## Facts

- Gary Knecht and Ronald Stevenson were confined at the Iowa Security Medical Facility, a secure state institution for persons in custody with mental-health needs.
- Facility staff used a behavior-modification program that administered apomorphine injections as an aversive stimulus in response to inmate misconduct.
- Apomorphine caused severe physical effects, including prolonged vomiting and temporary cardiovascular changes.
- Injections were used for a range of conduct, including relatively minor rule violations, and were sometimes administered based on reports rather than direct medical observation.
- The treatment was not commonly used in Iowa mental-health facilities, and expert testimony questioned its effectiveness.
- Plaintiffs alleged they did not give meaningful consent to the injections and that attempted withdrawals of consent were refused while injections continued.
- Plaintiffs sued under 42 U.S.C. § 1983 seeking injunctive relief, alleging the nonconsensual use of apomorphine constituted cruel and unusual punishment.
- A magistrate recommended dismissal but proposed precautionary guidelines for future use; the district court dismissed and did not adopt the guidelines.
- Plaintiffs appealed; factual findings were not seriously contested on appeal.

## Issues

1. Whether injecting inmates with apomorphine as an aversive behavior-control measure, without knowing and voluntary consent, constitutes cruel and unusual punishment under the Eighth Amendment.
2. Whether characterizing the program as medical “treatment” removes it from Eighth Amendment scrutiny when it is imposed without valid consent.

## Decision

- The court reversed the dismissal and remanded.
- The court held that administering apomorphine to nonconsenting inmates as an aversive stimulus constitutes cruel and unusual punishment.
- The court directed entry of injunctive relief barring further use of apomorphine except under constitutionally adequate conditions, centered on knowing, intelligent, and voluntary consent.
- The court concluded that proposed procedural safeguards could not cure the constitutional defect where consent was absent or not meaningfully voluntary.

## Legal Principles

- A practice labeled “treatment” remains subject to Eighth Amendment review when, in operation, it functions as punishment and inflicts severe physical distress.
- In custodial settings, invasive or harsh interventions used primarily for behavioral control may constitute “punishment” for Eighth Amendment purposes.
- Nonstandard or medically contested interventions used as aversive stimuli cannot be imposed on inmates without knowing, intelligent, and voluntary consent, including a meaningful ability to refuse or withdraw consent.
- When a challenged practice violates the Eighth Amendment, injunctive relief is an appropriate remedy to prevent continued unconstitutional conduct.

## Conclusion

The Eighth Circuit ruled that forcing apomorphine-induced vomiting on inmates as a behavior-modification tool, without knowing and voluntary consent, is unconstitutional punishment and required an injunction limiting any future use to constitutionally valid consent-based conditions.


Knecht v. Gillman, 488 F.2d 1136 (8th Cir. 1973)