knew, or should have known, that Romeo was suffering injuries and that they failed to institute appropriate preventive procedures, thus violating his rights under the Eighth and Fourteenth Amendments.
Thereafter, in late 1976, Romeo was transferred from his ward to the hospital for treatment of a broken arm. While in the infirmary, and by order of a doctor, he was physically restrained during portions of each day.4 These restraints were ordered by Dr. Gabroy, not a defendant here, to protect
An 8-day jury trial was held in April 1978. Petitioners introduced evidence that respondent participated in several programs teaching basic self-care skills.7 A comprehensive behavior-modification program was designed by staff members to reduce Romeo‘s aggressive behavior,8 but that program was never implemented because of his mother‘s objec-
At the close of the trial, the court instructed the jury that “if any or all of the defendants were aware of and failed to take all reasonable steps to prevent repeated attacks upon Nicholas Romeo,” such failure deprived him of constitutional rights. App. 73a. The jury also was instructed that if the defendants shackled Romeo or denied him treatment “as a punishment for filing this lawsuit,” his constitutional rights were violated under the Eighth Amendment. Id., at 73a-75a. Finally, the jury was instructed that only if they found the defendants “deliberate[ly] indifferen[t] to the serious medical [and psychological] needs” of Romeo could they find that his Eighth and Fourteenth Amendment rights had been violated. Id., at 74a-75a.11 The jury returned a verdict for the defendants, on which judgment was entered.
The Court of Appeals for the Third Circuit, sitting en banc, reversed and remanded for a new trial. 644 F. 2d 147 (1980). The court held that the Eighth Amendment, prohibiting cruel and unusual punishment of those convicted of crimes, was not an appropriate source for determining the rights of the involuntarily committed. Rather, the Fourteenth Amendment and the liberty interest protected by that Amendment provided the proper constitutional basis for these rights. In ap-
The en banc court did not, however, agree on the relevant standard to be used in determining whether Romeo‘s rights had been violated.13 Because physical restraint “raises a presumption of a punitive sanction,” the majority of the Court of Appeals concluded that it can be justified only by “compelling necessity.” Id., at 159-160 (footnote omitted). A somewhat different standard was appropriate for the failure to provide for a resident‘s safety. The majority considered that such a failure must be justified by a showing of “substantial necessity.” Id., at 164. Finally, the majority held that when treatment has been administered, those responsible are liable only if the treatment is not “acceptable in the light of present medical or other scientific knowledge.” Id., at 166-167 and 173.14
Chief Judge Seitz, concurring in the judgment, considered the standards articulated by the majority as indistinguishable from those applicable to medical malpractice claims. In Chief Judge Seitz’ view, the Constitution “only requires that the courts make certain that professional judgment in fact was exercised.” Id., at 178. He concluded that the appropriate standard was whether the defendants’ conduct was “such a substantial departure from accepted professional judgment, practice, or standards in the care and treatment of this plaintiff as to demonstrate that the defendants did not base their conduct on a professional judgment.” Ibid.15
We granted the petition for certiorari because of the importance of the question presented to the administration of state institutions for the mentally retarded. 451 U. S. 982 (1981).
II
We consider here for the first time the substantive rights of involuntarily committed mentally retarded persons under the Fourteenth Amendment to the Constitution.16 In this
The mere fact that Romeo has been committed under proper procedures does not deprive him of all substantive liberty interests under the Fourteenth Amendment. See, e. g., Vitek v. Jones, 445 U. S. 480, 491-494 (1980). Indeed, the State concedes that respondent has a right to adequate food, shelter, clothing, and medical care.17 We must decide whether liberty interests also exist in safety, freedom of movement, and training. If such interests do exist, we must further decide whether they have been infringed in this case.
