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Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 

---

[PUBLISH]

In the

United States Court of Appeals

For the Eleventh Circuit

____________________

No. 21-14275

____________________

BETTY WADE, 

in her capacity as Personal Representative of the Estate of David 

Henegar, 

Plaintiff-Appellant,

versus

CINDY MCDADE, et al.,

Defendants-Appellees.

____________________

Appeal from the United States District Court

for the Northern District of Georgia

D.C. Docket No. 4:18-cv-00192-AT

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2 Opinion of the Court 21-14275

____________________

Before NEWSOM, LUCK, and TJOFLAT, Circuit Judges.

NEWSOM, Circuit Judge:

Over a four-day stretch during his incarceration at Walker 

State Prison in Georgia, David Henegar failed to receive his prescribed seizure medication. On the fourth night, Henegar had two 

seizures that he claimed caused permanent brain damage. Proceeding under 42 U.S.C. § 1983, Henegar sued five prison employees—Lieutenant John Stroh and Sergeant Jerome Scott Keith, as 

well as nurses Sherri Lee, Julie Harrell, and Cindy McDade—alleging that they were deliberately indifferent to his medical needs in 

violation of the Eighth Amendment.

The district court granted summary judgment to all five defendants on the ground that they were entitled to qualified immunity. Shortly thereafter, Henegar died from causes unrelated to the 

seizures that he suffered while in prison. His sister, Betty Wade, 

now pursues his claims on appeal as the personal representative of 

his estate. 

Before us, Wade asserts that the district court improperly 

accorded the defendants qualified immunity. In order to address 

that question, we find that we must first decide, by reference to our 

existing precedent, what mens rea a plaintiff has to prove to make 

out an Eighth Amendment deliberate-indifference claim. Must she 

show, as some of our decisions have said, that the defendant whose 

conduct she challenges acted with “more than mere negligence,” or 

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must she go further, as others have held, and show that the defendant acted with “more than gross negligence”? Applying our priorpanel-precedent rule—and, in particular, following the first of two 

decisions that squarely addressed and purported to resolve the tension in our case law—we conclude, for reasons that we will explain,

that a deliberate-indifference plaintiff must prove (among other 

things) that the defendant acted with “more than gross negligence.” 

Applying that standard to each of the five defendants here, 

we conclude that none of them was deliberately indifferent to 

Henegar’s medical needs and, accordingly, that none of them violated the Eighth Amendment—and, accordingly, that the district 

court was correct to grant all of them summary judgment.

I

A

Because this case comes to us on appeal from a decision 

granting summary judgment, “we must view all the evidence and 

all factual inferences reasonably drawn from the evidence in the 

light most favorable to the nonmoving party.” Stewart v. Happy 

Herman’s Cheshire Bridge, Inc., 117 F.3d 1278, 1285 (11th Cir. 1997). 

We therefore construe the facts in Wade’s favor, noting factual disputes—overwhelmingly here, between and among the various defendants—where necessary. 

While serving his sentence at Walker State Prison, Henegar 

was diagnosed with epilepsy. Initially, his condition was well-controlled with a daily anticonvulsant called Dilantin. The epileptic 

episode at issue here followed a four-day period—from Sunday, 

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August 28, to Wednesday, August 31, 2016—during which Henegar

didn’t receive his medication. 

First, a brief introduction of the five defendants: Nurses Julie Harrell and Sherri Lee worked the day shift on weekdays in the 

prison medical unit. As relevant here, both were on duty from 

Monday, August 29, through Thursday, September 1. Lieutenant 

John Stroh and Sergeant Jerome Scott Keith worked the night shift 

on Sunday, August 28, when Henegar missed his first dose of Dilantin, and then didn’t return to work until the evening of Wednesday, August 31. Nurse Cindy McDade was the nursing manager; 

the parties agree that she neither treated Henegar nor saw or spoke 

to him during the four days in question. 

In August 2016, Nurse Mary Ann Melton, who isn’t a party 

to this litigation, was responsible for ordering inmates’ medications. She worked at the prison until Thursday, August 25, at which 

point she went on medical leave for several months. Nurse Melton

usually ordered refills of inmates’ medications from the Georgia 

Department of Corrections’ pharmacy shortly before they ran out. 

On Tuesday, August 23—just before going on leave—Nurse 

Melton ordered Henegar’s Dilantin. Medications ordinarily arrived 

within one to two business days, and almost always within three. 

For reasons still unknown, Henegar’s Dilantin wasn’t delivered until sometime after Wednesday, August 31. Typically, if a prisoner’s 

medicine didn’t arrive as expected, Nurse Melton would follow up 

with the pharmacy. In Nurse Melton’s absence, Nurse Harrell ordered medications, recorded them in a binder when they arrived, 

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cross-checked to ensure all orders had been delivered, and inventoried and stocked the prison’s “pill cart.” Nurse McDade occasionally helped order and stock medicines, but it typically fell to Nurse 

Harrell to cover Nurse Melton’s duties. 

As it turns out, despite the delay in the delivery of Henegar’s 

Dilantin, the prison had the medication on hand; there was a

backup supply in the medical department’s “standard ward inventory.” All nurses had access to that supply, and any nurse could also 

obtain Dilantin on short notice from a local pharmacy. Corrections 

officers, by contrast, didn’t have access to the backup supply and 

couldn’t order new medicines. 

There were four “pill calls” each day at regular intervals—

5:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. Henegar was assigned to receive his medication at the 9:00 p.m. call. During regular hours on weekdays, nurses administered inmates’ medicines; 

Nurse Lee, for instance, conducted the 5:00 a.m. pill call each

morning. At night and on weekends, though, no medical personnel were onsite, so corrections officers distributed medications. 

During those pill calls, an officer would review a prisoner’s medication administration record (“MAR”) to determine what medicine

he needed and then retrieve it from the pill cart. If there was an 

issue with distributing or administering an inmate’s medication, 

the officer was supposed to make a notation to that effect in his

MAR. Standard notations included “A” for “administered,” “N” for 

“no-show,” “R” for “refused,” and “A/W” for “accepted but 

wasted.” 

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When Henegar attended the 9:00 p.m. pill call on Sunday,

August 28, his Dilantin wasn’t on the cart. Lieutenant Stroh was 

supervising that night, and Sergeant Keith, who was administering 

the pill call, made an “unidentifiable marking” in Henegar’s MAR. 

It wasn’t one of the four standard notations that officers had been 

trained to use in MARs. 

Having missed his August 28 dose, Henegar returned to the

9:00 p.m. pill calls on August 29 and 30, to no avail. As already explained, both Lieutenant Stroh and Sergeant Keith were off those 

days. The corrections officers who conducted those pill calls put

“question marks” in Henegar’s MAR. It is undisputed that “it 

would be unusual for [a question mark] to appear in the medication 

[b]inder.” Although we don’t know who, someone also put a postit note on Henegar’s file to indicate that there had been a problem 

with administering his medication—the parties agree that it

“st[uck] out . . . like a flag” from Henegar’s file in the pill cart.

