2009 D e c i sion s O p inion s of the U nit e d S t at e s C our t of Appe al s for the Thir d C ir c uit 10-22-2009 

# M onro e M e rritt v

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___________ M ON RO E M ERRI TT, A ppel l ant v. A L A N B . FO G E L , D i r ect or , PA D . O . C . B ur eau of H eal th C ar e Ser vi ces ; N I C H O L A S SC H A R FF, M edi cal D i r ect or , PA D . O . C . B ur eau of H e a l th Car e Se r vi c e s ; EU G EN E H . G I N CH ER EA U , A s s i s t a ntM e di c a l D i r e c t or , PA D . O . C . B ur eau of

H eal th C ar e Servi ces ; K R I ST E N P. R E I SI N G E R , PA D . O . C . C hi ef Gr i e v a n c e Of

f i c e r ; M ARY S. REE S E, Co rr e c t i o n s He a l th Ca r e Ad mi n i s tr a t o r ; DR. STAN LEY FALO R, Ph y s i c i a n ; DR . BY UN GH AK J I N, Ph y s i c i a n ; M I CH ELE L. HOWARD - DI GGS , P h y s i c i a n ' s As s i s t a n t ; J OHN MCANAN Y, RN S

____________________________________ O n A p p ea l Fro m the U n it ed S tat es D istri ct C o u rt F o r th e W e ste rn D istric t o f P e n n sy lv a n ia ( D . C . C i v. N o. 07- cv- 01681) D i s tr i ctJ udge: H onor abl e D avi d S. C er cone

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( O pi ni on Fi l ed: O ct ober22, 2009

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P E R C UR I AM M o n ro e M e rritt ap p e a ls p ro se f ro m th e D istric t C o u rt’s o rd e r d ism iss in g h is c o mp l a i n ta n d d e n y i n g h i s mo t i o n s f o rl e a v e t o a me n d . F o rth e f o l l o wi n g r e a s o n s , we w i l l vacate the D i stri ctC ou rt ’s j ud gm ent and rem and for further proceedings. I. M erritt i s a P en n sy lvan ia st ate p ri so n er se rvin g a se n tenc e o f li fe im p ri so n m en t. In 2007, he fi l ed s ui tpr o s e aga i ns tvar i ous m edi cal pr ofes s i onal s and D epart m entof C o rre c tio n s e m p lo y e e s u n d e r 4 2 U .S .C . § 1 9 8 3 , as se rtin g a n E ig h th A m e n d m e n t cla im th a t th e yh a v e b e e n d e lib e ra telyin d if f e re n t to h is m e d ica l n e e d s. H e a lso a ss e rte d a c laim form edi cal m al pr act i ce unde rs t at e l aw . W e t ake the fol l ow i ng fac tual al l egat i ons as t rue fo r pu rpo ses o f th is ap p ea l. S ee A sh cro ft v . Iqb al, – U . S . – , 1 2 9 S . C t. 1 9 3 7 , 1 9 4 9 (20 0 9 ). M erritt has the H ep ati ti s C v iru s (“H C V ”) a n d h as tri ed rep ea tedlyfo r m an yy ea rs t o obt ai n tr eatm entbuthas been r efus ed. M err i t tal l eges thathe bega n s eeki ng a c o m b in e d d ru g tr e a tm e n t f o r H C V w ith In te rf

e ro n a n d R ib a v ir in in 1 9 9 8 . In 2 0 0 0 , a phy s i ci an’ s as s i s t anti ni t i al l yt ol d hi m thathe had t o compl et e drug and al cohol ther apy b e f o re re c e iv in g th e tre a tm e n t. M e rritt co m p lete d th e th e ra p yin 2 0 0 1 a n d a g a in req u ested tr ea tm en t. D ef en d an ts Fa irm an an d H o w ard -D igg s (bo th p h y sici an ’s as s i s t ant s ) , how ever , t ol d hi m thathi s w hi t e bl ood cel l countw as t oo l ow t o r ece i ve tr e a t m e n t . M e r r i t ta l l e g e s h e w a s u l t i m a t e l y a p p r o v e d f o rth e tr e a t m e n ti n 2 0 0 3 ( b y a p s y c h ia tr is t) , b u t d o e s n o t a lle g e w h yth e tr e a tm e n t w a s n e v e r b e g u n .3

