Tyrone Petties v. Imhotep Carter

• Court: Court of Appeals for the Seventh Circuit
• Decided: August 23, 2016
• Docket: 14-2674
• Status: Published

Opinion

In the

United States Court of Appeals For the Seventh Circuit ____________________ȱ No.ȱ14Ȭ2674ȱ TYRONEȱPETTIES,ȱ PlaintiffȬAppellant,ȱ

v.ȱ

IMHOTEPȱCARTERȱandȱSALEHȱOBAISI,ȱȱ DefendantsȬAppellees.ȱ ____________________ȱ

AppealȱfromȱtheȱUnitedȱStatesȱDistrictȱCourtȱforȱtheȱ NorthernȱDistrictȱofȱIllinois,ȱEasternȱDivision.ȱ No.ȱ12ȱCȱ9353ȱ—ȱGeorgeȱM.ȱMarovich,ȱJudge.ȱ ____________________ȱ

ARGUEDȱAPRILȱ28,ȱ2015ȱ

REARGUEDȱENȱBANCȱDECEMBERȱ1,ȱ2015ȱ

DECIDEDȱAUGUSTȱ23,ȱ2016ȱ ____________________ȱ

Beforeȱ WOOD,ȱ Chiefȱ Judge,ȱ andȱ POSNER,ȱ FLAUM,ȱ EASTERBROOK,ȱ KANNE,ȱ ROVNER,ȱ WILLIAMS,ȱ SYKES,ȱ andȱ HAMILTON,ȱCircuitȱJudges.ȱ WILLIAMS,ȱCircuitȱJudge.ȱTyroneȱPettiesȱsufferedȱaȱdebilitatȬ ingȱruptureȱinȱhisȱAchillesȱtendon,ȱwhichȱcausedȱhimȱextremeȱ 2ȱ ȱNo.ȱ14Ȭ2674ȱ

painȱandȱimpededȱhisȱmobilityȱoverȱtheȱcourseȱofȱthreeȱyears.ȱ Heȱbroughtȱaȱlawsuitȱunderȱ42ȱU.S.C.ȱ§ȱ1983ȱagainstȱhisȱdocȬ torsȱatȱStatevilleȱCorrectionalȱFacility,ȱallegingȱtheyȱfailedȱtoȱ alleviateȱhisȱsufferingȱandȱtoȱenableȱhisȱrecoveryȱfromȱtheȱinȬ jury.ȱWeȱheardȱthisȱcaseȱenȱbancȱtoȱclarifyȱwhenȱaȱdoctor’sȱraȬ tionaleȱforȱhisȱtreatmentȱdecisionsȱsupportsȱaȱtriableȱissueȱasȱ toȱwhetherȱthatȱdoctorȱactedȱwithȱdeliberateȱindifferenceȱunȬ derȱtheȱEighthȱAmendment.ȱWeȱconcludeȱthatȱevenȱifȱaȱdoctorȱ deniesȱknowingȱthatȱheȱwasȱexposingȱaȱplaintiffȱtoȱaȱsubstanȬ tialȱ riskȱ ofȱ seriousȱ harm,ȱ evidenceȱ fromȱ whichȱ aȱ reasonableȱ juryȱ couldȱ inferȱ aȱ doctorȱ knewȱ heȱ wasȱ providingȱ deficientȱ treatmentȱisȱsufficientȱtoȱsurviveȱsummaryȱjudgment.ȱBecauseȱ weȱ findȱ thatȱ Pettiesȱ hasȱ producedȱ sufficientȱ evidenceȱ forȱ aȱ juryȱ toȱ concludeȱ thatȱ theȱ doctorsȱ knewȱ theȱ careȱ theyȱ wereȱ providingȱ wasȱ insufficient,ȱ weȱ reverseȱ theȱ districtȱ court’sȱ grantȱofȱsummaryȱjudgmentȱtoȱtheȱdefendants.ȱ I.ȱBACKGROUNDȱ PettiesȱwasȱwalkingȱupȱtheȱstairsȱofȱhisȱcellȱhouseȱatȱStatȬ evilleȱinȱJanuaryȱ2012ȱwhenȱheȱheardȱaȱloudȱpopȱandȱfeltȱexȬ cruciatingȱ painȱ andȱ weaknessȱ inȱ hisȱ leftȱ Achillesȱ tendon.ȱ Itȱ wasȱnotȱtheȱfirstȱtimeȱheȱhadȱsufferedȱsuchȱanȱinjury.ȱInȱ2010ȱ heȱsufferedȱaȱpartialȱruptureȱinȱhisȱrightȱAchillesȱtendonȱatȱtheȱ prisonȱwhichȱhadȱnotȱfullyȱhealed.ȱ AnȱAchillesȱtendonȱruptureȱisȱaȱtearȱinȱtheȱtendonȱwhichȱ impedesȱ theȱ abilityȱ ofȱ theȱ footȱ toȱ pointȱ downward,ȱ causingȱ painȱ andȱ limitingȱ mobility.ȱ Walkingȱ aroundȱ onȱ aȱ rupturedȱ tendonȱexacerbatesȱtheȱinjury,ȱincreasingȱtheȱgapȱbetweenȱtheȱ tornȱedgesȱofȱaȱtendonȱbecauseȱofȱtheȱwayȱthatȱmusclesȱconȬ tractȱinȱtheȱfootȱandȱcalf.ȱImmobilizingȱtheȱinjuredȱfootȱpreȬ ventsȱstretchingȱofȱtheȱtearȱandȱallowsȱtheȱtornȱedgesȱofȱtheȱ tendonȱtoȱsitȱtogether,ȱandȱscarȱtissueȱtoȱform,ȱrejoiningȱtheȱ No.ȱ14Ȭ2674ȱ ȱ3ȱ

edges.ȱ Whenȱ anȱ Achillesȱ ruptureȱ isȱ notȱ immobilized,ȱ theȱ stretchingȱ apartȱ ofȱ theȱ tornȱ tendonȱ edgesȱ whenȱ theȱ injuredȱ footȱhitsȱtheȱgroundȱcausesȱsevereȱpainȱandȱweakness.ȱ PettiesȱwentȱtoȱStateville’sȱhealthȱclinicȱandȱeventuallyȱsawȱ Dr.ȱImhotepȱCarter,ȱtheȱmedicalȱdirectorȱofȱStatevilleȱ(thoughȱ hisȱ actualȱ employerȱ wasȱ Wexfordȱ Healthȱ Sources,ȱ aȱ privateȱ contractorȱofȱmedicalȱservicesȱtoȱcorrectionalȱfacilities).ȱBeforeȱ Petties,ȱ Dr.ȱ Carterȱ hadȱ seenȱ approximatelyȱ tenȱ Achillesȱ tenȬ donȱrupturesȱinȱhisȱtwentyȬyearȱcareer.ȱAsȱtheȱprison’sȱmediȬ calȱdirector,ȱDr.ȱCarterȱwasȱinȱchargeȱofȱimplementingȱWexȬ ford’sȱmedicalȱpoliciesȱandȱprocedures,ȱamongȱwhichȱwasȱaȱ specificȱtreatmentȱprotocolȱforȱpatientsȱwithȱrupturedȱAchilȬ lesȱ tendons.ȱ Theȱ protocolȱ advisedȱ thatȱ patientsȱ receiveȱ aȱ splint,ȱcrutches,ȱandȱantibioticsȱifȱthereȱwereȱlacerationsȱtoȱtheȱ siteȱofȱinjury,ȱandȱthenȱbeȱsentȱtoȱaȱspecialistȱforȱfurtherȱtreatȬ ment.ȱ Dr.ȱ Carter’sȱ notesȱ reflectȱ thatȱ heȱ thoughtȱ Pettiesȱ hadȱ anȱ Achillesȱtendonȱrupture,ȱandȱthatȱheȱfollowedȱsomeȱofȱWexȬ ford’sȱprotocol,ȱbutȱnotȱallȱofȱit.ȱHeȱgaveȱPettiesȱcrutches,ȱice,ȱ andȱVicodin.ȱHeȱalsoȱauthorizedȱoneȱweekȱofȱ“layȬin”ȱmeals,ȱ whichȱmeantȱthatȱPettiesȱdidȱnotȱhaveȱtoȱwalkȱtoȱtheȱcafeteria,ȱ butȱcouldȱeatȱinȱhisȱcell.ȱFinally,ȱheȱreferredȱPettiesȱtoȱaȱspeȬ cialist,ȱ butȱ thatȱ appointmentȱ didȱ notȱ happenȱ forȱ almostȱ sixȱ weeks.ȱ Inȱ theȱ meantime,ȱ Dr.ȱ Carterȱ didȱ notȱ provideȱ Pettiesȱ withȱaȱsplint,ȱboot,ȱcast,ȱorȱotherȱdeviceȱthatȱwouldȱimmobiȬ lizeȱhisȱfoot.ȱAboutȱaȱmonthȱlater,ȱafterȱPettiesȱreportedȱtoȱtheȱ infirmaryȱthatȱhisȱtendonȱwasȱ“killingȱhim”ȱandȱkeepingȱhimȱ fromȱ climbingȱ stairs,ȱ Pettiesȱ sawȱ Dr.ȱ Carterȱ againȱ andȱ reȬ ceivedȱaȱrenewedȱprescriptionȱforȱcrutches,ȱpainȱmedication,ȱ layȬinȱmeals,ȱandȱassignmentȱtoȱaȱlowerȱbunkȱtoȱkeepȱpressureȱ offȱhisȱfoot.ȱButȱheȱstillȱdidȱnotȱreceiveȱaȱsplint.ȱ 4ȱ ȱNo.ȱ14Ȭ2674ȱ

