Opinion ID: 782823
Heading Depth: 4
Heading Rank: 1

Heading: Were the physical examinations in this case searches for Fourth Amendment purposes?

Text: 29 The Fourth Amendment to the United States Constitution provides that the Government shall not violate [t]he right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures.... U.S. Const. amend IV. Under our jurisprudence, [s]earches conducted without a warrant are per se unreasonable under the Fourth Amendment—subject only to a few `specifically established and well-delineated exceptions.' Roska v. Peterson, 328 F.3d 1230, 1248 (10th Cir.2003), quoting Katz v. United States, 389 U.S. 347, 357, 88 S.Ct. 507, 19 L.Ed.2d 576 (1967). 30 The defendants contend that because the exams were not conducted upon suspicion of criminal activity and the data collected were not to be used for law enforcement purposes, the examinations were not searches subject to Fourth Amendment requirements. Relying on United States v. Attson, 900 F.2d 1427, 1429-30 (9th Cir.1990), cert. denied, 498 U.S. 961, 111 S.Ct. 393, 112 L.Ed.2d 403 (1990), they argue that where the alleged search is noncriminal and noninvestigatory, the application of the Fourth Amendment is limited. CAP Br. 5. 31 The district court concluded that the defendants were not entitled to summary judgment on this issue, because there was evidence in the record (controverted, to be sure) that discovery of child abuse was one purpose of the exams. Indeed, the district court noted, citing 10 O.S. §§ 7103, 7104, that under Oklahoma law medical professionals would be required to report any evidence of abuse encountered during such routine exams. We agree. 32 More fundamentally, however, the defendants' contention that the Fourth Amendment does not apply in the noncriminal and noninvestigatory context is without foundation. The Fourth Amendment protects the right of the people to be secure in their persons from government intrusion, whether the threat to privacy arises from a policeman or a Head Start administrator. There is no social worker exception to the Fourth Amendment. See Ferguson v. City of Charleston, 532 U.S. 67, 76 n. 9, 121 S.Ct. 1281, 149 L.Ed.2d 205 (2001) (we have routinely treated urine screens taken by state agents as searches within the meaning of the Fourth Amendment even though the results were not reported to the police.); Doe v. Heck, 327 F.3d 492, 509 (7th Cir.2003) (the strictures of the Fourth Amendment apply to child welfare workers, as well as all other governmental employees). 6 33 The defendants rely on United States v. Attson, 900 F.2d 1427, 1429 (9th Cir.1990), cert. denied, 498 U.S. 961, 111 S.Ct. 393, 112 L.Ed.2d 403 (1990), for the proposition that because the intent in collecting the data was not for law enforcement purposes the exams were not searches subject to Fourth Amendment protections. In Attson, a man injured in an automobile accident was taken to a public hospital for emergency treatment. He gave express consent for the taking of blood for medical purposes and blood was drawn for medical purposes, after which information regarding his blood alcohol level was supplied to the police for law enforcement purposes. The Ninth Circuit ruled that the doctor had not performed a search in violation of the Fourth Amendment because the record reflected that the doctor acted solely for health purposes of the patient and acted entirely independently of a governmental intent to collect evidence for use in the defendant's prosecution. Id. at 1433. The case is thus distinguishable. In Attson, the medical procedure was consensual; the real issue was the legality of providing the results to police. Here, the plaintiffs contend that the medical examination itself was performed without consent. 34 Moreover, contrary to the defendants' argument, the Attson decision did not suggest that all noncriminal, noninvestigatory examinations fall outside the protection of the Fourth Amendment. The court held: for the conduct of a governmental party to be subject to the fourth amendment, the governmental party engaging in that conduct must have acted with the intent to assist the government in its investigatory or administrative purposes and not for an independent purpose. 900 F.2d at 1433 (emphasis added). Thus, even under the Ninth Circuit's interpretation, Fourth Amendment protections extend to searches conducted for administrative purposes. In its brief, CAP itself asserts that the exams in this case were mandated by federal regulation and that its policy of conducting these exams within ninety days of enrollment was to ensure that it followed these regulations. CAP Br. at 5. The nurses and the County Health Department also characterize the exams as solely for medical evaluation required by the government. County Health Department and Nurses Br. at 14. Thus, even under the standard of Attson, the examinations were searches for Fourth Amendment purposes because they were to determine whether the children were in compliance with federal Head Start regulations. 