In 2 0 0 5 , M e rritt’s liv e r c o n d iti o n b e g a n to d e ter io ra te, w h ich h e a ttribu tes to m edi cat i on he w as pr es cr i bed af t era t ooth extr act i on. M err i t tagai n began s eeki ng treatm ent. In 200 7, defe nd ant Fal or ( a ph y si ci an) t old M err i t tthat hi s l i ver fun ct i on t est n u m b e rs w e re “ a ll o u t o f w a c k ,” b u t d e n ied tre a tm e n t an d to ld M e rritt to “ p ra y .” M e rritt w a s re f e rre d to d e f

e n d a n t Jin (a n o th e r p h y sic ian ), b u t h e to o d e n ied tre a tm e n t. M e rritt a lleg e s th a t Jin re f

u se d to c o n sid e r th e e f

f e c t o f th e m e d ica tio n h e h a d b e e n tak in g o n h is l i ver . H e al s o al l eges that , w hi l e he w as r evi ew i ng hi s m edi cal r ecor ds , he overhead a p h y sic ian ’s a ss ista n t tell a tec h n icia n th a t h e h a d “ sh re d d e d a ll o f p lain tiff ’s s ick c a ll r eques t s . ” S h o rtlyth e re a f

ter , h e a g a in re q u e ste d tre a tm e n t, bu t d e f e n d a n t H o w a rd -D ig g s to ld h i m th a th e h a d n o tq u a l i f i e d f o rtr e a t me n tu n d e rth e De p a r t me n to f Co rr e c t i o n s HCV tr eatm entpr ot ocol forthe pas ttw o and one- hal f y ear s beca us e he ha d turned 50 y ear s of a g e . H e a lleg e s th a t h e f in a llyo b tain e d a c o p yo f th a t p ro to c o l an d lea rn e d th a t h is w h ite bl ood cel l counthad i n fac tbeen w i thi n the pr ot ocol r ange f ortr eatm enti n 2001 and that th e p ro to c o l co n tem p late s tre a tm e n t u n til th e a g e o f 6 0 , n o t 5 0 a s H o w a rd -D ig g s h a d to ld hi m . A ft erfi l i ng m ul t i pl e gr i evanc es , he fi l ed the i ns t ants ui t , s eeki ng both an i nj unct i on r e q u i r i n g d e f

e n d a n t s t o p r o v i d e h i m w i th HC V tr e a t me n ta n d mo n e t a ryd a ma g e s . He fi l ed al ong w i th hi s compl ai nta mot i on forthe appoi nt m entof couns el , w hi ch a M agi s tr at e J udge deni ed. M err i t tt i m el yappea l ed thatrul i ng t o the D i s tr i ctC our t , butt he D is tr ic t C o u rt n e v e r r u le d o n h is a p p e a l.4

T h e d e f e n d a n ts f ile d m o tio n s to d is m is s M e rr itt’ s c o m p la in t u n d e r R u le 1 2 (b )( 6 ). M err i t tther eaf

t erfi l ed a mot i on forl eave t o amend hi s compl ai nt , a s econd mot i on for l eave t o amend hi s compl ai nt , and s ever al “adde nda” i n s uppor tof hi s m ot i ons t o amend. B ythes e fi l i ngs , he s oughtt o i ncl ude the fol l ow i ng addi t i onal al l egat i ons . I n 2004, m ed ical st af

f d en ied h im tr ea tm en t on the g rou n d s tha t his “A L T an d A S T v alue s” w ere no rm al and t old hi m that he cou l d n ot r ecei ve tr eat m ent unt i l tho se val ues w ere atl east thr ee t i m es nor m al , though nor m al A L T and A ST val ues ar e notexcl us i onarycr i t er i a for tr eatm entunderthe pr ot ocol . T hen, i n 2005, he r ece i ved a l i verbi ops y , w hi ch r evea l ed thathi s A L T and A ST val ues w er e overs i x and one- hal f and f i ve and one - hal f t i m es n o rm a l, r e s p e c tiv e ly, b u t th a t h e w a s s till r e f u s e d tr e a tm e n t. M err i t tfur theral l eges that , i n 2007, defe ndantFal or , the phy s i ci an def endantw ho h a d t o l d h i m t o “ p r a y ” a f t e rd e n y i n g h i m tr e a t me n t , a l s o t o l d h i m “ th a twh e n e v e rth e S CI G r eene m edi cal s t aff

