PUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

No. 15-1587

PAUL SCINTO, SR.,

Plaintiff - Appellant,

v.

WARDEN PATRICIA STANSBERRY, FCI - Butner-Low; SUSAN 

MCCLINTOCK, Camp Administrator, FPC-Butner; R. HOLT, Senior 

Officer Specialist; DR. PHILLIPS; OFFICER COORS,

Defendants - Appellees,

and

FEDERAL BUREAU OF PRISONS, a division of the U.S. Department 

of Justice; HARLEY G. LAPPIN, Director, Bureau of Prisons; 

KIM WHITE, Mid Atlantic Regional Director,

Defendants.

Appeal from the United States District Court for the Eastern 

District of North Carolina, at Raleigh. James C. Dever III, 

Chief District Judge. (5:10-ct-03165-D)

Argued: September 23, 2016 Decided: November 4, 2016

Before NIEMEYER, MOTZ, and WYNN, Circuit Judges.

Affirmed in part and reversed in part by published opinion. 

Judge Wynn wrote the opinion, in which Judge Niemeyer and Judge 

Motz joined.
2

ARGUED: Adam H. Farra, COHEN MILSTEIN SELLERS & TOLL PLLC, 

Washington, D.C., for Appellant. Robert J. Dodson, OFFICE OF 

THE UNITED STATES ATTORNEY, Raleigh, North Carolina, for 

Appellees. ON BRIEF: Paul J. Zidlicky, SIDLEY AUSTIN LLP, 

Washington, D.C., for Appellant. John Stuart Bruce, Acting 

United States Attorney, G. Norman Acker, III, Assistant United 

States Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Raleigh, 

North Carolina, for Appellees.
3

WYNN, Circuit Judge:

Plaintiff Paul Scinto, Sr. (“Plaintiff”), a former federal 

prisoner, sued several federal prison officials pursuant to 

Bivens v. Six Unknown Named Agents of Federal Bureau of 

Narcotics, 403 U.S. 388 (1971), alleging a number of violations 

under the Fourth, Fifth, Eighth, and Fourteenth Amendments. 

Defendants are Dr. Derick Phillip (“Dr. Phillip”); Patricia 

Stansberry, former Federal Prison Camp Butner Warden (“Warden 

Stansberry”); and Susan McClintock, former Butner Camp 

Administrator (“Administrator McClintock”). Collectively, these 

Defendants successfully moved for summary judgment on all of 

Plaintiff’s claims.

On appeal, Plaintiff limits his arguments to the district 

court’s dismissal of three claims that Defendants were 

deliberately indifferent to his medical needs, in violation of 

the Eighth Amendment. Plaintiff argues that, in dismissing 

these claims, the district court made credibility determinations 

and weighed the parties’ evidence, thus violating the summary 

judgment standard.

For the reasons that follow, we reverse the district 

court’s disposition of the two Eighth Amendment claims against 

Dr. Phillip and Administrator McClintock but affirm its 

resolution of the claim against Warden Stansberry.
4

I.

The Eighth Amendment prohibits the infliction of “cruel and 

unusual punishments.” U.S. Const. amend. VIII. This

prohibition “proscribes more than physically barbarous 

punishments.” Estelle v. Gamble, 429 U.S. 97, 102 (1976). It 

also encompasses “the treatment a prisoner receives in prison 

and the conditions under which he is confined.” Helling v. 

McKinney, 509 U.S. 25, 31 (1993). In particular, the Eighth 

Amendment imposes a duty on prison officials to “provide humane 

conditions of confinement . . . [and] ensure that inmates 

receive adequate food, clothing, shelter, and medical care.” 

Farmer v. Brennan, 511 U.S. 825, 832 (1994). To that end, a

prison official’s “deliberate indifference to serious medical 

needs of prisoners constitutes the unnecessary and wanton 

infliction of pain proscribed by the Eighth Amendment.” 

Estelle, 429 U.S. at 104 (internal quotation marks and citation 

omitted). Prisoners alleging that they have been subjected to

unconstitutional conditions of confinement must satisfy the 

Supreme Court’s two-pronged test set forth in Farmer v. Brennan, 

511 U.S. 825 (1994). 

First, Farmer’s “objective” prong requires plaintiffs to 

demonstrate that “the deprivation alleged [was], objectively, 

‘sufficiently serious.’” Farmer, 511 U.S. at 834 (quoting 

Wilson v. Seiter, 501 U.S. 294, 298 (1991)). To be 
5

“sufficiently serious,” the deprivation must be “extreme”--

meaning that it poses “a serious or significant physical or 

emotional injury resulting from the challenged conditions,” or

“a substantial risk of such serious harm resulting from . . . 

exposure to the challenged conditions.” De’Lonta v. Angelone, 

330 F.3d 630, 634 (4th Cir. 2003) (internal quotation marks and 

citation omitted). In medical needs cases, like the case at 

bar, the Farmer test requires plaintiffs to demonstrate 

officials’ deliberate indifference to a “serious” medical need

that has either “been diagnosed by a physician as mandating 

treatment or . . . is so obvious that even a lay person would 

easily recognize the necessity for a doctor’s attention.” Iko 

v. Shreve, 535 F.3d 225, 241 (4th Cir. 2008).

Second, under Farmer’s “subjective” prong, plaintiffs must 

show that prison officials acted with a “sufficiently culpable 

state of mind.” Farmer, 511 U.S. at 834 (internal quotation 

marks omitted) (quoting Wilson, 501 U.S. at 297). In conditions 

of confinement cases, the requisite state of mind is deliberate 

indifference. Id. To prove deliberate indifference, plaintiffs 

must show that “the official kn[ew] of and disregard[ed] an 

excessive risk to inmate health or safety.” Id. at 837. Put 

differently, the plaintiff must show that the official was 

“aware of facts from which the inference could be drawn that a 

substantial risk of serious harm exist[ed], and . . . dr[ew] 
6

th[at] inference.” Id. (emphasis added). Deliberate 

indifference is “more than mere negligence,” but “less than acts 

or omissions [done] for the very purpose of causing harm or with 

knowledge that harm will result.” Id. at 835. It “lies 

somewhere between negligence and purpose or knowledge: namely, 

recklessness of the subjective type used in criminal law.” 