35 Nothing in the language of the Fourth Amendment or the precedents of the Supreme Court supports the defendants' restrictive interpretation. The Amendment is expressed in passive voice (the right of the people to be secure in their persons... shall not be violated) without specifying or limiting the governmental actors who are to be constrained. The focus of the Amendment is thus on the security of the person, not the identity of the searcher or the purpose of the search. The Supreme Court has posed the Fourth Amendment inquiry in terms of whether the governmental conduct at issue compromises an expectation of privacy that society is prepared to consider reasonable. O'Connor v. Ortega, 480 U.S. 709, 715, 107 S.Ct. 1492, 94 L.Ed.2d 714 (1987) (internal quotation omitted); see also Camara v. Municipal Court, 387 U.S. 523, 528, 87 S.Ct. 1727, 18 L.Ed.2d 930 (1967) (The basic purpose of this Amendment ... is to safeguard the privacy and security of individuals against arbitrary invasions by governmental officials.). As the Court has explained: 36 Because the individual's interest in privacy and personal security suffers whether the government's motivation is to investigate violations of criminal laws or breaches of other statutory or regulatory standards, ... it would be anomalous to say that the individual ... [is] fully protected by the Fourth Amendment only when the individual is suspected of criminal behavior. 37 O'Connor, 480 U.S. at 715, 107 S.Ct. 1492 (internal quotations and citations omitted). 38 In accordance with this understanding of the purposes of the Amendment, the Supreme Court has held that medical examinations including a blood or urine test trigger, at a minimum, the Fourth Amendment balancing test. See, e.g., Schmerber v. State of California, 384 U.S. 757, 767-68, 86 S.Ct. 1826, 16 L.Ed.2d 908 (1966) (compelled blood test an intrusion constituting search); Skinner v. Railway Labor Executives' Ass'n, 489 U.S. 602, 616-17, 109 S.Ct. 1402, 103 L.Ed.2d 639 (1989) (breathalyzer exam for chemical analysis constitutes search); Board of Educ. of Indep. Sch. Dist. No. 92 of Pottawatomie, County v. Earls, 536 U.S. 822, 122 S.Ct. 2559, 2568-69, 153 L.Ed.2d 735 (2002) (urine test search triggering Fourth Amendment inquiry under special needs balancing test); Vernonia Sch. Dist. 47J v. Acton, 515 U.S. 646, 656-58, 115 S.Ct. 2386, 132 L.Ed.2d 564 (1995) (same); see Yin v. State of California, 95 F.3d 864, 874 (9th Cir.1996), cert. denied, 519 U.S. 1114, 117 S.Ct. 955, 136 L.Ed.2d 842 (1997) (O'Scannlain, J., concurring) (certain aspects of the routine physical examination at issue here would implicate the requisite `concerns about bodily integrity,' and thus trigger protection under the Fourth Amendment). Indeed, in the Court's special needs cases involving medical examination procedures, the Court did not hold that the practices at issue were or were not constitutional because they were or were not searches; rather, their permissibility under the Fourth Amendment depended upon the reasonableness of the procedure. See, e.g., Earls, 122 S.Ct. at 2564 (finding school policy of urine testing a governmental search but reasonable). 39 The defendants' argument seems to be based, at bottom, on the view that in the absence of a criminal or other investigatory purpose, medical examinations such as those conducted at CAP's Head Start program at Roosevelt Elementary are for the good of the children and should not be hamstrung by legalistic requirements like warrants or consent. We do not doubt that CAP was acting in the interest of the children, as it understood them. But the requirement of patient consent, or of parental consent in the case of minor children, serves important practical as well as dignitary concerns, even when a social welfare agency, like CAP, believes it is acting for the good of the child. 40 It should go without saying that adequate consent is elemental to proper medical treatment. In medical procedures involving children, ensuring the existence of parental consent is critical, because children rely on parents or other surrogates to provide informed permission for medical procedures that are essential for their care. American Academy of Pediatrics, Informed Consent, Parental Permission, and Assent in Pediatric Practice, 95 Pediatrics 314-17 (February, 1995). 41 Even beyond constitutional values of privacy, dignity, and autonomy, parental notice and consent for childhood physical examinations are of significant practical value. Because of CAP's failure to notify parents in advance of the examinations, no parents were present to provide medical histories, discuss potential issues with the health care professionals, help to explain the procedures to the children, and reassure them about the disturbing and unfamiliar aspects of the exam — which included blood-letting, which is painful, as well as visual and sometimes tactile inspection of genitals by strangers. At least half of the plaintiff children were subjected to a duplicative exam by unfamiliar health care professionals in a makeshift setting, even though they had already obtained exams from their own doctors. These practical consequences might well have been averted by more careful attention to the children's Fourth Amendment rights. 42 Accordingly, we agree with the district court's conclusion that the physical examinations performed by the defendants in this case constituted searches within the meaning of the Fourth Amendment, and thus were unconstitutional unless they were performed with warrant or parental consent, or fall within the special needs exception to the warrant requirement. 