If you are accused of a crime and held in custody in lieu of bond you have a constitutional right to receive adequate medical treatment. See Estelle v. Gamble, 429 U.S. 97 (1976). However, pretrial detainees with serious medical needs who have the misfortune of being housed at institutions such as the Cook County Jail will find that news a small comfort. The fact is, pretrial detainees who file federal lawsuits pursuant to 42 U.S.C. section 1983 are treated no better than convicted felons even though a pretrial detainee has not been convicted of a crime and is presumed innocent. It may be that mainstream society is not overly sympathetic to the medical needs of persons who are detained in jail. However, we need to understand that many pretrial detainees have been accused of relatively minor crimes. Moreover, some detainees are actually innocent. In extreme cases, they have been arrested on warrants meant for other individuals who have misappropriated their identities.

Health care is a sensitive issue in the United States and many law abiding hard working people have none whatsoever. This is a national embarrassment. However, even uninsured Americans receive emergency medical care. Pretrial detainees very often don't. PRESUMED INNOCENT? The United States Supreme Court has never fully explained why a pretrial detainee with a denial of medical treatment claim must meet the rigorous standards of the Eighth Amendment which prohibits cruel and unusual punishment. In theory, a pretrial detainee cannot be punished since he has not been convicted of a crime. While a pretrial detainee technically must plead a denial of medical treatment claim under the 14th Amendment it is an insignificant distinction for the Supreme Court has specifically held that the deliberate indifference standard raised by the Eighth Amendment is the appropriate standard of culpability in these types of 14th Amendment claims. See Bell v. Wolfish, 441 U.S. 520 (1979).

Predictably, in Board v. Farnham, 394 F.3d 469 (7th Cir. 2005) the Appellate Court for the Northern District of Illinois stated, "We have found it convenient and entirely appropriate to apply the same standard to claims arising under the 14th Amendment (detainees) and 8th Amendment (convicted prisoners) without differentiation." Convenient, yes. Appropriate? Hardly. The 14th Amendment protects pretrial detainees from punishment without due process of law. Since a pretrial detainee has not been convicted of a crime it follows that he should not be punished by being denied basic human rights such as necessary medical care while in custody awaiting trial. Yet, because courts apply the Eighth and Fourteenth Amendments as if they are inter-changeable it is far more difficult to prove a section 1983 claim for denial of medical care by pretrial detainees than it should be. To succeed on a section 1983 claim, the pretrial detainee must show that the prison official(s) was deliberately indifferent to his medical needs, which involves proving both an objective component-a sufficiently serious medical need-and a subjective component-a sufficiently culpable state of mind on the part of the defendant(s) in denying medical care. See Greeno v. Daley, 414 F.3d 645, 653 (7th Cir.2005). In other words, to be liable, the defendants must have known of the detainee's serious medical need and consciously disregard that need so as to inflict cruel and unusual punishment upon him. See Johnson v. Doughty, 433 F.3d 1001, 1010 (7th Cir.2006).

To prove the objective prong the plaintiff must show that the medical condition is sufficiently serious. This can be done by demonstrating that it has either been diagnosed by a physician as mandating treatment or that the condition is so obvious that even a lay person would perceive the need for a doctor's attention. See Thomas v. Cook County Sheriff's Dep't, 588 F.3d 445, 452 (7th Cir.2009). The second prong of the test is more difficult. A prison official may be held liable under the Eighth Amendment...only if he knows that the inmate faces a substantial risk of harm and disregards that risk by failing to take reasonable measures to abate it. See Farmer v. Brennan, 511 U.S. 825 (1994). In other words, plaintiff must prove subjectively that the defendant had a guilty state of mind, which is tantamount to proving that the defendant knew the risks of injury to the plaintiff and ignored them. Defendants invariably claim that they did not know of the extent of the detainee's medical needs or that their response was reasonable. Simple medical negligence is not actionable under an Eighth Amendment standard. However, this subjective state of mind can be inferred when the plaintiff's serious medical need was so obvious that even a lay person would have known that medical treatment was needed. In addition, circumstantial evidence alone can sustain the plaintiff's burden.

Nonetheless, proving that a sheriff, a guard or medical personnel employed by a local government entity such as Cook County were deliberately indifferent to a pretrial detainee's serious medical needs is a difficult hurdle to clear. 1983 LIABILITY AGAINST THE GOVERNMENT ENTITY MONELL Establishing liability against the government entity itself is an even greater task. Liability against the City of Chicago or Cook County based on the constitutional violations of its employees is far from automatic. The doctrine of respondeat superior may not be invoked under section 1983 to prove government liability. In other words, in denial of medical treatment cases at the Cook County Jail, the County or Sheriff Tom Dart will not be held liable based on the torts of their employees. However, a local governing body may be liable for monetary damages under section 1983 if the unconstitutional act complained of is caused by: (1) an official policy adopted and promulgated by its officers; (2) a governmental practice or custom that, although not officially authorized, is widespread and well settled; or (3) an official with final policy-making authority. Monell v. Dept. of Social Services, 436 U.S. 658, 690-91 (1978); Valentino v. Vill. of S. Chi. Heights, 575 F.3d 664, 674 (7th Cir.2009).

Courts have refused to adopt a bright-line rule defining what constitutes a widespread custom or practice. There is no clear consensus as to how frequently such conduct must occur to impose Monell liability, except that it must be more than one instance, See Cosby v. Ward, 843 F.2d 967, 983 (7th Cir.1988). But the plaintiff must demonstrate that there is a policy at issue rather than a random event. This may take the form of an implicit policy or a gap in expressed policies, Phelan v. Cook County, 463 F.3d 773, 790 (7th Cir.2006), or a series of violations to lay the premise of deliberate indifference. See Palmer v. Marion County, 327 F.3d 588, 596 (7th Cir. 2003). The jury must make a factual determination: whether the evidence demonstrates that the County had a widespread practice that caused the alleged constitutional harm. See Woodward v. Corr. Med. Serv. of Ill., Inc., 368 F.3d 917, 928 (7th Cir.2004). Proving a policy, custom or practice is extremely difficult and the Supreme Court has recently made it a Sisyphean task with its ruling in Ashcroft v. Iqbal, 129 S. Ct. 1937, 1942, 1943, 1949-54 (2009). But, as we shall see below, the Cook County Jail's policies are so egregious that it can be done. See Part Two