Brice v. Va. Beach Corr. Ctr., 58 F.3d 101, 105 (4th Cir. 1995)

(citing Farmer, 511 U.S. at 835). Under this standard, mere 

“[d]isagreements between an inmate and a physician over the 

inmate’s proper medical care” are not actionable absent 

exceptional circumstances. Wright v. Collins, 766 F.2d 841, 849 

(4th Cir. 1985) (citing Gittlemacker v. Prasse, 428 F.2d 1, 6 

(3d Cir. 1970)).

In deliberate indifference to medical needs cases, Farmer’s 

subjective prong requires proof of the official’s “actual 

subjective knowledge of both the inmate’s serious medical 

condition and the excessive risk posed by [the official’s] 

action or inaction.” Jackson v. Lightsey, 775 F.3d 170, 178 

(4th Cir. 2014) (citing Farmer, 511 U.S. at 837–39). A 

plaintiff can meet the subjective knowledge requirement through 

direct evidence of a prison official’s actual knowledge or 

circumstantial evidence tending to establish such knowledge, 

including evidence “that a prison official knew of a substantial 

risk from the very fact that the risk was obvious.” Makdessi v. 
7

Fields, 789 F.3d 126, 133 (4th Cir. 2015) (quoting Farmer, 511 

U.S. at 842). 

A plaintiff also makes out a prima facie case of deliberate 

indifference when he demonstrates “that a substantial risk of 

[serious harm] was longstanding, pervasive, well-documented, or 

expressly noted by prison officials in the past, and the 

circumstances suggest that the defendant-official . . . had been 

exposed to information concerning the risk and thus must have 

known about it . . . .” Parrish ex rel. Lee v. Cleveland, 372 

F.3d 294, 303 (4th Cir. 2004) (first alteration in original) 

(internal quotation marks omitted) (quoting Farmer, 511 U.S. at 

842). Similarly, a prison official’s “[f]ailure to respond to 

an inmate’s known medical needs raises an inference [of] 

deliberate indifference to those needs.” Miltier v. Beorn, 896 

F.2d 848, 853 (4th Cir. 1990), overruled in part on other 

grounds by Farmer, 511 U.S. at 837. However, even officials who 

acted with deliberate indifference may be “free from liability 

if they responded reasonably to the risk.” Farmer, 511 U.S. at 

844.
8

II.

Plaintiff entered federal custody at Federal Prison Camp 

Seymour Johnson in October 2002.1 At that time, he suffered from 

myriad medical conditions, including hepatitis C, a knee 

infection, insulin-dependent diabetes, and high blood pressure. 

In the years that followed, Plaintiff was confined in various 

federal prison facilities. In particular, from June 2005 to 

March 2006, Plaintiff was incarcerated at Federal Prison Camp 

Butner in Butner, North Carolina. During that time, several 

incidents purportedly occurred and gave rise to a number of 

constitutional claims. Following a circuitous journey through 

the federal judicial system, the present appeal addresses only a 

subset of these claims.

On February 28, 2008, Plaintiff filed a Bivens action pro 

se in the United States District Court for the District of 

Columbia. Plaintiff’s original complaint sought relief for 

alleged violations of his rights under the Fourth, Fifth, 

Eighth, and Fourteenth Amendments, naming as defendants various 

federal officials, including the Bureau of Prisons, then-Bureau 

Director Harley Lappin, Regional Director Kim White, Warden 

 1 After pleading guilty to maintaining a place for the 

purpose of manufacturing, distributing, or using phencyclidine, 

Plaintiff was sentenced to 78 months’ imprisonment. The nature 

of his conviction and sentence are irrelevant to this appeal.
9

Stansberry, Administrator McClintock, and Butner Correctional 

Officer Richard Holt (“Officer Holt”). After dismissing a 

number of these claims on jurisdictional and sovereign immunity 

grounds, the district court transferred Plaintiff’s remaining 

claims against Warden Stansberry, Administrator McClintock, and 

Officer Holt to the United States District Court for the Eastern 

District of North Carolina. Scinto v. Fed. Bureau of Prisons, 

608 F. Supp. 2d 4, 10 (D.D.C.), aff’d, 352 F. App’x 448 (D.C. 

Cir. 2009). Following a second appeal in this Circuit, 

Plaintiff successfully amended his complaint to include 

additional Eighth Amendment claims against defendants Dr. 

Phillip and Butner Correctional Officer Lawrence Coor (“Officer 

Coor”). Scinto v. Stansberry, 507 F. App’x 311 (4th Cir. 2013) 

(per curiam). Cross-motions for summary judgment followed and, 

on September 9, 2014, the district court denied Plaintiff’s 

motion for summary judgment and granted summary judgment to the 

defendants on each of Plaintiff’s claims.

Plaintiff appeals only three of the claims dismissed on 

summary judgment, each arising under the Eighth Amendment. 

These include: (1) Plaintiff’s claim against Dr. Phillip for 

allegedly denying Plaintiff insulin to treat his diabetes; (2) 

Plaintiff’s claims against Dr. Phillip and Administrator 

McClintock for allegedly failing to provide aid in a medical 

emergency; and (3) Plaintiff’s claim against Warden Stansberry 
10

for her alleged failure to provide Plaintiff with a diabetic 

diet during Plaintiff’s incarceration in administrative 

segregation (the “Special Housing Unit”). We address the facts 

relevant to each claim below.

III.