At some point on either August 29, 30, or 31, Henegar also 

attended a daytime pill call but still didn’t receive his Dilantin. He 

spoke to a nurse at the time, although he couldn’t remember exactly when or which one. The only nurses working daytime pill 

calls on those days were Nurses Harrell and Lee. Nurse Harrell 

admits having inventoried the pill cart at least once during the days 

when Henegar went without his medication and checking the 

binder of prescription deliveries daily. Nonetheless, she insists that 

she didn’t know that Henegar was out of his Dilantin.

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On Wednesday night, August 31, Lieutenant Stroh and Sergeant Keith were back on duty together, and Sergeant Keith once 

again conducted the 9:00 p.m. pill call. When Henegar showed up 

and his Dilantin still wasn’t on the pill cart, Sergeant Keith recorded

another question mark in the MAR. One of the two officers told

Henegar to go to the sick bay the following morning. 

At 10:50 p.m. that same day, having been without his Dilantin for four days, Henegar suffered a nearly 20-minute seizure that 

induced status epilepticus—a condition that can cause brain damage. The resulting injury usually centers in the hippocampus, 

which regulates memory and mood. The on-call doctor didn’t answer Lieutenant Stroh’s call, so he phoned Nurse McDade, who instructed him to call 911. Henegar was transported to the emergency room, treated, and returned to the prison at around 2:30 a.m.

on September 1. 

Just two hours later, Henegar suffered another seizure that 

left him oxygen-deprived for about 20 minutes. When Lieutenant 

Stroh and Sergeant Keith arrived at Henegar’s cell, his seizure had 

subsided. Lieutenant Stroh called Nurse McDade again at home to 

report the incident, and she told him to have Nurse Lee examine 

Henegar when she arrived.

When Nurse Lee got to the prison around 5:00 a.m., she

took Henegar to the medical unit, examined him, and found that 

his oxygen level was 81%—a low but not critical level—and that his 

pupils were slow to dilate but otherwise functioning correctly. She 

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determined that he needed supplemental oxygen and additional 

seizure-prevention measures, so she sent him back to the hospital. 

Later that day, Nurse McDade investigated the incident and 

contacted the pharmacy to ensure that Henegar’s Dilantin was delivered. She also switched administration of all anti-seizure medications from the 9:00 p.m. pill call to the 4:00 p.m. pill call so that 

nurses, rather than corrections officers, would be in charge of distribution. Nurse McDade reports that a similar situation had never 

occurred before. 

Following the August 2016 incident, Henegar regularly received his medication until his release a year later. The defendants 

all but acknowledge that a breakdown in communication between 

nurses, the pharmacy, and corrections officers caused Henegar’s 

injuries. After his release, Henegar began to struggle with his 

short-term memory, finding himself unable to remember everyday 

conversations and keep up with his welding job. He came to rely

on his mother, with whom he lived, to remind him about medical

appointments, and he suffered strained relationships because he 

was no longer able to regulate his emotions. 

* * *

One last “factual” issue: There’s a fair amount of fingerpointing among the defendants. For instance, Nurse McDade insists that she trained corrections officers to communicate with 

nurses about an inmate’s medication both “through the MAR and 

verbally.” (For her part, Wade likewise alleges that the officers had 

been trained to contact the on-call nurse immediately when a 

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question about medication arose.) And it is undisputed that neither 

Lieutenant Stroh nor Sergeant Keith called a nurse immediately 

when Henegar initially missed his medication on August 28. 

Lieutenant Stroh and Sergeant Keith respond in three ways. 

First, they say—and all agree about this much—that they believed

(even if incorrectly) that the medical staff reviewed their notations 

in the MARs every morning, although Nurse McDade rejoins that 

she didn’t train them to think that. Second, the officers assert that 

they considered it an inmate’s responsibility to notify the medical 

staff if his medicine was unavailable and that officers were supposed to communicate with the medical staff exclusively through 

MARs. Sergeant Keith, in particular, testified that his practice was 

to contact the on-call nurse only when there were discrepancies 

with a prisoner’s medication—say, if a pill on the cart didn’t match 

the prisoner’s prescription—not when medication was missing entirely. Finally, Sergeant Keith claims (1) that he did tell at least one

nurse verbally about the problem either late on August 28 or early 

on August 29, (2) that it must have been Nurse Lee because she was 

the only one whose shift overlapped with his, and (3) that, in any 

event, the nurse with whom he spoke told him that Henegar’s Dilantin was “on order.”

In return, the nurses seek to shift blame back to the officers. 

For instance, Nurse Lee denies that Sergeant Keith ever told her 

about Henegar’s missing Dilantin. And more generally, all of the 

nurses deny that either Lieutenant Stroh or Sergeant Keith told 

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them anything—they insist that they were completely unaware 

that Henegar was out of Dilantin. 

The nurses also point fingers at one another. Nurse Melton, 

for instance, testified that it was Nurse Lee’s responsibility to check 

the MARs from the previous night’s 9:00 p.m. pill call to determine 

whether there had been medication-related problems. Wade 

agrees that Nurse Lee was supposed to check the MARs and, accordingly, that she either knew or should have known that Henegar 

had been missing his Dilantin doses. Nurse Lee, naturally, denies 

that it was her responsibility either (1) to review the previous 

night’s or weekend’s MARs or (2) to communicate with corrections 

officers or solicit reports on the nighttime pill call. For her part, 

Nurse McDade testified that she didn’t double-check to ensure that 

line nurses were reviewing the nighttime MARs or the medicationorder binder because she didn’t want to “micromanage” them. 

B

Henegar sued Lieutenant Stroh, Sergeant Keith, and Nurses 

Harrell, Lee, and McDade under 42 U.S.C. § 1983, alleging that 

each of them had been deliberately indifferent to his serious medical needs in violation of the Eighth Amendment. The district court 

granted summary judgment to all defendants on the ground that 

they were entitled to qualified immunity. In particular, the court 

held that even if one or more of the defendants had violated the 

Constitution, the law in August 2016 was insufficiently “clearly established” to give them fair notice of the unlawfulness of their conduct: “Assuming Defendants’ conduct here constituted deliberate 

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indifference to a serious medical need in violation of Plaintiff’s 

Eighth Amendment rights, Plaintiff has failed to point to any law 

applicable to the circumstances presented in this case that clearly 

established the alleged violation of Plaintiff’s rights.” 

Henegar’s sister, Betty Wade, assumed responsibility for his

suit following his death, and on appealshe contends that the district 

court erred in granting the defendants summary judgment.1 

II

A government official sued under § 1983 may defend on the 

ground that he or she has qualified immunity from suit. Qualified 

immunity protects officials “from liability for civil damages insofar 

as their conduct does not violate clearly established statutory or 

constitutional rights of which a reasonable person would have 

known.” Pearson v. Callahan, 555 U.S. 223, 231 (2009) (quoting Harlow v. Fitzgerald, 457 U.S. 800, 818 (1982)). Because it is undisputed

that the defendants here were at all relevant times performing discretionary functions of their offices, see Glasscox v. City of Argo, 903 

F.3d 1207, 1213 (11th Cir. 2018), Wade has the burden both (1) to

“make out a violation of a constitutional right” and (2) to show that

the right that she claims the defendants violated was “clearly established at the time of [their] alleged misconduct.” Pearson, 555 U.S.

at 232 (quotation omitted). 

1 We review a district court’s grant of summary judgment de novo. See Stewart

v. Happy Herman’s Cheshire Bridge, Inc., 117 F.3d 1278, 1284 (11th Cir. 1997).

