Long before Guantánamo, the United States had its own domestic prisoner-abuse problem. The high rate of incarceration in county jails, and in state and federal prisons, coupled with a general lack of public awareness, makes such abuse almost inevitable.

Take a case I am familiar with, that of twenty-one-year-old Timothy Joe Souders of Adrian, Michigan. He died in an isolation cell in the Southern Michigan Correctional Facility at Jackson on August 6, 2006. Souders was mentally ill, and spent the last four days of his life naked and shackled to his bed in a four-point restraint. An autopsy, released last November thanks to the American Civil Liberties Union, listed the cause of death as an accident resulting from hyperthermia and dehydration.* Partly because of this case, Federal District Court Judge Richard Enslen ruled that medical care at the facility—whose Web site describes it as housing inmates with “specific needs,” including medical needs—was deficient, and he placed Southern Michigan Correctional Facility under federal supervision.

Timothy Souders arrived at the facility after being sentenced to two to four years for attempted robbery. According to the local paper, he was carrying a knife when the police approached him. Souders walked toward them and called out, “Go ahead, kill me.” After being put in jail, Souders tried to commit suicide, using another knife he had managed to conceal.

News of Souders’s death generated heated discussion among both defenders and critics of the justice system. Dr. Robert L. Cohen, assigned to monitor the prison in the wake of the judge’s ruling, was shocked. “Actively psychotic patients with cardiac conditions placed in four-point restraint are at significant risk of death,” said Cohen. He concluded that what happened to Souders was “a terrible, unnecessary tragedy.”

Russ Marlan, a spokesman for the Michigan Department of Corrections, defended the prison. He said that Souders had been unmanageable and that he had destroyed everything in his cell and assaulted another inmate. When Souders was placed in an isolation unit, he stuffed his clothes down a toilet to flood the room. Even after Judge Enslen ordered the prison to stop using four-point restraints, Marlan insisted that in Souders’s case the method had been legal and appropriate. Prison officials appealed the judge’s decision.

When the autopsy concluded Souders’s death had been an accident (he expired two hours after being released from his restraints), the search began for a scapegoat. A staff nurse and a physician’s assistant who worked in the prison were cited—the nurse for allegedly not reading Souders’s physical condition correctly, the physician’s assistant for failing to properly chart the matter. No one higher in the chain of command was questioned about why Souders had been placed in detention when the temperature was nearly 100 degrees for four days in a row. Nor did the authorities inquire whether the medications he was taking might put him at risk. On December 7, Judge Enslen held the State Department of Corrections in contempt, threatening $2 million in fines unless it hired more doctors and nurses for the prisons it runs in Jackson.

Beyond the legal wrangling, a deeper question remains: Who is responsible for Souders’s death? According to Marlan, Souders couldn’t be managed without using restraints. Prison personnel monitored him every fifteen minutes and gave him bathroom breaks every two hours. “He was fed. He was given water. He was given his medication,” said Marlan. Yet, if that was the case, why was dehydration listed as a cause of death? According to Sandra L. Girard, executive director of Prison Legal Services of Michigan, Souders died from inadequate medical care, which constitutes cruel and unusual punishment. Souders would be alive had less draconian means been used to subdue him and had there been proper supervision of his physical condition.

Future tragedies of this kind can be prevented by forbidding methods like four-point restraints, by providing more public oversight of prisons, and by placing mentally ill prisoners in residential treatment programs. Legislation has been introduced to create special courts in Michigan so that judges can offer mental-health treatment to certain kinds of offenders. But until it passes, a judge cannot sentence an offender to such a facility. And once a mentally ill person is in the system, it is difficult to get him out for treatment. These simple changes would shield the justice system from further embarrassment, and more important, they would save lives.

* This sentence has been corrected.

Related: Letters, December 21, 2007