“We review the district court’s grant of summary judgment 

de novo, viewing the facts and the reasonable inferences 

therefrom in the light most favorable to the nonmoving party.” 

Bonds v. Leavitt, 629 F.3d 369, 380 (4th Cir. 2011). Summary 

judgment must be granted “if the movant shows that there is no 

genuine dispute as to any material fact and the movant is 

entitled to judgment as a matter of law.” Fed. R. Civ. P. 

56(a). To survive summary judgment, “there must be evidence on 

which the jury could reasonably find for the [nonmovant].” 

Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252 (1986).

A.

1.

Plaintiff’s first claim alleges that Dr. Phillip violated 

Plaintiff’s Eighth Amendment rights by denying Plaintiff insulin 

to treat his diabetes. Dr. Phillip was Plaintiff’s prison 

doctor at Federal Prison Camp Butner and treated several of

Plaintiff’s medical conditions, including his diabetes. On 

June 5, 2005, shortly after Plaintiff’s arrival at Butner, Dr. 

Phillip prescribed Plaintiff morning and evening insulin 
11

injections, as well as supplemental insulin injections based 

upon a “sliding scale” keyed to his blood sugar. According to 

that sliding scale, Plaintiff was prescribed two units of 

insulin when his blood sugar was between 141 and 150 milligrams

(“mg”) per deciliter (“dL”), four units when his blood sugar was 

between 151 and 200mg/dL, and so on.

On June 14, 2005, Plaintiff requested from Dr. Phillip and 

other medical personnel at Federal Medical Camp Butner a 

supplemental insulin injection because his blood sugar was 

200mg/dL. Based on the sliding scale Dr. Phillip prescribed, 

Plaintiff should have received four units of insulin. At the 

time of his request, Plaintiff admits that he was “angry”--at 

least in part because his blood sugar was high. The parties 

agree that, rather than providing four units of insulin as 

dictated by Plaintiff’s prescription, Dr. Phillip terminated 

Plaintiff’s visit to the medical clinic and declined to provide 

him with insulin. Instead, Dr. Phillip developed an alternative 

plan to monitor Plaintiff’s blood sugar levels at mealtimes and 

to “cover each meal with short acting insulin” if Plaintiff

desired. J.A. 521.2

 2 Citations to “J.A. __” refer to the Joint Appendix filed 

by the parties in this appeal.
12

According to Plaintiff’s evidence, the June 14 incident was 

not the first time Dr. Phillip denied Plaintiff prescribed

insulin injections. Nor, according to Plaintiff, was it the 

last. Although medical records reflect Dr. Phillip’s plan to 

monitor Plaintiff’s blood sugar and provide supplemental insulin 

at mealtimes, Plaintiff filed two Inmate Request to Staff forms 

(“cop-outs”) that suggest this plan was never followed. First, 

on June 22, 2005, Plaintiff directed a cop-out to Dr. Phillip 

“request[ing] insulin coverage whenever my blood glucose levels 

rise above 200mg/dl.” J.A. 88. And on July 27, 2005, Plaintiff

addressed another cop-out to Dr. Phillip referencing his June 22 

request for supplemental insulin (along with several other, 

unrelated requests for medical attention) and stating that his 

conditions “remain untreated [and] uncured.” J.A. 82. Dr. 

Phillip admits that he did not provide Plaintiff with insulin

during the June 14 appointment, but asserts that the denial was 

justified based on Plaintiff’s threatening behavior and that his 

treatment of Plaintiff’s diabetes before and after this incident

was appropriate.

Plaintiff claims that Dr. Phillip’s alleged repeated 

denials of supplemental insulin resulted in an unhealthy 

increase in Plaintiff’s blood sugar and his hemoglobin A1C

levels, which rose from approximately 7 (within the normal range 

for diabetics) to 9.8 (an unhealthy level for diabetics) from 
13

January to September 2005. More generally, Plaintiff claims 

that the inadequate treatment of his diabetes resulted in 

“unnecessary exacerbation of his serious diabetic . . . 

condition[], causing serious harm to the Plaintiff [that] 

resulted in damage to the Plaintiff’s kidney’s [sic], eyesight, 

nervous system, . . . and psychological well being.” J.A. 165.

2.

Contrary to the district court’s holding, Plaintiff adduced 

sufficient evidence to establish a genuine dispute of fact as to 

both Farmer’s objective and subjective prongs.

Regarding the objective prong, Plaintiff’s evidence 

established that he suffers from a serious medical condition: 

insulin-dependent diabetes. This medical condition was 

diagnosed by a medical professional, and Dr. Phillip provided 

treatment for the condition by prescribing Plaintiff’s insulin 

regimen. Moreover, Plaintiff has created a genuine issue of 

material fact regarding whether Dr. Phillip’s failure to provide 

him with insulin was an “extreme deprivation” resulting in “a

serious or significant physical or emotional injury” or “a 

substantial risk” thereof actionable under the Eighth Amendment. 

See De’Lonta, 330 F.3d at 634. Dr. Phillip admits that he 

denied Plaintiff a supplemental dose of insulin on June 14, 

2005, at a time when Plaintiff’s blood sugar was 200mg/dL. This 

may be sufficient alone to meet the objective test set forth in 
14

Farmer. See, e.g., Lolli v. Cty. of Orange, 351 F.3d 410, 420

(9th Cir. 2003) (“Leaving a diabetic . . . without proper food 

or insulin when it is needed creates an objectively, 

sufficiently serious risk of harm.” (internal quotation marks 

omitted)).

Even without drawing this conclusion, however, Plaintiff 

raises a genuine dispute of material fact as to whether the 

deprivation of his prescribed insulin caused serious injury or a 

substantial risk of serious injury as required by the objective 

prong. He does so by pointing to his deposition testimony and 

medical records showing an increase in his blood sugar and 

hemoglobin A1C values from January to September 2005, which 

encompasses the period from June to August 2005 during which Dr. 