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A reviewing court may consider the two prongs of the qualified-immunity standard in either order. Id. at 236. As already explained, the district court here bypassed the first prong—“[a]ssuming” that the defendants had violated the Eighth Amendment—in 

favor of deciding the case on the ground that Wade hadn’t shown 

that applicable law was “clearly established.” We think it best—and 

find that we are able—to resolve the case on the first, “violation” 

prong.

* * *

In relevant part, the Eighth Amendment forbids the “inflict[ion]” of “cruel and unusual punishments.” U.S. Const. amend 

VIII. The Supreme Court first held in Estelle v. Gamble that the 

Cruel and Unusual Punishments Clause should be understood to 

prohibit “deliberate indifference to serious medical needs of prisoners.” 429 U.S. 97, 104–05 (1976). As it has evolved in the years 

since Estelle, a deliberate-indifference claim has come to entail both

an objective and a subjective component. See Keohane v. Florida 

Dep’t of Corr. Sec’y, 952 F.3d 1257, 1266 (11th Cir. 2020). As an initial 

matter, the plaintiff-inmate must establish an “objectively serious 

medical need.” Id. It is undisputed, as relevant here, that an unmedicated seizure disorder satisfies that objective threshold. 

A deliberate-indifference claim’s subjective component entails three subparts: The plaintiff must prove that the defendant (1) 

actually knew about a risk of serious harm; (2) disregarded that 

risk; and (3) acted with more than ______ negligence. See Hoffer v. 

Secretary, Fla. Dep’t of Corr., 973 F.3d 1263, 1270 (11th Cir. 2020). To 

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be clear, the blank in our paraphrase is intentional. For more than 

25 years now, our case law regarding a deliberate-indifference 

claim’s mens rea element has been hopelessly confused, resulting 

in what we’ll charitably call a “mess.” We’ve tried to clean up that 

mess at least twice, but seemingly to no avail, as panels continue to 

flip-flop between two competing formulations: “more than mere

negligence” and “more than gross negligence.” We find it necessary 

to address the mens rea issue once again—this time, we hope more 

definitively—because, as it turns out, the standard is dispositive 

with respect to two of our defendants.

In the discussion that follows, we will explain the dissonance 

in our precedent and our resolution of it, and then, having done so, 

apply the governing deliberate-indifference standard to each of our 

five defendants.

A

The confusion in our case law arose in the wake of the Supreme Court’s decision in Farmer v. Brennan, 511 U.S. 825 (1994). 

Farmer was a successor to Estelle and, for the first time, set out to 

explain the term “deliberate indifference.” Id. at 829. In particular, 

the Farmer Court said that “[w]hile Estelle establishes that deliberate 

indifference entails something more than mere negligence, the 

cases are also clear that it is satisfied by something less than acts or 

omissions for the very purpose of causing harm or with knowledge 

that harm will result.” Id. at 835. The Court thus likened deliberate 

indifference to “subjective recklessness as used in the criminal law.” 

Id. at 839. 

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Our post-Farmer decisions are a jumble, with different panels 

adopting one of two different mens rea standards at different times. 

On the one hand, some have interpreted Estelle and Farmer to require a deliberate-indifference plaintiff to show only that the defendant acted with “more than mere negligence.” See, e.g., Adams v. 

Poag, 61 F.3d 1537, 1543 (11th Cir. 1995); McElligott v. Foley, 182 F.3d 

1248, 1255 (11th Cir. 1999); Brown v. Johnson, 387 F.3d 1344, 1351 

(11th Cir. 2004); Mann v. Taser Int’l, Inc., 588 F.3d 1291, 1307 (11th 

Cir. 2009); Bingham v. Thomas, 654 F.3d 1171, 1176 (11th Cir. 2011); 

Jackson v. West, 787 F.3d 1345, 1353 (11th Cir. 2015); Melton v. Abston, 

841 F.3d 1207, 1223 (11th Cir. 2016); Mitchell v. Nobles, 873 F.3d 869, 

876 (11th Cir. 2017); Swain v. Junior, 961 F.3d 1276, 1285 (11th Cir. 

2020); Keohane, 952 F.3d at 1266. On the other hand, just as many 

(if not more) of our opinions have said that a deliberate-indifference plaintiff must prove that the defendant acted with “more than 

gross negligence.” See, e.g., Cottrell v. Caldwell, 85 F.3d 1480, 1490 

(11th Cir. 1996); Bozeman v. Orum, 422 F.3d 1265, 1272 (11th Cir. 

2005); Burnette v. Taylor, 533 F.3d 1325, 1330 (11th Cir. 2008); Townsend v. Jefferson Cnty., 601 F.3d 1152, 1158 (11th Cir. 2010); Harper v. 

Lawrence Cnty., 592 F.3d 1227, 1234 (11th Cir. 2010); Youmans v. Gagnon, 626 F.3d 557, 564 (11th Cir. 2010); Pourmoghani-Esfahani v. Gee, 

625 F.3d 1313, 1317 (11th Cir. 2010); Liese v. Indian River Cnty. Hosp. 

Dist., 701 F.3d 334, 344 (11th Cir. 2012); Goodman v. Kimbrough, 718 

F.3d 1325, 1332 (11th Cir. 2013); Keith v. DeKalb Cnty., 749 F.3d 1034, 

1047 (11th Cir. 2014); Valderrama v. Rousseau, 780 F.3d 1108, 1116 

(11th Cir. 2015); Patel v. Lanier Cnty., 969 F.3d 1173, 1188 (11th Cir. 

2020); Hoffer, 973 F.3d at 1270; Wade v. Daniels, 36 F.4th 1318, 1326 

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(11th Cir. 2022); Ireland v. Prummell, 53 F.4th 1274, 1293 (11th Cir. 

2022). As the dates in our string cites attest, we have pitched back 

and forth—and back and forth and back and forth—between the 

“more than mere negligence” and “more than gross negligence” 

standards for the better part of the last three decades.

As already noted, on at least two separate occasions, panels 

of this Court have squarely confronted the mere-vs.-gross issue 

and attempted to set circuit law straight. First, in 2010, the panel

in Townsend v. Jefferson County expressly adopted the “more than 

gross negligence” standard. A deliberate-indifference plaintiff, it 

held, must prove, among other things, that the defendant engaged 

in conduct that amounted to “more than [gross] negligence.” 601 

F.3d at 1158 (alteration in original).2 In doing so, the Townsend

panel acknowledged that some opinions had “occasionally stated, 

in dicta, that a claim of deliberate indifference requires proof of 

‘more than mere negligence,’” citing for that proposition McElligott 

v. Foley, 182 F.3d at 1255. Townsend, 601 F.3d at 1158. Importantly, 

though, the Townsend panel concluded that the “earlier holding in 

Cottrell [v. Caldwell], 85 F.3d at 1490, made clear that, after Farmer v. 