m etforthei rs t aff

m eet i ngs , and the ques t i on of w hattheyar e goi ng t o d o ab ou ti nm at es w i th H epati t i s C com es up, SC I G reene m edical st aff m em bers j ust sh rug their sho u lders, i n d icati n g n o thing . ” H e a lso a ll eg es th at, d u ri n g that sam e y ea r, defe ndantJ i n r evi ew ed hi s m os tr ece ntl i vert es tand t ol d hi m that“i tl ooks bad” butt hat

“ I w i l l n o tb e tr e a t e d . ” F i n a l l y, h e a l l e g e s th a th e o b t a i n e d f r o m d e f e n d a n t s i n d i s c o v e r y a 1 9 9 6 l e t t e rf

r o m a Dr . F r e d e r i c k Ru th a r d t , wh o m h e c h a r a c t e r i z e s a s “ d e f e n d a n t s ’ o wn s peci al i s t , ” s t at i ng thatM err i t t“w oul d be an e xcel l entcandi dat e forther apyw i th al pha i nter feron” an d “w ou l d b enef i tfrom the tr eat m ent. ” M err i t tal l eges t hat defend ants ’M err i t tal s o chal l enges the D i s tr i ctC our t ’ s ( 1) deni al of hi s m ot i on forcouns el , ( 2) 1 den i al of a m oti on for di scoveryhe sou gh tt o respon d to defen dan t s’ m oti on s t o d i sm i ss, and ( 3) appl i cat i on of Penns y l vani a’ s cert i fi cat e of mer i tr equi r ement . I n l i ghtof our d isp o sitio n a n d th e p o stu re o f th is c a se , w e d o n o t re a c h th e se iss u e s, th o u g h w e b rie f ly d i s c u s s th e i s s u e o f

c o u n s e l b e l o w. 5 re f u sa l to p ro v id e tre a tm e n t h a s c a u se d h is liv e r c o n d iti o n to d e ter io ra te a n d m a ylea d to hi s death. T he M agi s tr at e J udge i s s ued a Repor tand R ecomm endat i on r ecomm endi ng that th e D istric t C o u rt d ism iss M e rritt’s E ig h th A m e n d m e n t cla im f o r f a ilu re to sta te a c laim a n d h is m a lp ra c tice c laim f o r f a ilu re to c o m p lyw ith P e n n sy lv a n ia’ s c e rtific a te o f m e rit r equi r ement . H e al s o r ecomm ended de ny i ng M err i t t ’ s m ot i ons t o amend on the gr ounds thatamendm entw oul d be fut i l e. T he D i s tr i ctC our tfol l ow ed thatr ecomm endat i on by order ent ered A ug ust1, 20 08 . M err i t tapp eal s. II. W e have j ur i s di ct i on pur s uantt o 28 U . S. C . § 1291. O n appea l , M err i t tchal l enges th e d i s m i s s a l o f

h i s c o m p l a i n ta n d th e d e n i a l o f h i s m o t i o n s f

o rl e a v e t o a m e n d . We r evi ew the fi r s tof thos e rul i ngs de novo, s ee Phi l l i ps v. C ountyof A l l egheny , 515 F. 3d 224, 230 ( 3d C i r . 2008) , and the s econd f orabus e of di s cr et i on, s ee Si ngl et aryv. Pa. D ep ’to f C o rr. , 2 6 6 F . 3 d 1 8 6 , 1 9 3 (3d C ir . 2 0 0 1 ). 1 W e begi n byaddr es s i ng a pr ocedur al w r i nkl e i dent i fi ed bynei therthe part i es nor th e D istric t C o u rt. A f

ter M e rritt file d h is in iti a l co m p lain t an d d e f e n d a n ts f iled th e ir m o tio n s to d is m is s , M e rr itt f ile d h is f ir s t m o tio n “ f