InȱMarchȱ2012,ȱPettiesȱhadȱanȱMRIȱtakenȱwhichȱshowedȱanȱ Achillesȱ tendonȱ rupture.ȱ Thereȱ wasȱ aȱ gapȱ betweenȱ theȱ tornȱ endsȱofȱtheȱtendonȱthatȱmeasuredȱapproximatelyȱ4.7ȱcentimeȬ ters.ȱAboutȱaȱweekȱlater,ȱPettiesȱmetȱwithȱDr.ȱAnujȱPuppala,ȱ anȱorthopedicȱspecialist,ȱwhoȱnotedȱthatȱtheȱlackȱofȱ“anyȱsortȱ ofȱ cast”ȱ wasȱ potentiallyȱ creatingȱ theȱ gappingȱ atȱ theȱ tendonȱ ruptureȱsite.ȱHeȱrecommendedȱanȱorthopedicȱbootȱtoȱpreventȱ furtherȱgappingȱandȱtoȱalleviateȱpain,ȱandȱgaveȱoneȱtoȱPetties.ȱ Finally,ȱheȱthoughtȱthatȱsurgeryȱmightȱbeȱnecessaryȱdueȱtoȱtheȱ gapping,ȱandȱreferredȱPettiesȱtoȱanȱankleȱspecialist.ȱWhenȱPetȬ tiesȱ returnedȱ toȱ Stateville,ȱ Dr.ȱ Carterȱ authorizedȱ useȱ ofȱ theȱ boot,ȱ alongȱ withȱ crutches,ȱ ice,ȱ andȱ assignmentȱ toȱ aȱ lowerȱ bunk.ȱPettiesȱassertsȱthatȱDr.ȱCarterȱsaidȱheȱwouldȱnotȱorderȱ surgeryȱbecauseȱitȱwasȱtooȱcostly.ȱ Inȱ Julyȱ 2012,ȱ Pettiesȱ finallyȱ sawȱ anȱ ankleȱ specialist,ȱ Dr.ȱ Samuelȱ Chmell,ȱ whoȱ orderedȱ aȱ secondȱ MRIȱ afterȱ notingȱ weaknessȱinȱPetties’sȱankle.ȱDr.ȱChmellȱalsoȱorderedȱphysicalȱ therapy,ȱgentleȱstretchingȱexercises,ȱandȱfollowȬupȱtreatment.ȱ InȱAugustȱ2012,ȱDr.ȱCarterȱwasȱreplacedȱasȱtheȱmedicalȱdirecȬ torȱofȱStatevilleȱbyȱDr.ȱSalehȱObaisi.ȱDr.ȱObaisiȱapprovedȱtheȱ orderȱforȱaȱsecondȱMRI,ȱbutȱdidȱnotȱauthorizeȱphysicalȱtherȬ apy.ȱ Accordingȱ toȱ Petties,ȱ heȱ alsoȱ saidȱ thatȱ surgeryȱ wasȱ tooȱ expensive.ȱ Thatȱ September,ȱ Pettiesȱ hadȱ hisȱ secondȱ MRI,ȱ whichȱ showedȱaȱpartialȱtearȱinȱhisȱtendon,ȱindicatingȱsomeȱhealing.ȱ Butȱheȱcontinuedȱtoȱcomplainȱofȱpain,ȱandȱDr.ȱObaisiȱgaveȱhimȱ Tylenol,ȱapprovedȱaȱlowȱbunkȱpermit,ȱandȱcontinuedȱhisȱuseȱ ofȱtheȱboot.ȱDr.ȱObaisiȱrenewedȱtheȱlowȱbunkȱpermitȱandȱuseȱ ofȱtheȱbootȱinȱNovember,ȱandȱagainȱtheȱfollowingȱJune.ȱPettiesȱ experiencedȱpain,ȱsorenessȱandȱstiffnessȱasȱlateȱasȱMarchȱ2014,ȱ overȱtwoȱyearsȱafterȱtheȱinjury.ȱ No.ȱ14Ȭ2674ȱ ȱ5ȱ

InȱNovemberȱ2012,ȱPettiesȱfiledȱaȱlawsuitȱunderȱ42ȱU.S.C.ȱ §ȱ1983ȱagainstȱDr.ȱCarterȱandȱDr.ȱObaisiȱforȱdeliberateȱindifȬ ferenceȱ inȱ violationȱ ofȱ theȱ Eighthȱ Amendment.ȱ Theȱ districtȱ courtȱ grantedȱ summaryȱ judgmentȱ toȱ Dr.ȱ Carterȱ andȱ Dr.ȱ Obaisi.ȱPettiesȱappeals.ȱ II.ȱANALYSISȱ Weȱreviewȱtheȱdistrictȱcourt’sȱgrantȱofȱsummaryȱjudgmentȱ deȱnovo,ȱviewingȱtheȱrecordȱinȱtheȱlightȱmostȱfavorableȱtoȱPetȬ ties,ȱandȱdrawingȱallȱinferencesȱinȱhisȱfavor.ȱPagalȱv.ȱTINȱInc.,ȱ 695ȱF.3dȱ622,ȱ624ȱ(7thȱCir.ȱ2012).ȱȱ “TheȱConstitutionȱdoesȱnotȱmandateȱcomfortableȱprisons,ȱ butȱneitherȱdoesȱitȱpermitȱinhumaneȱones.”ȱFarmerȱv.ȱBrennan,ȱ 511ȱ U.S.ȱ 825,ȱ 832ȱ (1994)ȱ (internalȱ citationsȱ andȱ quotationȱ marksȱomitted).ȱEveryȱclaimȱbyȱaȱprisonerȱthatȱheȱhasȱnotȱreȬ ceivedȱ adequateȱ medicalȱ treatmentȱ isȱ notȱ aȱ violationȱ ofȱ theȱ EighthȱAmendment.ȱEstelleȱv.ȱGamble,ȱ429ȱU.S.ȱ97,ȱ105ȱ(1976).ȱ ButȱtheȱEighthȱAmendmentȱsafeguardsȱtheȱprisonerȱagainstȱaȱ lackȱ ofȱ medicalȱ careȱ thatȱ “mayȱ resultȱ inȱ painȱ andȱ sufferingȱ whichȱ noȱ oneȱ suggestsȱ wouldȱ serveȱ anyȱ penologicalȱ purȬ pose.”ȱId.ȱatȱ103.1ȱToȱdetermineȱifȱtheȱEighthȱAmendmentȱhasȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1ȱOur dissenting colleagues suggest that Estelle shields doctors from lia- bility if they provide palliative care to prisoners. Unless a doctor refuses to provide care or leaves the inmate worse off than before, the dissent would have us draw the legal conclusion that the prison doctor did not intentionally disregard a prisoner’s serious medical needs. But Estelle ex- plicitly held that a violation of the Eighth Amendment can be established whether “the indifference is manifested by prison doctors in their response to the prisoner's needs or by prison guards in intentionally denying or de- laying access to medical care or intentionally interfering with the treat- ment once prescribed. Regardless of how evidenced, deliberate indifference to a prisoner's serious illness or injury states a cause of action under § 1983.” 429 U.S. 97, 104–05 (emphasis added). The dissent collapses these distinct avenues to proving deliberate indifference into one—any response 6ȱ ȱNo.ȱ14Ȭ2674ȱ

beenȱ violatedȱ inȱ theȱ prisonȱ medicalȱ context,ȱ weȱ performȱ aȱ twoȬstepȱanalysis,ȱfirstȱexaminingȱwhetherȱaȱplaintiffȱsufferedȱ fromȱanȱobjectivelyȱseriousȱmedicalȱcondition,ȱandȱthenȱdeterȬ miningȱwhetherȱtheȱindividualȱdefendantȱwasȱdeliberatelyȱinȬ differentȱ toȱ thatȱ condition.ȱ Farmer,ȱ 511ȱ U.S.ȱ atȱ 834;ȱ seeȱ alsoȱ Berryȱv.ȱPeterman,ȱ604ȱF.3dȱ435,ȱ440ȱ(7thȱCir.ȱ2010).ȱ InȱevaluatingȱanȱEighthȱAmendmentȱclaim,ȱweȱstartȱbyȱdeȬ terminingȱifȱtheȱmedicalȱconditionȱtheȱplaintiffȱsufferedȱwasȱ objectivelyȱserious.ȱ Farmer,ȱ511ȱU.S.ȱatȱ834;ȱseeȱalsoȱWalkerȱv.ȱ Peters,ȱ233ȱF.3dȱ494,ȱ498ȱ(7thȱCir.ȱ2000).ȱHere,ȱtheȱpartiesȱagreeȱ thatȱanȱAchillesȱtendonȱruptureȱisȱanȱobjectivelyȱseriousȱconȬ dition,ȱbutȱtheyȱdisputeȱwhetherȱinȱrespondingȱtoȱtheȱrupture,ȱ theȱdefendantsȱactedȱwithȱdeliberateȱindifference.ȱȱ ToȱdetermineȱifȱaȱprisonȱofficialȱactedȱwithȱdeliberateȱinȬ difference,ȱ weȱ lookȱ intoȱ hisȱ orȱ herȱ subjectiveȱ stateȱ ofȱ mind.ȱ Vanceȱv.ȱPeters,ȱ97ȱF.3dȱ987,ȱ992ȱ(7thȱCir.ȱ1996)ȱ(citingȱFarmer,ȱ 511ȱU.S.ȱatȱ842).ȱForȱaȱprisonȱofficial’sȱactsȱorȱomissionsȱtoȱconȬ stituteȱ deliberateȱ indifference,ȱ aȱ plaintiffȱ doesȱ notȱ needȱ toȱ showȱ thatȱ theȱ officialȱ intendedȱ harmȱ orȱ believedȱ thatȱ harmȱ wouldȱoccur.ȱId.ȱatȱ992.ȱButȱshowingȱmereȱnegligenceȱisȱnotȱ enough.ȱEstelle,ȱ429ȱU.S.ȱatȱ106ȱ(“Medicalȱmalpracticeȱdoesȱnotȱ becomeȱaȱconstitutionalȱviolationȱmerelyȱbecauseȱtheȱvictimȱ isȱ aȱ prisoner.”);ȱ McGeeȱ v.ȱ Adams,ȱ 721ȱ F.3dȱ 474,ȱ 481ȱ (7thȱ Cir.ȱ 2013)ȱ(“Deliberateȱindifferenceȱisȱnotȱmedicalȱmalpractice.”).ȱ Evenȱobjectiveȱrecklessness—failingȱtoȱactȱinȱtheȱfaceȱofȱanȱunȬ justifiablyȱ highȱ riskȱ thatȱ isȱ soȱ obviousȱ thatȱ itȱ shouldȱ beȱ known—isȱinsufficientȱtoȱmakeȱoutȱaȱclaim.ȱFarmer,ȱ511ȱU.S.ȱ atȱ836–38.ȱInstead,ȱtheȱSupremeȱCourtȱhasȱinstructedȱusȱthatȱaȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ by a physician, so long as it is not harmful, satisfies the Eighth Amend- ment. But that is not the holding of Estelle, and we decline to make such a leap here. No.ȱ14Ȭ2674ȱ ȱ7ȱ