Brennan, 511 U.S. 825, 114 S. Ct. 1970, 128 L.E. 2d 811 (1994), a claim 

2 To be clear, the Townsend panel didn’t insert the word “gross” into its recitation of the governing standard. Rather, it quoted Bozeman v. Orum, 422 F.3d 

at 1272, which in turn quoted Brown v. Johnson, 387 F.3d at 1351, but substituted the word “gross” for Brown’s “mere” on the ground that the decisions in 

Miller v. King, 384 F.3d 1248, 1261 (11th Cir. 2004), and Cottrell v. Caldwell, 85 

F.3d at 1491, had recognized that “after [Farmer], gross negligence fails to satisfy [the] state-of-mind requirement for deliberate indifference.” Bozeman, 422 

F.3d at 1272.

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of deliberate indifference requires proof of more than gross negligence.” Id.

Notwithstanding Townsend’s embrace of Cottrell and the 

“more than gross negligence” standard, within a few years some 

panels reverted to the “more than mere negligence” formulation. 

See, e.g., Bingham, 654 F.3d at 1176; West, 787 F.3d at 1353. So in 

2016, another three-judge panel re-engaged the mere-vs.-gross issue. In Melton v. Abston, the panel held that “[a] plaintiff claiming 

deliberate indifference to a serious medical need must prove,” inter 

alia, that the defendant engaged in conduct that amounted to

“more than mere negligence.” 841 F.3d at 1223 (emphasis added). 

The Melton panel acknowledged Townsend’s earlier conclusion that 

“under [Cottrell] and [Farmer], ‘a claim of deliberate indifference requires proof of more than gross negligence.’” Id. at 1223 n.2 (quoting Townsend, 601 F.3d at 1158). But the Melton panel “disagree[d]” 

with Townsend “for three main reasons.” Id. First, the Melton panel 

expressed the view that “the ‘more than mere negligence’ standard 

in McElligott” was “more consistent with Farmer than the ‘more 

than gross negligence’ standard in Townsend.” Id. Second, and relatedly, it observed that the phrase “more than gross negligence” 

didn’t appear (at least in so many words) in either Cottrell or Farmer. 

Id. And finally, the Melton panel said that Cottrell’s adoption of the 

“more than gross negligence” standard came only in dicta: “[T]he 

panel in Cottrell,” it said, “found no deliberate indifference where 

the plaintiff failed to prove ‘the subjective intent element prescribed 

in Farmer,’ and therefore, did not reach whether Farmer requires 

‘more than mere negligence’ or ‘more than gross negligence.’” Id.

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(quoting Cottrell, 85 F.3d at 1491–92). Accordingly, the Melton panel

held that the 1999 decision in McElligott—rather than the 1996 decision in Cottrell—was the “earliest Eleventh Circuit case after 

Farmer to directly address” the mens rea issue, that the McElligott

panel’s determination of the mens rea issue was not dicta, as Townsend had said, and, therefore, that the “more than mere negligence”

standard controlled. Id.

What to do with Townsend’s and Melton’s dueling attempts 

to answer the mere-vs.-gross question? The short answer is that 

our prior-panel-precedent rule binds us to Townsend’s earlier resolution. “When there is no method for reconciling an intracircuit 

conflict of authority”—as there isn’t here, given the Melton panel’s 

explicit “disagree[ment]” with and rejection of Townsend—“the earliest panel opinion resolving the issue in question binds this circuit 

until the court resolves the issue en banc.” United States v. Dailey, 

24 F.3d 1323, 1327 (11th Cir. 1994) (quoting Clark v. Housing Auth. of 

Alma, 971 F.2d 723, 726 n.4 (11th Cir. 1992)); see also United States v. 

Archer, 531 F.3d 1347, 1352 (11th Cir. 2008) (emphasizing “the 

strength of the prior panel precedent rule in this circuit”).3 

3 To be clear, the “issue in question” with respect to which we apply the priorpanel-precedent rule here, see Dailey, 24 F.3d at 1327 (quoting Clark, 971 F.2d 

at 726 n.4), isn’t whether “more than mere negligence” or “more than gross 

negligence” is the proper mens rea standard as an initial matter. If that were 

the proper object of our prior-panel-precedent-rule inquiry, then we would 

seek out the “earliest panel opinion” addressing that issue, whatever that opinion might be. Id. But that’s not our task; rather, the prior-panel-precedent 

issue that we confront now, in the wake of Townsend and Melton, is which of 

those two previous efforts to clarify circuit law controls our decision. Cf.

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To summarize the key points about Townsend and Melton: In 

2010, Townsend held that our then-existing decisions could be read 

consistently (and in any event were best read) to impose a “more 

than gross negligence” standard. In particular, Townsend held (1) 

that the existing decisions did not embody conflicting holdings on 

the mere-vs.-gross issue, (2) that McElligott’s adoption of the “more 

than mere negligence” standard was mere “dicta,” and (3) that the 

“earlier holding” in Cottrell was clear that the “more than gross negligence” standard applied. Townsend, 601 F.3d at 1158. Six years 

later, the Melton panel expressly “disagree[d] with” Townsend on the 

grounds (1) that in fact (and contra Townsend) there was a split in 

our cases that required resolving, (2) that in fact (and contra Townsend) Cottrell had not “h[eld]” that a “more than gross negligence” 

standard applied, and (3) that in fact (and contra Townsend) McElligott’s adoption of the “more than mere negligence” standard was

not just “dicta” but instead a binding holding.

With all due respect to the Melton panel, under our priorpanel-precedent rule, it had no authority to “disagree with” Townsend—either Townsend’s treatment of McElligott as “dicta,” its treatment of Cottrell as a “holding,” or its resulting conclusion that circuit precedent, properly understood, embraces a “more than gross 

Offshore of the Palm Beaches, Inc. v. Lynch, 741 F.3d 1251, 1256–57 (11th Cir. 2014) 

(applying the prior-panel-precedent rule not to the first case to decide the underlying question—there, whether the court had appellate jurisdiction over 

interlocutory admiralty-related orders under 28 U.S.C. § 1292(a)(1)—but, rather, to the first of several conflicting cases to determine whether an intervening Supreme Court decision had abrogated contrary circuit precedent).

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21-14275 Opinion of the Court 19

negligence” mens rea standard. We too are bound by Townsend. 

Whatever we might think about the confusion surrounding the

mens rea issue or its resolution, Townsend settled matters by embracing Cottrell and the “more than gross negligence” standard. 

The Melton panel was powerless to decide otherwise, and so are 

we.4

Filling in the blank, then: To make out the subjective component of an Eighth Amendment deliberate-indifference claim, a 

plaintiff must establish that the defendant (1) had subjective 

knowledge of a risk of serious harm, (2) disregarded that risk, and 

(3) acted with more than gross negligence.

B

Having resolved the standard that governs our analysis, we 

now proceed to apply it to each of our five defendants. 

1

We consider the corrections officers first. Our analysis of 

Wade’s claim against Lieutenant Stroh is straightforward, as it 

founders on the subjective component’s first subpart: Lieutenant 

Stroh didn’t have “subjective knowledge of a risk of serious harm.” 

4 Were the rule otherwise—such that any panel was free to re-decide what it 

thought the first-in-time case actually was, even in the face of intervening decisions resolving that very issue—there could, by definition, be no closure. 

Every day would be a new day. That is precisely the situation that our priorpanel-precedent rule is designed to prevent.

