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First Circuit: Surgery performed on inmate to locate alleged contraband a violation of the Fourth Amendment

Court declares surgeon to be a “state actor” subject to federal civil rights law and rejects qualified immunity for her and two prison officials


Angel Sanchez was a prisoner at the Puerto Rico Bayamon correctional facility. Corrections Sergeant Cabán-Rosados (“Cabán”) and other correctional officers under his command conducted a search of his cell area. They used a handheld metal detector to scan Sanchez and it indicated the possibility of contraband inside his body. He was removed from his cell and taken to another area of the prison, where he was sniffed by a dog. The dog failed to react positively to the presence of contraband. Sanchez was strip-searched, but no contraband was found. He was scanned again with the metal detector while naked with a negative result.

Sergeant Cabán and/or Commander Sanchez, the prison Commander of the Guard, requested a prison doctor to order an abdominal x-ray of Sanchez. Without examining Sanchez, the doctor ordered an x-ray. Sanchez objected but was informed that there was a judicial order for the procedure. Sanchez asked Caban to see the order, but Cabán refused to produce it. According to the complaint, no order existed.

The prison Medical Director examined the x-ray film and informed Sanchez that the x-ray disclosed the presence of an object in his rectum consistent with a cellphone. Sanchez denied having a cellphone in his rectum and requested a second x-ray. His request was refused.

Sanchez also had two bowel movements monitored by correctional officers, which proved negative for contraband. After the second bowel movement, the Medical Director issued an order for Sanchez to be examined at the Río Piedras Medical Center emergency room for possible medical intervention.

Sanchez again requested that a second abdominal x-ray be taken, but his request was denied. He was taken to the hospital by a correctional officer identified in the complaint as John Doe and examined by a third doctor, identified in the lawsuit complaint as Dr. Richard Roe III. Dr. Roe III conducted a manual rectal examination and ordered several lab tests. The rectal examination failed to disclose the presence of a foreign object, and the laboratory tests were normal.

Dr. Roe III performed a second rectal examination, with the assistance of his superior, identified in the complaint as Dr. Richard Roe IV. This rectal examination likewise failed to reveal the presence of any foreign object in Sanchez’s rectum. Sanchez alleged that both rectal examinations were conducted at the insistence of Corrections Officer John Doe. Moreover, he alleged that Officer Doe pressured the two emergency room doctors to order a medical procedure to remove a cellphone from his rectum.

The emergency room doctors consulted with hospital surgeon, Dr. Sandra Deniz, concerning possible surgery for Sanchez. She was informed of the two negative emergency room rectal examinations; the normal results of the tests ordered by Dr. Roe III; the two contraband negative bowel movements monitored by corrections officers; Sanchez’s continual denials regarding a cellular telephone in his rectum; and his several requests for a second x-ray. Dr. Deniz ignored the background information provided; failed to order a new x-ray exam; failed to conduct her own manual rectal exam; and scheduled Sanchez for emergency exploratory surgery under total anesthesia.

Dr. Deniz obtained Sanchez’s written consent before operating. However, Sanchez alleged that he signed the consent form because of pressure from officer John Doe and a verbal promise from Dr. Deniz that she would perform another rectal examination under total anesthesia before conducting the surgery. Dr. Deniz did not perform another rectal examination to confirm the presence of a foreign object before performing the surgery. Instead, after anesthesia was administered, she immediately performed exploratory surgery. The surgery disclosed no cellphone or other foreign object in Sanchez’s gastrointestinal tract. Two days after the surgery, Sanchez was returned to his prison cell.

Sanchez subsequently sued the involved correctional officers, doctors and the hospital where his surgery was performed. Pursuant to 42 U.S.C. § 1983 (the federal civil rights law), he alleged a violation of his constitutional rights. The federal district court dismissed the suit and Sanchez appealed.

The Decision of the First Circuit Court of Appeals [1]

The First Circuit reversed the district court lawsuit dismissal pertaining to Sergeant Caban, Officer John Doe and Doctor Deniz. The court ruled that this case involves a search for evidence and thus is governed by the Fourth Amendment. The court noted that “the Supreme Court in Hudson [2] ‘foreclosed any [F]ourth [A]mendment challenge to the search of a prison cell, [however], this court, like those in most other circuits, has recognized a qualitative difference between property searches [e.g., cell searches] and searches of a prisoner’s person.’” [3]

The First Circuit observed that the Supreme Court instructed in Bell v. Wolfish [4] that the validity of a search of a prisoner’s body cavities depends upon whether the search was reasonable under its particular circumstances. Moreover, in Wolfish the Supreme Court provided additional guidance to the lower courts: “Courts must consider the scope of the particular intrusion, the manner in which it is conducted, the justification for initiating it, and the place in which it is conducted.”[5] The Supreme Court in Wolfish found no Fourth Amendment violation in an institutional practice involving visual inspection of inmates’ body cavities after contact visits with persons from outside the institution.

The digital rectal examinations

In the instant matter, the First Circuit observed that the two rectal examinations conducted upon Sanchez by doctors at the hospital were digital and involved physical “touching and intrusion.” The court observed further that such examinations are “’highly intrusive and humiliating.’” [6] Nonetheless, the court noted, “physical rectal examinations of prisoners, when carried out by trained medical staff under sanitary conditions, are at times ‘a necessary and reasonable concomitance of ... imprisonment.’” [7]

The court applied the Wolfish standards to the Sanchez digital rectal examinations at the hospital and found that the scope, place and manner in which these examinations were conducted was reasonable. Moreover, they were justified and “carried out for the legitimate penological objective of locating and removing contraband.” The court ruled that these digital rectal exams did not violate the Fourth Amendment.

