PUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

No. 21-1555

JACOB PFALLER, Administrator of the Estate of Danny Harold Pfaller,

 Plaintiff - Appellee,

v.

DR. MARK AMONETTE, in his individual capacity,

 Defendant - Appellant,

and

DR. LAURENCE SHU-CHUNG WANG, in his individual capacity,

 Defendant.

------------------------------

RIGHTS BEHIND BARS,

 Amicus Supporting Appellee.

No. 21-1612

JACOB PFALLER, Administrator of the Estate of Danny Harold Pfaller,

 Plaintiff - Appellee,

v.

DR. LAURENCE SHU-CHUNG WANG, in his individual capacity,

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 Defendant - Appellant,

and

DR. MARK AMONETTE, in his individual capacity,

 Defendant.

------------------------------

RIGHTS BEHIND BARS,

 Amicus Supporting Appellee.

Appeal from the United States District Court for the Eastern District of Virginia, at 

Richmond. Robert E. Payne, Senior District Judge. (3:19-cv-00728-REP)

Argued: September 16, 2022 Decided: December 15, 2022

Before WILKINSON, WYNN, and DIAZ, Circuit Judges.

Affirmed in part, reversed in part, and remanded by published opinion. Judge Wynn wrote 

the opinion, in which Judge Diaz joined. Judge Wilkinson wrote a separate opinion

concurring in part and dissenting in part.

ARGUED: Andrew Nathan Ferguson, Erika L. Maley, OFFICE OF THE ATTORNEY 

GENERAL OF VIRGINIA, Richmond, Virginia, for Appellants. John Michael Shoreman, 

MCFADDEN & SHOREMAN, Washington, D.C., for Appellee. ON BRIEF: Mark R. 

Herring, Attorney General, K. Scott Miles, Deputy Attorney General, Laura Maughan, 

Assistant Attorney General, Michelle S. Kallen, Acting Solicitor General, Brittany M. 

Jones, Deputy Solicitor General, Laura H. Cahill, Assistant Attorney General, Rohiniyurie 

Tashima, John Marshall Fellow, OFFICE OF THE ATTORNEY GENERAL OF 

VIRGINIA, Richmond, Virginia, for Appellant Dr. Amonette. Erin B. Ashwell, Chief 

Deputy Attorney General, A. Anne Lloyd, Assistant Attorney General, OFFICE OF THE 

ATTORNEY GENERAL OF VIRGINIA, Richmond, Virginia; Lynne Jones Blain, M. 

Scott Fisher, Jr., HARMAN CLAYTOR CORRIGAN WELLMAN, Glen Allen, Virginia, 

for Appellant Dr. Wang. Mario B. Williams, Dallas S. LePierre, HDR LLC, Atlanta, 

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Georgia, for Appellee. Oren Nimmi, RIGHTS BEHIND BARS, Washington, D.C., for 

Amicus Rights Behind Bars. 

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WYNN, Circuit Judge:

Danny Pfaller died from liver cancer while he was a prisoner with the Virginia 

Department of Corrections (“Department”). His estate sued several prison officials under

42 U.S.C. § 1983 and Virginia law, alleging that they violated the Eighth Amendment and 

state law by failing to provide Pfaller treatment for his chronic hepatitis C until it was too 

late. 

Defendants in this appeal are Dr. Mark Amonette and Dr. Laurence Shu-Chung 

Wang. Plaintiff alleges that Dr. Amonette designed treatment guidelines for inmates with 

hepatitis C that unconstitutionally excluded Pfaller from receiving treatment. Plaintiff also 

alleges that Dr. Wang failed to follow those guidelines and committed both medical 

malpractice and Eighth Amendment violations in denying him appropriate treatment. 

Defendants unsuccessfully moved for summary judgment, alleging that they were 

protected by qualified immunity and, on Dr. Wang’s part, derivative sovereign immunity.

For the reasons that follow, we reverse the district court’s denial of sovereign 

immunity to Dr. Wang and denial of qualified immunity to Dr. Amonette but affirm its 

denial of qualified immunity to Dr. Wang. 

I.

Because this case is before us on interlocutory appeal, the following facts are 

recounted as the district court viewed them, and in the light most favorable to Pfaller. See 

Hicks v. Ferreyra, 965 F.3d 302, 305 (4th Cir. 2020). 

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A.

Hepatitis C is a disease caused by a viral infection of the liver. In certain individuals, 

hepatitis C can persist as an asymptomatic infection for years. In others, the virus can lead 

to liver inflammation, fibrosis (liver scarring), cirrhosis (liver tissue death), and even 

terminal liver cancer.

For many years, the only curative treatment for hepatitis C was a course of 

interferon-based drugs. However, these drugs offered a low cure rate (40 to 50%) and 

caused major side effects, including life-threatening neuropsychiatric and autoimmune 

disorders. In 2014, the Food and Drug Administration began approving a suite of new drugs 

called direct-acting antivirals for treatment of hepatitis C patients. These drugs offered

great promise. Not only were they less likely to cause serious side effects, but they also 

boasted cure rates of 90 to 100%. By 2015, direct-acting antivirals were available for 

treating hepatitis C patients.

In response to these medical advances, Dr. Amonette, the Department’s chief 

physician, developed new hepatitis C treatment guidelines (“Guidelines”) for the 

Department. Under the Guidelines, the Department agreed to refer inmates with hepatitis 

C to a clinic at Virginia Commonwealth University (“VCU”) based on certain criteria. 

These criteria sorted inmates into three groups based on APRI and FIB-4 scores that 

assessed their level of fibrosis (if any).1 Inmates who scored at the high end of the scale

1 “APRI” stands for “aspartate aminotransferase to platelet ratio.” J.A. 116. It is a 

noninvasive way to estimate fibrosis, or liver scarring. J.A. 397. “FIB-4” is short for 

“Fibrosis-4 index,” and is another formula used to assess fibrosis based on a patient’s age, 

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were to be “automatically referred to VCU for evaluation without any additional testing.” 

J.A. 116. Inmates who scored in the middle tier were to receive “additional testing to 

determine whether [they] should be referred for evaluation.” Id. And those who scored at 

the low end were not to be referred for treatment and instead were to “receive periodic 

laboratory blood testing and chronic care appointments with a medical provider.” Id.

Outside of these criteria, a physician could also refer an inmate to the VCU clinic “if there 

[were] other findings suggestive of advanced liver disease.” J.A. 303. Once referred, the 

inmate would receive an antiviral prescription unless there was some other medical reason 

not to treat them. 

Dr. Amonette explains that these Guidelines were designed to ensure that those with 

the greatest need were treated first. Plaintiff’s expert disputes this, stating that the 

Guidelines were actually a tool for excluding patients from treatment. The parties agree 

that when resources are limited, prioritization of patients with the most advanced disease 

can be a reasonable strategy. But whether the Department’s resources were actually limited 

is disputed. 

B. 

Danny Pfaller was an inmate with the Department from 1999 to 2018. As early as 

2007, Pfaller tested positive for hepatitis C. Beginning in 2015, Pfaller had his blood drawn 

platelet count, and other factors. J.A. 116, 397. Citations to the “J.A.” refer to the parties’

Joint Appendix filed in this appeal.

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every six to twelve months to assess his APRI and FIB-4 scores, consistent with the 

Guidelines. During this time, Dr. Wang served as Pfaller’s primary physician. 

Between 2015 and 2018, Dr. Wang twice failed to follow the Guidelines in treating 

Pfaller. On October 16, 2015, Pfaller tested into the middle tier of the Guidelines criteria

and therefore qualified for fibroscan testing to determine the extent of any fibrosis. But Dr. 

Wang did not refer him. Two years later, following several tests that fell into the lowest 

tier, Pfaller tested into the middle tier again. But once again, Dr. Wang did not refer him

for more testing. Dr. Wang claims both failures were a mistake. He states that he did not 

refer Pfaller for a fibroscan because he thought the inclusion number for the middle tier 

was 1.5 on the FIB-4 test, when it was in fact 1.45.

On May 7, 2018, Pfaller tested for a third time into the middle criteria, and this time, 

Dr. Wang acted. He submitted a request for a fibroscan on May 14. Meanwhile, Dr. Wang 

began to see Pfaller for numerous physical examinations showing increasingly severe signs

of liver disease. In early June, Pfaller visited Dr. Wang for abdominal pain and swelling, 

and Dr. Wang ordered hepatitis C genotype testing and prescribed medication to alleviate 

the symptoms. Later that month, Pfaller visited Dr. Wang for weight gain and bowel 

obstruction. Dr. Wang found that Pfaller’s abdomen was distended, and he was retaining 

fluid—symptoms of liver disease—so Dr. Wang prescribed diuretics. During this time, Dr. 

Wang knew Pfaller “was on the list to be scheduled for a Fibroscan at VCU,” but took no 

further measures to ensure Pfaller was actually tested. J.A. 1958. In early July, Pfaller 

visited the clinic three more times, complaining of shortness of breath, a cough, and fluid 

retention. 

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On July 11, 2018, Pfaller visited Dr. Wang again for fullness in his abdomen. Dr. 

