Comfort Items: Why Not?

Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.”  This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc.  This, of course, never happens in an outside medical practice.  When was the last time you heard of a patient asking for a prescription for a pillow?  Yet such requests are extremely common in correctional medicine.  You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic:  a second mattress.

When inmates are first booked into a jail, they are issued (among other things) a mattress to sleep on.  Jail mattresses are thin and not very comfortable, especially when placed over a concrete or metal bed frame.  Why are they so thin?  I have been told that the main reason is security:  the thicker a mattress is, the easier it is to slice open and hide contraband inside.  Conversely, the thinner a mattress is, the easier it is for security personnel to find hidden contraband. While this may be true, I suspect that a more important reason why jails use thin mattresses is that they are cheap.  Also, many jail administrators are OK with the fact that the mattresses are uncomfortable since, after all, jails are supposed to be punitive places.

When patients come to me complaining that the mattresses are not comfortable, I understand and even sympathize with the complaint. Many aspects of jail life suck; including the mattresses.  So if a jail patient says, for example, that sleeping on the thin mattress aggravates his chronic back pain, I tend to believe him. So why not just authorize the second mattress as medically necessary?  The answer lies in the first rule of correctional medicine:  Fairness.  If I authorize a second mattress for one inmate with back pain, then the principle of Fairness says I must authorize a second mattress for every inmate with back pain.  Otherwise, I have treated the first inmate with favoritism. 

This is why “scoring” a second mattress or a second pillow can be a source of considerable prestige in jails and prisons. And not just prestige, money.  Comfort items have value in the jail’s black market.  I learned this lesson the hard way early in my jail career when I authorized a second pillow for a patient and later learned that this patient had been selling use of the pillow overnight to other inmates in exchange for commissary items.  Comfort items are valuable commodities.

Inmates know all of this and expect me to be fair.  That is why, if I authorize a second mattress for one patient, I will quickly get several more requests from others for a second mattress. “I also have back pain . . . I want a second mattress, too!” And if I say then “No” to these patients, many of them will file a formal Grievance.  And rightly so! On what basis do I give a second mattress to one patient with back pain but not others?  It is wrong to show favoritism.

But aren’t there some patients with a legitimate medical need for a special mattress?  Yes, there are!  There is also a true medical device designed for those with a medical need for a special mattress: it is commonly called a hospital bed.  I have had several patients in my career who needed to use a hospital bed while in jail.  The most memorable was a patient who was quadriplegic and spent over a month in the county jail. Not only did we get him a hospital bed; it was one of those high-tech beds that rotated slowly over time to prevent decubitus ulcers. 

On the other hand, I can confidently say that a double thin mattress is not a true medical device.  It is not mentioned in any medical textbook that I have ever found. A double mattress is, instead, a comfort item:  it makes life in the jail a bit more comfortable. 

Some jails recognize this and have written objective guidelines as to which inmates will be issued items designed to make jail life more comfortable, like a second mattress or a second pillow.  Examples are pregnant women after 20 weeks and those more than 70 years old.  Some jail administrators make some comfort items, such as better-quality shoes and better food, a reward for inmate workers or for good behavior. Some jails put comfort items like extra pillows or shoe insoles on the inmate commissary for purchase.

My personal opinion is that jail inmates should have better living conditions than most do now, including better mattresses. And there is a role for jail medical staff to advocate for these changes.  I believe this and have done so myself.  However, the wrong way to do this is to “medically authorize” comfort items willy-nilly for some inmates but not for others.

As always, what I have written here is my opinion, based on my training, research and experience. I could be wrong! If you think that I am wrong, please say why in COMMENTS!

This article was originally published in MedPage Today.

Doing Time is written by Charlie Zaylor, a Correctional Psychiatrist

12 thoughts on “Comfort Items: Why Not?

  1. Bertram Moshier

    ” Also, many jail administrators are OK with the fact that the mattresses are uncomfortable since, after all, jails are supposed to be punitive places.”

    My issue with administrators having this opinion for all is not all inmates are – yet – convicted. Those not convicted of a crime are not there for punitive reasons, but because they couldn’t make bail. If we truly believe in “innocent until convicted,” we need to treat those not yet convicted of a crime be treated in a non-punitive manner.

    I apologize for the outburst. While I have never been arrested, it is my opinion people are innocent till convicted and thus entitle to non-punitive procedures and policies. I dislike situations where the yet convicted are punished simply for not making bail.

    Reply
    1. Jeffrey Keller MD Post author

      I agree with you, Bertram. Most ail administrators (and most of the general public, for that matter) think of jails as places to punish those convicted of a crime. The “innocent until proven guilty,” who are housed with and under identical circumstances as those convicted of a crime, are not even considered.