plaintiffȱmustȱprovideȱevidenceȱthatȱanȱofficialȱactuallyȱknewȱ ofȱandȱdisregardedȱaȱsubstantialȱriskȱofȱharm.ȱId.ȱatȱ837.ȱOffiȬ cialsȱcanȱavoidȱliabilityȱbyȱprovingȱtheyȱwereȱunawareȱevenȱ ofȱanȱobviousȱriskȱtoȱinmateȱhealthȱorȱsafety.ȱId.ȱatȱ844.ȱ Theȱdifficultyȱ isȱ thatȱ exceptȱinȱtheȱmostȱ egregiousȱcases,ȱ plaintiffsȱgenerallyȱlackȱdirectȱevidenceȱofȱactualȱknowledge.ȱ Rarelyȱifȱeverȱwillȱanȱofficialȱdeclare,ȱ“IȱknewȱthisȱwouldȱprobȬ ablyȱharmȱyou,ȱandȱIȱdidȱitȱanyway!”ȱMostȱcasesȱturnȱonȱcirȬ cumstantialȱevidence,ȱoftenȱoriginatingȱinȱaȱdoctor’sȱfailureȱtoȱ conformȱtoȱbasicȱstandardsȱofȱcare.ȱWhileȱevidenceȱofȱmedicalȱ malpracticeȱoftenȱformsȱtheȱbasisȱofȱaȱdeliberateȱindifferenceȱ claim,ȱtheȱSupremeȱCourtȱhasȱdeterminedȱthatȱplaintiffsȱmustȱ showȱmoreȱthanȱmereȱevidenceȱofȱmalpracticeȱtoȱproveȱdelibȬ erateȱ indifference.ȱ Estelle,ȱ 429ȱ U.S.ȱ atȱ 106.ȱ Butȱ blatantȱ disreȬ gardȱforȱmedicalȱstandardsȱcouldȱsupportȱaȱfindingȱofȱmereȱ medicalȱmalpractice,ȱorȱitȱcouldȱriseȱtoȱtheȱlevelȱofȱdeliberateȱ indifference,ȱdependingȱonȱtheȱcircumstances.ȱAndȱthatȱisȱtheȱ questionȱweȱareȱfacedȱwithȱtoday—howȱbadȱdoesȱanȱinmate’sȱ careȱhaveȱtoȱbeȱtoȱcreateȱaȱreasonableȱinferenceȱthatȱaȱdoctorȱ didȱnotȱjustȱslipȱup,ȱbutȱwasȱawareȱof,ȱandȱdisregarded,ȱaȱsubȬ stantialȱriskȱofȱharm?ȱWeȱmustȱdetermineȱwhatȱkindȱofȱeviȬ denceȱ isȱ adequateȱ forȱ aȱ juryȱ toȱ drawȱ aȱ reasonableȱ inferenceȱ thatȱaȱprisonȱofficialȱactedȱwithȱdeliberateȱindifference.ȱȱ Weȱstartȱthisȱinquiryȱbyȱexaminingȱourȱexistingȱprecedent.ȱ Asȱanȱinitialȱmatter,ȱweȱlookȱatȱtheȱtotalityȱofȱanȱinmate’sȱmedȬ icalȱcareȱwhenȱconsideringȱwhetherȱthatȱcareȱevidencesȱdelibȬ erateȱ indifferenceȱ toȱ seriousȱ medicalȱ needs.ȱ Cavalieriȱ v.ȱ Shephard,ȱ321ȱF.3dȱ616,ȱ625–26ȱ(7thȱCir.ȱ2003).ȱWeȱhaveȱidentiȬ fiedȱseveralȱcircumstancesȱthatȱcanȱbeȱenoughȱtoȱshowȱdelibȬ erateȱindifference.ȱFirst,ȱandȱmostȱobvious,ȱisȱaȱprisonȱofficial’sȱ decisionȱtoȱignoreȱaȱrequestȱforȱmedicalȱassistance.ȱEstelle,ȱ429ȱ 8ȱ ȱNo.ȱ14Ȭ2674ȱ

U.S.ȱatȱ104Ȭ05.ȱButȱanȱinmateȱisȱnotȱrequiredȱtoȱshowȱthatȱheȱ wasȱliterallyȱignoredȱbyȱprisonȱstaffȱtoȱdemonstrateȱdeliberateȱ indifference.ȱSherrodȱv.ȱLingle,ȱ223ȱF.3dȱ605,ȱ611ȱ(7thȱCir.ȱ2000).ȱ Ifȱaȱriskȱfromȱaȱparticularȱcourseȱofȱmedicalȱtreatmentȱ(orȱlackȱ thereof)ȱisȱobviousȱenough,ȱaȱfactfinderȱcanȱinferȱthatȱaȱprisonȱ officialȱknewȱaboutȱitȱandȱdisregardedȱit.ȱNorfleetȱv.ȱWebster,ȱ 439ȱF.3dȱ392,ȱ396ȱ(7thȱCir.ȱ2006);ȱColeȱv.ȱFromm,ȱ94ȱF.3dȱ254,ȱ260ȱ (7thȱCir.ȱ1996).ȱȱ Inȱtheȱmedicalȱcontext,ȱofȱcourse,ȱobviousnessȱofȱaȱriskȱcanȱ beȱ obscuredȱ byȱ theȱ needȱ forȱ specializedȱ expertiseȱ toȱ underȬ standȱtheȱvariousȱimplicationsȱofȱaȱparticularȱcourseȱofȱtreatȬ ment.ȱSoȱweȱhaveȱfoundȱinȱthoseȱcasesȱwhereȱunnecessaryȱriskȱ mayȱbeȱimperceptibleȱtoȱaȱlayȱpersonȱthatȱaȱmedicalȱprofesȬ sional’sȱtreatmentȱdecisionȱmustȱbeȱ“suchȱaȱsubstantialȱdeparȬ tureȱfromȱacceptedȱprofessionalȱjudgment,ȱpractice,ȱorȱstandȬ ardsȱ asȱ toȱ demonstrateȱ thatȱ theȱ personȱ responsibleȱ didȱ notȱ baseȱtheȱdecisionȱonȱsuchȱaȱjudgment.”ȱCole,ȱ94ȱF.3dȱatȱ261–62;ȱ seeȱalsoȱCollignonȱv.ȱMilwaukeeȱCnty.,ȱ163ȱF.3dȱ982,ȱ989ȱ(7thȱCir.ȱ 1998)ȱ(“Aȱplaintiffȱcanȱshowȱthatȱtheȱprofessionalȱdisregardedȱ theȱneedȱonlyȱifȱtheȱprofessional’sȱsubjectiveȱresponseȱwasȱsoȱ inadequateȱ thatȱ itȱ demonstratedȱ anȱ absenceȱ ofȱ professionalȱ judgment,ȱ thatȱ is,ȱ noȱ minimallyȱ competentȱ professionalȱ wouldȱ haveȱ soȱ respondedȱ underȱ thoseȱ circumstances.”).ȱ Byȱ contrast,ȱ evidenceȱ thatȱ someȱ medicalȱ professionalsȱ wouldȱ haveȱchosenȱaȱdifferentȱcourseȱofȱtreatmentȱisȱinsufficientȱtoȱ makeȱoutȱaȱconstitutionalȱclaim.ȱSteeleȱv.ȱChoi,ȱ82ȱF.3dȱ175,ȱ179ȱ (7thȱCir.ȱ1996).ȱ Evenȱ amongȱ theȱ medicalȱ community,ȱ theȱ permissibleȱ boundsȱofȱcompetentȱmedicalȱjudgmentȱareȱnotȱalwaysȱclear,ȱ particularlyȱ becauseȱ “itȱ isȱ implicitȱ inȱ theȱ professionalȱ judgȬ mentȱ standardȱ itself…thatȱ inmateȱ medicalȱ careȱ decisionsȱ No.ȱ14Ȭ2674ȱ ȱ9ȱ

mustȱbeȱfactȬbasedȱwithȱrespectȱtoȱtheȱparticularȱinmate,ȱtheȱ severityȱandȱstageȱofȱhisȱcondition,ȱtheȱlikelihoodȱandȱimmiȬ nenceȱ ofȱ furtherȱ harmȱ andȱ theȱ efficacyȱ ofȱ availableȱ treatȬ ments.”ȱRoe,ȱ631ȱF.3dȱatȱ859.ȱSoȱitȱcanȱbeȱchallengingȱtoȱdrawȱ aȱlineȱbetweenȱanȱacceptableȱdifferenceȱofȱopinionȱ(especiallyȱ becauseȱ evenȱ admittedȱ medicalȱ malpracticeȱ doesȱ notȱ autoȬ maticallyȱgiveȱriseȱtoȱaȱconstitutionalȱviolation),ȱandȱanȱactionȱ thatȱreflectsȱsubȬminimalȱcompetence2ȱandȱcrossesȱtheȱthreshȬ oldȱintoȱdeliberateȱindifference.ȱOneȱhintȱofȱsuchȱaȱdepartureȱ isȱwhenȱaȱdoctorȱrefusesȱtoȱtakeȱinstructionsȱfromȱaȱspecialist.ȱ Arnettȱ v.ȱ Webster,ȱ 658ȱ F.3dȱ 742,ȱ 753ȱ (7thȱ Cir.ȱ 2011);ȱ Jonesȱ v.ȱ Simek,ȱ193ȱF.3dȱ485,ȱ490ȱ(7thȱCir.ȱ1999).ȱAnotherȱisȱwhenȱheȱorȱ sheȱfailsȱtoȱfollowȱanȱexistingȱprotocol.ȱ“WhileȱpublishedȱreȬ quirementsȱforȱhealthȱcareȱdoȱnotȱcreateȱconstitutionalȱrights,ȱ suchȱprotocolsȱcertainlyȱprovideȱcircumstantialȱevidenceȱthatȱ aȱprisonȱhealthȱcareȱgatekeeperȱknewȱofȱaȱsubstantialȱriskȱofȱ seriousȱharm.”ȱMataȱv.ȱSaiz,ȱ427ȱF.3dȱ745,ȱ757ȱ(10thȱCir.ȱ2005).ȱ Anotherȱ situationȱ thatȱ mightȱ establishȱ aȱ departureȱ fromȱ minimallyȱcompetentȱmedicalȱjudgmentȱisȱwhereȱaȱprisonȱofȬ ficialȱpersistsȱinȱaȱcourseȱofȱtreatmentȱknownȱtoȱbeȱineffective.ȱ Walker,ȱ 233ȱ F.3dȱ atȱ 499ȱ (citationsȱ omitted).ȱ Forȱ example,ȱ ifȱ knowingȱ aȱ patientȱ facesȱ aȱ seriousȱ riskȱ ofȱ appendicitis,ȱ theȱ

ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2 Our colleagues take issue with our repeated references to the competence of medical professionals, suggesting we are injecting state malpractice standards into the constitutional test for deliberate indifference. But we do not suggest that incompetent doctors violate the Constitution. We simply note that a medical decision that has no support in the medical commu- nity, along with a suspect rationale provided for making it, can support a jury finding that a doctor knew his decision created a serious risk to an inmate’s health. To hold otherwise would mean that any treatment deci- sion a doctor made, regardless of whether it had any scientific basis, would be immune from scrutiny. 10ȱ ȱNo.ȱ14Ȭ2674ȱ

prisonȱofficialȱgivesȱtheȱpatientȱanȱaspirinȱandȱsendsȱhimȱbackȱ toȱ hisȱ cell,ȱ aȱ juryȱ couldȱ findȱ deliberateȱ indifferenceȱ evenȱ thoughȱ theȱ prisonerȱ receivedȱ someȱ treatment.ȱ Sherrod,ȱ 223ȱ F.3dȱatȱ612;ȱseeȱalsoȱGreenoȱv.ȱDaley,ȱ414ȱF.3dȱ645,ȱ655ȱ(7thȱCir.ȱ 2005)ȱ(continuingȱtoȱtreatȱsevereȱvomitingȱwithȱantacidsȱoverȱ threeȱyearsȱcreatedȱmaterialȱfactȱissueȱofȱdeliberateȱindifferȬ ence);ȱSnipesȱv.ȱDetella,ȱ95ȱF.3dȱ586,ȱ592ȱ(7thȱCir.ȱ1996)ȱ(holdingȱ EighthȱAmendmentȱclaimȱmayȱexistȱifȱmedicalȱtreatmentȱisȱsoȱ blatantlyȱ inappropriateȱ asȱ toȱ evidenceȱ intentionalȱ mistreatȬ mentȱ likelyȱ toȱ seriouslyȱ aggravateȱ theȱ prisoner’sȱ condition);ȱ Kelleyȱv.ȱMcGinnis,ȱ899ȱF.2dȱ612,ȱ616–17ȱ(7thȱCir.ȱ1990)ȱ(perȱcuȬ riam).ȱȱ Ifȱaȱprisonȱdoctorȱchoosesȱanȱ“easierȱandȱlessȱefficaciousȱ treatment”ȱwithoutȱexercisingȱprofessionalȱjudgment,ȱsuchȱaȱ decisionȱcanȱalsoȱconstituteȱdeliberateȱindifference.ȱEstelle,ȱ429ȱ U.S.ȱatȱ104ȱn.10;ȱConleyȱv.ȱBirch,ȱ796ȱF.3dȱ742,ȱ747ȱ(7thȱCir.ȱ2015)ȱ (materialȱfactȱissueȱwhetherȱprovisionȱofȱonlyȱpainkillersȱandȱ iceȱtoȱanȱinmateȱsufferingȱfromȱsuspectedȱfractureȱconstitutedȱ deliberateȱindifference).ȱWhileȱtheȱcostȱofȱtreatmentȱisȱaȱfactorȱ inȱ determiningȱ whatȱ constitutesȱ adequate,ȱ minimumȬlevelȱ care,ȱ medicalȱ personnelȱ cannotȱ simplyȱ resortȱ toȱ anȱ easierȱ courseȱofȱtreatmentȱthatȱtheyȱknowȱisȱineffective.ȱJohnson,ȱ433ȱ F.3dȱatȱ1013;ȱRoe,ȱ631ȱF.3dȱatȱ863ȱ(althoughȱadministrativeȱconȬ venienceȱandȱcostȱmayȱbeȱpermissibleȱfactorsȱforȱcorrectionalȱ systemsȱ toȱ consider,ȱ theȱ Constitutionȱ isȱ violatedȱ whenȱ theyȱ areȱ consideredȱ toȱ theȱ exclusionȱ ofȱ reasonableȱ medicalȱ judgȬ mentȱaboutȱinmateȱhealth).ȱ Yetȱanotherȱtypeȱofȱevidenceȱthatȱcanȱsupportȱanȱinferenceȱ ofȱdeliberateȱindifferenceȱisȱanȱinexplicableȱdelayȱinȱtreatmentȱ whichȱ servesȱ noȱ penologicalȱ interest.ȱ Grievesonȱ v.ȱ Anderson,ȱ No.ȱ14Ȭ2674ȱ ȱ11ȱ

538ȱF.3dȱ763,ȱ779ȱ(7thȱCir.ȱ2008)ȱ(guardsȱcouldȱbeȱliableȱforȱdeȬ layingȱtreatmentȱofȱbrokenȱnoseȱforȱaȱdayȱandȱhalf);ȱEdwardsȱ v.ȱSnyder,ȱ478ȱF.3dȱ827,ȱ830–31ȱ(7thȱCir.ȱ2007)ȱ(aȱplaintiffȱwhoȱ painfullyȱ dislocatedȱ hisȱ fingerȱ andȱ wasȱ needlesslyȱ deniedȱ treatmentȱforȱtwoȱdaysȱstatedȱaȱclaimȱforȱdeliberateȱindifferȬ ence).ȱOfȱcourse,ȱdelaysȱareȱcommonȱinȱtheȱprisonȱsettingȱwithȱ limitedȱresources,ȱandȱwhetherȱtheȱlengthȱofȱaȱdelayȱisȱtoleraȬ bleȱdependsȱonȱtheȱseriousnessȱofȱtheȱconditionȱandȱtheȱeaseȱ ofȱprovidingȱtreatment.ȱCompareȱMillerȱv.ȱCampanella,ȱ794ȱF.3dȱ 878,ȱ880ȱ(7thȱCir.ȱ2015)ȱ(givenȱextremeȱeaseȱofȱsupplyingȱsufȬ fererȱofȱgastroȬesophagealȱrefluxȱdiseaseȱwithȱoverȬtheȬcounȬ terȱpills,ȱfailingȱtoȱdoȱsoȱforȱtwoȱmonthsȱcreatedȱfactȱquestionȱ overȱ deliberateȱ indifference),ȱ Berry,ȱ 604ȱ F.3dȱ atȱ 441ȱ (findingȱ refusalȱtoȱreferȱpatientȱtoȱaȱdentistȱactionableȱbecauseȱ“aȱbasicȱ dentalȱ examinationȱ isȱ notȱ anȱ expensiveȱ orȱ unconventionalȱ treatment,ȱnorȱisȱitȱesotericȱorȱexperimental”)ȱ(internalȱquotaȬ tionȱmarksȱomitted),ȱArnett,ȱ658ȱF.3dȱatȱ752ȱ(medicalȱpersonȬ nelȱcouldȱnotȱstandȱidlyȱbyȱforȱmoreȱthanȱtenȱmonthsȱwhileȱ patient’sȱrheumatoidȱarthritisȱprogressivelyȱworsened),ȱSimek,ȱ 193ȱF.3dȱatȱ490ȱ(viableȱclaimȱwhereȱdoctorȱdelayedȱschedulingȱ appointmentȱwithȱspecialistȱandȱthenȱfailedȱtoȱfollowȱspecialȬ ist’sȱadvice,ȱwhileȱinmate’sȱconditionȱworsened);ȱRodriguezȱv.ȱ Plymouthȱ Ambulanceȱ Serv.,ȱ 577ȱ F.3dȱ 816,ȱ 832ȱ (7thȱ Cir.ȱ 2009)ȱ (stateȱ employeesȱ couldȱ beȱ liableȱ forȱ fourȬdayȱ delayȱ whereȱ prisonerȱ complainedȱ hisȱ intravenousȱ therapyȱ wasȱ causingȱ himȱpain),ȱwithȱGutierrezȱv.ȱPeters,ȱ111ȱF.3dȱ1364,ȱ1374ȱ(7thȱCir.ȱ 1997)ȱ(noȱvalidȱclaimȱforȱsixȬdayȱdelayȱinȱtreatingȱaȱmildȱcystȱ infection).ȱToȱshowȱthatȱaȱdelayȱinȱprovidingȱtreatmentȱisȱacȬ tionableȱunderȱtheȱEighthȱAmendment,ȱaȱplaintiffȱmustȱalsoȱ provideȱindependentȱevidenceȱthatȱtheȱdelayȱexacerbatedȱtheȱ injuryȱorȱunnecessarilyȱprolongedȱpain.ȱWilliamsȱv.ȱLiefer,ȱ491ȱ F.3dȱ710,ȱ716ȱ(7thȱCir.ȱ2007)ȱ(delayȱactionableȱwhereȱmedicalȱ 12ȱ ȱNo.ȱ14Ȭ2674ȱ

recordsȱ showedȱ itȱ unnecessarilyȱ prolongedȱ plaintiff’sȱ painȱ andȱ highȱ bloodȱpressure);ȱ Gilȱv.ȱReed,ȱ 381ȱF.3dȱ649,ȱ 662ȱ (7thȱ Cir.ȱ2004)ȱ(hoursȱofȱneedlessȱsufferingȱcanȱconstituteȱharm).ȱȱ Theseȱ casesȱ bearȱ aȱ fewȱ notableȱ commonalities.ȱ Mostȱ ofȱ themȱinvolveȱtreatment,ȱsometimesȱoverȱanȱextendedȱperiodȱ ofȱtime.ȱButȱrepeatedly,ȱweȱhaveȱrejectedȱtheȱnotionȱthatȱtheȱ provisionȱ ofȱ someȱ careȱ meansȱ theȱ doctorȱ providedȱ medicalȱ treatmentȱwhichȱmeetsȱtheȱbasicȱrequirementsȱofȱtheȱEighthȱ Amendment.ȱRather,ȱtheȱcontextȱsurroundingȱaȱdoctor’sȱtreatȬ mentȱdecisionȱcanȱsometimesȱoverrideȱhisȱclaimedȱignoranceȱ ofȱtheȱrisksȱstemmingȱfromȱthatȱdecision.ȱWhenȱaȱdoctorȱsaysȱ heȱ didȱ notȱ realizeȱ hisȱ treatmentȱ decisionsȱ (orȱ lackȱ thereof)ȱ couldȱ causeȱ seriousȱ harmȱ toȱ aȱ plaintiff,ȱ aȱ juryȱ isȱ entitledȱ toȱ weighȱ thatȱ explanationȱ againstȱ certainȱ cluesȱ thatȱ theȱ doctorȱ didȱknow.ȱThoseȱcontextȱcluesȱmightȱincludeȱtheȱexistenceȱofȱ documentsȱ theȱ doctorȱ regularlyȱ consultedȱ whichȱ advisedȱ againstȱhisȱcourseȱofȱtreatment,ȱevidenceȱthatȱtheȱpatientȱreȬ peatedlyȱcomplainedȱofȱenduringȱpainȱwithȱnoȱmodificationsȱ inȱcare,ȱinexplicableȱdelaysȱorȱdeparturesȱfromȱcommonȱmedȬ icalȱstandards,ȱorȱofȱcourse,ȱtheȱdoctor’sȱownȱtestimonyȱthatȱ indicatesȱknowledgeȱofȱnecessaryȱtreatmentȱheȱfailedȱtoȱproȬ vide.ȱWhileȱevidenceȱofȱmalpracticeȱisȱnotȱenoughȱforȱaȱplainȬ tiffȱtoȱsurviveȱsummaryȱjudgmentȱonȱanȱEighthȱAmendmentȱ claim,ȱnorȱisȱaȱdoctor’sȱclaimȱheȱdidȱnotȱknowȱanyȱbetterȱsufȬ ficientȱtoȱimmunizeȱhimȱfromȱliabilityȱinȱeveryȱcircumstance.ȱ Otherwise,ȱprisonȱdoctorsȱwouldȱgetȱaȱfreeȱpassȱtoȱignoreȱprisȬ oners’ȱ medicalȱ needsȱ byȱ hidingȱ behindȱ theȱ precedentȱ thatȱ medicalȱ malpracticeȱ isȱ notȱ actionableȱ underȱ theȱ Eighthȱ Amendment.ȱ Prisonersȱ areȱ notȱ entitledȱ toȱ stateȬofȬtheȱ artȱ medicalȱtreatment.ȱButȱwhereȱevidenceȱexistsȱthatȱtheȱdefendȬ antsȱknewȱbetterȱthanȱtoȱmakeȱtheȱmedicalȱdecisionsȱthatȱtheyȱ No.ȱ14Ȭ2674ȱ ȱ13ȱ