Wang examined him and concluded his hepatitis C was causing fluid retention and 

cirrhosis. Two months after he originally put in a referral, he now ordered a fibroscan 

“asap,” which was performed six days later. J.A. 1959. A follow-up CT scan revealed a 

mass on Pfaller’s liver. After further testing, Dr. Wang referred Pfaller to VCU’s oncology 

department. Pfaller was diagnosed with untreatable liver cancer in early September. He 

died only a month later, on October 3, 2018. 

C.

Plaintiff Jacob Pfaller, who is Pfaller’s son and the administrator of Pfaller’s estate, 

filed suit on behalf of the estate in October 2019. Three claims are relevant to this appeal.

To start, Plaintiff filed Eighth Amendment claims against Dr. Wang and Dr. Amonette in 

their individual capacities, alleging they were each deliberately indifferent to Pfaller’s 

serious medical needs. Additionally, Plaintiff filed a state-law medical-malpractice claim 

against Dr. Wang in his individual capacity.

At the close of discovery, Dr. Wang and Dr. Amonette each moved for summary 

judgment. The district court rejected Defendants’ arguments in two separate decisions. 

First, the court found that Plaintiff had pointed to several genuine disputes of material fact 

as to whether Dr. Wang and Dr. Amonette were deliberately indifferent. See Pfaller v. 

Clarke, 630 B.R. 197, 207 (E.D. Va. 2021) (Dr. Amonette); Pfaller v. Clarke, No. 

3:19CV728, 2021 WL 1776189, at *6 (E.D. Va. May 4, 2021) (Dr. Wang). The court also 

concluded that “Pfaller’s Eighth Amendment right to receive adequate medical care and to 

be free from officials’ deliberate indifference to his known medical needs” was clearly 

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established at the time in question, so Defendants were not entitled to qualified immunity.

Pfaller, 630 B.R. at 215; Pfaller, 2021 WL 1776189, at *10. Finally, the court rejected Dr. 

Wang’s sovereign-immunity defense to the malpractice claim. Pfaller, 2021 WL 1776189, 

at *14. Both Defendants timely appealed.

II.

We first examine the district court’s denial of qualified immunity to both defendants 

on the constitutional claim. Our review is limited by the posture of this case on 

interlocutory appeal. Hicks, 965 F.3d at 308.

Although denials of summary judgment are generally not subject to appellate 

review, denials of qualified immunity are an exception and may be appealed immediately. 

Id. Nonetheless, our review is limited only “to the extent [a denial of qualified immunity] 

turns on an issue of law.” Id. (emphasis omitted) (quoting Gould v. Davis, 165 F.3d 265, 

268 (4th Cir. 1998)).

In conducting such a review, we answer only a “narrow legal question: if we take 

the facts as the district court gives them to us, and we view those facts in the light most 

favorable to the plaintiff, is the defendant still entitled to qualified immunity?” Williams v. 

Strickland, 917 F.3d 763, 768 (4th Cir. 2019) (footnote omitted); see also Iko v. Shreve, 

535 F.3d 225, 234 (4th Cir. 2008) (“[W]e possess no jurisdiction over a claim that a 

plaintiff has not presented enough evidence to prove that the plaintiff’s version of the facts 

actually occurred, but we have jurisdiction over a claim that there was no violation of 

clearly established law accepting the facts as the district court viewed them.” (quoting 

Winfield v. Bass, 106 F.3d 525, 530 (4th Cir. 1997) (en banc))). 

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A. 

Our qualified-immunity inquiry proceeds in two steps, which we may address in 

whichever sequence “will best facilitate the fair and efficient disposition of [the] case.”

Halcomb v. Ravenell, 992 F.3d 316, 319 (4th Cir. 2021) (citation omitted). First, a plaintiff 

must show a violation of a constitutional right. Thompson v. Virginia, 878 F.3d 89, 97 (4th 

Cir. 2017). And second, “the right at issue must have been ‘clearly established’ at the time 

of the defendant’s alleged misconduct.” Id. (quoting Pearson v. Callahan, 555 U.S. 223, 

232 (2009)). 

The source of the right at issue here is the Eighth Amendment, which prohibits the 

infliction of “cruel and unusual punishments.” U.S. Const. amend. VIII. This prohibition 

extends to “the treatment a prisoner receives in prison and the conditions under which he 

is confined.” Helling v. McKinney, 509 U.S. 25, 31 (1993). Because “adequate . . . medical 

care” is a basic condition of humane confinement, Farmer v. Brennan, 511 U.S. 825, 832 

(1994), 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 v. Gamble, 429 U.S. 97, 104 (1976) (citation and internal quotation 

marks omitted). 

To establish a claim for deliberate indifference to serious medical needs, a prisoner 

“must satisfy the Supreme Court’s two-pronged test set forth in Farmer v. Brennan.” Scinto 

v. Stansberry, 841 F.3d 219, 225 (4th Cir. 2016). Farmer’s first, “objective” prong requires 

a plaintiff to prove that the alleged deprivation was “sufficiently serious.” Farmer, 511 

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U.S. at 834 (citation omitted). Farmer’s second, “subjective” prong requires a plaintiff to 

show that prison officials acted with “deliberate indifference.” Scinto, 841 F.3d at 225.

This second prong itself has two subparts: a plaintiff must show the prison official 

(1) had “actual knowledge of the risk of harm to the inmate” and (2) “‘recognized that his 

actions were insufficient’ to mitigate the risk of harm to the inmate arising from his medical 

needs.” Iko, 535 F.3d at 241 (emphasis omitted) (quoting Parrish ex rel. Lee v. Cleveland, 

372 F.3d 294, 303 (4th Cir. 2004)). “[M]ere negligence” won’t meet this standard, De’lonta 

v. Angelone, 330 F.3d 630, 634 (4th Cir. 2003), but neither is “actual purposive intent”

required, De’lonta v. Johnson, 708 F.3d 520, 525 (4th Cir. 2013). Instead, deliberate 

indifference is most akin to criminal-law recklessness. Campbell v. Florian, 972 F.3d 385, 

395 (4th Cir. 2020), as amended (Aug. 28, 2020). Further, so long as the official who knew 

of a substantial risk to inmate health or safety “responded reasonably to the risk,” they 

cannot be found liable under the Eighth Amendment, “even if the harm ultimately was not 

averted.” Farmer, 511 U.S. at 844.

Even if a plaintiff proves an Eighth Amendment right was violated, our inquiry isn’t 

over. Under the second prong of the qualified-immunity analysis, an official is nonetheless 

entitled to immunity “if the right was not so ‘clearly established’ that ‘a reasonable official 

would understand that what he is doing violates that right.’” Thompson, 878 F.3d at 98 

(quoting Hope v. Pelzer, 536 U.S. 730, 739 (2002)). The state of the law at the time must 

have given an official “fair warning” that his treatment of the prisoner was unconstitutional. 

Id. (quoting Hope, 536 U.S. at 741). 

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In performing this analysis, a court must pinpoint the precise constitutional right at 

issue in order to determine whether it was clearly established. See Halcomb, 992 F.3d at

319–20. In doing so, a court must be careful not to define the right “at a high level of 

generality ‘[b]ecause the dispositive question is whether the violative nature of particular

conduct is clearly established.’” Id. at 320 (quoting Estate of Armstrong ex rel. Armstrong 

v. Village of Pinehurst, 810 F.3d 892, 907 (4th Cir. 2016)). Nonetheless, Eighth 

Amendment claims don’t require the same level of specificity that is needed in, for 

example, the Fourth Amendment context. See Thorpe v. Clarke, 37 F.4th 926, 940 (4th Cir. 

2022). And “[t]here 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.” Scinto, 841 F.3d at 236 (quoting Hope, 536 U.S. at 739).

The extent of the analysis required for this second prong, however, varies 

considerably across cases. This Court recently held in Thorpe v. Clarke that “when 

‘plaintiffs have made a showing sufficient to’ demonstrate an intentional violation of the 

Eighth Amendment, ‘they have also made a showing sufficient to overcome any claim to 

qualified immunity.’” 37 F.4th at 934 (quoting Beers-Capitol v. Whetzel, 256 F.3d 120, 

142 n.15 (3d Cir. 2001)). That’s because, as Thorpe opined, “qualified immunity does not 

shield ‘those who knowingly violate the law.’” Id. (quoting Ashcroft v. al-Kidd, 563 U.S. 

731, 743 (2011)). And because the Eighth Amendment’s deliberate-indifference standard 

requires knowing conduct, an official who was deliberately indifferent could not also 

believe “that [their] actions comported with clearly established law.” Id. at 939 (quoting 

Beers-Capitol, 256 F.3d at 142 n.15). Thus, in Thorpe, we “effectively collapse[d]” 

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qualified immunity’s two inquiries into one, holding that dismissal on qualified-immunity

grounds “remains improper so long as the officers’ mental state remains genuinely in 

issue.” Id. at 934 (citation omitted). 

We don’t believe, however, that Thorpe directs this Court to eliminate the clearly 

established law prong in every case where a dispute of fact related to the defendant’s mental 

state remains.2 Critically, the Supreme Court has not so limited itself. 