43 2. Did CAP have a reasonable basis for believing that the parents gave consent for the physical examinations? 44 As already noted, the central disputed issue in this case is consent. It is well established that a search conducted pursuant to a valid consent is constitutionally permissible. Schneckloth v. Bustamonte, 412 U.S. 218, 222, 93 S.Ct. 2041, 36 L.Ed.2d 854 (1973). Thus, if the trier of fact concluded that the parents in this case, on behalf of their minor children, actually consented to the examinations, there would be no Fourth Amendment violation. United States v. Rith, 164 F.3d 1323, 1330 (10th Cir.1999). Moreover, because the Fourth Amendment prohibits only unreasonable searches and seizures, the Supreme Court has held that the Amendment is satisfied when, under the circumstances, it is objectively reasonable for the official to believe that the scope of a person's consent permitted him to conduct the search. Florida v. Jimeno, 500 U.S. 248, 251, 111 S.Ct. 1801, 114 L.Ed.2d 297 (1991); Illinois v. Rodriguez, 497 U.S. 177, 186, 110 S.Ct. 2793, 111 L.Ed.2d 148 (1990); United States v. Osage, 235 F.3d 518, 519-21 (10th Cir.2000). 45 CAP maintains that the evidence unequivocally established, and the district court correctly held, that the parents consented to the medical examinations of their children. CAP Br. 9. That is a misstatement of the district court's holding. The district court analyzed the consent forms used by CAP in this case and found sufficient ambiguities and inconsistencies to permit a jury to conclude that the parents had not given their consent: 46 [T]he consent forms are not models of draftsmanship. At one point in their supplemental brief, defendants assert the Authorization for Treatment to Minors form must be read in bifurcated fashion, the bottom half limited to emergency care and the top half not so limited. The language of the forms is ambiguous at times. For example, plaintiffs' expert Dr. Nelson testified that the Authorization for Treatment to Minors form is limited to treatment, as the title suggests. However, defendants point out that, in smaller print within the body of the form, it authorizes  diagnosis or treatment (emphasis added), which more clearly suggests a routine physical examination. The forms utilized, as this litigation has brought home to CAP, could have been crafted more precisely. In other words, if the dispositive issue were whether Parent Plaintiffs gave a fully-informed consent to the specific procedures of genital examination and blood test, the Court would deny summary judgment based upon a genuine issue of material fact. 47 Order Granting CAP's Motion for Summary Judgment, dated May 16, 2001 at 11, App. 202 (citations omitted; emphasis added). The district court granted summary judgment on the theory that CAP had an objectively reasonable, good-faith belief in the fact of consent and the scope of that consent. Id. See also id. at 203 (the examinations of all of the Minor Plaintiffs in this case were conducted with a reasonable belief that parental consent had been properly obtained and the scope included genital examination and blood tests). In other words, the record did not show that the parents actually consented, but CAP had a reasonable belief that they did. 48 As the Supreme Court's decisions illustrate, there can be cases of ambiguous consent; there is a difference between an individual's actual consent to a search and the reasonableness of a government official's belief that consent was given. Rodriguez, 497 U.S. at 183-84, 110 S.Ct. 2793. But this is not one of them. In this case, consent — if it existed — took the form of signatures on forms prepared by CAP and distributed to the parents. The forms themselves indicate precisely what the parents consented to. It is a common-law rule to construe ambiguous language against the interest of the party that drafted it. Cf. Mastrobuono v. Shearson Lehman Hutton, Inc., 514 U.S. 52, 62-63, 115 S.Ct. 1212, 131 L.Ed.2d 76 (stating this principle in the context of contract interpretation). If there are any ambiguities here, the drafter of the forms — CAP — is responsible. A trier of fact might well conclude that it is not reasonable to allow the drafter of a defective consent form to claim latitude to go beyond the express terms of the consent on the basis of ambiguities that are its own handiwork. 49 In the context of a criminal investigation, the Supreme Court has held that the standard for measuring the scope of a suspect's consent under the Fourth Amendment is that of `objective' reasonableness — what would the typical reasonable person have understood by the exchange between the officer and the suspect? Jimeno, 500 U.S. at 251, 111 S.Ct. 1801. In the context of this case, the parallel standard of objective reasonableness is: what would the typical reasonable person have understood by the exchange between the Head Start agency and the parents? Because it is undisputed that the only relevant exchange between CAP and the parents was the distribution of the consent forms by CAP to the parents and the return of those forms to CAP, the issue here is what the typical reasonable person would have understood by the forms. We must bear in mind that the persons for whom the forms were prepared were not sophisticated professionals, but ordinary parents of low-income children, who had no reason to suppose that they had to parse the small print for hidden meanings. 