A
Respondent‘s first two claims involve liberty interests recognized by prior decisions of this Court, interests that involuntary commitment proceedings do not extinguish.18 The first is a claim to safe conditions. In the past, this Court has noted that the right to personal security constitutes a “historic liberty interest” protected substantively by the Due Process Clause. Ingraham v. Wright, 430 U. S. 651, 673 (1977). And that right is not extinguished by lawful confinement, even for penal purposes. See Hutto v. Finney, 437 U. S. 678 (1978). If it is cruel and unusual punishment to
Next, respondent claims a right to freedom from bodily restraint. In other contexts, the existence of such an interest is clear in the prior decisions of this Court. Indeed, “[l]iberty from bodily restraint always has been recognized as the core of the liberty protected by the Due Process Clause from arbitrary governmental action.” Greenholtz v. Nebraska Penal Inmates, 442 U. S. 1, 18 (1979) (POWELL, J., concurring in part and dissenting in part). This interest survives criminal conviction and incarceration. Similarly, it must also survive involuntary commitment.
B
Respondent‘s remaining claim is more troubling. In his words, he asserts a “constitutional right to minimally adequate habilitation.” Brief for Respondent 8, 23, 45. This is a substantive due process claim that is said to be grounded in the liberty component of the Due Process Clause of the Fourteenth Amendment.19 The term “habilitation,” used in psychiatry, is not defined precisely or consistently in the opinions below or in the briefs of the parties or the amici.20 As
In addressing the asserted right to training, we start from established principles. As a general matter, a State is under no constitutional duty to provide substantive services for those within its border. See Harris v. McRae, 448 U. S. 297, 318 (1980) (publicly funded abortions); Maher v. Roe, 432 U. S. 464, 469 (1977) (medical treatment). When a person is institutionalized—and wholly dependent on the State—it is conceded by petitioners that a duty to provide certain services and care does exist, although even then a State necessarily has considerable discretion in determining the nature and scope of its responsibilities. See Richardson v. Belcher, 404 U. S. 78, 83-84 (1971); Dandridge v. Williams, 397 U. S. 471, 478 (1970). Nor must a State “choose between attacking every aspect of a problem or not attacking the problem at all.” Id., at 486-487.
Respondent, in light of the severe character of his retardation, concedes that no amount of training will make possible his release. And he does not argue that if he were still at home, the State would have an obligation to provide training at its expense. See Tr. of Oral Arg. 33. The record reveals that respondent‘s primary needs are bodily safety and a minimum of physical restraint, and respondent clearly claims
Chief Judge Seitz, in language apparently adopted by respondent, observed:
“I believe that the plaintiff has a constitutional right to minimally adequate care and treatment. The existence
of a constitutional right to care and treatment is no longer a novel legal proposition.” 644 F. 2d, at 176.
Chief Judge Seitz did not identify or otherwise define—beyond the right to reasonable safety and freedom from physical restraint—the “minimally adequate care and treatment” that appropriately may be required for this respondent.24 In the circumstances presented by this case, and on the basis of the record developed to date, we agree with his view and conclude that respondent‘s liberty interests require the State to provide minimally adequate or reasonable training to ensure safety and freedom from undue restraint. In view of the kinds of treatment sought by respondent and the evidence of record, we need go no further in this case.25
III
A
We have established that Romeo retains liberty interests in safety and freedom from bodily restraint. Yet these in-
In determining whether a substantive right protected by the Due Process Clause has been violated, it is necessary to balance “the liberty of the individual” and “the demands of an organized society.” Poe v. Ullman, 367 U. S. 497, 542 (1961) (Harlan, J., dissenting). In seeking this balance in other cases, the Court has weighed the individual‘s interest in liberty against the State‘s asserted reasons for restraining individual liberty. In Bell v. Wolfish, 441 U. S. 520 (1979), for example, we considered a challenge to pretrial detainees’ confinement conditions. We agreed that the detainees, not yet convicted of the crime charged, could not be punished. But we upheld those restrictions on liberty that were reasonably related to legitimate government objectives and not tantamount to punishment.27 See id., at 539. We have taken a
Accordingly, whether respondent‘s constitutional rights have been violated must be determined by balancing his liberty interests against the relevant state interests. If there is to be any uniformity in protecting these interests, this balancing cannot be left to the unguided discretion of a judge or jury. We therefore turn to consider the proper standard for determining whether a State adequately has protected the rights of the involuntarily committed mentally retarded.