o r l e a v e ” to f

ile a n a m e n d e d c o m p la in t.6

M err i t t , ho w ever, w as ent i t l ed to fi l e t hat am end ed co m plai nt as of ri gh t . D efen dan t s’ m ot i ons t o di s m i s s w er e not“pl eadi ngs , ” s ee Fed. R . C i v. P. 7( a) , s o M err i t tr emai ned e n title d to a m e n d h is c o m p la in t o n c e a s a m a tte r o f c o u rs e , s e e F e d . R . C iv . P . 1 5 (a )( 1 ). T h u s, th e D istric t C o u rt sh o u ld h a v e c o n stru e d M e rritt’s in iti a l m o tio n , to w h ich h is amended compl ai ntw as att ache d, as the fi l i ng of thatamended compl ai nt . T hatfi l i ng w oul d have r ender ed moot defe ndant s ’ m ot i ons t o di s m i s s . See Pur e C ountry , I nc. v. Si gm a C hi Fr at erni ty , 312 F. 3d 952, 956 ( 8th C i r . 2002) . T echni cal l ys peaki ng, then, ther e w er e no mot i ons t o di s m i s s pr oper l ypendi ng w hen the D i s tr i ctC our tdi s m i s s ed M e rritt’s c o m p lain t. I n anyevent , w e bel i eve thatthe D i s tr i ctC our t ’ s di s m i s s al of M err i t t ’ s compl ai nt a n d d e n ial o f

lea v e to a m e n d w e re e rro n e o u s o n th e m e rits, an d w e a d d re ss th o se iss u e s in t andem underthe pos tur e pr es ent ed her e. “To survi ve a mot i on t o di s m i s s , a compl ai nt m u st c o n tain su f

f icie n t f a c tu a l m a tter, a c c e p ted a s tru e , to ‘ sta te a c laim f o r re lief th a t is pl aus i bl e on i t s fac e. ’ A cl ai m has fac i al pl aus i bi l i tyw hen the pl ai nt i ff pl eads fac tual c o n ten t th a t allo w s th e c o u rt to d ra w th e re a so n a b le in f e re n c e th a t th e d e f

e n d a n t is liab le forthe mi s conductal l eged. ’ ” I qbal , 129 S. C t . at1949 ( quot i ng B el l A t l ant i c C orp. v. T w om bl y , 550 U . S. 544, 570 ( 2007) ) . C om pl ai nt s fi l ed pr o s e, l i ke M err i t t ’ s , m us tbe l i ber al l ycons trued. See Eri cks on v. Par dus , 551 U . S. 89, __, 127 S. C t . 2197, 2000 ( 2007) . B efor e di s m i s s i ng a compl ai nt , “a di s tr i ctcourtm us tperm i ta cur at i ve amendm entunl es s s uch an a m endmentw oul d be i nequi t abl e orfut i l e. ” Phi l l i ps , 515 F. 3d at245.7

I n thi s cas e, M err i t t ’ s E i ghth A m endmentcl ai m r equi r ed hi m t o al l ege thatthe d e f e n d a n ts (1 ) w e re d e lib e ra telyin d if f e re n t to (2 ) h is s e rio u s m e d ica l n e e d s. S e e S p ru ill v. G i l l i s, 37 2 F . 3d 21 8, 23 5 (3d C i r. 20 04 ). T here i s no d i spute that H C V con st i tutes a se rio u s m e d ica l n e e d . In ste a d , the D istric t C o u rt d ism iss e d th is c laim a n d d e n ied lea v e to am en d o n the g rou n d s tha t M erritt had n o t ade q u atelyall eg ed that d ef en d an ts w ere d e lib e ra telyin d if