In Taylor v. Barkes, 575 U.S. 822 (2015) (per curiam), the Supreme Court reversed

the lower courts’ denial of qualified immunity. The lower courts had held there were 

genuine issues of material fact as to whether there was an Eighth Amendment violation. 

Yet the Court concluded that, even if that were so, qualified immunity nevertheless 

attached because the right at issue was not clearly established. Id. at 827. Thus, we know 

from Taylor that not all disputes of material fact as to deliberate indifference will freeze 

our application of qualified immunity where warranted. 

Instead, Eighth Amendment cases exist on a spectrum of intent and harm. Thorpe 

most neatly applies to a prison doctor, who doesn’t need case law to tell him his patient 

2 Defendants argue that Thorpe only applies to cases at the motion-to-dismiss stage.

As discussed below, the lack of factual development at that stage does appear to have been 

relevant to the outcome in Thorpe. But Thorpe’s reasoning doesn’t hinge on its procedural 

posture. Moreover, this Court has already relied on Thorpe to vacate a grant of summary 

judgment where the district court found that the defendants may have intentionally 

discriminated against the plaintiff based on his religion yet nonetheless granted immunity 

because the defendants did not violate a clearly established right. Coleman v. Jones, No. 

20-7382, 2022 WL 2188402, at *6 (4th Cir. June 17, 2022) (unpublished but orally argued)

(“[W]hen . . . there is a triable issue as to whether defendants engaged in a constitutional 

violation that incorporates intent as an element, qualified immunity may be 

inappropriate.”). 

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deserves fair treatment. Or a prison guard, who doesn’t need case law to tell him he can’t 

abuse an inmate. Thorpe collapses qualified immunity’s two-pronged inquiry in these cases 

because each prong merely duplicates the other’s work; these Eighth Amendment 

violations inherently include knowing disregard for the law. See Thorpe, 37 F.4th at 938–

40. 

But in other cases, there may be more attenuation between the risk of harm and the 

defendant’s knowledge that his conduct is constitutionally deficient. And in these cases, a 

defendant is less able to “use his own ‘state of mind’ as ‘a reference point’ to ‘assess 

conformity to the law,’” as Thorpe envisions. Id. at 939 (quoting Thompson, 878 F.3d at 

106). Thorpe itself recognized this: “What Defendants actually demur is that they did not 

know, until [a later] decision . . . , that the . . . conditions they promulgated posed a 

substantial risk of serious harm in violation of the Eighth Amendment. They may well end 

up on the winning side of that argument after the evidence comes in, but for now, these 

fact[ual] issues compel us to move this case forward unless Defendants’ entitlement to 

qualified immunity appears on the face of the complaint.” Id. at 935 (emphasis added) 

(citations and internal quotation marks omitted). 

This principle is illustrated by the very cases at hand—Thorpe on one end of the 

spectrum, Taylor on the other. In Thorpe, we found (and the defendants didn’t even 

challenge) that the plaintiffs adequately alleged that prison officials knew the harm that 

long-term solitary confinement caused, yet disregarded it. Id. at 933. We emphasized the 

officials’ consciousness of a serious risk of harm: that the plaintiffs suffered a range of 

severe physical and mental harms, such as schizoaffective disorder, psychosis, bouts of 

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disorientation, and severe weight loss; that for years, the defendants “had daily contact with 

[the p]laintiffs”; that the defendants had been pressured to abandon similar solitaryconfinement systems several times before; and that numerous studies and judicial 

precedents had documented “the severe and often permanent damage caused by” such 

systems. Id. at 935–96. In short, the harm was “obvious,” id. at 934, and “the pre-existing 

law [was] not in controversy,” id. at 935 (quoting Ortiz v. Jordan, 562 U.S. 180, 190 

(2011)). 

Under those facts, which sufficiently alleged “an intentional violation of the Eighth 

Amendment,” we concluded that the plaintiffs “‘also made a showing sufficient to 

overcome any claim to qualified immunity.’” Id. at 934 (emphasis added) (quoting BeersCapitol, 256 F.3d at 142 n.15). We relied on the Supreme Court’s decision in Ortiz v. 

Jordan, where the Court likewise declined to grant qualified immunity to officers who were 

deliberately indifferent to an inmate’s safety. See id. at 934–35. The facts in Ortiz, like 

those in Thorpe, demonstrated an obvious harm, where prison officials failed to distance 

the plaintiff from her assailant after they were “adequately informed” of a sexual assault. 

Ortiz, 562 U.S. at 191. Ortiz indicated that those facts plainly fell under the clearly 

established law that the Eighth Amendment protects prisoners from situations where an 

official knows they face a substantial risk of serious harm in the form of violence, but 

“disregards that risk by failing to take reasonable measures to abate it.” Id. at 190 (quoting 

Farmer, 511 U.S. at 847).

In Taylor, by contrast, the Supreme Court examined whether a prison implemented 

adequate suicide prevention protocols and concluded that the defendants were entitled to 

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qualified immunity because the right at issue was not clearly established. Unlike the 

defendants in Thorpe and Ortiz, the Taylor defendants had not “personally interacted with 

[the prisoner] or knew of his condition before his death.” Taylor, 575 U.S. at 824. A 

constitutional violation could arise, then, only if the prison’s suicide-screening measures 

were inadequate. Id. at 824–25. Yet as the Court opined, no case law actually identified

what minimum procedures a prison had to use. Id. at 826–27. Thus, the Court held that 

“even if the [prison’s] suicide screening and prevention measures contained the 

shortcomings that [the plaintiffs] allege[d], no precedent . . . would have made clear to [the 

defendants] that they were overseeing a system that violated the Constitution.” Id. at 827.

Put another way, even if the defendants’ suicide-prevention protocols were wanting, 

they weren’t clearly unconstitutional. The defendants’ states of mind in crafting those 

policies, then, could not be a guiding compass to ensuring those policies met constitutional 

muster, unlike in Thorpe. See Thorpe, 37 F.4th at 939 (stating that precedent isn’t needed 

when an official can “use his own state of mind as a reference point to assess conformity 

to the law” (citation and internal quotation marks omitted)). In such a case, the “clearly

established” prong of the qualified-immunity analysis continues to perform work

independent of the “constitutional-violation” prong—again, unlike in Thorpe. And so, in 

cases like Taylor, even where they may be a dispute of material fact as to the underlying 

constitutional violation, a court may still inquire into whether a right was clearly 

established to determine if the defendants are entitled to qualified immunity. 

To review, in order to defeat a defendant’s claim for qualified immunity, a plaintiff 

must show: (1) a violation of a constitutional right, which in the case of alleged deliberate 

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indifference to serious medical needs requires a showing that (A) the alleged deprivation 

was sufficiently serious (the objective prong) and (B) prison officials acted with deliberate 

indifference (the subjective prong), which in turn requires a showing that the prison official 

(i) had actual knowledge of the risk of harm and (ii) recognized that his actions were 

insufficient to mitigate that risk of harm; and (2) that the constitutional right was clearly 

established at the time of the defendant’s actions. If a plaintiff fails to satisfy either prong

of the qualified-immunity test, the defendant is entitled to qualified immunity. But in some 

cases, like Thorpe, the court need not separately determine whether the constitutional right 

was clearly established if there remains a genuine issue of material fact as to an official’s 

deliberate indifference, because that potential deliberate indifference would, if established, 

necessarily include an awareness of the illegality of the defendant’s actions. 

B.

We turn first to whether Dr. Wang, Pfaller’s primary physician, is entitled to 

qualified immunity under this two-step framework. We conclude that (1) Plaintiff has 

presented sufficient facts for a reasonable jury to find that Dr. Wang was deliberately 

indifferent to Pfaller’s serious medical needs and (2) Pfaller’s right to treatment was clearly 

established by 2015, the year of Dr. Wang’s first alleged violation. Thus, we affirm the 

district court’s denial of qualified immunity to Dr. Wang.

1.

Dr. Wang doesn’t contest Farmer’s first, objective prong that the alleged 

deprivation here was sufficiently serious. Nor could he. We have previously found that this 

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prong is satisfied by failure to treat an “inmate’s serious medical needs,” including, 

specifically, hepatitis C. Gordon v. Schilling, 937 F.3d 348, 356–57 (4th Cir. 2019).

Dr. Wang’s dispute instead centers on the subjective prong and whether he was 

deliberately indifferent to Pfaller’s hepatitis C. On this issue, the district court found that 

Plaintiff had established at least two genuine disputes of material fact. The first dispute 

concerns Dr. Wang’s failure to refer Pfaller for additional testing on two occasions. As the 

court recognized, it is undisputed that Pfaller’s bloodwork qualified him for additional 

testing three times: 1) on October 16, 2015, Pfaller’s FIB-4 score was 1.48, which exceeded 

the 1.45 cutoff for referral; (2) on July 12, 2017, Pfaller had a FIB-4 score of 1.46, which 

again exceeded the 1.45 cutoff; and (3) on May 7, 2018, Pfaller had an APRI of 0.55 and 

a FIB-4 of 2.18, both of which exceeded the criteria for additional testing. But Dr. Wang 

only referred Pfaller for a fibroscan after the last encounter. By then, it was much too late. 

