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 a patient asked you 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, 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 then say "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.
Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his "true calling" of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at .