f e re n t to th a t n e e d . “W e h a v e f o u n d ‘d e lib e ra te in d if

f e re n c e ’ in a v a rie ty of ci r cumst ance s , i ncl udi ng w her e a pr i s on offi ci al ( 1) know s of a pr i s oner ’ s need f or m edi cal tr eatm entbuti nt ent i onal l yr efus es t o pr ovi de i t ; ( 2) del ay s nece s s arym edi cal tr eatm entbas ed on a non- m edi cal r eas on; or( 3) pr event s a pr i s onerfr om r ece i vi ng neede d orr ecomm ended medi cal tr eatm ent . ” R ous e v. Pl ant i er , 182 F. 3d 192, 197 ( 3d C i r . 1999) . D el i ber at e i ndi ffe r ence , how ever , r equi r es m or e than mer e mal pr act i ce or d is a g re e m e n t w ith a p a rt ic u la r c o u rs e o f tr e a tm e n t. S e e S p ru ill, 3 7 2 F .3 d a t 2 3 5 . T he M agis trat e Judg e t ho ug ht M err i t t ’s cl ai m defici ent as a m at t er of l aw becau se hi s ow n al l egat i ons s how thatdefe ndant s have r epea t edl ym oni t or ed and t es t ed hi m and have de t erm i ned thathe does notqual i fyforH C V tr eatm ent . I n r eac hi ng thatconcl us i on, th e M a g istra te J u d g e re lied p rim a rilyo n re sp o n se s b yc e rta in d e f e n d a n ts a n d o th e rs to M err i t t ’ s gr i evanc es thathe att ache d t o hi s i ni t i al compl ai nt . A s the M agi s tr at e J udge n o ted , tho se re sp o n se s in d ica te th a t M e rritt h a s b e e n tes ted a n d th a t ce rta in d e f e n d a n ts and other s have c oncl uded thathe i s nota ca ndi dat e forcombi ned drug tr eatm entforT h e re sp o n se s s tate th a t M e rritt is n o t a c a n d id a te f o r tre a tm e n t b e c a u se h e is 2 “asym ptom at i c, ” his biopsyshow ed “g rade 1 i nflam at i on and no fi brosi s, ” and becau se hi s l ab t es t s have s how n i m pr ovementi n hi s l i vercondi t i on. M err i t t , how ever , al l eges thathi s l i vercondi t i on cont i nues t o det er i or at e. T he M agi s tr at e J udge pr oper l ydi d not purpor tt o r es ol ve thatfac tual i s s ue atthe pl eadi ng s t age. 8 var i ous r eas ons . T hus , the M agi s tr at e J udge r eas oned thatM err i t t ’ s al l egat i ons s how 2 thathe mer el ydi s agr ees w i th defe ndant s ’ m edi cal j udgm entand i ns i s t s on the tr eatm ent of hi s choi ce. If th a t w e re a ll th a t M e rr itt a lle g e d , th e n th e M a g is tr a te J u d g e w o u ld b e ri g h t. M err i t t , how ever , m akes m anyot hers peci fi c fa ctual al l egat i ons thatthe M agi s tr at e J udge di d notdi s cus s and that , t aken a s true as theym us tbe atthi s s t age, r ai s e an i nfer ence of d e l i b e r a t e i n d i f

f e r e n c e . F o re x a mp l e , M e rr i t ta l l e g e s th a to n e o f d e f e n d a n t s ’ o wn sp e c ialists re c o m m e n d e d h im f o r tre a tm e n t as lo n g a g o a s 1 9 9 6 b u t th a t d e f e n d a n ts fraudu l entl ycon ceal ed thati nfo rm at i on from him un t i l he final l yfi l ed suit . H e al so a lleg e s th a t h e is w ith in th e p ro to c o l f o r tre a tm e n t, th o u g h v a rio u s d e f e n d a n ts h a v e f

a lse ly t ol d hi m otherw i s e. T hus , as M err i t tar gues , he cl ai m s t o s eek, notm er el ythe tr eatm ent o f h is o w n c h o ice , b u t trea tm e n t th a t h a s b e e n re c o m m e n d e d b ya sp e c ialist a n d th a t is c a lle d f o r b yth e D e p a rt m e n t o f C o rr e c tio n s p ro to c o l. M or eover , hi s al l egat i ons perm i tthe i nfer ence thatdefe ndant s m ayhave nonm edi cal r eas ons forr efus i ng t o pr ovi de thi s tr eatm ent . Forexampl e, he al l eges that defe ndantFal ort ol d hi m both thatm edi cal s t aff m er el y“s hrug thei rs houl der s , i ndi cat i ng n o th in g ” w h e n th e su b