did,ȱaȱjuryȱshouldȱdecideȱwhetherȱorȱnotȱtheȱdefendantsȱwereȱ actuallyȱignorantȱtoȱriskȱofȱtheȱharmȱthatȱtheyȱcaused.ȱ WeȱnowȱturnȱourȱattentionȱtoȱPetties’sȱclaimsȱagainstȱhisȱ doctors.ȱ A. Materialȱ Factualȱ Disputeȱ Existsȱ asȱ toȱ Whetherȱ Dr.ȱ CarterȱWasȱDeliberatelyȱIndifferentȱ Petties’sȱ principalȱ claimsȱ againstȱ Dr.ȱ Carterȱ areȱ thatȱ heȱ actedȱwithȱdeliberateȱindifferenceȱtoȱhisȱinjuryȱwhenȱheȱfailedȱ toȱ immobilizeȱ Petties’sȱ rupturedȱ tendonȱ forȱ sixȱ weeks,ȱ deȬ layedȱPetties’sȱappointmentȱwithȱaȱspecialist,ȱandȱrefusedȱtoȱ orderȱsurgeryȱtoȱrepairȱtheȱtendon.3ȱ Dr.ȱCarter’sȱdeposition,ȱasȱwellȱasȱStateville’sȱmedicalȱrecȬ ords,ȱconfirmȱthatȱDr.ȱCarter’sȱinitialȱdiagnosisȱofȱPetties’sȱinȬ juryȱwasȱanȱAchillesȱtear.ȱDr.ȱCarterȱalsoȱtestifiedȱthatȱtheȱapȬ propriateȱtreatmentȱforȱaȱcompleteȱAchillesȱruptureȱisȱtoȱimȬ mobilizeȱtheȱankle,ȱputȱitȱinȱaȱnonȬweightȱbearingȱstatus,ȱandȱ prescribeȱantiȬinflammatoryȱdrugsȱandȱpassiveȱstretchingȱexȬ ercises.ȱHeȱexplainedȱtheȱpurposeȱofȱimmobilization,ȱstating,ȱ “inȱtheȱacuteȱphaseȱofȱhealing,ȱyouȱareȱgeneratingȱanȱimmuneȱ systemȱresponseȱinȱtheȱbody,”ȱandȱwhenȱaskedȱifȱkeepingȱtheȱ tendonȱinȱoneȱplaceȱenablesȱthisȱhealingȱprocessȱtoȱgoȱforwardȱ favorably,ȱheȱreplied,ȱ“Correct.ȱAndȱifȱyou’reȱcontinuouslyȱinȬ juringȱ it,ȱ itȱ hindersȱ thatȱ process.”ȱ Heȱ alsoȱ testifiedȱ thatȱ forȱ

ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3 We reject the dissent’s characterization of Petties’s claims against both of his doctors as a challenge to the quality of his medical care. Rather, Petties argued that his doctors’ treatment decisions—and their harmful conse- quences—supported his claim that the defendants deliberately refused to pursue care they knew he needed. Petties has never argued that his doc- tors’ poor care by itself violated the Eighth Amendment. 14ȱ ȱNo.ȱ14Ȭ2674ȱ

bothȱpartialȱandȱcompleteȱAchillesȱruptures,ȱheȱwouldȱalwaysȱ immobilizeȱtheȱtendon.ȱȱ Dr.ȱ Carter’sȱ opinionȱ wasȱ consistentȱ withȱ theȱ depositionȱ testimonyȱofȱPetties’sȱorthopedicȱspecialist,ȱDr.ȱPuppala,ȱwhoȱ testifiedȱthatȱheȱwouldȱalwaysȱimmobilizeȱaȱrupturedȱAchillesȱ tendon,ȱunlessȱtheȱinjuryȱhadȱanȱopenȱsoreȱthatȱneededȱtoȱbeȱ addressedȱ first.ȱ Itȱwasȱ alsoȱconsistentȱwithȱ theȱtestimonyȱofȱ Dr.ȱChmell,ȱtheȱankleȱspecialistȱwhoȱtreatedȱPettiesȱafterȱDr.ȱ CarterȱhadȱleftȱStateville.ȱHeȱtestifiedȱthatȱimmobilizationȱisȱ essentialȱtoȱtheȱhealingȱofȱanȱAchillesȱtendon,ȱandȱthatȱhealingȱ withoutȱimmobilizationȱisȱ“possibleȱbutȱnotȱveryȱlikely.”4ȱAndȱ finally,ȱWexford’sȱownȱprotocol,ȱwhichȱDr.ȱCarterȱtestifiedȱheȱ wasȱ responsibleȱ forȱ implementing,ȱ statedȱ thatȱ theȱ primaryȱ courseȱofȱtreatmentȱforȱanȱAchillesȱruptureȱincludedȱaȱsplint.ȱ Dr.ȱCarterȱalsoȱtestifiedȱheȱwasȱnotȱawareȱofȱanyȱshortageȱofȱ splintsȱatȱStatevilleȱduringȱtheȱtimeȱthatȱheȱwasȱtreatingȱPetȬ ties.ȱ Together,ȱtheseȱpiecesȱofȱcircumstantialȱevidenceȱsupportȱ aȱreasonableȱinferenceȱthatȱDr.ȱCarterȱknewȱthatȱfailureȱtoȱimȬ mobilizeȱanȱAchillesȱruptureȱwouldȱimpedeȱPetties’sȱrecoveryȱ andȱprolongȱhisȱpain.ȱItȱisȱcertainlyȱtrueȱthatȱDr.ȱCarter’sȱdeciȬ sionȱ notȱ toȱ immobilizeȱ Petties’sȱ ankleȱ couldȱ haveȱ beenȱ anȱ oversight,ȱorȱaȱfundamentalȱmisunderstandingȱofȱtheȱproperȱ courseȱofȱtreatment.ȱSomeȱofȱhisȱtestimonyȱsuggestsȱthatȱheȱ believedȱcrutchesȱservedȱtheȱsameȱpurposeȱasȱaȱboot.ȱButȱthatȱ testimonyȱconflictsȱwithȱotherȱpartsȱofȱhisȱdepositionȱthatȱexȬ plainedȱtheȱdistinctȱpurposeȱofȱimmobilization,ȱwhichȱisȱnotȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4 We are puzzled by the dissent’s proposition that the care Petties received did not worsen his condition because his health eventually improved. We do not ascribe to the view that the eventual resolution of a long-ignored medical issue establishes compliance with the Eighth Amendment. No.ȱ14Ȭ2674ȱ ȱ15ȱ

toȱpreventȱbearingȱweightȱonȱtheȱinjuredȱfoot,ȱbutȱtoȱkeepȱtheȱ rupturedȱtendonȱinȱoneȱplace.ȱItȱalsoȱconflictsȱwithȱtheȱtestiȬ monyȱofȱtheȱotherȱdoctorsȱwhoȱtreatedȱPetties.ȱAȱjuryȱcouldȱ alsoȱfindȱsuspiciousȱthatȱDr.ȱCarterȱdidȱnotȱprovideȱtheȱbootȱ untilȱanȱoutsideȱdoctorȱdocumentedȱtheȱimportanceȱofȱimmoȬ bilizationȱinȱwriting.ȱAȱreasonableȱinferenceȱtoȱdrawȱfromȱthisȱ evidenceȱisȱthatȱDr.ȱCarterȱwasȱawareȱofȱtheȱneedȱforȱimmobiȬ lizingȱaȱrupturedȱtendon,ȱbutȱsimplyȱdecidedȱnotȱtoȱuntilȱheȱ cameȱunderȱscrutiny.ȱAlso,ȱaȱjuryȱcouldȱreasonablyȱconcludeȱ thatȱDr.ȱCarter’sȱdecisionȱcausedȱsubstantialȱharm—Petties’sȱ affidavitȱstatedȱthatȱwithoutȱaȱsplint,ȱheȱhadȱnothingȱtoȱkeepȱ hisȱ ankleȱ fromȱ movingȱ around,ȱ whichȱ madeȱ himȱ feelȱ “conȬ stant,ȱ severeȱ pain”ȱ wheneverȱ heȱ gotȱ upȱ toȱ walk,ȱ andȱ madeȱ sleepingȱdifficult.ȱ BesidesȱDr.ȱCarter’sȱfailureȱtoȱimmobilizeȱhisȱfoot,ȱPettiesȱ alsoȱclaimsȱthatȱDr.ȱCarterȱwasȱresponsibleȱ forȱ theȱ sixȬweekȱ delayȱ inȱ seeingȱ Dr.ȱ Puppalaȱ toȱ confirmȱ Petties’sȱ diagnosis,ȱ whichȱisȱwhenȱheȱfinallyȱreceivedȱaȱboot.ȱAsȱanȱinitialȱmatter,ȱ Pettiesȱhasȱprovidedȱcorroboratingȱmedicalȱevidenceȱthatȱtheȱ delayȱ hadȱ aȱ detrimentalȱ effectȱ onȱ hisȱ conditionȱ throughȱ Dr.ȱ Puppala’sȱtreatmentȱnotes,ȱwhichȱindicateȱPettiesȱwasȱsufferȬ ingȱ painȱ andȱ gappingȱ atȱ theȱ ruptureȱ siteȱ dueȱ toȱ theȱ lackȱ ofȱ immobilization.ȱThisȱfindingȱisȱconsistentȱwithȱPetties’sȱownȱ testimonyȱthatȱheȱwasȱinȱconstantȱandȱsevereȱpainȱwhileȱheȱ waitedȱtoȱseeȱaȱspecialist.ȱ Dr.ȱCarterȱarguesȱthatȱtheȱdelayȱwasȱattributableȱtoȱprisonȱ lockȬdowns,ȱwhichȱbarredȱvisitsȱtoȱoutsideȱspecialistsȱunlessȱ heȱ issuedȱ anȱ emergencyȱ overrideȱ orderȱ whichȱ allowedȱ paȬ tientsȱ toȱ receiveȱ emergencyȱ care.ȱ Butȱ immobilizationȱ couldȱ haveȱalleviatedȱPetties’sȱpainȱwhileȱheȱwaited,ȱsoȱthisȱexplanaȬ 16ȱ ȱNo.ȱ14Ȭ2674ȱ