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20 Opinion of the Court 21-14275

Hoffer, 973 F.3d at 1270.5 “Whether a prison official had the requisite knowledge of a substantial risk is a question of fact subject to 

demonstration in the usual ways, including inference from circumstantial evidence.” Farmer, 511 U.S. at 842. Here, Lieutenant Stroh

testified—without contradiction—that he didn’t “have a sense of 

urgency” about Henegar’s missing Dilantin because (1) he had a 

son with epilepsy and (2) his son could miss doses of his seizure 

medication without incident. So while Lieutenant Stroh acknowledged that he knew that an unmedicated seizure disorder constituted a serious health risk, he didn’t know that missing medication 

for just a few days could produce that risk. Because he lacked the 

requisite subjective knowledge, Lieutenant Stroh was not deliberately indifferent to Henegar’s medical needs, and the district court 

correctly granted him summary judgment.

Next, Sergeant Keith. It’s undisputed that Sergeant Keith 

made MAR notations on the first and fourth nights that Henegar 

missed his Dilantin, a fact from which one could reasonably (if uncharitably) infer that he had a subjective awareness of a serious risk

to Henegar’s health. Construing the facts in Wade’s favor vis-à-vis 

Sergeant Keith, one could also reasonably infer that he had been

5 Although Lieutenant Stroh was Sergeant Keith’s supervisor, “[i]t is well established in this circuit that supervisory officials are not liable under § 1983 for 

the unconstitutional acts of their subordinates on the basis of respondeat superior or vicarious liability.” Hartley v. Parnell, 193 F.3d 1263, 1269 (11th Cir. 

1999) (internal quotation and citation omitted). Accordingly, our review is 

limited to the question whether Lieutenant Stroh himself exhibited deliberate 

indifference to Henegar’s serious medical needs.

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21-14275 Opinion of the Court 21

trained not only to convey medication-administration problems 

through MAR notations, but also to communicate them directly to 

nurses. All agree that Sergeant Keith made notations in Henegar’s 

MAR in an attempt to signal problems with administering his Dilantin and that he believed (even if incorrectly) that the nurses generally reviewed MAR notations. The defendants dispute among

themselves, though, whether Sergeant Keith ever told a nurse. 

Construing the facts in the light most favorable to Wade—again,

vis-à-vis Sergeant Keith—we must assume that he never verbally 

told a nurse about the problem as he had been told to do. Based on 

the facts as thus understood, we conclude that Wade has shown not 

only that Sergeant Keith was subjectively aware of a risk of serious 

harm but also that he at least partially disregarded that risk. Hoffer, 

973 F.3d at 1270. 

But was he more than grossly negligent? We hold, especially 

in light of his attempt to communicate with the prison’s medical 

staff through notations in Henegar’s MAR, that he was not. In Cottrell, we described the “more than gross negligence” standard as 

“‘the equivalent of recklessly disregarding’ a substantial risk of serious harm to the inmate.” Cottrell, 85 F.3d at 1490–91 (quoting 

Farmer, 511 U.S. at 836). Sergeant Keith’s partial disregard of (what 

we will assume to be) his training doesn’t satisfy that high standard. 

Accordingly, the district court correctly granted him summary 

judgment.

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22 Opinion of the Court 21-14275

2

Nurses Harrell and Lee are closer calls. The subjective 

prong’s first subpart is pretty easily satisfied. Circumstantial evidence, which Farmer says we may consider and from which we may 

draw reasonable inferences, indicates that both knew that Henegar 

wasn’t getting his Dilantin, and we may further assume that, as

medical professionals, both knew that he faced a risk of serious 

harm. 

Nurse Harrell, in particular, doesn’t dispute either that she 

staffed the daytime pill calls on three of the four days that Henegar 

missed his medication or that he attended at least one daytime pill 

call during those days. She also admits that she inventoried the pill 

cart at least once during those days—on either Monday, August 29,

or Wednesday, August 31—and that an unusual post-it note had 

been attached to and was protruding from Henegar’s MAR during

that period. Beyond her conclusory testimony, Nurse Harrell has 

done nothing to demonstrate that she was unaware of the serious 

risk that Henegar faced. 

So, too, with respect to Nurse Lee. We must assume that 

she was supposed to check the previous night’s MARs to determine 

whether there were problems with administering an inmate’s medications. And taking the facts in the light most favorable to Wade 

vis-à-vis Nurse Lee, we must also assume that Sergeant Keith actually told her early on Monday that Henegar was missing his medication. 

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Construing the facts in Wade’s favor, we further conclude 

that Nurses Harrell and Lee “disregarded th[e] risk” of a serious 

health concern. Hoffer, 973 F.3d at 1270. The parties agree that 

they knew about the backup Dilantin supply, had access to it, and 

had the ability to order medications from either the prison-system

pharmacy or a local pharmacy. And yet no one suggests that either

attempted to order or obtain backup Dilantin for Henegar. Based 

on the totality of the circumstances, we can reasonably infer not 

only that both knew Henegar was out of Dilantin, but also that at 

least one of them—and perhaps both—did little to remedy the situation. Henegar testified that when he told the daytime-pill-call 

nurse that he was out—he couldn’t remember who it was—she 

simply responded that his Dilantin was “on order” from the prison 

system’s pharmacy. And Sergeant Keith, of course, said that Nurse 

Lee responded the same way—that the medicine was “on order”—

when he told her that Henegar’s Dilantin had run out. 

Even so, we hold that both Nurses Harrell and Lee are entitled to summary judgment because their conduct was not more 

than grossly negligent. The nurses’ responses—replying that 

Henegar’s Dilantin was “on order” rather than obtaining a substitute dose from the supply closet or a local pharmacy—was regrettable, and we think it was likely more than merely negligent. But it 

is axiomatic that simple medical malpractice does not rise to the 

level of a constitutional violation. Estelle, 429 U.S. at 106. If (as we 

assume for present purposes) Nurses Harrell and Lee were told verbally that Henegar was missing his Dilantin, the facts show that 

they both checked to ensure that it would be arriving soon and 

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24 Opinion of the Court 21-14275

reported that it was “on order.” We cannot say that their actions in 

that respect constitute the sort of “reckless[ ] disregard[ ]” that we 

have held characterizes conduct that is more than grossly negligent. Cottrell, 85 F.3d at 1490–91; see also Poag, 61 F.3d at 1543 (stating, even in what appears to be a “more than mere negligence” 

case, that “it is obduracy and wantonness, not inadvertence or error in good faith, that violates the Eighth Amendment in supplying 

medical needs” (alteration in original) (internal quotations omitted) (quoting Whitley v. Albers, 475 U.S. 312, 319 (1986))). 

Our decisions imposing deliberate-indifference liability have 

typically involved egregious circumstances, often involving prison 

officials denying inmates medication for no reason at all. Nothing 

like that happened here. See Goebert v. Lee Cnty., 510 F.3d 1312, 1330

(11th Cir. 2007) (applying a more-than-gross-negligence standard 

and observing that “an official acts with deliberate indifference 

when he intentionally delays providing an inmate with access to 

medical treatment, knowing that the inmate has a life-threatening 

condition or an urgent medical condition that would be exacerbated by delay” (quoting Lancaster v. Monroe Cnty., 116 F.3d 1419,

1425 (11th Cir. 1997))). Compare, e.g., Lawrence Cnty., 592 F.3d at 

1234–35 (holding that the complaint plausibly alleged that prison 

officials were more than grossly negligent when they failed to treat 

an alcoholic suffering from severe withdrawal and obvious delirium for four days until he eventually died), with, e.g., Burnette, 533 

F.3d at 1328–31 (holding that officers were not more than grossly

negligent when they failed to obtain medical attention for a lucid 

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21-14275 Opinion of the Court 25

arrestee who had “glassy eyes and dilated pupils” and died hours 

later of an overdose). 