Phillip was assigned to treat Plaintiff’s diabetes. Viewing 

these facts in the light most favorable to Plaintiff, there are 

genuine disputes of material fact as to whether (1) this 

increase is itself a serious injury and (2) the act of 

withholding insulin from an insulin-dependent diabetic alone 

creates a serious injury or a substantial risk of such injury.

Plaintiff’s evidence also created a genuine dispute of 

material fact as to Farmer’s subjective prong. As Plaintiff’s 

prison doctor, Dr. Phillip knew of Plaintiff’s serious medical 

condition. Indeed, Dr. Phillip prescribed the insulin regimen 

under which Plaintiff was to receive supplemental insulin 
15

injections when his blood sugar was above 140mg/dL. This 

evidence establishes that Dr. Phillip was aware of facts--

Plaintiff’s diabetes and his blood sugar value at the time of 

his request for insulin--giving rise to an inference that 

failing to provide insulin could result, at least, in a 

substantial risk of serious harm.

Moreover, viewed in the light most favorable to Plaintiff, 

Plaintiff’s lengthy prison medical records show that his

diabetes diagnosis was “longstanding, pervasive, welldocumented, [and] expressly noted by prison officials,” Parrish, 

372 F.3d at 303--including by Dr. Phillip himself. This is 

sufficient to prove a prima facie case of deliberate 

indifference. Id. Furthermore, as in Miltier, Dr. Phillip knew 

of Plaintiff’s medical need for insulin at the time of the 

request and failed to respond to that known need, raising an 

inference of deliberate indifference. 896 F.2d at 853, 

overruled in part on other grounds by Farmer, 511 U.S. at 837. 

The district court erred in failing to apply the Parrish

presumption and infer deliberate indifference from Dr. Phillip’s 

knowledge of Plaintiff’s diabetes and disregard of his own 

prescription designed to manage that condition.

Notwithstanding the factual disputes outlined above, the 

district court granted Dr. Phillip’s motion for summary judgment 

for two principal reasons. First, the court found fault with 
16

Plaintiff’s failure to offer medical expert testimony (a) that 

his blood sugar level during the June 14 appointment “created a 

substantial harm” under the objective prong of Farmer and (b) 

that Dr. Phillip’s failure to provide insulin during the 

appointment “resulted in some substantial harm” sufficient to 

satisfy the objective prong.3 J.A. 956. Second, the district 

court concluded that Dr. Phillip had no obligation under the 

Eighth Amendment to provide Plaintiff, “an angry and hostile 

patient,” with the requested insulin. J.A. 956. Accordingly, 

the district court held, Dr. Phillip satisfied his 

constitutional burden by ordering staff to monitor Plaintiff’s 

condition and provide supplemental insulin at mealtimes. We 

disagree with both conclusions.

Regarding the absence of expert medical testimony, 

plaintiffs alleging deliberate indifference must, “[a]t a 

 3 We emphasize that the correct standard to apply when 

considering the objective prong of deliberate indifference 

claims is whether there is an “extreme deprivation” and “a 

serious or significant physical or emotional injury resulting 

from the challenged conditions or . . . a substantial risk of 

such serious harm resulting from . . . exposure to the 

challenged conditions.” De’Lonta, 330 F.3d at 634. The 

district court’s reference to a “substantial harm” requirement 

does not change this analysis substantively, but does alter 

unnecessarily the language set forth in Fourth Circuit 

precedent. We caution that the “serious or significant” injury 

or “substantial risk” standard, not the district court’s 

“substantial harm” standard, should be used when instructing the 

jury on the objective prong of the Farmer test.
17

minimum, . . . specifically describe not only the injury but 

also its relation to the allegedly unconstitutional condition.” 

Strickler v. Waters, 989 F.2d 1375, 1381 n.9 (4th Cir. 1993). 

There is no requirement, however, that a plaintiff alleging 

deliberate indifference present expert testimony to support his 

allegations of serious injury or substantial risk of serious 

injury. Rather, the Federal Rules of Evidence apply, and expert 

testimony is necessary--indeed, permissible--only when it will 

“help the trier of fact to understand the evidence or to 

determine a fact in issue.” Fed. R. Evid. 702(a). When 

laypersons are just “as capable of comprehending the primary 

facts and of drawing correct conclusions from them” as are 

experts, expert testimony may properly be excluded. Salem v. 

U.S. Lines Co., 370 U.S. 31, 35 (1962). As a result, when the 

seriousness of an injury or illness and the risk of leaving that 

injury or illness untreated would be apparent to a layperson, 

expert testimony is not necessary to establish a deliberate 

indifference claim. See, e.g., Blackmore v. Kalamazoo Cty., 390 

F.3d 890, 899–900 (6th Cir. 2004); Boring v. Kozakiewicz, 833 

F.2d 468, 473 (3d Cir. 1987).

Recognizing that it is a “[w]ell-known” fact that diabetes 

is a “common yet serious illness that can produce harmful 

consequences if left untreated for even a short period of time,” 

several of our Sister Circuits have denied defendants summary
18

judgment on Eighth Amendment claims alleging that prison 

officials deprived diabetic inmates of insulin, even when those 

claims were not supported by expert testimony. Lolli, 351 F.3d 

at 419–20 (concluding, based on the plaintiff’s testimony, that 

a diabetic person who is “unable to take insulin . . . 

regularly” suffers a sufficiently serious risk of harm); Natale 

v. Camden Cty. Corr. Facility, 318 F.3d 575, 582–83 (3d Cir. 

2003) (holding, in the absence of expert testimony, that a 

reasonable jury could conclude that prison officials who knew 

the inmate was diabetic and needed insulin regularly were 

deliberately indifferent in denying insulin for nonmedical 

reasons). We agree: a jury is capable of understanding, 

unaided, the risks of failing to provide insulin to a diabetic 

and of a trained doctor’s denial of a diabetic’s known need for 

insulin. Accordingly, we reject the district court’s contention 

that Plaintiff was required to adduce expert testimony to 

demonstrate an objectively serious deprivation giving rise to a 

claim under the Eighth Amendment. 