Drawing all reasonable inferences in Plaintiff’s favor, as we must at summary 

judgment, Knibbs v. Momphard, 30 F.4th 200, 213 (4th Cir. 2022), Plaintiff raises a 

genuine issue of material fact as to whether Dr. Wang was deliberately indifferent. 

Specifically, a reasonable jury could conclude that Dr. Wang knew Pfaller qualified for 

additional testing but declined to do anything about it. As Dr. Wang acknowledges, he 

understood that the Guidelines set the standard of care for the treatment of patients with 

chronic hepatitis C. The Guidelines explicitly and unambiguously indicated that Pfaller 

qualified on each occasion. It is a reasonable inference that Dr. Wang, as a staff physician, 

was aware of those Guidelines.

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This inference is further bolstered by the fact that, although the relevant portions of 

the Guidelines did not change between June 2015 and May 2018, they were revised as a 

whole at least six times in that time period. Presumably, Dr. Wang would have received a 

copy of these revised guidelines each time; after all, he acknowledged the Guidelines set 

the standard of care for treating prisoners with hepatitis C. If we infer that Dr. Wang did 

his job and reviewed each copy carefully to ensure nothing important had changed, that 

means he had at least six opportunities to confirm the FIB-4 cutoff for additional testing 

was indeed 1.45. A reasonable jury could therefore infer that Dr. Wang knew the true APRI 

and FIB-4 cutoffs but nevertheless declined to refer Pfaller for testing for two and a half 

years.

Dr. Wang counters that he did not refer Pfaller because he made a simple mistake. 

Specifically, he claims in his declaration that he “believed the inclusion number for the 

[FIB-4] was 1.50 when in fact it was 1.45.” J.A. 1954. For support, Dr. Wang points to the 

fact that once Pfaller’s FIB-4 score exceeded 1.5 on May 7, 2018, he referred him for a 

fibroscan. Dr. Wang argues that without any direct evidence to contradict his account, there 

is no genuine issue of material fact. At most, he contends, the facts show only negligence, 

which is not enough to state an Eighth Amendment violation. 

Like the district court, we decline at this stage to accept Dr. Wang’s self-serving 

assertion as fact, for several reasons. First, Dr. Wang tries to bolster his claim of mistake

by noting that as soon as Pfaller’s FIB-4 score exceeded 1.5 on May 7, 2018—the number 

he allegedly believed was the threshold—Dr. Wang referred him for testing. But as the 

district court observed, Pfaller’s May 7 APRI score also exceeded the cutoff for additional 

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testing. So, critically, we have no way of knowing which score actually influenced Dr.

Wang’s referral, other than his own testimony. Moreover, the May 7, 2018, FIB-4 score 

was 2.18—far higher than the earlier scores of 1.48 and 1.46. A reasonable jury could infer 

that Dr. Wang opted to ignore the first two scores, despite knowing about the Guideline 

cutoff, but felt the third score was too high to reasonably ignore.

Next is Dr. Wang’s testimony itself. To accept that Dr. Wang’s repeated errors were 

at most mere negligence would require crediting his own self-serving assertion. Of course, 

a jury may ultimately choose to credit Dr. Wang’s assertion over Plaintiff’s circumstantial 

evidence that Dr. Wang was aware Pfaller qualified for further testing. But that decision 

rests on an evaluation of Dr. Wang’s credibility, which we are not permitted to weigh at 

the summary-judgment stage. See Hensley ex rel. North Carolina v. Price, 876 F.3d 573, 

584 n.6 (4th Cir. 2017). And while self-serving affidavits offered by the non-movant can

sometimes defeat summary judgment, e.g., Lovett v. Cracker Barrel Old Country Store, 

Inc., 700 F. App’x 209, 212 (4th Cir. 2017) (unpublished but orally argued), here it is the 

movant—Dr. Wang—who offers his own statements as the key evidence in support of 

summary judgment. That is insufficient. E.g., Knibbs, 30 F.4th at 222 (“Because [the 

defendant] is the moving party, we are constrained to assume that the jury will not credit 

his evidence and will instead accept the [plaintiff]’s proffered evidence on disputed fact 

questions. . . . [We would] contravene[] Rule 56 [if we were to] accept[] [the 

defendant]’s self-serving statements and read[] the evidence in the light most favorable 

to him.”).

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Moreover, even if we did credit Dr. Wang’s self-serving assertion, it is not the 

panacea he believes it is. To accept Dr. Wang’s claim of mistake, we would need to assume 

that he did not verify the Guidelines criteria either time he reviewed Pfaller’s bloodwork, 

since the Guidelines explicitly set forth the 1.45 threshold for FIB-4 scores. But this, too, 

raises an issue of deliberate indifference, because “prison officials may not simply bury 

their heads in the sand and thereby skirt liability.” Makdessi v. Fields, 789 F.3d 126, 133 

(4th Cir. 2015). For example, we have held that a prison guard may not avoid liability if he 

“refused to verify ‘underlying facts that he strongly suspected to be true’ [or] ‘declined to 

confirm inferences of risk that he strongly suspected to exist.’” Id. at 133–34 (quoting Brice 

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

Here, it is undisputed that Dr. Wang knew Pfaller’s blood results fell right near the 

line of warranting further screening. Yet, by his own account, he failed to check his guess 

about their meaning against the Guidelines, despite knowing the increasing risk of liver 

disease that higher scores denoted. 

Finally, Dr. Wang is incorrect when he argues that Plaintiff has failed to produce 

any evidence contradicting Dr. Wang’s account. To be sure, Plaintiff relies on 

circumstantial evidence to establish an issue of material fact as to Dr. Wang’s deliberate 

indifference. But that isn’t a problem. Our Court has consistently recognized that a plaintiff 

can show subjective knowledge through circumstantial evidence. See, e.g., id. at 133. After 

all, rarely will courts see a case where a defendant readily agrees that he was deliberately 

indifferent. And here, the fact alone that Dr. Wang failed to refer Pfaller for further testing 

when he demonstrated signs of an increasingly serious medical condition “raises an 

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inference [of] deliberate indifference.” Scinto, 841 F.3d at 232 (quoting Miltier v. Beorn, 

896 F.2d 848, 853 (4th Cir. 1990)). 

Our colleague in dissent chafes against the inferences for Pfaller that we must make 

at this stage. Instead, the dissent accepts one conclusion and one alone: that Dr. Wang made 

a mistake. To be sure, not just one mistake, but two mistakes, in two different years. 

Because Dr. Wang uttered it, the dissent concludes that it must be. And apparently it need 

not matter that we can only believe this conclusion if we believe Dr. Wang himself—

undoubtedly a question weighing on his credibility and therefore the province of a jury 

alone. But the law here is simple: we cannot contravene Rule 56 by crediting Dr. Wang’s

self-serving affidavit. See Knibbs, 30 F.4th at 222. 

Beyond that most fundamental error, the dissent’s view comes with other hitches. 

Take one: the dissent suggests that there’s no evidence Dr. Wang even read or knew the 

Guidelines’ cutoffs at all. See Dissent at 44 (arguing that the Guidelines’ existence is not 

evidence that Dr. Wang knew the correct thresholds for further testing or treatment). But 

even accepting that Dr. Wang had “access” to the Guidelines yet did not “actually use[] 

that information,” id. (quoting Danser v. Stansberry, 772 F.3d 340, 348 n.10 (4th Cir. 

2014)), that too demonstrates an issue of deliberate indifference for the reasons stated 

earlier. That is, of course, if reasonable inferences are actually drawn as they should be at 

summary judgment. And surely Dr. Wang himself would not go so far as to argue cavalierly 

that he never even used the very Guidelines he testified were the Department’s standard of 

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care for treating hepatitis C.

3 See Farmer, 511 U.S. at 842 (explaining that the Eighth 

Amendment doesn’t allow prison officials “to take refuge in the zone between ignorance 

of obvious risks and actual knowledge of risks.” (citation and internal quotation marks 

omitted)). 

The district court also found that Plaintiff established a genuine dispute of material 

fact as to whether Dr. Wang responded appropriately once he did finally request a fibroscan 

for Pfaller. As noted earlier, Dr. Wang requested a fibroscan about a week after Pfaller’s 

May 7 bloodwork came back. However, Dr. Wang did not definitively order a fibroscan 

until July 11—around two months later. In the interim, Pfaller visited Dr. Wang several 

times complaining of abdominal pain, swelling, a distended abdomen, and fluid retention. 

All of these conditions are symptoms of advancing liver disease. Even though Dr. Wang 

knew Pfaller “was on the list to be scheduled for a Fibroscan at VCU” and that no fibroscan 

had taken place, J.A. 1958, Dr. Wang “did not press to have the previously ordered test 

performed.” Pfaller, 2021 WL 1776189, at *7. By the time he did, it was too late. Based 

on these facts, we believe a reasonable jury could conclude that Dr. Wang knew about the 

risk of Pfaller’s advancing liver disease yet took no concrete actions between May and July 

2018 to diagnose or treat the disease.