50 The record contains three forms distributed and used by CAP: (1) a Form 3 provided to at least some of the parents at the time of enrollment, but not signed by the parent, to be completed by a medical professional; (2) a form entitled Parent Consent Form that contains consent to certain procedures such as hemoglobin/HCT tests and ear exams; and (3) a form entitled Authorization for Treatment of Minors that pertains to emergency procedures. CAP contends that [o]nce CAP received these consent forms, it believed it had parental consent to perform physical examinations on its enrollees. In addition to the forms, CAP points to Head Start program regulations that, it says, require each Head Start enrollee to receive a physical examination within ninety days of enrollment. It contends that, in light of these regulatory requirements, a Head Start grantee is reasonably entitled to interpret the consent forms signed by the parents as encompassing consent to a general physical examination, including genital examination. 7 51 None of these forms proves that the parents consented to the examinations performed here. Only Form 3 appears on its face to have anything to do with general physical examinations, and only Form 3 contains any reference to genital examinations. Form 3, however, is not an instrument for parental consent to an examination. It is a checklist for health care professionals to record medical histories and examination results. Its top portion, the medical history section, specifically says that it is to be filled out by Head Start Staff or Health Care Provider before Physical Examination/Assessment[,] while the bottom portion is to be completed by the Health Care Provider During and After Physical Examination/Assessment. Nowhere on the form is there any place for parental signature. 52 CAP appears to acknowledge that this form was not itself a consent form, but it argues, and the district court agreed, that the form gave notice to the parents that general physical examinations would include blood tests and genital examinations. See Order Granting CAP's Motion for Summary Judgment, dated May 16, 2001 at 13, App. 204 (referring to the defendants' objectively reasonable belief that the Form 3 gave Parent Plaintiffs at least constructive notice that the medical examinations would involve the genitalia and a blood test). The problem with this argument is that the parents did not consent to administration of general physical examinations by CAP-supplied health care professionals. Form 3 is the form that the parents are asked to supply to their own physicians to record the results of the physical exam and to report the results to the Head Start authorities. At least four of the eight plaintiffs took this form to their own doctors, and supplied the completed form to CAP. Nothing in the language of Form 3 provides any reason to suspect that CAP would conduct physical examinations on its own authority, without further notice or consent by parents. 53 This understanding is confirmed by the very regulations CAP relies upon. The regulations require the Head Start agency [i]n collaboration with the parents and as quickly as possible, but no later than 90 calendar days after enrollment to [m]ake a determination as to whether or not each child has an ongoing source of continuous, accessible health care, and to [o]btain from a health care professional a determination as to whether the child is up-to-date on a schedule of age appropriate preventive and primary health care.... 45 C.F.R. § 1304.20(a). As to both determinations, if the child does not have a source of ongoing health care or is not up-to-date on an age appropriate schedule of well child care, the regulations require the Head Start agency to assist the parents in satisfying the requirement. Id. In no circumstances do the regulations authorize the Head Start agency to subject enrolled children to physical examinations without parental notice or consent. The regulations contain a section entitled Involving parents, which explicitly requires Head Start agencies to [c]onsult with parents immediately when child health or developmental problems are suspected or identified, to [f]amiliarize parents with the use of and rationale for all health and developmental procedures administered through the program, and to obtain advance parent or guardian authorization for such procedures. Id., § 1304.20(e)(1), (e)(2). 54 According to these regulations, the parents of Head Start children are responsible in the first instance for obtaining a physical examination and medical history and for providing a report of this to the Head Start agency. This would appear to be the function of Form 3. If such a form is not provided, the Head Start agency must assist the parents in complying. It may well be reasonable for the Head Start agency to make arrangements with the County Health Department to provide free physicals on the premises of the Head Start project, but it is not reasonable to do so without notifying the parents and obtaining their consent, nor is it reasonable to subject children who have already filed an up-to-date Form 3 to a second examination. 