Regarding Dr. Phillip’s response to Plaintiff’s request for 

insulin, we agree that--even when both Farmer prongs are 

satisfied--a prison official who responds reasonably in the face 

of a known, serious risk of harm to an inmate may be “free from 

liability” under the Eighth Amendment even if harm is not 

avoided. Farmer, 511 U.S. at 844. But even assuming arguendo
19

that it was reasonable for Dr. Phillip to decline to provide 

Plaintiff insulin in the face of his “angry” demands and, 

instead, to plan to monitor Plaintiff’s blood sugar and provide 

supplemental insulin at mealtimes, Plaintiff nonetheless has 

established a genuine dispute of fact as to whether Dr. Phillip 

followed through with that plan. In particular, Plaintiff’s 

June 22 and July 27, 2005, cop-outs raise a reasonable inference 

that Dr. Phillip failed to provide supplemental insulin as 

proposed by his alternative plan. Therefore, the district court 

erred in concluding that there was no genuine dispute of fact as 

to whether Dr. Phillip reasonably responded to Plaintiff’s 

medical needs.

B.

1.

We now turn to Plaintiff’s second Eighth Amendment claim, 

which arises out of Dr. Phillip’s and Administrator McClintock’s 

alleged failure to provide aid to Plaintiff during a medical 

emergency. On August 24, 2005, Plaintiff was locked in his 

housing unit while prison officials conducted a “census count.”4 

During that time, the flow of water to Plaintiff’s unit was 

discontinued because maintenance workers were repairing the 

 4 During a census count, inmates must remain in place while 

prison officials conduct a count to ensure that all inmates are 

in their assigned locations.
20

unit’s showers. While locked down and unable to access water, 

Plaintiff began experiencing “extreme [stomach] pain . . . was 

throwing up vomit and blood . . . [and] became incontinent.” 

J.A. 846. In this state, Plaintiff used an emergency phone in 

the unit to call for help by dialing a “deuces alarm” (2-2-2).

The parties dispute Plaintiff’s reason for using the 

emergency phone. Plaintiff claims that he used the phone to 

report his illness, saying “I’m sick. The water is off. I 

can’t get anything to drink. I can’t wash up. I’ve got blood 

all over me.” J.A. 848–49. By contrast, in a now-expunged

incident report arising from the phone use, prison officials 

recorded that Plaintiff used the phone to complain about the 

lack of water. According to prison officials, Plaintiff 

complained that he “ha[d] to get a shower” before reporting to 

his work shift that afternoon. J.A. 327. Plaintiff asserts 

that the officials’ explanation is unfounded since prison 

records show that he worked only the morning shift on the day in 

question.

When prison officials responded to Plaintiff’s emergency 

call, they offered no assistance even though Plaintiff points to 

several “outward signs” of his need for medical attention, 

including that his cell “reeked to high heaven” and that his 
21

face was covered with partially wiped-up vomit and blood.5 J.A. 

867–68. Despite his distressed state, Plaintiff claims that Dr. 

Phillip simply “looked at [Plaintiff] in disgust and turned his

head and started to walk away,” providing no medical aid. J.A. 

858. According to Plaintiff’s evidence, Administrator 

McClintock also failed to provide Plaintiff with treatment or 

call for medical assistance, instead ordering prison guards to 

“lock him up” in the Special Housing Unit. J.A. 858–59. 

Thereafter, prison officials removed Plaintiff to the Special 

Housing Unit, where he was confined for six months.

Plaintiff’s evidence indicates he did not receive medical 

attention until at least two days after the August 24 incident, 

with the only related entry in his medical record appearing on 

August 29, 2005--five days after the purported emergency. In 

court documents, Plaintiff attributes his emergency to acute 

cholelithiasis (gallstones), signs of which were first 

documented in his medical record on July 20, 2005, over one 

month prior to the incident.

 5 In recounting their version of events, prison officials 

make no mention of Plaintiff’s physical appearance or medical 

condition.
22

2.

Again, Plaintiff’s evidence establishes genuine disputes of 

material fact as to both Farmer prongs. First, there is a 

genuine dispute regarding whether Dr. Phillip’s and 

Administrator McClintock’s failure to provide aid to Plaintiff 

after he used the emergency phone constituted an “objectively, 

sufficiently serious” deprivation. Viewing the facts in the 

light most favorable to Plaintiff, as we must, Plaintiff was 

suffering from a serious, visible medical need at the time Dr. 

Phillip and Administrator McClintock responded to his emergency 

call. In particular, Plaintiff was experiencing “extreme pain 

in [his] stomach, . . . throwing up vomit and blood[, and] 

became incontinent.” J.A. 846. This is the sort of serious 

medical condition “so obvious that even a lay person would 

easily recognize the necessity for a doctor’s attention.” Iko, 

535 F.3d at 241 (internal quotation marks omitted) (quoting 

Henderson v. Sheahan, 196 F.3d 839, 846 (7th Cir. 1999)). 

Further, Plaintiff’s evidence creates a genuine dispute of 

fact as to whether the denial of medical attention during this 

emergency resulted in serious injury or a substantial risk of 

serious injury. A juror could reasonably infer that failing to 

treat, for two to five days, an inmate who is vomiting blood and 

experiencing evident physical distress creates a substantial 

risk that serious bodily injury will result or has already 
23

occurred. This conclusion is supported by Plaintiff’s medical 

records, which indicate that, at the time of the alleged 

emergency, he may have been experiencing complications arising 

from an earlier gallstone diagnosis.