3 The dissent also blurs the deliberate-indifference standard with an intent-to-harm 

standard. But it wasn’t Plaintiff’s burden to show that Dr. Wang acted with hope that Pfaller 

actually be harmed. “[I]t is enough that the official acted or failed to act despite his 

knowledge of a substantial risk of serious harm.” Farmer, 511 U.S. at 842. 

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Dr. Wang’s arguments don’t persuade us otherwise. He argues that he took some

steps to follow up with Pfaller during this time, such as ordering hepatitis C genotype 

testing and prescribing medication to alleviate Pfaller’s symptoms. While that is more than 

nothing, a jury might conclude that Dr. Wang, as a medical doctor, must have known these 

half measures “were insufficient to mitigate the [true] risk of harm” from liver cirrhosis 

and cancer. Iko, 535 F.3d at 241 (citation, internal quotation marks, and emphasis omitted); 

see also Heyer v. U.S. Bureau of Prisons, 849 F.3d 202, 211 (4th Cir. 2017) (“[T]he mere 

fact that prison officials provide some treatment does not mean they have provided 

‘constitutionally adequate treatment.’” (quoting De’lonta, 708 F.3d at 526)). 

Indeed, we rejected a similar set of facts in an analogy in De’lonta. There, we 

imagined a scenario where prison officials prescribed a painkiller to a prisoner after a fall, 

but the prisoner continued showing symptoms that “by all objective measure, [showed that 

he] require[d] evaluation for surgery.” De’lonta, 708 F.3d at 526. In that scenario, we 

wondered, “[w]ould prison officials then be free to deny him consideration for surgery, 

immunized from constitutional suit by the fact they were giving him a painkiller?” Id. The 

answer was obvious: we thought not. See id.

Likewise, here. Dr. Wang wasn’t off the hook because he prescribed some

medication. It’s not a question of disagreement over Pfaller’s preferred care, as Dr. Wang 

unpersuasively argues. See Hixson v. Moran, 1 F.4th 297, 303 (4th Cir. 2021). Rather, it’s

a question of whether Pfaller failed to receive adequate treatment at all. 

The dissent repeatedly chastises this Court for interfering in a matter of “prison 

administration.” Dissent at 39, 47–48. But that’s not the issue in this appeal; instead, the 

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issue here concerns a prisoner’s constitutional right to adequate medical care. And while 

the dissent makes much of Virginia’s policy priorities, see id. at 49–51, it places 

considerably less emphasis on this constitutional guarantee. 

Lest we forget, prisoners are entirely “dependent on the State for food, clothing, and 

necessary medical care.” Brown v. Plata, 563 U.S. 493, 510 (2011). And a prison that 

deprives prisoners of those needs “is incompatible with the concept of human dignity.” Id.

at 511. We cannot turn a blind eye to such constitutional infirmities. Cf. id. (“Courts may 

not allow constitutional violations to continue simply because a remedy would involve 

intrusion into the realm of prison administration.”). In its rush to raise the alarm on a host 

of policy concerns, the dissent ignores this Court’s most basic role—and the limits of that 

role at summary judgment. 

Based on the disputed issues of material fact here, we believe the appropriateness 

of Dr. Wang’s actions should be resolved by a jury. 

2.

Having concluded that Plaintiff raises a genuine issue of material fact as to an Eighth 

Amendment violation, we turn to the other prong of the qualified-immunity analysis—

whether Pfaller’s right to treatment was clearly established. Of course, if Dr. Wang’s 

conduct sufficiently resembles that of the defendants in Thorpe, the analysis of the two 

prongs collapses into one, and we must find that Pfaller has made a showing sufficient to 

overcome qualified immunity at this stage. See Thorpe, 37 F.4th at 934. But, while we 

believe the facts here more closely resemble Thorpe than Taylor, we need not expressly 

decide whether to collapse our qualified immunity inquiry as to Dr. Wang. That’s because, 

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either way, we reach the same outcome: Dr. Wang was on notice that he was violating 

Pfaller’s constitutional rights. 

First, we must define the right. The district court held that the right at issue is 

“Pfaller’s Eighth Amendment right to receive adequate medical care and to be free from 

officials’ deliberate indifference to his known medical needs.” Pfaller, 2021 WL 1776189, 

at *10. This, Dr. Wang argues, is far too general. Instead, he proffers that the proper inquiry 

is “whether it would have been clear to Dr. Wang that he was providing inadequate medical 

care in violation of the Eighth Amendment by failing to schedule a specific type of followup test (fibroscan) for Pfaller until July 2018.” Wang’s Opening Br. at 24. 

We disagree with Dr. Wang’s overly narrow articulation. First, his argument is 

premised almost entirely on direction from the Supreme Court regarding Fourth 

Amendment claims. But as we recognized in Thorpe, the Supreme Court has not demanded 

the same level of specificity in Eighth Amendment cases. Thorpe, 37 F.4th at 940; see also 

Hope, 536 U.S. at 738–39 (declining to inquire whether “the very action in question has 

previously been held” to violate the Eighth Amendment and rejecting qualified immunity 

because “the risk of harm is obvious”); Taylor v. Riojas, 141 S. Ct. 52, 54 (2020) (per 

curiam) (“Confronted with the particularly egregious facts of this case, any reasonable 

officer should have realized that Taylor’s conditions of confinement offended the 

Constitution.”). 

As we explained in Scinto v. Stansberry, “[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.” Scinto, 841 F.3d at 

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236. As Pfaller’s treating physician, Dr. Wang was on notice at all relevant times—late 

2015 through 2018—that he could not choose to delay or withhold treatment from Pfaller 

when he knew it was medically necessary and was, in fact, mandated by the very 

Guidelines he operated under. See id. (holding that it was clearly established in 2005 that 

denying a prisoner his prescribed insulin can violate the Eighth Amendment); Jehovah v. 

Clarke, 798 F.3d 169, 181–82 (4th Cir. 2015) (emphasizing that refusal to treat serious 

medical needs can constitute deliberate indifference); Smith v. Smith, 589 F.3d 736, 739 

(4th Cir. 2009) (explaining that delay in treatment can violate Eighth Amendment). 

Take Smith as one case that put Dr. Wang on notice. There, an inmate alleged that 

he was prescribed treatment by his doctor for a foot infection but was unable to receive any 

treatment because a nurse later ripped up the order slip that authorized it. Smith, 589 F.3d 

at 737. The district court held there was no constitutional violation, but we reversed. We 

explained that “mere delay or interference [with medical treatment] can be sufficient to 

constitute a violation of the Eighth Amendment.” Id. at 739. By destroying the means for 

the inmate to access treatment, the nurse ultimately deprived him of necessary care. See id.

After Smith, Dr. Wang was on notice that he could not refuse necessary medical 

care to Pfaller. In this case, his supervisor—the Department’s chief physician—had ordered 

through the Guidelines that Pfaller receive further testing when his FIB-4 score rose above 

a specific level. That level was high enough to indicate progression of his hepatitis C and 

worrying signs of liver disease. Yet Dr. Wang allegedly ignored this directive and delayed 

the necessary treatment—for two and a half years. Smith, along with our other Eighth 

Amendment cases, put him on notice that this denial of care was constitutionally deficient.

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Dr. Wang counters that Smith “does not establish, much less clearly establish, that 

monitoring a patient’s chronic [hepatitis C virus] is unconstitutional.” Wang’s Reply Br. at 

6–7. But clearly established law doesn’t require identical facts. None of the above cases, 

of course, deal with the precise issue of hepatitis C treatment. But requiring such specificity 

in the case of a treatment provider’s decisions would allow a doctor limitless opportunity 

to deny medical care unless the precise required treatment for a specific underlying illness 

had been addressed by our Court. We decline to distort qualified immunity into such an 

absolute immunity.

Likewise, Dr. Wang was on notice that providing some care—even if unreasonable 

or deficient—does not clear the constitutional bar. See Jehovah, 798 F.3d at 181–82 

(establishing that providing “some treatment” but ignoring or failing to treat other serious 

symptoms can violate the Eighth Amendment); De’lonta, 330 F.3d at 635. Thus, he was 

on notice that failing to adequately respond to Pfaller’s signs of severe liver disease in 2018

could also be constitutionally deficient. The district court was correct to deny qualified 

immunity to Dr. Wang at this stage. 

C.

Next, we address whether Dr. Amonette, the Department’s chief physician who 

designed the Guidelines, is entitled to qualified immunity. Given the difference in the roles 

that Dr. Amonette and Dr. Wang played, it is necessary to analyze them separately. See 

Thompson, 878 F.3d at 107. And ultimately, the two officials go on separate tracks. 

We will assume without deciding that Dr. Amonette’s actions amounted to 

deliberate indifference and turn directly to the question of how to consider the clearly 

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established prong of the qualified-immunity analysis. We conclude that Dr. Amonette’s 

conduct appears closer to the defendants’ conduct in Taylor than in Thorpe, so we must 

proceed to our usual “clearly established” inquiry. And, after evaluating the case law, we 

conclude that Dr. Amonette was not on sufficient notice that he was violating a clearly 

established right.

