Court Opinion

ID: 194651
Source: CourtListenerOpinion
Date Created: 2011-02-07 02:21:59+00
Date Added: 2024-06-11T08:14:55.408729
License: Public Domain

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

                             -2-

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.
       

                             -3-

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.
                                    

                             -4-

"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.

                             -5-

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

                             -6-

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

                             -7-

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.

                             -8-

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.

                             -9-

     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.

                             -10-

     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

                             -11-

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 . . . .").  

                             -12-

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,

                             -13-

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.
         

                             -14-

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.
                         

                             -15-

     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

                             -16-

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

                             -17-

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.
                                                       

                             -18-

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

                             -19-

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.

                             -20-

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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