Plaintiff also has raised a genuine issue of material fact 

on the subjective prong of Farmer--whether Dr. Phillip and 

Administrator McClintock acted with deliberate indifference in 

failing to provide assistance in the face of Plaintiff’s alleged 

medical emergency. In particular, there is sufficient 

circumstantial evidence to suggest that Defendants were aware of 

facts giving rise to an inference that their decision to send 

Plaintiff to the Special Housing Unit without providing medical 

aid created a substantial risk of serious injury.

Plaintiff’s testimony that his cell “reeked” and his face 

exhibited visible signs of illness, as well as his 

contemporaneous account of his symptoms create a genuine factual 

dispute about whether his need for medical attention was so 

obvious that an official observing the scene would have both 

known of the facts giving rise to a risk of serious harm 

resulting from failure to provide medical attention and inferred 

that such a substantial risk was present. In addition, these 

outward signs of Plaintiff’s need for medical attention and

Defendants’ contemporaneous failure to offer aid give rise to an 

inference of deliberate indifference sufficient for Plaintiff’s
24

claim to survive summary judgment. See Miltier, 896 F.3d at 853 

(“Failure to respond to an inmate’s known medical needs raises 

an inference [of] deliberate indifference to those needs.”).

C.

1.

Plaintiff’s final Eighth Amendment claim is against Warden 

Stansberry and alleges a denial of a proper diabetic diet during 

his six-month confinement in the Special Housing Unit. 

According to Plaintiff’s evidence, the only meals available to 

Plaintiff in the Special Housing Unit were those served to every 

other inmate in the unit--meals high in sugar and accompanied by 

a sugary drink.

Plaintiff used several channels of communication to 

complain to Warden Stansberry about the unavailability of a 

diabetic diet. First, Plaintiff complained to the Warden during 

her weekly rounds in the unit. Second, Plaintiff submitted copouts to Warden Stansberry seeking redress for his complaints. 

Third, Plaintiff wrote to his congressman, asking him to inquire 

with prison officials about the deficiencies in his diet. After 

the congressman forwarded this correspondence to the Bureau of 

Prisons, Warden Stansberry addressed the allegations in a reply 

letter. She acknowledged that inmates in the Special Housing 

Unit did not receive special diets but maintained that inmates
25

were educated about how to select foods appropriate for their 

medical conditions.

Because of the alleged deficiencies in the diet offered in 

the Special Housing Unit, Plaintiff claims to have suffered an 

increase in his blood sugar and A1C levels. Prison medical 

officials sought to combat these symptoms by increasing his 

insulin dosage. This treatment purportedly “resulted in the

loss of . . . diabetic control . . . and severe painful and 

destructive episodes of diabetic hypoglycemia and . . . 

hyperglycemia.” J.A. 626.

The district court assumed without deciding that Plaintiff

raised a genuine issue of material fact on Farmer’s objective 

prong: that the lack of a diabetic diet constituted a 

sufficiently serious deprivation. The court went on to 

conclude, however, that there was no genuine dispute regarding 

whether Warden Stansberry knew of and disregarded Plaintiff’s 

need for a special diet. The court based its conclusion on 

Plaintiff’s log of interactions with prison officials, which

revealed that Plaintiff was “mainly focused on pursuing a 

collateral attack on his criminal conviction and on defending 

against his disciplinary charge, rather than on informing 

Stansberry of the conditions” he considered unconstitutional. 

J.A. 964. The court went on to note that even if there were a 

genuine dispute of material fact on this subjective prong, 
26

Plaintiff’s acknowledgement that he otherwise received adequate 

medical treatment for his diabetes while confined in the Special 

Housing Unit rendered a finding of deliberate indifference 

untenable.

2.

We affirm the district court’s award of summary judgment in 

favor of Warden Stansberry on this claim, but for a different 

reason. Viewing the record in the light most favorable to 

Plaintiff, we conclude that Plaintiff failed to raise a genuine 

dispute of material fact regarding whether, in this case, the 

lack of a diabetic diet was a sufficiently serious deprivation 

to be actionable under the Eighth Amendment. Warden Stansberry 

conceded in her deposition and in her letter to Plaintiff’s 

congressman that there was no diabetic diet provided to inmates 

in the Special Housing Unit. Even so, Warden Stansberry stated 

on at least two occasions that all inmates were educated about 

how to select from the available meals foods appropriate for 

their medical conditions.

In Farmer, the Supreme Court stated that the Eighth 

Amendment imposes a duty on prison officials to provide inmates 

with “adequate food.” Farmer, 511 U.S. at 832. Several of our 

Sister Circuits have reasoned, albeit in unpublished decisions,

that this duty includes an obligation to provide a medically 

appropriate diet when necessary. For instance, the Tenth 
27

Circuit has stated that the Eighth Amendment “requires officials 

to provide inmates with a special diet if such an accommodation 

is medically necessary.” Frazier v. Dep’t of Corr., No. 97-

2086, 1997 WL 603773, at *1 (10th Cir. Oct. 1, 1997) (citing 

Byrd v. Wilson, 701 F.2d 592, 595 (6th Cir. 1983)). Similarly, 

the Seventh Circuit has noted that the Amendment “assures 

prisoners a medically and nutritionally sound diet.” Jackson v. 

Hanlon, Nos. 89-2144, 89-2368, 1991 WL 3056, at *1 (7th Cir. 

Jan. 14, 1991). Likewise, the Sixth Circuit has concluded that 

“officials must provide inmates with a special diet if such an 

accommodation is obviously medically necessary.” Miller v. 

Cleek, No. 99-5145, 1999 WL 1045156, at *2 (6th Cir. Nov. 9, 

1999) (citing Byrd, 701 F.2d at 594–95). We agree.