To start, it bears emphasizing that “the lodestar for whether a right was clearly 

established is whether the law ‘gave the officials “fair warning” that their conduct was 

unconstitutional.’” Iko, 535 F.3d at 238 (quoting Ridpath v. Bd. of Governors Marshall 

Univ., 447 F.3d 292, 313 (4th Cir. 2006)). The district court defined the constitutional right 

at issue for Dr. Amonette in the same way it defined it as to Dr. Wang: “Pfaller’s Eighth 

Amendment right to receive adequate medical care and to be free from officials’ deliberate 

indifference to his known medical needs.” Pfaller, 630 B.R. at 215. But while the case law 

establishing that right sufficed to give Dr. Wang fair warning that he could not deny

necessary medical treatment to Pfaller as his primary care provider, it was not enough to 

give Dr. Amonette fair warning that his system-wide treatment Guidelines for a new drug

were constitutionally deficient. Those contexts differ. 

Like the defendants in Taylor, Dr. Amonette never “personally interacted with” 

Pfaller. Taylor, 575 U.S. at 824. He only learned of Pfaller’s medical condition shortly 

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before Pfaller’s cancer diagnosis. So Dr. Amonette’s conduct could have violated the 

Constitution only if the Guidelines themselves were inadequate.

4

On this question, we must remember qualified immunity’s purpose: it “gives 

government officials breathing room to make reasonable but mistaken judgments about 

open legal questions.” Ashcroft, 563 U.S. at 743. And here, there was—and remains—an 

open question as to what kind of treatment protocol for administering direct-acting 

antivirals is constitutionally sufficient in a prison system.

Dr. Amonette, for his part, created a system of prioritization where the sickest 

inmates received treatment first. Those that did not qualify for treatment nonetheless 

received continuous monitoring. At the time, the medical community and the Federal 

Bureau of Prisons agreed. They recognized that while immediate treatment of all hepatitis 

C patients was recommended, prioritization was reasonable where resources were limited.

The district court, of course, found there was a genuine issue of material fact as to 

whether the Department’s resources were actually limited. The limitation at issue here was 

the number of providers at the VCU clinic who could provide treatment to inmates. Dr. 

Amonette relied on VCU’s specialty providers because he believed it was not “clinically 

4 To be sure, we do not hold that an official must have personally interacted with a 

prisoner to have violated the Eighth Amendment. In fact, we have expressly rejected that 

view in a case involving Dr. Amonette himself. See Gordon, 937 F.3d at 362 (“Put simply, 

Amonette may not escape liability by claiming that he did not know the identities of the 

inmates who would suffer under his policies.”). But the attenuation between Dr. 

Amonette’s conduct and the risk here is relevant to why we find this case more similar to

Taylor than Thorpe and therefore why it is necessary to delve into the clearly established 

law analysis. 

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appropriate” to have the Department’s own primary care providers prescribe the new 

direct-acting antivirals “without specialty input.” J.A. 117. 

Plaintiff’s expert, however, stated that the Department’s providers could have felt 

comfortable treating inmates with direct-acting antivirals. Even assuming that is true, we 

find it notable that this dispute over resources arises directly from the novelty of the drug

and the open question of how to appropriately prescribe it. Under these facts, we decline 

to hold that Dr. Amonette was clearly on notice that he should have ordered the 

Department’s primary care providers to prescribe this novel treatment rather than referring 

patients to specialists for treatment.

Meanwhile, various Courts of Appeals opinions have cut different ways regarding 

whether similar treatment guidelines pass constitutional muster or violate clearly 

established law. Compare Atkins v. Parker, 972 F.3d 734, 739–40 (6th Cir. 2020) (holding 

that prison medical director was not deliberately indifferent for failing to provide directacting antivirals to all inmates), Hoffer v. Sec’y, Fla. Dep’t of Corr., 973 F.3d 1263, 1277 

(11th Cir. 2020) (same), and Bernier v. Allen, 38 F.4th 1145, 1157 (D.C. Cir. 2022)

(finding there was no clearly established right in 2015 that inmate should immediately 

receive new antiviral treatment), with Abu-Jamal v. Kerestes, 779 F. App’x 893, 900 (3d 

Cir. 2019) (holding that denying direct-acting antivirals to inmate could constitute an 

Eighth Amendment violation). 

This varying case law shows the inherent gray area that Dr. Amonette was operating 

in. And “qualified immunity protects public officials from bad guesses in gray areas.” 

Durham v. Horner, 690 F.3d 183, 190 (4th Cir. 2012) (citation and internal quotation marks 

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omitted); see also Taylor, 575 U.S. at 825 (“We do not require a case directly on point, but 

existing precedent must have placed the statutory or constitutional question beyond 

debate.” (quoting Ashcroft, 563 U.S. at 741)). Tasked with designing a treatment regimen

for a novel drug, Dr. Amonette wasn’t given notice by our case law that his ultimate 

choice—a system that prioritized treatment with direct-acting antivirals for the sickest 

patients while offering monitoring for others—was (as we have assumed) deficient. And 

the record, as the district court interpreted it, doesn’t sufficiently show that Dr. Amonette 

knew that the Guidelines, while wanting, violated the Eighth Amendment. “In short, even 

if the [Guidelines] contained the shortcomings that [Plaintiff] allege[d], no precedent on 

the books in [2015] would have made clear to [Dr. Amonette] that [he was] [designing] a 

system that violated the Constitution.” Taylor, 575 U.S. at 827.

That, of course, doesn’t mean that the novelty of a treatment regimen will always 

immunize an official’s bad guess. There are certainly situations where the risk of medical 

harm is obvious and a right to a specific treatment was clearly established. See Hope, 536 

at 741 (“[O]fficials can still be on notice that their conduct violates established law even in 

novel factual circumstances.”). But we can’t say that’s the case here. A prisoner’s 

purported right not to be subjected to a treatment regimen that prioritized antiviral 

treatment to prisoners with the most advanced levels of fibrosis was not clearly established

when Dr. Amonette designed the Guidelines in 2015.

III.

The final question posed in this appeal is whether Dr. Wang is entitled to sovereign 

immunity on Pfaller’s medical-malpractice claim. On appeal, Dr. Wang claims that he is 

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entitled to summary judgment on Plaintiff’s medical-malpractice claim because, as a 

Virginia state employee, he is shielded by derivative sovereign immunity. We agree. 

In Virginia, to determine whether derivative sovereign immunity applies to a state 

employee, a court must “focus on four, non-exclusive factors.” Patterson v. City of 

Danville, 875 S.E.2d 65, 70 (Va. 2022). These factors are (1) “the function th[e] employee 

was performing”; (2) “the extent of the state’s interest and involvement in that function”; 

(3) “[w]hether the act performed involves the use of judgment and discretion”; and (4) “the 

degree of control and direction exercised by the state over the employee.” James v. Jane, 

282 S.E.2d 864, 869 (Va. 1980). “Because this multi-factor test is broadly worded and 

capable of disparate applications,” courts should conduct a “fine-grained analysis that 

looks to prior applications involving fact patterns that most closely parallel the case before 

[them].” Patterson, 875 S.E.2d at 70 (citation and internal quotation marks omitted). And 

here, we are aided by a recent Supreme Court of Virginia decision that involves another 

medical-malpractice claim brought against none other than Dr. Wang himself. That 

decision, Patterson v. City of Danville, which arrived while this appeal was pending, 

largely controls the outcome here.

The first two factors—the nature of the function performed by the employee and the 

extent of the Government’s interest and involvement in that function—are usually 

considered together. See, e.g., Lohr v. Larsen, 431 S.E.2d 642, 644 (Va. 1993). In general, 

“if the function that a government employee was negligently performing was essential to a 

governmental objective and the government had a great interest and involvement in that 

function, those factors would weigh in favor of the employee’s claim of sovereign 

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immunity.” Id. In contrast, “if that function has only a marginal influence upon a 

governmental objective, and the government’s interest and involvement in that function 

are ‘slight,’” sovereign immunity is disfavored. Id. (quoting James, 282 S.E.2d at 870).

The district court found that both factors weighed against sovereign immunity in the 

present case. Specifically, the court noted that while Virginia “undoubtedly has an 

important interest [in] the provision of medical care to inmates, . . . the state’s ‘paramount’ 

interest at [the prison] is incarceration.” Pfaller, 2021 WL 1776189, at *12. Based on its 

reading of Virginia case law, the court concluded that “if the state’s paramount interest is 

not the provision of medical care, these factors weigh against sovereign immunity.” Id. 

That reading was squarely rejected by the Supreme Court of Virginia’s subsequent 

decision in Patterson. In that case, the court considered whether derivative sovereign 

immunity extended to Dr. Wang as an employee at another, minimum-security facility.

Patterson, 875 S.E.2d at 67. The court noted that Dr. Wang’s function—providing medical 

care to incarcerated patients—“was not simply a benevolent act of governmental grace.” 

