The U.S. Supreme Court declared in Estelle v. Gamble (1976) that 'the deliberate indifference' to serious medical needs of inmates constitutes unnecessary infliction of pain proscribed by the eighth amendment. In Todaro v. Ward, the Second Circuit Court mandated that screening must be conducted by licensed medical personnel and that specific written protocols must define evaluation procedures, thus providing a measure for the constitutional adequacy of care. Ethical issues in inmate health care arise because medical staff are responsible to their patients while simultaneously being constrained by the structure and routine of the institution; they must provide services in a setting designed to confine and punish. Some conflicts between treatment and custody can be resolved more easily when the health care delivery system is controlled by an independent health care provider; however, neither the courts nor the American Medical Association have supported this approach.