Because neither Nurse Harrell nor Nurse Lee was more than 

grossly negligent, neither exhibited deliberate indifference to 

Henegar’s medical needs. The district court properly granted them 

summary judgment.

3 

Wade’s claim against Nurse McDade is different in that it 

names her in her supervisory capacity. Where, as here, there is no 

allegation that a supervisor “personally participated” in any wrongdoing, she can be held liable only if she “instigated or adopted a 

policy that violated [the plaintiff’s] constitutional rights.” Poag, 61 

F.3d at 1544. We have emphasized that “[t]he standard by which a 

supervisor is held liable in her individual capacity for the actions of 

a subordinate is extremely rigorous.” Braddy v. Florida Dep’t of Lab.

& Emp. Sec., 133 F.3d 797, 802 (11th Cir. 1998).

Policy-based supervisory liability can result either where a

challenged policy is unconstitutional on its face or where it is implemented in an unconstitutional manner. See Goebert, 510 F.3d at 

1332. To succeed on an implementation-based challenge, a plaintiff must show, among other things, that the supervisor “had actual 

or constructive notice of a flagrant, persistent pattern of violations.” Id. 

Wade challenges two of Nurse McDade’s policies. First, she 

targets the MAR policy. Nurse McDade, of course, insists that she 

trained the officers to call a nurse immediately if a problem arose 

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26 Opinion of the Court 21-14275

dispensing an inmate’s medication; Lieutenant Stroh and Sergeant 

Keith deny that she did so. Construing the facts in the light most 

favorable to Wade vis-à-vis Nurse McDade, we will assume that 

she didn’t train the officers to contact a nurse if they encountered 

medication-related issues and that her system relied entirely on 

MAR notifications. Even so, an MAR-only policy—while not 

ideal—is not deliberately indifferent on its face. It would not, as 

Wade asserts, necessarily “fail[ ] to ensure that Lieutenant Stroh 

and Sergeant Keith had an effective mechanism to communicate 

with medical at times when there were no medical staff on duty.” 

Br. of Appellant at 30–31; see Goebert, 510 F.3d at 1332 (holding that 

a “policy of not permitting inmates to lie down at their leisure during the daytime” was “certainly [ ] not facially unconstitutional” in 

a case involving a pregnant woman who, when denied an exemption, suffered a miscarriage). That is especially true given the undisputed fact that there was a medical staff member on call. 

Second, Wade alleges that Nurse McDade was deliberately 

indifferent for “failing to properly ensure her subordinates, Nurses 

Lee and Harrell, searched the MARs daily for communications 

from security, or otherwise check to be sure all medications were 

on the pill cart.” Br. of Appellant at 31. To the extent that Wade

assails that policy on its face, her challenge fails. It was not facially 

deliberately indifferent for Nurse McDade to expect subordinates 

to check MARs daily without looking over their shoulders, especially given that she had established an elaborate system of ordering, cross-checking, and inventorying the pill cart to ensure that 

each inmate received his medicine. Cf. Goebert, 510 F.3d at 1332. 

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21-14275 Opinion of the Court 27

We likewise reject any implementation-based challenge, although doing so requires a bit more explanation. For implementation-related deliberate-indifference claims,

[w]e apply a three-prong test to determine a supervisor’s liability: (1) whether the supervisor’s failure to 

adequately train and supervise subordinates constituted deliberate indifference to an inmate’s medical 

needs; (2) whether a reasonable person in the supervisor’s position would understand that the failure to 

train and supervise constituted deliberate indifference; and (3) whether the supervisor’s conduct was 

causally related to the subordinate’s constitutional violation.

Poag, 61 F.3d at 1544. Here, for reasons we will explain, Wade cannot meet the third, causation element; accordingly, her challenge 

fails.

For our purposes, a causal connection is shown when: (1) “a 

history of widespread abuse puts the responsible supervisor on notice of the need to correct the alleged deprivation, and he fails to 

do so”; (2) “a supervisor’s custom or policy . . . results in deliberate 

indifference to constitutional rights”; or (3) “facts support an inference that the supervisor directed the subordinates to act unlawfully 

or knew that the subordinates would act unlawfully and failed to 

stop them from doing so.” Cottone v. Jenne, 326 F.3d 1352, 1360 

(11th Cir. 2003), abrogated in part on othergrounds by Randallv. Scott, 

610 F.3d 701 (11th Cir. 2010) (alteration accepted) (internal 

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28 Opinion of the Court 21-14275

citations and quotations omitted). None of those requirements is 

satisfied here.

First, Wade hasn’t alleged any facts to indicate that there 

was a “history of widespread abuse” sufficient to put Nurse 

McDade on “actual or constructive notice of a flagrant, persistent 

pattern of violations.” Goebert, 510 F.3d at 1332. It is undisputed 

(1) that Henegar’s condition was well-controlled before the incident that underlies this case and (2) that he received his medication 

regularly thereafter until his release. And Wade has pointed to no 

evidence of a pattern of similar violations with respect to other inmates, either. See Reply Br. of Appellant at 19 (“[T]hose cases involve allegations of widespread patterns of policy violation, which 

is not an issue here.”).

Second, and for similar reasons, there is no evidence that a

policy of trusting subordinates to monitor the MARs and manage 

the pill cart generally “results in deliberate indifference to constitutional rights.” Cottone, 326 F.3d at 1360. Lieutenant Stroh testified 

that in 23 years at the prison, it was not “typical” for medication to 

be missing, McDade testified that no comparable situation had ever 

occurred, and Wade has alleged no facts to the contrary. Though 

failing to double-check subordinates’ work might open cracks in 

the system to accidents and oversights, “[m]edical malpractice does 

not become a constitutional violation merely because the victim is 

a prisoner.” Estelle, 429 U.S. at 106. Compare, e.g., Doe v. School Bd. 

of Broward Cnty., Fla., 604 F.3d 1248, 1266 (11th Cir. 2010) (holding 

that allegations that supervisors had been aware of “two instances 

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21-14275 Opinion of the Court 29

of sexual harassment” were insufficient to “show the requisite 

causal connection” for deliberate-indifference purposes), with, e.g.,

Valdes v. Crosby, 450 F.3d 1231, 1243–44 (11th Cir. 2006) (holding 

that a prison warden was deliberately indifferent when he had received at least 13 complaints and inquiries in 13 months before the 

plaintiff’s son’s death at the hands of prison guards). 

Finally, there have been no allegations that Nurse McDade 

directed subordinates to act unlawfully or knew that subordinates 

would do so and failed to stop them. At worst, perhaps she should 

have assumed that mistakes might occur if she didn’t review 

nurses’ work on the MARs. That is not enough. 

III

We echo the district court’s lament that the defendants’ 

“careless actions and their systemic communication failures caused 

Mr. Henegar serious suffering” and “irreparably altered his life.” 