tionȱdoesȱnotȱresolveȱDr.ȱCarter’sȱtestimonyȱthatȱheȱwasȱunaȬ wareȱ ofȱ anyȱ shortageȱ ofȱ splintsȱ atȱ Statevilleȱ duringȱ theȱ sixȱ weeksȱthatȱPettiesȱsufferedȱsevereȱpainȱwhileȱwaitingȱtoȱseeȱ Dr.ȱPuppala.ȱItȱalsoȱdoesȱnotȱexplainȱwhyȱDr.ȱCarterȱdidȱnotȱ viewȱPetties’sȱsituationȱasȱanȱ“emergency”ȱasȱcomparedȱwithȱ otherȱseriousȱinjuries.ȱTheȱharmȱstemmingȱfromȱtheȱdelayȱinȱ receivingȱtheȱbootȱwouldȱhaveȱbeenȱavoidedȱbyȱsendingȱPetȬ tiesȱtoȱtheȱemergencyȱroomȱsoȱheȱcouldȱgetȱanȱMRI.ȱAndȱtheȱ harmȱfromȱtheȱdelayȱinȱseeingȱaȱspecialistȱwouldȱhaveȱbeenȱ mitigatedȱbyȱsplintingȱPetties’sȱfootȱwhileȱsecurityȱissuesȱwereȱ resolved.ȱTheȱdelayȱofȱboth,ȱwithoutȱ aȱ clearȱ justificationȱ forȱ either,ȱ doomsȱ Dr.ȱ Carter’sȱ argumentȱ thatȱ Petties’sȱ sufferingȱ wasȱunavoidable.ȱOnȱthisȱrecord,ȱwhetherȱtheȱdelayȱwasȱtheȱ resultȱofȱnegligenceȱorȱdeliberateȱindifferenceȱisȱaȱquestionȱforȱ theȱjuryȱtoȱdecide.ȱ Finally,ȱ Pettiesȱ arguesȱ thatȱ Dr.ȱ Carterȱ shouldȱ haveȱ folȬ lowedȱ Dr.ȱ Puppala’sȱ recommendationȱ toȱ exploreȱ surgeryȱ asȱ anȱoption.ȱButȱPettiesȱdidȱnotȱproduceȱmedicalȱevidenceȱconȬ firmingȱthatȱheȱwouldȱhaveȱbenefitedȱfromȱsurgery,ȱandȱwhenȱ heȱvisitedȱDr.ȱChmellȱinȱJulyȱ2012,ȱhisȱtendonȱshowedȱsignsȱofȱ improvement.ȱ However,ȱ Petties’sȱ contentionȱ thatȱ Dr.ȱ Carterȱ saidȱsurgeryȱwouldȱbeȱ“tooȱexpensive”ȱisȱaȱpieceȱofȱcircumȬ stantialȱ evidenceȱ thatȱ aȱ juryȱ couldȱ viewȱ asȱ supportingȱ hisȱ otherȱclaims.ȱIfȱaȱjuryȱbelievesȱthatȱDr.ȱCarterȱcitedȱcostȱasȱaȱ reasonȱforȱrefusingȱoneȱformȱofȱtreatment,ȱthenȱ itȱwouldȱbeȱ reasonableȱtoȱinferȱthatȱDr.ȱCarterȱmadeȱotherȱmedicalȱdeciȬ sionsȱinȱPetties’sȱcaseȱ—ȱfailingȱtoȱsplintȱhisȱfoot,ȱnotȱissuingȱ anȱemergencyȱoverrideȱorderȱsoȱheȱcouldȱseeȱaȱspecialistȱ—ȱ thatȱ wereȱ dictatedȱ byȱ cost,ȱ administrativeȱ convenience,ȱ orȱ both,ȱratherȱthanȱmedicalȱjudgment.ȱȱ No.ȱ14Ȭ2674ȱ ȱ17ȱ

Pettiesȱ hasȱ providedȱ sufficientȱ evidenceȱ toȱ surviveȱ sumȬ maryȱjudgmentȱonȱhisȱ§ȱ1983ȱclaimsȱagainstȱDr.ȱCarter.ȱ B. Materialȱ Factualȱ Disputeȱ Existsȱ asȱ toȱ Whetherȱ Dr.ȱ ObaisiȱWasȱDeliberatelyȱIndifferentȱ PettiesȱalsoȱarguesȱthatȱDr.ȱObaisiȱwasȱdeliberatelyȱindifȬ ferentȱ whenȱ heȱ refusedȱ toȱ orderȱ physicalȱ therapyȱ afterȱ Dr.ȱ Chmellȱ orderedȱ it.ȱ Dr.ȱ Obaisiȱ respondsȱ thatȱ Pettiesȱ didȱ notȱ needȱaȱphysicalȱtherapistȱbecauseȱheȱalreadyȱknewȱwhichȱexȬ ercisesȱtoȱuseȱfromȱaȱpriorȱAchillesȱinjury.ȱHeȱalsoȱarguesȱthatȱ Pettiesȱcouldȱhaveȱwalkedȱonȱhisȱinjuredȱankleȱtoȱstrengthenȱ it.ȱ TheȱproblemȱwithȱDr.ȱObaisi’sȱargumentsȱisȱthatȱtheyȱareȱ totallyȱatȱoddsȱwithȱtheȱevidenceȱinȱthisȱcase.ȱHeȱtestifiedȱthatȱ heȱalwaysȱfollowsȱtheȱadviceȱofȱspecialists,ȱthatȱPetties’sȱspeȬ cialistȱrecommendedȱphysicalȱtherapy,ȱandȱthatȱheȱdidȱnotȱorȬ derȱ physicalȱ therapyȱ forȱ Petties.ȱ Toȱ justifyȱ thisȱ questionableȱ decision,ȱheȱstatesȱthatȱPettiesȱknewȱwhatȱtoȱdoȱbasedȱonȱpriorȱ physicalȱtherapy.ȱThisȱisȱclearlyȱaȱpostȬhocȱrationalization,ȱbeȬ causeȱheȱalsoȱtestifiedȱheȱdidȱnotȱknowȱwhetherȱPettiesȱhadȱ previouslyȱundergoneȱphysicalȱtherapyȱatȱtheȱtimeȱthatȱheȱdeȬ cidedȱtoȱrefuseȱhimȱphysicalȱtherapy.ȱAndȱfinally,ȱhisȱcontenȬ tionȱ thatȱ walkingȱ onȱ anȱ injuryȱ isȱ theȱ equivalentȱ ofȱ physicalȱ therapyȱisȱunsupportedȱbyȱanyȱmedicalȱevidence,ȱandȱstrainsȱ evenȱaȱlayȱperson’sȱunderstandingȱofȱhowȱtoȱtreatȱanȱinjury.ȱ Professionalȱjudgmentȱisȱneededȱtoȱdetermineȱwhether,ȱwhenȱ andȱ howȱ muchȱ exertionȱ willȱ healȱ ratherȱ thanȱ aggravateȱ theȱ injury.ȱAndȱaȱreasonableȱjuryȱcouldȱfindȱleavingȱaȱpatientȱtoȱ makeȱthisȱdeterminationȱbyȱhimselfȱcarriedȱanȱimpermissibleȱ andȱunjustifiableȱriskȱofȱpainȱandȱprolongedȱrecovery.ȱAtȱtheȱ veryȱleast,ȱPettiesȱhasȱtheȱrightȱforȱaȱjuryȱtoȱhearȱDr.ȱObaisi’sȱ justificationsȱforȱhisȱtreatmentȱdecisionsȱ(orȱlackȱthereof)ȱandȱ 18ȱ ȱNo.ȱ14Ȭ2674ȱ

toȱdetermineȱifȱDr.ȱObaisiȱwasȱdeliberatelyȱindifferent,ȱratherȱ thanȱsimplyȱincompetent,ȱinȱtreatingȱhisȱinjury.ȱ C. Qualifiedȱ Immunityȱ Inappropriateȱ atȱ Summaryȱ JudgmentȱStageȱ Whileȱtheȱdistrictȱcourtȱdidȱnotȱreachȱtheȱissue,ȱinȱtheȱproȬ ceedingsȱbelow,ȱtheȱdefendantsȱpursuedȱtheȱadditionalȱarguȬ mentȱthatȱtheyȱwereȱentitledȱtoȱqualifiedȱimmunity.ȱButȱevenȱ assumingȱ theȱ defendantsȱ preservedȱ thisȱ argument,ȱ ifȱ aȱ juryȱ findsȱthatȱDr.ȱCarterȱandȱDr.ȱObaisiȱknewȱthatȱtheȱcourseȱofȱ treatmentȱ theyȱ wereȱ pursuingȱ wasȱ inadequateȱ toȱ meetȱ PetȬ ties’sȱseriousȱmedicalȱneeds,ȱsuchȱconductȱviolatesȱclearlyȱesȬ tablishedȱlawȱunderȱtheȱEighthȱAmendment.ȱSeeȱFarmer,ȱ511ȱ U.S.ȱatȱ837.ȱGivenȱthatȱtheȱthresholdȱfactualȱquestionsȱofȱtheȱ defendants’ȱstatesȱofȱmindȱremainȱdisputed,ȱsummaryȱjudgȬ mentȱonȱtheȱbasisȱofȱqualifiedȱimmunityȱisȱinappropriate.ȱSeeȱ DuFourȬDowellȱv.ȱCogger,ȱ152ȱF.3dȱ678,ȱ680ȱ(7thȱCir.ȱ1998).ȱ III.ȱCONCLUSIONȱ Forȱtheȱforegoingȱreasons,ȱweȱREVERSEȱtheȱdistrictȱcourt’sȱ grantȱ ofȱ summaryȱ judgmentȱ andȱ REMANDȱ forȱ furtherȱ proȬ ceedings.ȱ No.ȱ14Ȭ2674ȱ 19ȱ