The surgery

The First Circuit examined the nature and “scope” of Sanchez’ surgery and found it to involve “risk, trauma, [and] pain.’” [8] The court observed that the “surgery was unusual and required total anesthesia, surgical invasion of the abdominal cavity, and two days of recovery in the hospital.” Moreover, the court stated, “Adding to the egregious “scope” of the forced surgery was the lack of “justification” for the procedure. The surgery was conducted despite several indications of the absence of contraband, including the results of two monitored bowel movements and two rectal examinations. An x-ray – a much simpler, less invasive procedure – could have confirmed those results (and eventually did).” [9]

The court ruled that the surgery violated the Fourth Amendment and that Sanchez’ consent was invalid because the surgeon did not conduct her own rectal examination as promised before consent was given.

Qualified immunity

The court rejected qualified immunity for Sergeant Caban and Corrections Officer John Doe (the officer at the hospital with Sanchez). The court explained, “because the surgery described in the complaint and its attendant circumstances were so outrageous, we comfortably conclude that a reasonable officer would understand that, under the particular facts of this case, the surgery violated the plaintiff’s clearly established right to be free from an unreasonable search.”

Likewise, the court rejected the qualified immunity defense asserted by Dr. Deniz. First, the court determined that Dr. Deniz was acting under color of law and not as a private actor when she performed surgery upon Sanchez. The court applied a “state compulsion test” and explained that under this test a private actor becomes a state actor when his/her action follows coercive power or significant encouragement from state officials. The court ruled that the insistence and pressure exerted upon Dr. Deniz by Officer Doe was sufficient to make her a state actor in this matter.

The court next rejected her qualified immunity defense and ruled that a reasonable doctor would have known that this surgery violated clearly established constitutional rights. The court explained, “No detailed knowledge of the law was required to understand that a physician should not perform invasive, non-medically required surgery on a prisoner in circumstances such as those described in the complaint.”

Lessons learned

  • The Supreme Court ruled in Hudson v. Palmer that warrantless searches of prison cells by prison officials do not violate the Fourth Amendment.
  • The Supreme Court in Bell v. Wolfish provided a general formula for lower courts to follow when deciding whether warrantless inmate body cavity searches are reasonable under the Fourth Amendment. The Court stated, “Courts must consider the scope of the particular intrusion, the manner in which it is conducted, the justification for initiating it, and the place in which it is conducted.”
  • The Supreme Court in Bell found no Fourth Amendment violation in an institutional practice involving visual inspection of inmates’ body cavities after contact visits with persons from outside the institution.
  • The First Circuit applied the Wolfish standards to inmate Sanchez’ digital rectal examinations performed by doctors at the hospital. The court ruled that the exams were justified and the scope, place and manner in which the examinations were conducted was reasonable. No violation of the Fourth Amendment occurred.
  • The First Circuit ruled that the surgery performed on Sanchez at the hospital was egregious in scope; without reasonable justification and a violation of the Fourth amendment.
  • The court applied the “state compulsion test” to the surgeon’s interaction with prison officials and determined that she became a state actor due to the insistence and pressure visited upon her by prison officials. This finding permitted the court to treat her as a proper defendant and a potential violator of the federal civil rights statute.
  • The court rejected the qualified immunity defense asserted by the two prison officials and the surgeon, holding that their conduct violated clearly established Fourth Amendment law.

More case reviews: Third Circuit reverses qualified immunity granted for Delaware prison officials


1. Sanchez v. Pereira-Castillo, 590 F. 3d 31 (1st Cir. 2009).

2. See, Hudson v. Palmer, 468 U.S. 517 (1984)).

3. (Quoting, Dunn v. White, 880 F.2d 1188, 1191 (10th Cir. 1989)). See also, Bonitz v. Fair, 804 F 2d.164, 170 n. 6 (1st Cir. 1986), (overruled on other grounds) noting that after Hudson, "’plaintiffs can no longer claim that their cells or other parts of the prison were unreasonably searched,” while analyzing strip searches of prisoners under Bell v. Wolfish, 441 U.S. 520, 545 (1979).’”

4. 441 U.S. 520, 559 (1979).

5. Id.

6. (Quoting, Tribble v. Gardner, 860 F.2d321, 324 (9th Cir. 1988)).

7. (Quoting Daughtery v. Harris, 476 F.2d 292, 295 (10th Cir. 1973)).

8. (Quoting, Schmerber v. California, 384 U.S. 757, 771 (1966)).

9. See, Bell v. Wolfish, 441 U, S 520,. at 559. (1979).

John Michael Callahan served in law enforcement for 44 years. His career began as a special agent with NCIS. He became an FBI agent and served in the FBI for 30 years, retiring in the position of supervisory special agent/chief division counsel. He taught criminal law/procedure at the FBI Academy. After the FBI, he served as a Massachusetts Deputy Inspector General and is currently a deputy sheriff for Plymouth County, Massachusetts. He is the author of two published books on deadly force and an upcoming book on supervisory and municipal liability in law enforcement.

Contact Mike Callahan.