Id. at 72. Rather, the state “had a constitutional and statutory duty to provide medical care 

to incarcerated patients” through physicians like Dr. Wang. Id. “In such circumstances, the 

governmental ‘interest and involvement’ is at its apogee.” Id. (citation omitted). So, the 

court concluded that “[t]here can be little doubt” that the first two factors of the test favored 

sovereign immunity. Id. 

This case fares no different. Dr. Wang’s function at Pfaller’s prison was to provide

medical care to incarcerated patients, just as it was in Patterson. Under federal and state 

law, Virginia is required to provide such care. See Va. Code Ann. § 53.1-32(A); Williams 

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v. Commonwealth, 810 S.E.2d 885, 888 (Va. 2017). In those circumstances, the state’s 

interest and involvement in that function “is at its apogee.” Patterson, 875 S.E.2d at 72. 

The district court erred by discounting that interest and focusing too heavily on the state’s 

“paramount” interest in incarceration. Under Patterson, the first two factors clearly weigh 

in favor of finding sovereign immunity.

The third factor—whether the act performed involves the use of judgment and 

discretion—is a closer call. If the challenged act involves “broad discretion,” that tends to 

“weigh heavily in favor of a government employee’s claim of immunity.” Lohr, 431 S.E.2d 

at 645. Conversely, if the employee is merely “performing a ministerial act,” they will 

likely be liable in negligence. Id.

The district court found this factor weighed against sovereign immunity because 

“Wang’s discretion was severely curtailed by the [Department] Guidelines.” Pfaller, 2021 

WL 1776189, at *13. Specifically, it noted the Department “prescribed the course of 

monitoring and treatment for inmates with Hepatitis C” via the Guidelines, “and Wang’s 

role was to follow that prescription.” Id. So, it concluded that Dr. Wang was performing a 

primarily ministerial act, which is not shielded by sovereign immunity.

This analysis undercounts Dr. Wang’s discretion. Although his discretion was 

constrained by the Guidelines, it was not eliminated. Even if patients like Pfaller did not 

meet the APRI and FIB-4 cutoffs, Dr. Wang could still request a referral if he concluded 

that those patients were displaying other symptoms “suggestive of advanced liver disease.” 

J.A. 240. And as the district court recognized, in certain “emergency circumstances” Dr. 

Wang could circumvent the Guidelines criteria entirely. Pfaller, 2021 WL 1776189, at *13. 

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Decisions like these necessarily involve “the use of judgment and discretion.” Lohr, 431 

S.E.2d at 645; see also Pike v. Hagaman, 787 S.E.2d 89, 93 (Va. 2016) (nurse “was 

exercising discretion in caring for” plaintiff even if discretion was cabined by doctor’s 

orders); cf. Patterson, 875 S.E.2d at 72 (noting that the Supreme Court of Virginia’s “cases 

uniformly emphasize the highly discretionary character of professional medical care”).

Thus, while this factor tends to weigh against immunity, the district court overstated by 

how much. 

That leaves the fourth factor: the degree of government control over the employee. 

In general, “[a] high level of control weighs in favor of immunity; a low level of such 

control weighs against immunity.” Lohr, 431 S.E.2d at 646. At first glance, this fourth 

factor (government control) appears to be at odds with the third factor (employee 

discretion). However, the Supreme Court of Virginia has clarified that government control 

has “diminished relevance . . . in the context of a medical professional.” Patterson, 875 

S.E.2d at 71. After all, “when a government employee is specially trained to make 

discretionary decisions”—like a medical professional is—“the government’s control must 

necessarily be limited in order to make maximum use of the employee’s special training 

and subsequent experience.” Lohr, 431 S.E.2d at 646. Therefore, when examining 

government control of state physicians, we are less concerned with the government’s 

control of the disputed action at issue (which necessarily involves the use of medical 

judgment), and more concerned with the government’s control of the physician’s work 

environment in general. See id. (examining whether the clinic controlled the patients seen 

by the provider, the equipment he used, and the procedures he could perform).

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For example, in Patterson, the Supreme Court of Virginia found this factor weighed 

in favor of sovereign immunity because the evidence showed, among other things, that Dr. 

Wang (1) “had no control over the patients that he was obligated to treat”; (2) was required 

to use “City-owned medical equipment and supplies”; (3) “did not possess or control any 

of the medical records of his patients”; (4) “was governed by medical policies and 

procedures promulgated by the Virginia Board of Corrections”; and (5) was subject to 

supervision by the prison director. Patterson, 875 S.E.2d at 73. 

In the instant case, the district court concluded that this factor weighed in favor of 

sovereign immunity for many of the same reasons: (1) Dr. Wang “cannot choose his own 

patients or refuse to see certain patients”; (2) “[a]ll the equipment he uses is provided by” 

the Department; and (3) he was required to follow the Department’s Guidelines when 

treating hepatitis C patients. Pfaller, 2021 WL 1776189, at *14. Given the similarities of 

these facts to those that the Supreme Court of Virginia found determinative in Patterson, 

we agree with the district court that this factor favors sovereign immunity. 

Overall, three of the four factors strongly weigh in favor of sovereign immunity, 

and one only moderately weighs against it. Therefore, we conclude that the district court 

erred by rejecting Dr. Wang’s sovereign-immunity defense.

IV.

For the foregoing reasons, we affirm the district court’s denial of qualified immunity 

to Dr. Wang on the Eighth Amendment claim. But we must reverse the denial of qualified 

immunity to Dr. Amonette. Additionally, we reverse the denial of sovereign immunity to 

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Dr. Wang on the medical-malpractice claim. We remand for further proceedings consistent 

with this opinion. 

AFFIRMED IN PART,

REVERSED IN PART,

AND REMANDED

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WILKINSON, Circuit Judge, concurring in part and dissenting in part:

The plaintiff’s Eighth Amendment claim against Dr. Wang fails as a matter of law. 

The undisputed facts show that Dr. Wang was not deliberately indifferent to Pfaller’s 

serious medical needs. Pfaller proffered no evidence that Dr. Wang “had actual 

knowledge” that not ordering fibroscan testing when Pfaller’s FIB-4 scores were 1.46 and 

1.48 created “an excessive risk” to his health. Danser v. Stansberry, 772 F.3d 340, 347 (4th 

Cir. 2014). Nor was the risk “so obvious” that Dr. Wang must have known of it. Rish v. 

Johnson, 131 F.3d 1092, 1099 (4th Cir. 1997). Rather, all the evidence suggests that Dr. 

Wang acted in good faith and was, at worst, negligent. Because there is no evidence to the 

contrary, the “undisputed facts demonstrate” no violation of Pfaller’s constitutional rights. 

Winfield v. Bass, 106 F.3d 525, 533 (4th Cir. 1997) (en banc). 

The Supreme Court has clearly instructed that Eighth Amendment deliberateindifference claims are the narrow exception to the general rule that federal courts should 

not second-guess the medical judgments of doctors in state prisons. The Court has stated 

in no uncertain terms that “an inadvertent failure to provide adequate medical care” or a 

physician’s “negligent” diagnosis or treatment does not violate the Eighth Amendment. 

Estelle v. Gamble, 429 U.S. 97, 105–06 (1976). The majority contravenes Estelle and 

collapses the distinction between deliberate indifference and negligence. In so doing, it 

further thrusts the federal courts into the minutiae of state prison administration to the 

detriment of the Constitution’s reservation of powers to the states and sound state 

policymaking.

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When deliberate indifference bleeds into negligence, the losers will ultimately be 

inmates themselves. Inmates deserve decent medical care. Yet prison practice is not a 

desirable option for many physicians. Many doctors prefer to treat patients who have not 

been convicted of serious crimes. It would seem elemental that law should counter, not 

contribute to, these disincentives. Yet while doctors outside prison gates enjoy robust 

protections against negligent medical-malpractice suits, those treating the incarcerated 

face, as here, Eighth Amendment negligence claims in contravention of the deliberateindifference standard. Virginia law, as the panel unanimously concludes, would not permit 

this suit to proceed. See Patterson v. City of Danville, 875 S.E.2d 65 (Va. 2022). Yet 

Virginia’s red light is superseded by the majority’s green.

Privileging prisoner suits in this manner will chase more willing or altruistic doctors 

away. It is sad indeed that Pfaller died. It would also be sad, and very wrong, if we were to 

lay his death at this doctor’s door. Diluting the deliberate-indifference standard, and 

running roughshod over Virginia law, not only fractures our federal system. It will consign 

inmates over time to ever more substandard medical care. 

I.

We must journey to the headwaters of prisoner Eighth Amendment medical-care 

claims in order to appreciate how undesirably far from the Supreme Court’s teachings we 

have come. See Estelle v. Gamble, 429 U.S. 97 (1976). The language of limitation flows 

throughout the Estelle opinion. Estelle concluded that “deliberate indifference to serious 

medical needs of prisoners constitutes the unnecessary and wanton infliction of pain 

proscribed by the Eighth Amendment.” 429 U.S. at 104 (quotation marks and citation 

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omitted). But this does not mean “that every claim by a prisoner that he has not received 

adequate medical treatment states a violation of the Eighth Amendment.” Id. at 105. Rather, 

“an inadvertent failure to provide adequate medical care cannot be said to constitute an 

unnecessary and wanton infliction of pain or to be repugnant to the conscience of 

mankind.” Id. at 105–06 (quotation marks omitted). So, “a complaint that a physician has 

been negligent in diagnosing or treating a medical condition does not state a valid claim of 

medical mistreatment under the Eighth Amendment.” Id. at 106. “Medical malpractice” is 

not a “constitutional violation.” Id.