EASTERBROOK,ȱCircuitȱJudge,ȱjoinedȱbyȱFLAUMȱandȱKANNE,ȱ CircuitȱJudges,ȱdissenting.ȱMyȱcolleaguesȱtakeȱitȱasȱestablishedȱ thatȱtheȱConstitutionȱentitledȱPettiesȱtoȱanȱorthopedicȱboot,ȱorȱ someȱotherȱmeansȱtoȱimmobilizeȱhisȱfoot,ȱimmediatelyȱafterȱ hisȱinjury.ȱTheyȱremandȱforȱaȱtrialȱatȱwhichȱaȱjuryȱmustȱdeterȬ mineȱwhetherȱtheȱdefendantsȱwereȱdeliberatelyȱindifferentȱtoȱ theȱpainȱhisȱrupturedȱAchillesȱtendonȱcaused.ȱThisȱapproachȱ effectivelyȱbypassesȱoneȱofȱtheȱtwoȱissuesȱthatȱmatterȱtoȱanyȱ claimȱunderȱtheȱCruelȱandȱUnusualȱPunishmentsȱClause:ȱfirstȱ thereȱmustȱbeȱaȱcruelȱandȱunusualȱpunishment,ȱandȱonlyȱthenȱ doesȱitȱmatterȱwhetherȱtheȱdefendantȱactedȱwithȱtheȱmentalȱ stateȱ necessaryȱ forȱ liabilityȱ inȱ damages.ȱ See,ȱ e.g.,ȱ Hellingȱ v.ȱ McKinney,ȱ509ȱU.S.ȱ25ȱ(1993).ȱAȱcourtȱshouldȱbeginȱwithȱtheȱ conductȱissueȱandȱturnȱtoȱmentalȱstatesȱonlyȱifȱtheȱbehaviorȱ wasȱobjectivelyȱcruelȱandȱunusual.ȱAndȱEstelleȱv.ȱGamble,ȱ429ȱ U.S.ȱ97ȱ(1976),ȱtheȱSupremeȱCourt’sȱsoleȱdecisionȱaddressingȱ theȱquestionȱwhetherȱpalliativeȱmedicalȱtreatmentȱ(painȱreliefȱ withoutȱ anȱ effortȱ atȱ cure)ȱ violatesȱ theȱ Eighthȱ Amendment,ȱ holdsȱthatȱpalliationȱsufficesȱevenȱifȱtheȱcareȱisȱwoefullyȱdefiȬ cient.ȱ ToȱunderstandȱtheȱSupremeȱCourt’sȱconclusionȱthatȱmediȬ calȱmalpracticeȱisȱaȱproblemȱunderȱstateȱlawȱratherȱthanȱtheȱ Constitution,ȱitȱhelpsȱtoȱstartȱwithȱtheȱfactsȱofȱEstelle,ȱwhichȱ mayȱbeȱfoundȱinȱtheȱFifthȱCircuit’sȱopinion,ȱGambleȱv.ȱEstelle,ȱ 516ȱF.2dȱ937ȱ(5thȱCir.ȱ1975),ȱasȱwellȱasȱtheȱSupremeȱCourt’s.ȱ Gambleȱallegedȱthatȱaȱ600Ȭpoundȱbaleȱhadȱfallenȱonȱhimȱandȱ injuredȱ hisȱ back,ȱ leavingȱ himȱ inȱ painȱ soȱ severeȱ thatȱ heȱ freȬ quentlyȱ faintedȱ (hisȱ complaintȱ calledȱ theȱ episodesȱ “blankȬ outs”).ȱHeȱvisitedȱtheȱprisonȱinfirmaryȱandȱreceivedȱmedicineȱ designedȱtoȱdullȱtheȱpain.ȱWhenȱheȱsaidȱthatȱthisȱdidȱnotȱwork,ȱ andȱthatȱtheȱpainȱandȱblackoutsȱwereȱcontinuing,ȱtheȱprisonȱ gaveȱhimȱmoreȱofȱtheȱsameȱmedicine.ȱWhenȱheȱsaidȱthatȱhisȱ

ȱ 20ȱ No.ȱ14Ȭ2674ȱ

painȱpreventedȱhimȱfromȱworking,ȱheȱwasȱtreatedȱasȱaȱshirkerȱ andȱthrownȱintoȱsolitaryȱconfinement.ȱAlthoughȱtheȱprison’sȱ medicalȱstaffȱstuckȱtoȱineffectiveȱmedication,ȱitȱdidȱnothingȱtoȱ findȱoutȱwhatȱkindȱofȱinjuryȱGambleȱhadȱsufferedȱandȱhowȱ theȱproblemȱmightȱbeȱfixed.ȱ TheȱFifthȱCircuitȱruledȱthatȱGambleȱhadȱestablishedȱaȱconȬ stitutionalȱclaim,ȱbecauseȱ“theȱStateȱhasȱtotallyȱfailedȱtoȱproȬ videȱadequateȱtreatmentȱofȱ[his]ȱcondition.ȱAgainȱandȱagain,ȱasȱ theȱ complaintȱ makesȱ clear,ȱ theȱ onlyȱ medicationȱ prescribedȱ wasȱtoȱrelieveȱtheȱpain,ȱnotȱtoȱcureȱtheȱinjury;ȱindeed,ȱtheȱexactȱ natureȱofȱtheȱbackȱinjuryȱremainsȱunknown.”ȱ516ȱF.2dȱatȱ941ȱ (emphasisȱadded).ȱTheȱFifthȱCircuitȱthoughtȱthatȱtheȱConstiȬ tutionȱrequiresȱnotȱonlyȱpalliationȱbutȱalsoȱaȱmedicallyȱcomȬ petentȱeffortȱtoȱcure,ȱstartingȱwithȱanȱxȬray,ȱaȱdiagnosticȱproȬ cedureȱthatȱtheȱprisonȱhadȱnotȱemployed.ȱ Theȱreaderȱofȱtoday’sȱmajorityȱopinionȱwouldȱsupposeȱthatȱ theȱ Supremeȱ Courtȱ affirmedȱ theȱ Fifthȱ Circuit’sȱ demandȱ forȱ competentȱcare.ȱButȱthat’sȱnotȱwhatȱhappened.ȱTheȱSupremeȱ CourtȱreversedȱandȱheldȱthatȱpalliationȱsatisfiesȱtheȱConstituȬ tion,ȱevenȱifȱtheȱprison’sȱmedicalȱstaffȱdoesȱnotȱtryȱtoȱdeterȬ mineȱ howȱ painȱ isȱ beingȱ causedȱandȱ whatȱ mightȱ beȱ doneȱ toȱ cureȱ it.ȱ Thatȱ someȱcareȱ wasȱ givenȱ wasȱ enough.ȱ Theȱ Justicesȱ saidȱthatȱdeliberateȱindifferenceȱtoȱaȱprisoner’sȱpainȱviolatesȱ theȱ Constitutionȱ ifȱ itȱ leadsȱ theȱ staffȱ toȱ doȱ nothing,ȱ butȱ thatȱ medicalȱ careȱ meetsȱ theȱ constitutionalȱ standard.ȱ Gambleȱ reȬ ceivedȱcare.ȱHeȱreceivedȱwretchedȱcare,ȱbutȱtheȱCourtȱheldȱthatȱ aȱclaimȱbasedȱonȱdeficientȱcareȱdependsȱonȱstateȱmedicalȬmalȬ practiceȱlaw.ȱ429ȱU.S.ȱatȱ107ȱ&ȱn.15.ȱTheȱJusticesȱdisapprovedȱ theȱ Fifthȱ Circuit’sȱ conclusionȱ thatȱ theȱ Constitutionȱ entitlesȱ prisonersȱtoȱ“adequate”ȱcare.ȱ

ȱ No.ȱ14Ȭ2674ȱ 21ȱ

Ourȱinitialȱquestionȱthereforeȱoughtȱtoȱbe:ȱDidȱtheȱdefendȬ antsȱprovideȱPettiesȱwithȱmedicalȱcare?ȱThatȱquestionȱisȱeasilyȱ answered.ȱ Pettiesȱ concedesȱ thatȱ heȱ receivedȱ medicalȱ care— quiteȱaȱlotȱofȱit.ȱTheȱmajorityȱopinionȱoutlinesȱtheȱbasics.ȱInȱ Januaryȱ2012ȱDr.ȱImhotepȱCarterȱcorrectlyȱdiagnosedȱaȱrupȬ turedȱAchillesȱtendonȱandȱgaveȱPettiesȱcrutches,ȱice,ȱandȱViȬ codinȱ(aȱpainȬreducingȱdrug).ȱHeȱreferredȱPettiesȱtoȱaȱspecialȬ ist.ȱInȱMarchȱ2012ȱanȱMRIȱexamȱconfirmedȱCarter’sȱdiagnosis.ȱ Dr.ȱAnujȱPuppala,ȱanȱorthopedist,ȱgaveȱPettiesȱanȱorthopedicȱ bootȱtoȱreduceȱmotionȱofȱtheȱfootȱ(inȱrelationȱtoȱtheȱtendon)ȱ whenȱheȱwalked.ȱCarterȱauthorizedȱtheȱuseȱofȱtheȱbootȱinȱtheȱ prison,ȱassignedȱPettiesȱtoȱaȱlowerȱbunk,ȱandȱcontinuedȱtheȱ iceȱandȱdrugȱtreatments.ȱInȱJulyȱ2012ȱCarterȱreferredȱPettiesȱtoȱ Dr.ȱ Samuelȱ Chmell,ȱ anȱ ankleȱ specialistȱ whoȱ recommendedȱ physicalȱtherapy,ȱstretching,ȱandȱanotherȱMRI.ȱAfterȱreplacingȱ CarterȱasȱStateville’sȱmedicalȱdirector,ȱDr.ȱSalehȱObaisiȱcontinȬ uedȱtheȱcourseȱofȱtreatmentȱthatȱPettiesȱwasȱreceiving,ȱincludȬ ingȱuseȱofȱtheȱboot.ȱTheȱsecondȱMRI,ȱwhichȱObaisiȱapproved,ȱ showedȱpartialȱhealing.ȱ PettiesȱmaintainsȱthatȱCarterȱandȱObaisiȱshouldȱhaveȱdoneȱ more—thatȱCarterȱshouldȱhaveȱprovidedȱanȱorthopedicȱbootȱ inȱJanuaryȱ2012ȱratherȱthanȱwaitingȱuntilȱPettiesȱsawȱPuppalaȱ inȱ March,ȱ andȱ shouldȱ haveȱ authorizedȱ surgery;ȱ thatȱ Obaisiȱ shouldȱhaveȱauthorizedȱphysicalȱtherapyȱinȱadditionȱtoȱorderȬ ingȱ anotherȱ MRIȱ andȱcontinuingȱ theȱ treatmentȱ alreadyȱ proȬ videdȱ (theȱ boot,ȱ theȱ lowerȱ bunk,ȱ andȱ soȱ on).ȱ Nonetheless,ȱ thereȱcanȱbeȱnoȱquestionȱthatȱPettiesȱreceivedȱmore,ȱandȱbetȬ ter,ȱ medicalȱ careȱ thanȱ Gambleȱ received.ȱ Yetȱ Gambleȱ lostȱ onȱ theȱpleadings.ȱ Estelleȱ holdsȱ thatȱ aȱ claimȱ ofȱ deficientȱ medicalȱ careȱ mustȱ proceedȱunderȱstateȱlawȱratherȱthanȱtheȱConstitution.ȱWhenȱ