Yet the Eighth Amendment’s requirement that prisoners 

receive special diets when medically appropriate is not without 

limit. Courts have consistently held that prison officials 

comply with this mandate when they provide some food that the 

complaining prisoner is able to eat without compromising his 

health. For instance, in Frazier, the Tenth Circuit rejected a 

prisoner’s deliberate indifference claim when he “d[id] not 

contend that he [wa]s unable to eat any of the food provided by 

the correctional facility” and conceded that he was “able to eat 

certain items on the facility’s menu.” Frazier, 1997 WL 603773,

at *1. The same was true in Miller, where the Sixth Circuit 
28

affirmed dismissal of an inmate’s inadequate diet claim based in 

part on the lack of “evidence that [he] could not maintain his 

health based on the diet provided and [the fact that he] d[id] 

not contend that he was unable to eat any of the food provided 

by the jail.” Miller, 1999 WL 1045156, at *2.

Likewise, courts have found that inmates who are denied 

special diets suffer no constitutional harm so long as they are

instead given instruction on how to eat the available meals in a 

way that satisfies their medical needs. For example, the Tenth 

Circuit has found that an inmate who was served a universal, 

cafeteria-style diet but could use “nutritional break down 

cards” to determine what foods were amenable to his medical 

condition could not claim deliberate indifference based on the 

lack of a special diet. Moore v. Perrill, No. 94-1377, 1995 WL 

139407, at *1 (10th Cir. Mar. 31, 1995); see also Williams v. 

Hartz, 43 F. App’x 964, 966 (7th Cir. 2002) (affirming the 

district court’s award of summary judgment when the complaining 

prisoner was not given a special diet, but was “instructed” on 

medically appropriate food choices and given “snacks” when 

necessary to raise his blood sugar).

And a California district court held that a prisoner who 

received the “Heart Healthy” diet provided to all inmates in the 

state prison system and failed to present evidence that he could 

not eat certain menu items or that the “overall percentage” of 
29

such items in each meal was significant could not survive 

summary judgment on his deliberate indifference claim. Baird v. 

Alameida, 407 F. Supp. 2d 1134, 1140–41 (C.D. Cal. 2005).

We find these decisions persuasive. Only an “extreme 

deprivation” is actionable under the Eighth Amendment. 

According to Plaintiff, the meals in the Special Housing Unit 

included “a bread, a meat product[,] a vegetable[,] and a sweet 

dessert.” J.A. 279. Plaintiff has not offered evidence that 

there was no combination of foods in each meal that would have 

provided him with adequate sustenance without causing adverse 

medical consequences, instead asserting only that the meals were 

high in sugar and accompanied by a sugary drink. Plaintiff also 

does not contradict prison officials’ claims that he was 

educated on how to eat the available meals (which were from the 

“national diet” “approved for all” inmates, J.A. 462, 539) in a 

way that would not exacerbate his diabetic condition.6 

Accordingly, the district court properly awarded Warden 

 6 Because Plaintiff has not raised a genuine issue of 

material fact as to whether there was a sufficiently serious 

deprivation, we need not consider whether he has sufficiently 

established the subjective, deliberate indifference prong. See

Celotex Corp. v. Catrett, 477 U.S. 317, 322–23 (1986) (requiring 

the nonmovant to “make a sufficient showing on” every essential

element to survive summary judgment).
30

Stansberry summary judgment on Plaintiff’s diet and nutrition 

claim.7

IV.

Having determined that Plaintiff’s claims against Dr. 

Phillip and Administrator McClintock should go forward, we must 

address Defendants’ argument that they are entitled to qualified 

immunity. Defendants raised qualified immunity before the 

district court, but because the court ruled for Defendants on 

the merits, it did not reach the question of Defendants’ 

entitlement to qualified immunity. Qualified immunity may 

provide a basis for affirming the district court. R.R. ex rel. 

R. v. Fairfax Cty. Sch. Bd., 338 F.3d 325, 332 (4th Cir. 2003) 

(“[W]e may affirm the district court’s judgment on any ground 

properly raised below.”) (citing Nw. Airlines, Inc. v. Cty. of 

Kent, 510 U.S. 355, 364 (1994)).

Qualified immunity shields “government officials performing 

discretionary functions . . . from liability for civil damages 

 7 Though we affirm the district court’s award of summary 

judgment on Plaintiff’s diet and nutrition claim, we reject the 

district court’s reasoning that because Plaintiff received some 

adequate treatment for his diabetes while in the Special Housing 

Unit he cannot complain about other aspects of that treatment. 

To the contrary, this court has held that “just because [prison 

officials] have provided [an inmate] with some treatment . . . 

it does not follow that they have necessarily provided h[im] 

with constitutionally adequate treatment.” See De’lonta v. 

Johnson, 708 F.3d 520, 526 (4th Cir. 2013).
31

insofar as their conduct does not violate clearly established 

statutory or constitutional rights of which a reasonable person 

would have known.” Harlow v. Fitzgerald, 457 U.S. 800, 818 

(1982). In determining whether defendant government officials 

are protected by qualified immunity, the court considers both

“whether a constitutional right [was] violated on the facts 

alleged” and “whether the right was clearly established” at the 

time of the conduct in question. Saucier v. Katz, 533 U.S. 194, 

200 (2001), overruled in part by Pearson v. Callahan, 555 U.S. 

223 (2009).

As explained previously, Plaintiff has alleged facts 

sufficient for a reasonable jury to conclude that his 

constitutional rights were violated when Dr. Phillip denied 

Plaintiff his prescribed insulin and when Dr. Phillip and 

Administrator McClintock failed to aid Plaintiff during a 

medical emergency. See supra Parts III.A, B. Although a jury 

may ultimately decide that Defendants’ version of events is more 

credible, we are barred from making such a determination when 

deciding whether to grant summary judgment based on qualified 

immunity. See Meyers v. Balt. Cty., 713 F.3d 723, 733 (4th Cir. 

2013).