And we reiterate that “while engaged in the business of prison medicine”—no less so than on the outside, so to speak—“the essential 

command of the Hippocratic Oath is ‘first, do no harm.’” Even so, 

the bar to proving an Eighth Amendment deliberate-indifference 

claim is appropriately high, and we conclude that Wade hasn’t met 

it. We therefore affirm the district court’s order granting all five 

defendants summary judgment.

AFFIRMED.

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21-14275 Newsom, J., Concurring 1

NEWSOM, Circuit Judge, concurring:

As the majority opinion explains, our precedent has for years 

bobbed and weaved between two competing views regarding the 

mens rea that underlies an Eighth Amendment deliberate-indifference claim: Must an inmate prove that the prison official whose 

conduct he challenges acted with “more than gross negligence,” or 

is it enough to show “more than mere negligence”? Applying our 

prior-panel-precedent rule, the Court holds today—correctly, under existing law—that the former, “more than gross negligence” 

standard governs. See Maj. Op. at 13–19. 

I’d like to explore a more foundational question: Is any negligence-based standard consistent with the plain language and original understanding of the Eighth Amendment, which by its terms 

applies only to “punishments”? The answer, I think, is pretty 

clearly no. Just as a parent can’t accidentally punish his or her child, 

a prison official can’t accidentally—or even recklessly—“punish[]” 

an inmate.

I

The Eighth Amendment states that “[e]xcessive bail shall not 

be required, nor excessive fines imposed, nor cruel and unusual 

punishments inflicted.” U.S. Const. amend. VIII. To my mind, it is 

fairly well-established that, as originally understood, the Amendment’s Cruel and Unusual Punishments Clause prohibited only certain particularly objectionable methods of punishment imposed in 

conjunction with a criminal defendant’s judgment of conviction. It 

did not, for instance, entail a proportionality principle that 

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2 Newsom, J., Concurring 21-14275

empowered judges to determine that a particular penalty was excessive in relation to a particular crime, nor did it purport to regulate the conditions of a prisoner’s confinement. I won’t reinvent 

the wheel; I’ll simply say that I find myself persuaded by Justice 

Scalia’s thorough analysis in Harmelin v. Michigan, 501 U.S. 957, 961–

85 (1991) (Scalia, J.); see also, e.g., Anthony F. Granucci, Nor Cruel and 

Unusual Punishments Inflicted: The Original Meaning, 57 Calif. L. Rev. 

839 passim (1969). Be that as it may, the Supreme Court has moved 

on. It has read the Clause more broadly, not only to embrace a 

proportionality criterion, see Gre v. Georgia, 428 U.S. 153, 172 

(1976), but also to “appl[y] to some deprivations that were not specifically part of the sentence but were suffered during imprisonment,” see Wilson v. Seiter, 501 U.S. 294, 297 (1991), and, even more 

generally, to embody a fuzzy, eye-of-the-beholder “evolving standards of decency” criterion, see Trop v. Dulles, 356 U.S. 86, 101 (1958) 

(plurality opinion). 

It remains the case, though, that the Eighth Amendment, by 

its plain terms, applies only to “punishments.” And whatever the 

proper understanding of the phrase-of-art “cruel and unusual punishments,” the word “punishment[]” had—and has—a settled 

meaning. Samuel Johnson’s 1785 English dictionary, for instance, 

defined it as “[a]ny infliction or pain imposed in vengeance of a 

crime.” 2 Samuel Johnson, Dictionary of the English Language 424 

(6th ed. 1785). And nearly two centuries later, Americans were still 

using the term in fundamentally the same way to mean a “[p]enalty 

[or a] retributive suffering, pain, or loss.” Punishment, Webster’s 

New International Dictionary (2d ed. 1934). It seems plain to me 

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21-14275 Newsom, J., Concurring 3

that both of those definitions—and others like them—denote an 

element of intentionality. And that seems all the more plain in the 

specific context of the Eighth Amendment, which addresses not 

just “punishments” simpliciter, but their “infliction,” a term that

likewise indicates purposeful, directed conduct. See 1 Samuel Johnson, Dictionary of the English Language 1040 (6th ed. 1785) (defining 

“inflict” to mean “[t]o put in act or impose as punishment”); accord

Noah Webster, An American Dictionary of the English Language 444 

(1828) (“Inflict, verb transitive: To lay on; to throw or send on; to 

apply; as, to inflict pain or disgrace; to inflict punishment on an offender.”).

To be clear, I’m hardly the first person to make this observation about the Cruel and Unusual Punishments Clause’s text. Writing for the Second Circuit in Johnson v. Glick, Judge Friendly emphasized that “[t]he thread common to all [Eighth Amendment] cases 

is that ‘punishment’ has been deliberately administered for a penal 

or disciplinary purpose.” 481 F.2d 1028, 1032 (2d Cir. 1973). Even 

more directly to the point, Judge Posner has explained, pointing to 

what he called “normal meaning[],” that “[t]he infliction of punishment is a deliberate act intended to chastise or deter.” Duckworth 

v. Franzen, 780 F.2d 645, 651–52 (7th Cir. 1985). “That,” he correctly 

said, “is what the word means today; it is what it meant in the eighteenth century.” Id. at 652 (citing Samuel Johnson, Dictionary of the 

English Language (1755)). And Justice Scalia, writing for the Supreme Court in Wilson v. Seiter—citing and quoting, among others, 

Judges Friendly’s and Posner’s observations and adding his own 

emphasis for good measure—indicated that the Eighth 

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4 Newsom, J., Concurring 21-14275

Amendment entails an “intent requirement” and clarified that 

“[t]he source of t[hat] requirement is not the predilections of this 

Court, but the Eighth Amendment itself, which bans only cruel and 

unusual punishment.” 501 U.S. at 300 (emphasis in original).1

The undeniable linguistic fact that the term “punishment” 

entails an intentionality element would seem to preclude any legal 

standard that imposes Eighth Amendment liability for unintentional conduct, no matter how negligent—whether it be only 

“mere[ly]” so or even “gross[ly]” so. Negligence and recklessness, 

after all, are expressly defined in contradistinction to intentional conduct. See, e.g., Negligence, Black’s Law Dictionary (10th ed. 2015) 

(“[A]ny conduct that falls below the legal standard established to 

protect others against unreasonable risk of harm, except for conduct 

that is intentionally, wantonly, or willfully disregardful of others’ rights.” 

(emphasis added)); Recklessness, id. (“Recklessness involves a 

1 Tellingly, even those who contend that the constitutional term “cruel” 

should be understood by reference to a punishment’s effect on the punished, 

rather than to the punisher’s particular motivation, acknowledge my fundamental point—that, by definition, “all punishment involves intent.” John F. 

Stinneford, The Original Meaning of “Cruel”, 105 Geo. L.J. 441, 479 (2017). They 

admit that under “the Eighth Amendment’s intent requirement,” “[t]o violate 

the Cruel and Unusual Punishments Clause, some government official must 

intend to punish”; they just deny that the Clause requires the further proof 

that the official “intend[ed] to punish cruelly.” Id. at 493. Accord, e.g., John F. 