      Reply
  2. Nancy

    I have started a response three times to this thread and each time get frustrated and quit. The argument goes on and on even with myself. I say no to comfort items. Jail should not be comfortable or punitive for that matter, but for sure not comfortable. I’ve had many inmates age 25 and under tell me it’s not that big of a deal to be in jail. Actually, yes… yes it is big deal. The life is not normal and it is up to them to stay out and live their life as a contributing member of our society. I tell them to start taking their life seriously.

    There are no easy answers, but there is also not enough time to “fix” those in jail demanding a second mattress because it isn’t comfortable and they’re being mis-treated. The simple answer is “then don’t come back”. Maybe not coming back is not so easy for some, but not coming back does solve the issue of “not being comfortable”, doesn’t it.

    Reply
    1. Jeffrey Keller MD Post author

      Thanks Nancy! This is not the only aspect of the jail experience about which I have ambivalence and heartburn.

      Reply
  3. grid

    While it may seem that comfort makes for better health, or at least that lack of comfort is detrimental to one’s wellbeing, there are reasons to believe otherwise (such as the fact that deprivation drives adaptation). Beyond the inside market value of comfort commodities, lies the question of how beneficial they really are to the detained person. Matters would perhaps be simpler if all subjective motives could be tracked down to objective medical findings, which is obviously not the case.

    In conjunction to the other post (on how to avoid being the decider), it is probably safer for medical staff to not approve anything that is not listed as a medical device. The true need for a medical assistive device is not so simple to ascertain, while deciding on what is (or is not) a medical device may not be any simpler… Furthermore, there are medical devices that may pose a security threat (such as those that could be used as weapons – sprays, metal or hard plastic rods, powerful magnets, power adapters/transformers etc) and which will require a very sound medical justification before being approved (if they are not blacklisted already).

    Therefore, any requests for non-medical devices (that are the object of comfort prescriptions) is safer to be deflected to higher management, even if – as the case may be – the deciders might ask us for some input on the true medical needs of the inmate.

    Reply
  4. Jason

    I understand why these requests are problematic, but part of the rationale doesn’t really follow. It doesn’t make sense to me that only equipment that qualifies as durable medical equipment — that is, equipment that wouldn’t generally be useful to a non-ill/non-disabled person — can meet a “legitimate medical need”?

    I’m a lawyer, not a doctor, but I can think of two contexts in the community in which similar requests occur and are (as far as I know) routinely granted as far as there is some basis for the request:

    First, my college dorms had thin, poor-quality mattresses, but you could bring your own mattress with a doctor’s note endorsing this due to a medical condition. If I recall correctly, this was somewhat abused (and I didn’t do it). Presumably, the administration implemented this policy because storing a ton of unused mattresses was a pain. Assuming their patients really had back pain, were the doctors writing these notes doing so without a “legitimate medical need”?

    Second, you can request ADA accommodations at work, such as an ergonomic chair. My understanding is that using these chairs reduce the employee’s pain, but that denying them wouldn’t actually render the employee unable to do his/her job. Yet, physicians in the community routinely fill out paperwork endorsing provision of ergonomic aids for employees.

    Again, it seems like the standard of care is different in the community vs. in the jail. There are doubtless good reasons for that, but I don’t see the rationale for deeming these requests as merely for “comfort items” when society deems them legitimate medical requests outside of the correctional context. (I’m not sure it should matter, but as another commenter pointed out, most people in jails are unconvicted, so punishment can’t be the rationale.)

    Reply
  5. Jeffrey Keller MD Post author

    Thank you for the comments, Jason!
    Like your college dorm example, Jail patients sometimes also bring in notes or “prescriptions” from their outside doctors for a second mattress. I always call these doctors to ask about the prescription and invariably, I am told a something like this: “The patient asked me to write the prescription and I didn’t see any harm in it, so I did.” It basically was a favor they did for their patient. None did any objective testing. None said “Yes” to some patients and “No” to other patients based on some medical exam. So in answer to your question, Yes, the doctors in your dorm room example were probably doing so without a “legitimate medical need” (at least in my opinion).
    It is also interesting that the college kids were asking for their own mattresses and the jail inmates are asking for two thin mattresses stacked on top of one another.
    Your other example asks whether a second mattress could be considered to be an ADA accommodation. This is a great question! An accommodation to someone with a disability is different from a medical need. But to get an ADA accommodation, the person has to have a recognized disability. Most of my jail patients, do not. They have not even applied for disabled status. (One exception is the patient I mentioned who was quadriplegic. He did have a disability and we accommodated him with a special rotating hospital bed).
    As I said in my article, I personally think that all jail patients should have better quality bedding. And food, for that matter!

    Reply
    1. Jason

      I’m not an ADA lawyer, although others in my office do this work. “I need new office furniture because my back hurts” is enough to trigger an employer’s duty to start the ADA interactive process in the private-employment context. There isn’t really a concept of applying for disabled status.