B
We think the standard articulated by Chief Judge Seitz affords the necessary guidance and reflects the proper balance between the legitimate interests of the State and the rights of the involuntarily committed to reasonable conditions of safety and freedom from unreasonable restraints. He would have held that “the Constitution only requires that the courts make certain that professional judgment in fact was exercised. It is not appropriate for the courts to specify which of several professionally acceptable choices should have been made.” 644 F. 2d, at 178. Persons who have been involun-
Moreover, we agree that respondent is entitled to minimally adequate training. In this case, the minimally adequate training required by the Constitution is such training as may be reasonable in light of respondent‘s liberty interests in safety and freedom from unreasonable restraints. In determining what is “reasonable“—in this and in any case presenting a claim for training by a State—we emphasize that courts must show deference to the judgment exercised by a qualified professional. By so limiting judicial review of challenges to conditions in state institutions, interference by the federal judiciary with the internal operations of these institutions should be minimized.29 Moreover, there certainly
IV
In deciding this case, we have weighed those postcommitment interests cognizable as liberty interests under the Due Process Clause of the Fourteenth Amendment against legitimate state interests and in light of the constraints under which most state institutions necessarily operate. We repeat that the State concedes a duty to provide adequate food, shelter, clothing, and medical care. These are the essentials of the care that the State must provide. The State also has the unquestioned duty to provide reasonable safety for all residents and personnel within the institution. And it may not restrain residents except when and to the extent professional judgment deems this necessary to assure such safety or to provide needed training. In this case, therefore, the State is under a duty to provide respondent with such training as an appropriate professional would consider reasonable to ensure his safety and to facilitate his ability to function free from bodily restraints. It may well be unreasonable not to provide training when training could significantly reduce the need for restraints or the likelihood of violence.
Respondent thus enjoys constitutionally protected interests in conditions of reasonable care and safety, reasonably nonrestrictive confinement conditions, and such training as may be required by these interests. Such conditions of confinement would comport fully with the purpose of respondent‘s commitment. Cf. Jackson v. Indiana, 406 U. S. 715, 738 (1972); see n. 27, supra. In determining whether the State has met its obligations in these respects, decisions made by the appropriate professional are entitled to a presumption of correctness. Such a presumption is necessary to enable institutions of this type—often, unfortunately, overcrowded and understaffed—to continue to function. A single professional may have to make decisions with respect to a number of residents with widely varying needs and problems in the course of a normal day. The administrators, and par-
In this case, we conclude that the jury was erroneously instructed on the assumption that the proper standard of liability was that of the Eighth Amendment. We vacate the decision of the Court of Appeals and remand for further proceedings consistent with this decision.
So ordered.
JUSTICE BLACKMUN, with whom JUSTICE BRENNAN and JUSTICE O‘CONNOR join, concurring.
I join the Court‘s opinion. I write separately, however, to make clear why I believe that opinion properly leaves unresolved two difficult and important issues.
The first is whether the Commonwealth of Pennsylvania could accept respondent for “care and treatment,” as it did under the Pennsylvania Mental Health and Mental Retardation Act of 1966,
In Jackson v. Indiana, 406 U. S. 715 (1972), this Court, by a unanimous vote of all participating Justices, suggested a constitutional standard for evaluating the conditions of a civilly committed person‘s confinement: “At the least, due process requires that the nature and duration of commitment bear some reasonable relation to the purpose for which the individual is committed.” Id., at 738. Under this standard,
If a state court orders a mentally retarded person committed for “care and treatment,” however, I believe that due process might well bind the State to ensure that the conditions of his commitment bear some reasonable relation to each of those goals. In such a case, commitment without any “treatment” whatsoever would not bear a reasonable relation to the purposes of the person‘s confinement.
In respondent‘s case, the majority and principal concurring opinions in the Court of Appeals agreed that “[b]y basing [respondent‘s] deprivation of liberty at least partially upon a promise of treatment, the state ineluctably has committed the community‘s resources to providing minimal treatment.” 644 F. 2d 147, 168 (CA3 1980).2 Neither opinion clarified, however, whether respondent in fact had been totally denied “treatment,” as that term is defined under Pennsylvania law. To the extent that the majority addressed the question, it found that “the evidence in the record, although somewhat contradictory, suggests not so much a total failure to treat as an inadequacy of treatment.” Ibid.