jec t o f H C V tre a tm e n t ar ise s a t sta f f m e e tin g s a n d th a t M e rrittD efe ndant s m oved t o di s m i s s M err i t t ’ s compl ai nton othergr ounds , i ncl udi ng the 3 s t atut e of l i m i t at i ons and fa i l ur e t o exhaus thi s cl ai m s agai ns tone def endant . T he D i s tr i ct C our tdi d notaddr es s thos e ar gum ent s , and w e w i l l notdo s o i n the fi r s ti ns t ance on the r ecor d pr es ent ed her e. 9 w oul d notr ece i ve tr eatm entthough hi s l i vernum ber s w er e “a l l outof w ack” and thathe sh o u ld in ste a d “ p ra y .” H e a lso a lleg e s th a t h e o v e rh e a rd a p h y sic ian ’s a ss ista n t ad m it t o havi ng s hr edded hi s s i ck ca l l r eques t s . Fi nal l y , he al l eges thathas been de ni ed tr eatm ent foratl eas tfi ve di ffe r entr eas ons overthe y ear s , m os tof w hi ch he a l l eges w er e fa br i cat ed. T aken t og et her, and i n li gh tof M err i t t ’s pro se st atus, w e beli eve thatthese s peci fi c fa ctual al l egat i ons perm i tthe i nfer ence thatatl eas ts om e def endant s have a ct ed w i th d el i berat e i nd i fference to M err i t t ’s m edical need s. T hu s, for pl eading p urposes, M e rritt’s f

a c tu a l alle g a tio n s h a v e “ ‘n u d g e d h is c laim . . . ac ro ss th e lin e f ro m c o n c e iv a b le t o pl aus i bl e. ’ ” I qbal , 129 S. C t . at1951 ( quot i ng T w om bl y , 550 U . S. at570) . Forthat re a so n , the D istric t C o u rt sh o u ld n o t h a v e d ism iss e d M e rritt’s c o m p lain t w ith o u t lea v e to a m e n d a n d s h o u l d n o th a v e d e n i e d h i s m o t i o n s f o rl e a v e t o a m e n d a s f

u t i l e . A c c o r d i n g l y, w e w ill v a c a te th e d ism iss a l o f M e rritt’s c o m p lain t an d re m a n d w ith a n in stru c tio n to a llo w h im to f

ile a n a m e n d e d c o m p lain t. 3 M err i t tal s o chal l enges the M agi s tr at e J udge’ s or derdeny i ng hi s m ot i on forthe appoi nt m entof couns el . M err i t tt i m el yappea l ed thator dert o the D i s tr i ctC our t , butt he D i s tr i ctC our tneveraddr es s ed i t . B eca us e the Feder al M agi s tr at e J udges A ct co n tem p lat es a firstleve l of rev iew in the D istri ct C o u rt , see 2 8 U . S . C . § 6 3 6 (b)(1 )(A ),A s the D epart m entof C orr ect i ons defe ndant s not e i n thei rbr i ef, w e pr evi ous l ydeni ed 4 M err i t t ’ s m ot i on forthe appoi nt m entof couns el i n thi s C our t . A l though i ts houl d go w i thouts ay i ng, m anyof the cons i der at i ons r el evantt o the appoi nt m entof couns el i n a tr i al courtar e notr el evantt o t he appoi nt m entof couns el i n an appe l l at e court . See M ont gom ery , 294 F. 3d at498- 99. 10 w e w i l l notr eac h thati s s ue i n the fi r s ti ns t ance . I ns t ead, M err i t t ’ s appea l t o the D i s tr i ct C our tw i l l r emai n pendi ng on r emand. A l though w e do notaddr es s the mer i t s of the M agi s tr at e J udge’ s rul i ng, w e obs erve thatthe pot ent i al m er i tand medi cal compl exi tyof M err i t t ’ s cl ai m s m ayw arr antthe appoi nt m entof couns el i n the D i s tr i ctC our t . See M o n tgo m eryv . P inch ak , 2 9 4 F . 3 d 4 9 2 , 5 0 1 -06 (3d C ir . 2 0 0 2 ) (ho lding that D istri ct C o u rt a b u s e d i t s d i s c r e t i o n i n r e f u s i n g t o a p p o i n tc o u n s e l f o rp r i s o n e ra s s e r t i n g p o t e n t i a l l ym er i t or i ous cl ai m of del i ber at e i ndi ffe r ence t o m edi cal needs ) ; Parham v. J ohns on, 126 F . 3 d 4 5 4 , 4 5 8 -46 1 (3d C ir . 1 9 9 7 ) (sam e). 4