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theȱprisonȱ providesȱ noȱcareȱforȱaȱseriousȱmedicalȱcondition,ȱ thatȱcountsȱasȱcruelȱandȱunusualȱpunishmentȱifȱtheȱphysiciansȱ orȱotherȱresponsibleȱactorsȱareȱdeliberatelyȱindifferentȱtoȱtheȱ condition.ȱ(Farmerȱv.ȱBrennan,ȱ511ȱU.S.ȱ825ȱ(1994),ȱsuppliesȱtheȱ Court’sȱdefinitionȱofȱ“deliberateȱindifference”.)ȱEstelleȱrecogȬ nizedȱoneȱmoreȱpotentialȱcategory:ȱharmfulȱinterventions.ȱ429ȱ U.S.ȱatȱ104ȱ&ȱn.10.ȱButȱPettiesȱdoesȱnotȱcontendȱthatȱtheȱcareȱ heȱreceivedȱfromȱCarterȱandȱObaisiȱmadeȱhisȱconditionȱworse,ȱ comparedȱwithȱnoȱcareȱatȱall.ȱ Notesȱ10ȱandȱ12ȱofȱEstelleȱsuggestȱaȱpotentialȱwayȱtoȱdisȬ tinguishȱ malpracticeȱ fromȱ aȱ violationȱ ofȱ theȱ Constitution:ȱ whetherȱtheȱprison’sȱstaffȱexercisedȱmedicalȱjudgment.ȱPettiesȱ doesȱnotȱpursueȱthisȱpossibility;ȱheȱdoesȱnotȱdenyȱthatȱtheȱdeȬ fendantsȱexercisedȱmedicalȱjudgment.ȱInsteadȱheȱinsistsȱthatȱ theyȱexercisedȱbadȱmedicalȱjudgment,ȱleadingȱtoȱinferiorȱcare.ȱ AndȱEstelleȱholdsȱthatȱaȱclaimȱofȱpoorȱcareȱmustȱbeȱclassifiedȱ underȱtheȱlawȱofȱmedicalȱmalpractice.ȱ(Pettiesȱcomplainsȱthatȱ CarterȱandȱObaisiȱdeemedȱsurgeryȱandȱrehabilitativeȱtherapyȱ tooȱ expensive,ȱ butȱ askingȱ whetherȱ aȱ potentialȱ treatmentȱ isȱ costȬjustifiedȱisȱpartȱofȱprofessionalȱjudgment.ȱOutsideȱofȱprisȬ ons,ȱsolventȱpatientsȱandȱtheirȱinsurers,ȱasȱwellȱasȱphysicians,ȱ routinelyȱconsiderȱwhetherȱaȱparticularȱdrugȱorȱmedicalȱproȬ cedureȱisȱworthȱtheȱprice.)ȱ Atȱ leastȱ threeȱ circuitsȱ askȱ whetherȱ theȱ prisonerȱ receivedȱ someȱtreatment,ȱratherȱthanȱwhetherȱtheȱtreatmentȱwasȱinfeȬ riorȱ (evenȱ grosslyȱ deficient).ȱ See,ȱ e.g.,ȱ Inmatesȱ ofȱ Alleghenyȱ CountyȱJailȱv.ȱPierce,ȱ612ȱF.2dȱ754,ȱ762ȱ(3dȱCir.ȱ1979);ȱDurmerȱv.ȱ O’Carroll,ȱ991ȱF.2dȱ64,ȱ68–69ȱ(3dȱCir.ȱ1993);ȱSelfȱv.ȱCrum,ȱ439ȱ F.3dȱ1227,ȱ1230–33ȱ(10thȱCir.ȱ2006)ȱ(discussingȱotherȱcasesȱinȱ theȱcircuit);ȱFarmerȱv.ȱMoritsugu,ȱ163ȱF.3dȱ610,ȱ614–16ȱ(D.C.ȱCir.ȱ 1998).ȱToday’sȱdecisionȱisȱincompatibleȱwithȱtheȱapproachȱofȱ

ȱ No.ȱ14Ȭ2674ȱ 23ȱ

thoseȱcircuits,ȱthoughȱitȱhasȱsupportȱinȱdecisionsȱofȱtheȱNinthȱ Circuit.ȱSee,ȱe.g.,ȱSnowȱv.ȱMcDaniel,ȱ681ȱF.3dȱ978ȱ(9thȱCir.ȱ2012);ȱ Hamiltonȱv.ȱEndell,ȱ981ȱF.2dȱ1062,ȱ1066–67ȱ(9thȱCir.ȱ1992).ȱTheȱ FirstȱCircuitȱmayȱhaveȱanȱintraȬcircuitȱconflict.ȱCompareȱPerryȱ v.ȱRoy,ȱ 782ȱF.3dȱ73ȱ(1stȱ Cir.ȱ2015),ȱwithȱFeeneyȱ v.ȱ Correctionalȱ MedicalȱServices,ȱInc.,ȱ464ȱF.3dȱ158ȱ(1stȱCir.ȱ2006).ȱStillȱotherȱcirȬ cuitsȱareȱhardȱtoȱclassify.ȱ MyȱcolleaguesȱsayȱthatȱprisonersȱareȱentitledȱtoȱreliefȱunȬ derȱ theȱ Eighthȱ Amendmentȱ whenȱ prisonȱ physiciansȱ doȱ notȱ employȱ “competentȱ medicalȱ judgment”ȱ (opinionȱ atȱ 8)ȱ orȱ “minimallyȱ competentȱ medicalȱ judgment”ȱ (id.ȱ atȱ 9).ȱ Thatȱ tracksȱ stateȱ tortȱ lawȱ andȱ isȱ incompatibleȱ withȱ Estelle.ȱ Otherȱ phrasesȱinȱtheȱopinion,ȱsuchȱasȱ“professionalȱjudgment”ȱ(id.ȱ atȱ10ȱandȱ17)ȱandȱ“reasonableȱmedicalȱjudgment”ȱ(id.ȱatȱ10)ȱ alsoȱseemȱtoȱbeȱproxiesȱforȱtheȱlawȱofȱmedicalȱmalpracticeȱandȱ equallyȱatȱoddsȱwithȱEstelle.ȱ Andȱifȱweȱwereȱauthorizedȱtoȱfindȱaȱ“competentȱmedicalȱ judgment”ȱstandardȱinȱtheȱConstitution,ȱwhyȱshouldȱweȱwantȱ toȱfederalizeȱtheȱlawȱofȱmedicalȱmalpractice?ȱPrisonersȱsuchȱ asȱ Pettiesȱ haveȱ aȱ tortȱ remedyȱ underȱ stateȱ law.ȱ Carterȱ andȱ ObaisiȱwereȱemployedȱbyȱWexfordȱratherȱthanȱtheȱstate.ȱTheyȱ oweȱprisonersȱtheȱsameȱdutiesȱasȱanyȱphysicianȱowesȱtoȱpriȬ vateȱpatientsȱandȱareȱsubjectȱtoȱtheȱsameȱremediesȱunderȱIlliȬ noisȱlaw.ȱSeeȱJinkinsȱv.ȱLee,ȱ209ȱIll.ȱ2dȱ320,ȱ336ȱ(2004).ȱEvenȱphyȬ siciansȱemployedȱbyȱtheȱstateȱareȱsubjectȱtoȱtheȱnormalȱrulesȱ ofȱ tortȱ law.ȱ Seeȱ 745ȱ ILCSȱ 10/6Ȭ106(d);ȱ Mossȱ v.ȱ Miller,ȱ 254ȱ Ill.ȱ App.ȱ3dȱ174,ȱ181–82ȱ(1993).ȱWhenȱprisonȱphysiciansȱareȱemȬ ployedȱ byȱ theȱ state,ȱ inmatesȱ haveȱ anȱ extraȱ remedyȱ byȱ suitȱ againstȱtheȱstateȱitself,ȱseeȱ745ȱILCSȱ5/1;ȱ705ȱILCSȱ505/8(d),ȱjustȱ asȱinmatesȱinjuredȱbyȱmedicalȱmalpracticeȱinȱfederalȱprisonsȱ canȱuseȱtheȱFederalȱTortȱClaimsȱAct.ȱPerhapsȱprisonersȱhopeȱ

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thatȱ constitutionalȱ claimsȱ willȱ produceȱ awardsȱ ofȱ attorneys’ȱ feesȱunderȱ42ȱU.S.C.ȱ§1988(b),ȱwhileȱIllinoisȱrequiresȱplaintiffsȱ toȱbearȱtheirȱownȱfees,ȱbutȱ§1988ȱisȱnotȱaȱgoodȱreasonȱtoȱconȬ stitutionalizeȱtortȱlaw.ȱAndȱfederalȱlawȱcomesȱwithȱcomplicaȬ tions,ȱsuchȱasȱqualifiedȱimmunityȱandȱtheȱdeliberateȬindifferȬ enceȱstandard,ȱmissingȱfromȱstateȱlaw.ȱEstelleȱtoldȱtheȱcourtsȱ ofȱ appealsȱ toȱ relegateȱ badȬtreatmentȱ situationsȱ toȱ stateȱ law,ȱ andȱweȱshouldȱcarryȱoutȱitsȱapproach.ȱ

ȱ