To determine whether the right was clearly established, we 

first must define the right at issue. Occupy Columbia v. Haley, 

738 F.3d 107, 118 (4th Cir. 2013). Dr. Phillip maintains that 
32

we should frame our analysis of qualified immunity as to 

Plaintiff’s insulin claim as whether it is “clearly established 

that a prison medical provider runs afoul of the Eighth 

Amendment when he does not give one single dose of insulin to a 

federal inmate, after the inmate becomes angry and hostile 

. . ., and the doctor implements a plan to monitor the inmate 

thereafter.” Appellees’ Br. at 44. Similarly, Dr. Phillip and 

Administrator McClintock assert that we should consider their 

qualified immunity as to Plaintiff’s medical emergency claim 

based on whether a reasonable official would have known it 

violated a clearly established constitutional right to follow 

protocol by placing an inmate in administrative detention after 

he receives an incident report.

But “[f]or a constitutional right to be clearly 

established, its contours ‘must be sufficiently clear that a 

reasonable official would understand that what he is doing 

violates that right.’” Hope v. Pelzer, 536 U.S. 730, 739 (2002) 

(quoting Anderson v. Creighton, 483 U.S. 635, 640 (1987)). 

There is no requirement that the “very action in question [must 

have] previously been held unlawful” for a reasonable official 

to have notice that his conduct violated that right. Id. 

Accordingly, we reject Dr. Phillip’s and Administrator 
33

McClintock’s invitations to define the rights at issue in 

accordance with the “very action[s] in question.”8

Rather, we define the right in question as the right of 

prisoners to receive adequate medical care and to be free from 

officials’ deliberate indifference to their known medical needs. 

This definition is consistent with previous deliberate 

indifference cases from this Circuit. For example, in Iko v. 

Shreve--a case in which a prisoner alleged government officials 

failed to conduct a medical evaluation after pepper-spraying him 

to compel compliance during a cell removal--this Court defined 

the right at issue as “the right to adequate medical care.” 535 

F.3d at 243 n.12. This definition also accords with Supreme 

Court jurisprudence, which has long dictated that the Eighth 

Amendment confers a duty upon prison officials to ensure that 

prisoners “receive adequate . . . medical care.” Farmer, 511 

U.S. at 832.

A prisoner’s right to adequate medical care and freedom 

from deliberate indifference to medical needs has been clearly 

established by the Supreme Court and this Circuit since at least 

1976 and, thus, was clearly established at the time of the 

 8 We reject Dr. Phillip’s and Administrator McClintock’s 

framing of the right at issue in Plaintiff’s medical emergency 

claim for the additional reason that it would require us to make 

a credibility determination inappropriate at the summary 

judgment stage of litigation.
34

events in question. See, e.g., Estelle, 429 U.S. at 104–05 (“We 

therefore conclude that deliberate indifference to serious 

medical needs of prisoners constitutes the ‘unnecessary and 

wanton infliction of pain’ proscribed by the Eighth Amendment.”

(citation omitted) (quoting Gregg v. Georgia, 428 U.S. 153, 182–

83 (1976))); Farmer, 511 U.S. at 832 (“[P]rison officials must 

ensure that inmates receive adequate food, clothing, shelter, 

and medical care.”); Bowring v. Godwin, 551 F.2d 44, 47 (4th 

Cir. 1977) (“This circuit has consistently adhered to the 

prevailing view in requiring reasonable medical treatment [for 

inmates].”) (citing authorities).

Because we conclude that there is sufficient evidence that 

Plaintiff’s Eighth Amendment right to adequate medical care and 

freedom from officials’ deliberate indifference to his medical 

needs was violated and that the right was clearly established, 

Dr. Phillip and Administrator McClintock are not entitled to 

qualified immunity.9

 9 Although we need not reach the issue here, we note once 

again the “special problem” of “‘applying an objective qualified 

immunity standard in the context of an Eighth Amendment claim 

that is satisfied only by a showing of deliberate indifference’-

-that is, a knowing violation of the law.” Cox v. Quinn, 828 

F.3d 227, 238 n.4 (4th Cir. 2016) (quoting Rish v. Johnson, 131 

F.3d 1092, 1098 n.6 (4th Cir. 1997)). 

Some Circuits have resolved this problem by concluding that 

qualified immunity is unavailable when the plaintiff presents a 

genuine dispute of material fact regarding the defendant’s 

(Continued)
35

V.

For the foregoing reasons, we affirm the district court’s 

disposition of Plaintiff’s deliberate indifference claim against 

Warden Stansberry, reverse its resolution of the claims against 

Dr. Phillip and Administrator McClintock, and reject Dr. 

Phillip’s and Administrator McClintock’s invocations of

qualified immunity.

AFFIRMED IN PART AND REVERSED IN PART

 

deliberate indifference. The Seventh Circuit, for example, has 

held that the subjective prong of the Farmer test and the 

objective, clearly established prong of the qualified immunity 

test “effectively collapse into one” when the plaintiff raises 

genuine factual disputes regarding the defendant’s deliberate 

indifference. Walker v. Benjamin, 293 F.3d 1030, 1037 (7th Cir. 

2002). That court explained that when a plaintiff raises 

genuine disputes of fact on Farmer’s subjective prong, “a 

defendant may not avoid trial on the grounds of qualified 

immunity” even though qualified immunity protects covered 

government officials from suit, not merely from liability. Id.; 

see also, e.g., Beers-Capitol v. Whetzel, 256 F.3d 120, 142 n.15 

(3d Cir. 2001) (“[T]o the extent that the plaintiffs have made a 

showing sufficient to overcome summary judgment on the merits 

[of their deliberate indifference claim], they have also made a 

showing sufficient to overcome any claim to qualified 

immunity.”). But see Estate of Ford v. Ramirez-Palmer, 301 F.3d 

1043, 1049–50 (9th Cir. 2002) (rejecting the view that the 

deliberate indifference and clearly established inquiries 

merge).