55 Nor do the other two forms evince consent to the examinations. The Parent Consent Form contained in the record provides permission for the following if needed: TB Test, Speech/Language Services, Dental Examination/Treatment, Developmental Screenings, Hearing Screening, Hemoglobin/HCT, Vision Screening, Hearing Screening, and Permission ... to Collect, Maintain, Use and Release ... Child's Complete History. Nowhere on this form is consent given to the procedures complained of here, such as genital examination. 8 While some of these procedures are typically performed as part of a well-child examination, as the record shows, most or all of them can also be performed outside the context of a physical exam. A form granting consent to certain specified procedures does not constitute consent to other procedures, or to a general physical examination. 56 Similarly, the form entitled Authorization for Treatment to Minors does not evince consent to the examination at issue here. In bold print at the top of the document, the form is entitled Authorization for Treatment To Minors. Treatment is obviously not the same thing as a routine physical examination, and a parent is unlikely to understand it as such. In the middle section, the form authorizes CAP to transport the child for emergency care or emergency dental care, allowing the parents to designate the hospital or dentist of their choice. The bottom of the form is entitled Refusal to Grant Permission. It allows the parent to sign a statement that I do not give permission to Tulsa County Head Start to transport my child [space for name] for emergency medical/dental care. 9 The plaintiffs' expert, an experienced pediatrician, testified that a physician would understand this form as a form for emergency treatment, having nothing to do with specific on-site consent for a physical examination. 57 As the district court noted, CAP argued that the Authorization for Treatment to Minors form must be read in a bifurcated fashion, the bottom half limited to emergency care and the top half not so limited. Order of Granting CAP's Motion for Summary Judgment, dated May 16, 2001 at 11, App. 202. Focusing solely on the top half, CAP argued that although the title of the form is limited to Treatment, in smaller print within the body of the form, it authorized ` diagnosis or treatment' (emphasis added). Diagnosis, CAP says, includes examination. But consent forms for parents of children in Head Start programs should not be an exercise in obfuscation and misdirection. The question is what a typical reasonable person would understand from the form. A three-part form, whose top part is entitled treatment, and whose middle and bottom parts are explicitly confined to emergency treatment, falls considerably short of the evidence that would be needed to establish conclusively the consensual character of these examinations. At the very least, we cannot agree with the district court's conclusion that there was no issue of material fact regarding the objective reasonableness of CAP's belief that it had consent based on these forms. 58 Indeed, even if we were to accept CAP's invitation to read [the form] in a bifurcated fashion, and to focus on the smaller print within the body of the form instead of the bold print title at the top, we still would come to the same conclusion: the Authorization for Treatment To Minors Form does not grant consent for well-child physical examinations. The top portion of the form reads as follows, in full: Authorization For Treatment to Minors 59 We, the undersigned parent(s) or legal guardian of the minor listed below: 60 ___________ Birth date: ____________ 61 Do hereby authorize any x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any physician or dentist licensed by the State of Oklahoma and hospital service that may be rendered to said minor under the general, specific or special consent of the TULSA COUNTY HEAD START PROGRAM, the temporary custodian of the minor, whether such diagnosis or treatment is rendered at the office of the physician or dentist to call in any necessary consultants, in his/their discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise his/their best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment. 62 This consent shall remain effective during the 1998/99 school year, unless sooner revoked in writing to the Tulsa County Head Start Program. Parent's Legal Signature ______________ Date __________ 63 Putting aside the fact that the first paragraph contains garbled syntax and evidently is missing some words, it does not grant consent for the type of examination at issue here. To begin with, the form does not mention well-child examinations or any other form of general physical exam. It refers, instead, to diagnosis or treatment. Contrary to CAP's argument in district court, diagnosis does not suggest[] a routine physical examination. The term diagnosis is defined as the art or act of identifying a disease from its signs and symptoms. Webster's Third New International Dictionary 622 (1976). While a general physical examination might disclose a disease or condition that warrants a diagnosis, the well-child examination itself is not a diagnosis. Moreover, the form is limited to treatment or diagnosis by a physician or dentist licensed by the State of Oklahoma. Nurses Baker and Strayhorn are neither physicians nor dentists. 