This Court‘s reading of the record, ante, at 311-312, and n. 7, supports that conclusion. Moreover, the Court today finds that respondent‘s entitlement to “treatment” under Pennsylvania law was not properly raised below. See ante,
The second difficult question left open today is whether respondent has an independent constitutional claim, grounded in the Due Process Clause of the Fourteenth Amendment, to that “habilitation” or training necessary to preserve those basic self-care skills he possessed when he first entered Pennhurst—for example, the ability to dress himself and care for his personal hygiene. In my view, it would be consistent with the Court‘s reasoning today to include within the “minimally adequate training required by the Constitution,” ante, at 322, such training as is reasonably necessary to prevent a person‘s pre-existing self-care skills from deteriorating because of his commitment.
The Court makes clear, ante, at 315-316 and 324, that even after a person is committed to a state institution, he is entitled to such training as is necessary to prevent unreasonable losses of additional liberty as a result of his confinement—for example, unreasonable bodily restraints or unsafe institutional conditions. If a person could demonstrate that he entered a state institution with minimal self-care skills, but lost those skills after commitment because of the State‘s unreasonable refusal to provide him training, then, it seems to me, he has alleged a loss of liberty quite distinct from—and as serious as—the loss of safety and freedom from unreasonable restraints. For many mentally retarded people, the difference between the capacity to do things for themselves within an institution and total dependence on the institution for all of their needs is as much liberty as they ever will know.
Although respondent asserts a claim of this kind, I agree with the Court that “[o]n the basis of the record before us, it is quite uncertain whether respondent [in fact] seeks any
If respondent actually seeks habilitation in self-care skills not merely to reduce his aggressive tendencies, but also to maintain those basic self-care skills necessary to his personal autonomy within Pennhurst, I believe he is free on remand to assert that claim. Like the Court, I would be willing to defer to the judgment of professionals as to whether or not, and to what extent, institutional training would preserve re-
If expert testimony reveals that respondent was so retarded when he entered the institution that he had no basic self-care skills to preserve, or that institutional training would not have preserved whatever skills he did have, then I would agree that he suffered no additional loss of liberty even if petitioners failed to provide him training. But if the testimony establishes that respondent possessed certain basic self-care skills when he entered the institution, and was sufficiently educable that he could have maintained those skills with a certain degree of training, then I would be prepared to listen seriously to an argument that petitioners were constitutionally required to provide that training, even if respondent‘s safety and mobility were not imminently threatened by their failure to do so.
The Court finds it premature to resolve this constitutional question on this less than fully developed record. Because I agree with that conclusion, I concur in the Court‘s opinion.
CHIEF JUSTICE BURGER, concurring in the judgment.
I agree with much of the Court‘s opinion. However, I would hold flatly that respondent has no constitutional right to training, or “habilitation,” per se. The parties, and the Court, acknowledge that respondent cannot function outside the state institution, even with the assistance of relatives. Indeed, even now neither respondent nor his family seeks his discharge from state care. Under these circumstances, the State‘s provision of food, shelter, medical care, and living conditions as safe as the inherent nature of the institutional environment reasonably allows, serves to justify the State‘s custody of respondent. The State did not seek custody of respondent; his family understandably sought the State‘s aid to meet a serious need.
I also point out that, under the Court‘s own standards, it is largely irrelevant whether respondent‘s experts were of the opinion that “additional training programs, including self-care programs, were needed to reduce [respondent‘s] aggressive behavior,” ibid.—a prescription far easier for “spectators” to give than for an institution to implement. The training program devised for respondent by petitioners and other professionals at Pennhurst was, according to the Court‘s opinion, “presumptively valid“; and “liability may be imposed only when the decision by the professional is such a substantial departure from accepted professional judgment, practice, or standards as to demonstrate that the person responsible actually did not base the decision on such a judg-
Finally, it is worth noting that the District Court‘s instructions in this case were on the whole consistent with the Court‘s opinion today; indeed, some instructions may have been overly generous to respondent. Although the District Court erred in giving an instruction incorporating an Eighth Amendment “deliberate indifference” standard, the court also instructed, for example, that petitioners could be held liable if they “were aware of and failed to take all reasonable steps to prevent repeated attacks upon” respondent. See ante, at 312. Certainly if petitioners took “all reasonable steps” to prevent attacks on respondent, they cannot be said to have deprived him either of reasonably safe conditions or of training necessary to achieve reasonable safety.