      The definition of a disability under the ADA is very broad, especially after Congress amended the ADA in 2008. The condition must significantly impair a major life activity (such as sleeping) while the condition is active, without regard to the use of medications or assistive devices (other than standard eyeglasses). I have no idea whether these back-pain patients have a disability under the ADA — and a lack of objective findings on exam or imaging would make me doubt it — but the standard is much, much easier to meet than quadriplegia.

      In the private-employment context, I’d advise clients against denying minor accommodations on the ground that the employee didn’t actually have a disability. Way too much legal risk to save a little money (I think correctional mattresses are ~ $100?). The risk tolerance in jails may be different — I suspect this may come more from legal restrictions on lawsuits against government agencies rather than the terms of the ADA itself.

      The ADA requires a reasonable accommodation, not provision of the disabled person’s accommodation of choice. A second mattress probably would have been a reasonable accommodation for the students in my story, even if they had a disability under the ADA — but from the school’s perspective, these were paying customers, and anyway it was more cost-effective to grant them their desired accommodation of choice than to pay their own doctors and lawyers to vet whether two mattresses would also be reasonable.

      I definitely agree that giving everyone a better mattress is the best solution!

      Reply
      1. Jeffrey Keller MD Post author

        Excellent comment, Jason!

        I had never heard the double mattress issue framed as an ADA accommodation issue before. It seems a stretch to me, especially since even if subjective “back pain” is indeed an ADA disability, special mattresses are not prescribed for this on the outside. In other words, you doctor does not write a prescription for a special mattress which your health insurance then pays for–with the exception of a true hospital bed.

        Reply
  6. grid

    When various people in management positions within institutions / organizations require some form of medical proof (be it prescriptions, recommendations, certificates etc.) from those employees / customers who demand special treatment or privileges based on some loose health motivation, they do so because they want to be fair and to prevent abuse. When facing any form of social constraint, there’s plenty of room for abusers of rights to manifest. The medical profession, as many other liberal professions operating under the protection and authority of State is bound, in such cases, to stick to its basic tenets and to refrain from issuing any kind of dispensations or prescriptions the do not normally fall into their area of competence. Behind any patient waiving before his doctor an unusual prescription request lies another request – that of the authority unwilling to grant him something that will not otherwise be granted. People tend to use doctors in these power games, more or less knowingly, and it is important for us to be able to stand firm on what we know and not be driven on to the abusers’ pathway. Depending on their interest, a patient may go a long way to earn your trust (up to making you swear that he has a certain condition) before asking for some form of confirmation on our part – then you may be surprised to learn of the many ways in which the paper you willingly signed was used…

    It is important to know that those who require medical proofs are not doctors themselves and do not know what a doctor can or cannot prescribe, based on his/her formal competence, but are instead relying on a doctor’s legitimate authority in issuing a statement. The fact that I cannot perceive a malicious way of using the paper I just signed does not mean there is no such way. As a rule, medical waivers or prescriptions do help people to get ahead one another and, therefore, if we do not want to be accomplices in such petty power games, we better steer off promiscuous prescriptions. At some point, someone may come forward and present us the unfortunate result of a such a prescription we wrote in good faith. And that will be the end of all our future people-pleasing practice.

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  7. darin haugland

    I am asked daily for these types of requests and I can tell you without question that Dr. Keller is 100% correct in that once you authorize an item- you set a precedent on this item. From there- you better be able to medically defend why you approve said item to all future patients that request. This is why I pretty much have a criteria already in mind and I am almost indifferent to the request. If the patient’s medical condition meets criteria – I can issue and defend the authorization. If not- no. Tennis shoes are a huge request – we only consider approval for “special” shoes for objective foot and ankle conditions of significant severity. We do not approve not back or knee pain, nor simply foot pain not involving previous fractures/surgeries/congential deformity nor pes planus. One last suggestion- when a patient asks me for a second mattress for non-descript back pain- I ask them if Medicare or Medicaid would provide this mattress. They are often rightly confused but I tell them that Medicare does not consider them a medical treatment for back pain. If Medicare does not say they are a medical treatment for back pain – exactly how can I make this assertion? They really have no where to go with this answer and it is quite defendable in court. In my 25 years in correctional medicine – I failed to see any board complaint or legal case ding any provider over comfort items.

    Reply
  8. Alfred Cichon

    A couple of thoughts – any intervention by the health care staff should be based on a medical necessity; the idea that it should be something that requires a ‘prescription’ from a licensed provider does cut through the chaff. That said, there are some times when an ‘extra’ or ‘medical’ mattress is appropriate: surgery / fracture (particularly of back / shoulder less than 60 days old, metal protrusions (compression / Harrington rods), GERD (to elevate upper torso). One may expand / contract or quibble with these examples.
    Health and hygiene are second cousins but not members of the same nuclear family. It is true that inattention to hygiene may lead to a risk of health compromise but does not represent a ‘clear and present’ danger. Again, if it does not require a prescription health care staff should leave it alone. IMNHE (in my not humble enough) opinion this also applies to dentures , contacts etc. [though it may be different in prison]

    Reply

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