64 In summary, because no form signed by the parents gave CAP explicit authorization to conduct general well-child examinations, including genitalia examinations, the district court should not have held, as a matter of law, that it was objectively reasonable for CAP to believe that it had been given consent to authorize and arrange for the children to be examined. It bears emphasis that this case comes to this Court on appeal of an order granting summary judgment in favor of the defendants. The parents did not move for summary judgment and there is no need for this Court to consider whether, on this record, they would be entitled to it. We hold only that the district court correctly held that the examinations at issue were a search for Fourth Amendment purposes, and that the evidence in the record is at least sufficient to permit a trier of fact to conclude that the examinations were not consensual and that it was not objectively reasonable to believe that they were. Accordingly, it is necessary to consider whether these examinations were otherwise reasonable or fell within an exception to the warrant requirement. 65 3. Did the examinations fall within the special needs exception to the requirement of consent or a warrant? 66 Not all searches lacking warrants or consent are unconstitutional under the Fourth Amendment. The touchstone of the Fourth Amendment is reasonableness. Jimeno, 500 U.S. at 250, 111 S.Ct. 1801; Vernonia, 515 U.S. at 652, 115 S.Ct. 2386; see also California v. Acevedo, 500 U.S. 565, 581-83, 111 S.Ct. 1982, 114 L.Ed.2d 619 (1991) (Scalia, J., concurring); Akhil Reed Amar, The Constitution and Criminal Procedure: First Principles 7-19 (1997); Telford Taylor, Two Studies in Constitutional Interpretation 24-29 (1969). The general rule is that a warrantless search conducted without consent is presumptively unconstitutional unless it fits within certain narrow exceptions to the general rule. Roska, 328 F.3d at 1240. One of those exceptions is the so-called special needs doctrine. Id. at 1241. 67 Special needs is the label attached to certain cases where special needs, beyond the normal need for law enforcement, make the warrant and probable-cause requirement impracticable. Earls, 122 S.Ct. at 2565, quoting Griffin v. Wisconsin, 483 U.S. 868, 873, 107 S.Ct. 3164, 97 L.Ed.2d 709 (1987). In special needs cases, the Court replaces the warrant and probable cause requirement with a balancing test that looks to the nature of the privacy interest, the character of the intrusion, and the nature and immediacy of the government's interest. Id. at 2565-67. Justice Blackmun first coined the term special needs in his concurrence in New Jersey v. T.L.O., 469 U.S. 325, 351, 105 S.Ct. 733, 83 L.Ed.2d 720 (1985). The Court thereafter adopted the terminology in O'Connor, 480 U.S. at 720, 107 S.Ct. 1492, and Griffin, 483 U.S. at 873, 107 S.Ct. 3164, concluding that in limited circumstances, a search unsupported by either warrant or probable cause can be constitutional when `special needs' other than the normal need for law enforcement provide sufficient justification. Ferguson, 532 U.S. at 76 n. 7, 121 S.Ct. 1281. 68 At this stage in development of the doctrine, the special needs category is defined more by a list of examples than by a determinative set of criteria. Among the cases said by the Court to involve special needs are: a principal's search of a student's purse for drugs in school; a public employer's search of an employee's desk; a probation officer's warrantless search of a probationer's home; a Federal Railroad Administration regulation requiring employees to submit to blood and urine tests after major train accidents; drug testing of United States Customs Service employees applying for positions involving drug interdiction; schools' random drug testing of athletes; and drug testing of public school students participating in extracurricular activities. 10 The Supreme Court has not told us what, precisely, this set of cases has in common, but the cases seem to share at least these features: (1) an exercise of governmental authority distinct from that of mere law enforcement — such as the authority as employer, the in loco parentis authority of school officials, or the post-incarceration authority of probation officers; (2) lack of individualized suspicion of wrongdoing, and concomitant lack of individualized stigma based on such suspicion; and (3) an interest in preventing future harm, generally involving the health or safety of the person being searched or of other persons directly touched by that person's conduct, rather than of deterrence or punishment for past wrongdoing. It also appears significant that each of these cases involved extraction of consent through a threatened withholding of a benefit, rather than lack of consent. In Griffin, the convicted felon agreed to the terms of probation as a condition to release from incarceration; in Skinner and Von Raab, the employees agreed to drug testing as a condition of employment; in Vernonia and Earls, the students were forced to agree to the drug testing if they wished to participate in specified extracurricular activities. 