Stinneford, Is Solitary Confinement a Punishment?, 115 Nw. L. Rev. 9, 17 (2020) 

(reviewing historical and modern definitions of “punishment” and concluding 

that the term “involves intent to inflict pain or suffering, [just] not necessarily 

culpable intent”).

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21-14275 Newsom, J., Concurring 5

greater degree of fault than negligence but a lesser degree of fault 

than intentional wrongdoing.” (emphasis added)).

So on a plain reading, the Cruel and Unusual Punishments 

Clause applies only to penalties that are imposed intentionally and 

purposefully.

II

How is it, then, that we find ourselves debating which of two 

negligence-based standards governs a particular species of Eighth 

Amendment claim? When and where did things go so wrong? It 

started innocently enough, with Estelle v. Gamble, 429 U.S. 97 (1976), 

in which the Supreme Court minted what it dubbed (and we still 

call) a “deliberate indifference” claim under the Eighth Amendment. There, the Court was pretty good about minding the line 

between intentional and negligent conduct—but it sowed seeds 

that would later flower into a clean break from the text’s intentionality criterion. On the one hand, the Estelle Court made clear that 

ordinary negligence does not constitute “punishment” within the 

meaning of the Eighth Amendment: Neither “[a]n accident” nor 

“an inadvertent failure to provide adequate medical care,” it said—

even one that would give rise to a “medical malpractice” claim—

crosses the constitutional line. Id. at 105–06. And, in fact, in describing the types of conduct that could “manifest” sufficiently culpable conduct, the Court twice adverted to purposeful actions: 

prison guards “intentionally denying or delaying access to medical 

care or intentionally interfering with the treatment once prescribed.” Id. at 104–05 (emphasis added). On the other hand, 

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6 Newsom, J., Concurring 21-14275

though, the Court also repeated language from its “evolving standards of decency” line of decisions asserting that the “unnecessary 

and wanton infliction of pain” could give rise to an Eighth Amendment claim. Id. at 103 (emphasis added) (quoting Gre, 428 U.S. at 

173). “Wanton”-ness is a heightened mental state, to be sure, but 

it is not the same thing as intent or purpose.

Next came Wilson v. Seiter, to which I’ve already referred. Respectfully, Wilson is an odd opinion. The question there was 

whether an ordinary conditions-of-confinement claim should be 

decided under Estelle’s “deliberate indifference” standard, whatever 

its precise parameters—or instead under a higher standard that applies when “officials act in response to a prison disturbance,” in 

which the complaining inmate must prove that officers acted “maliciously and sadistically for the very purpose of causing harm.” 

501 U.S. at 302 (quoting Whitley v. Albers, 475 U.S. 312, 320–21 

(1986)). In the course of its opinion, the Court nodded strongly 

toward a true intentionality criterion. As already noted, the Court 

stated that the source of what it called “the intent requirement” 

was “the Eighth Amendment itself, which bans only cruel and unusual punishment,” id. at 300, and went on to quote favorably Judge 

Posner’s definition of the term “punishment” as “a deliberate act 

intended to chastise or deter,” as well as Judge Friendly’s observation that “punishment” is “deliberately administered for a penal or 

disciplinary purpose,” id. (quoting Duckworth, 780 F.2d at 652, and 

Glick, 481 F.2d at 1032, respectively).

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21-14275 Newsom, J., Concurring 7

Strangely, though, having made the case—and a convincing 

one—that “[a]n intent requirement is . . . implicit in the word ‘punishment,’” id. at 301, the Wilson Court then pivoted, in the second 

part of its opinion, to decide what it (somewhat inconsistently) presented as an open question: “[I]t remains for us to consider what 

state of mind applies in cases challenging prison conditions” as violative of the Eighth Amendment. Id. at 302. And in answer to 

that question, the Court deferred to language in its earlier decisions 

(including Estelle) rather than the language of the Constitution itself: “[O]ur cases say that the offending conduct must be wanton.” 

Id. (emphasis in original). In particular, the Wilson Court said that 

the form of wantonness to which Estelle had adverted was sufficient: In the ordinary prison-conditions “context, as Estelle held, 

‘deliberate indifference’ would constitute wantonness.” Id.

Lastly—in the Supreme Court, anyway—came Farmer v. 

Brennan, 511 U.S. 825 (1994). There, the Court set out to specify 

“the proper test for deliberate indifference,” as adopted in Estelle

and seconded in Wilson. Id. at 834. Canvassing its earlier decisions, 

the Court opted for a standard “lying somewhere between the 

poles of negligence at one end and purpose or knowledge at the 

other,” settling on one that it loosely called “recklessness.” Id. at 

836. More precisely, the Court embraced a criminal-recklessness 

standard, which, it explained, requires a complaining prisoner to 

prove that the prison official whose conduct he challenges subjectively “kn[ew] of and disregard[ed] an excessive risk to inmate 

health or safety.” Id. at 837. In justifying its choice, the Court 

briefly adverted to the Eighth Amendment’s language, noting that 

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it “does not outlaw cruel and unusual ‘conditions’” but only “cruel 

and unusual ‘punishments.’” Id. It never explained, though, how 

even a criminal-recklessness standard followed from the text itself. 

Rather, the most the Court could muster was that “subjective recklessness as used in the criminal law is a familiar and workable standard that is consistent with the Cruel and Unusual Punishments 

Clause as interpreted in our cases”—that is, as glossed in decisions 

like Estelle and Wilson. Id. at 839–40 (emphasis added). Having said 

so, the Farmer Court “adopt[ed]” criminal recklessness “as the test 

for ‘deliberate indifference’ under the Eighth Amendment.” Id. at 

840.

With Farmer, the retreat from the Eighth Amendment’s 

“punishment” requirement—and the intentionality criterion that it 

indicates—was complete. And our own post-Farmer decisions have 

only widened the gap between text and doctrine. As today’s majority opinion explains, at times we have stated that a deliberateindifference plaintiff need only prove that an official acted with a 

mental state of “more than mere negligence.” See, e.g., Melton v. 

Abston, 841 F.3d 1207, 1223 n.2 (11th Cir. 2016). At others, we’ve 

insisted that a plaintiff prove a mens rea of “more than gross negligence.” Townsend v. Jefferson Cnty., 601 F.3d 1152, 1158 (11th Cir. 

2010). Notably, even the higher gross-negligence standard seems 

to set a lower bar than Farmer’s criminal-recklessness criterion. See 

Farmer, 511 U.S. at 837 (rejecting a standard grounded in recklessness as used in civil tort law). And in any event, neither of our 

competing negligence-based standards—whether “mere” or 

“gross”—has any foundation in, or even connection to, the Eighth 

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21-14275 Newsom, J., Concurring 9

Amendment’s “punishment” requirement, which, as a matter of 

both language and logic, demands proof of intentionality.

III

Maybe it makes sense to hold prison officials liable for negligently or recklessly denying inmates appropriate medical care. 

Maybe not. But any such liability, should we choose to recognize 

it, must find a home somewhere other than the Eighth Amendment. We—by which I mean the courts generally—have been ignoring that provision’s text long enough. Whether we like it or 

not, the Cruel and Unusual Punishments Clause applies, as its moniker suggests, only to “punishments.” And whether we like it or 

not, “punishment[]” occurs only when a government official acts 

intentionally and with a specific purpose to discipline or deter.

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