11 This latter factor suggests that the special needs doctrine is a subspecies of the unconstitutional conditions doctrine. See Kathleen Sullivan, Unconstitutional Conditions, 102 Harv. L. Rev. 1413, 1433-42 (1989); Richard Epstein, The Supreme Court, 1987 Term—Forward: Unconstitutional Conditions, State Power, and the Limits of Consent, 102 Harv. L. Rev. 4, 92-94 (1988); Kenneth W. Simmons, Offers, Threats, and Unconstitutional Conditions, 26 San Diego L.Rev. 289, 291-92 (1989). 69 It is not clear, therefore, that the special needs doctrine has any place in this case. To be sure, the Head Start agency may have been exercising a form of in loco parentis authority; there was no individualized suspicion of wrongdoing and hence no stigma from being singled out for a search; and the stated purpose of the examinations was to promote the health and educational readiness of the children. On the other hand, the claim in this case involves lack of consent rather than compelled consent. According to the plaintiffs, CAP simply used its power over the children to conduct the examinations. Had CAP instead required the parents to consent to an unscheduled examination, on condition of not permitting their children to enroll in the Head Start program, this case would more closely resemble a classic special needs case. 70 We need not resolve whether the special needs doctrine applies, however, because it is plain that, if performed without the necessary consent, the searches were unconstitutional even if we employ the special needs balancing test. The sole special need invoked by CAP, and accepted by the district court, was the `special need' that the physical examination of a child, `done in order to comply with federal regulations, is an effective means of identifying physical and developmental impediments in children prior to them starting school, a goal of Head Start....' Order of Granting CAP's Motion for Summary Judgment, dated May 16, 2001 at 7, App. 198 (ellipses in original). The district court found that this qualified as a special need because CAP is bound to follow the Head Start regulations and those regulations require a health determination for each child.... [I]t is clearly impracticable to demand adherence to the traditional warrant and probable cause requirements considering the number of children dealt with by the Head Start program. Id. 71 We cannot agree with this logic. While it is certainly true that a properly conducted physical examination is an effective means of identifying physical and developmental impediments in children, this supplies no justification for proceeding without parental notice and consent. The premise of the special needs doctrine is that these are cases in which compliance with ordinary Fourth Amendment requirements would be impracticable. Earls, 122 S.Ct. at 2564, quoting Griffin, 483 U.S. at 873, 107 S.Ct. 3164. There is no reason, however, to think that parental notice and consent is impracticable in this context. On the contrary, CAP claims to adhere to a policy of obtaining parental consent and providing advance notice to the parents so that they can be present at the examination. The failure to do so in this case appears to be a product of sloppy draftsmanship (with respect to consent forms) and carelessness (with respect to notice), rather than to any inherent impracticability of compliance with ordinary Fourth Amendment norms. 12 72 Nor does compliance with Head Start regulations excuse CAP's failure to obtain parental consent. On the contrary, the regulations expressly require Head Start grantees to obtain advance parent or guardian authorization for all health and developmental procedures administered through the program. 45 C.F.R. § 1304.20(e)(2). Contrary to CAP's interpretation, the regulations do not require them to obtain a physical examination within 90 days of enrollment. The regulations require Head Start grantees, within 90 days of enrollment, to make a determination as to whether enrolled children have an ongoing source of continuous, accessible health care and whether they are up-to-date on a schedule of appropriate preventive and primary health care. 45 C.F.R. § 1304.20(a)(1)(i), (ii). If the children are lacking in these respects, it is an obligation of the Head Start grantee to assist the parents in making the necessary arrangements. Id., § 1304.20(a)(1)(ii)(A). It is not the place of a Head Start agency to usurp the parental role. Indeed, to schedule medical examinations without the knowledge of the parents would thwart the purpose of the regulations. Examinations performed on the children without parental participation could not reveal whether they had access to ongoing medical care or whether they were up to date on a schedule of preventive and primary health care. To make those determinations, the agency has to communicate with the parents and with the children's regular doctors. 73 For these reasons, we conclude that the special needs doctrine would not excuse the failure to obtain parental consent for the examinations. We turn now to the defenses put forward by each of the appellees.