The facts of Estelle are instructive. “Even applying the[] liberal standards” 

applicable to pro se complaints, the Court held that the plaintiff failed to state an Eighth 

Amendment claim against his treating physician. Id. at 107. The plaintiff’s doctors had 

diagnosed his injury and prescribed medication, but the plaintiff complained that he should 

have received additional diagnostic testing and treatment. Id. The Court disagreed, noting 

that “the question whether an X-ray or additional diagnostic techniques or forms of 

treatment is indicated is a classic example of a matter for medical judgment.” Id. The 

“medical decision not to order an X-ray, or like measures, does not represent cruel and 

unusual punishment” and is “[a]t most . . . medical malpractice.” Id. The Court held that 

the plaintiff’s complaint against his doctor did not survive a motion to dismiss, id. at 108—

a conclusion that applies with special force here given that Pfaller needed to meet an even 

higher burden at summary judgment, see infra Part II. Thus, Estelle created the Eighth 

Amendment deliberate-indifference claim but, from the very beginning, limited such 

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claims to conduct that is far more egregious than mere negligence and indeed far more 

egregious than anything that took place in this case.

Estelle controls this decision. 

II.

Our circuit has tried to give effect to Estelle and its progeny by establishing a “very 

high standard” that deliberate-indifference plaintiffs must meet to survive a defendant’s 

motion for summary judgment. Danser, 772 F.3d at 347 (quoting Grayson v. Peed, 195 

F.3d 692, 695 (4th Cir. 1999)). The majority today ignores that standard, strays from Estelle

and our caselaw, and collapses the distinction between deliberate indifference and 

negligence. In truth, the undisputed facts refute the suggestion that Dr. Wang was 

deliberately indifferent to Pfaller’s medical needs. 

A.

Let’s give Estelle its due. To establish deliberate indifference, a plaintiff must 

“show[] that the prison official ‘kn[ew] of and disregard[ed] an excessive risk to inmate 

health or safety.’” Danser, 772 F.3d at 347 (quoting Farmer v. Brennan, 511 U.S. 825, 837 

(1994)). This is a “very high standard,” Grayson, 195 F.3d at 695, “which requires that a 

plaintiff introduce evidence suggesting that the prison official had actual knowledge of an 

excessive risk” to the plaintiff’s health or safety, Danser, 772 F.3d at 347 (emphasis 

added). The official “must both be aware of facts from which the inference could be drawn 

that a substantial risk of serious harm exists, and he must also draw the inference.” Id. 

(quotation marks omitted). Crucially, a plaintiff’s “unsupported speculation” that the 

defendant was aware of the risk “is insufficient to create a disputed issue of material fact 

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for purposes of summary judgment.” Id. at 348 n.10; see Elliott v. Leavitt, 99 F.3d 640, 

644 (4th Cir. 1996).

Rather, a plaintiff can show actual knowledge in either of two ways: The plaintiff 

can produce “direct evidence supporting a conclusion that the prison officials actually 

knew” of a risk of harm—for instance, “deposition testimony or affidavit[s].” Rish, 131 

F.3d at 1099. Short of such direct evidence, the plaintiff can demonstrate knowledge 

through “circumstantial evidence” by showing that the “risk was so obvious that it can be 

inferred that the prison officials knew of it.” Id. (citing Farmer, 511 U.S. at 842); see Brice 

v. Va. Beach Corr. Ctr., 58 F.3d 101, 105 (4th Cir. 1995) (noting that the risk must be “so 

obvious . . . that the [officer] did know of it because he could not have failed to know of 

it.”). If the plaintiff cannot make at least one of these showings, his deliberate-indifference 

claim fails as a matter of law. See Rish, 131 F.3d at 1100–01; Danser, 772 F.3d at 348–49. 

B.

The undisputed facts here negate any possibility of deliberate indifference and 

instead show Dr. Wang’s good faith. The plaintiff failed to produce even an iota of 

evidence that Dr. Wang was deliberately indifferent to Pfaller’s serious medical needs. He 

produced no direct evidence that Dr. Wang had actual knowledge of an excessive risk to 

his health. Nor was the risk so obvious that Dr. Wang must have known of it. All Pfaller 

can muster is “unsupported speculation” that Dr. Wang was aware of the risk, which “is 

insufficient to create a disputed issue of material fact for purposes of summary judgment.” 

Danser, 772 F.3d at 348 n.10.

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Pfaller first alleges that Dr. Wang was deliberately indifferent in failing to order a 

fibroscan when Pfaller’s FIB-4 scores were 1.48 in October 2015 and 1.46 in July 2017. 

See J.A. 1954–57; Br. of Appellee at 10–11. He argues that Dr. Wang was deliberately 

indifferent because he ignored the VDOC guidelines recommending fibroscans for FIB-4 

scores greater than 1.45. Br. of Appellee at 10–11; see J.A. 1954–55. But the VDOC 

guidelines are not evidence that Dr. Wang knew the correct thresholds and ignored them: 

“[D]efendants’ mere access to information [is] insufficient to show on summary judgment 

that defendants actually used that information.” Danser, 772 F.3d at 348 n.10 (citing 

Othentec Ltd. v. Phelan, 526 F.3d 135, 142 (4th Cir. 2008)). Pfaller produced no evidence

that Dr. Wang “had actual knowledge” that not ordering a fibroscan when Pfaller’s FIB-4 

scores were 1.48 and 1.46 would create an “excessive risk” to his health. Id. at 347.

Nor was this risk “so obvious” that Dr. Wang must have known about it. Rish, 131 

F.3d at 1099. The lack of obvious risk here is apparent given the undisputed facts: Pfaller 

showed no symptoms of liver decompensation when these FIB-4 scores were calculated. 

See J.A. 1713–14. Dr. Wang was a family medicine doctor, not a specialist in HCV. Id. at 

1496–97. And the actual VDOC FIB-4 cutoff (1.45) was very close to and easily confused 

with what Dr. Wang believed to be the cutoff (1.5), and a different VDOC HCV policy 

used 1.5 as its cutoff. See id. at 1954–55. This is scarcely the sort of mistake that was so 

obvious that Dr. Wang must have been aware of it. 

Pfaller also argues that Dr. Wang exhibited deliberate indifference between May 

and July 2018, when he ordered a fibroscan but did not immediately follow up. Br. of 

Appellee at 10–11. But Pfaller has introduced no evidence that in so doing, Dr. Wang 

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“knew of and disregarded an excessive risk” to Pfaller’s health. Danser, 772 F.3d at 347 

(quotation marks omitted and alterations adopted). 

The following facts are undisputed: Dr. Wang calculated Pfaller’s FIB-4 score to be 

2.18 on May 9, 2018 and ordered a fibroscan less than a week later, on May 14. J.A. 1958. 

There was no way for Dr. Wang to conduct a fibroscan himself; he had to request that a 

third party, VCU, schedule Pfaller for a fibroscan. Id. Dr. Wang saw Pfaller twice in June 

for symptoms of liver disease and prescribed him seven different medications to relieve 

those symptoms. Id. at 1958–59. At this time, Dr. Wang knew that Pfaller was already “on 

the list to be scheduled for a Fibroscan at VCU.” Id. at 1958. When Pfaller appeared in Dr. 

Wang’s clinic on July 11, 2018 “with complaints of fullness in his abdomen,” Dr. Wang 

followed up with VCU, ordering a fibroscan “asap.” Id. at 1959. 

As a matter of law, these undisputed facts do not establish deliberate indifference. 

There is no evidence that Dr. Wang actually knew that his course of action—continuing to 

treat Pfaller with medication while waiting for VCU to complete his request for a 

fibroscan—created an excessive risk to Pfaller’s health. Nor was this risk so obvious that 

Dr. Wang must have been aware of it: There is surely some reasonable period that a doctor 

might wait after ordering testing from a third party. That decision, like the question whether 

to order “additional diagnostic techniques” in the first place, “is a classic example of a 

matter for medical judgment.” Estelle, 429 U.S. at 107. Treating Pfaller with medication 

while waiting a month or two for VCU to conduct a fibroscan was a “medical judgment” 

that “does not represent cruel and unusual punishment.” Id. 

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C.

Even assuming, purely arguendo, that Dr. Wang had actual knowledge of a 

substantial risk to Pfaller’s health, no case can be made that Dr. Wang deliberately 

disregarded that risk. See Estelle, 429 U.S. at 104; Danser, 772 F.3d at 347. There is not a 

single shred of evidence that Dr. Wang had any animus or other motive to deliberately 

ignore Pfaller’s medical needs. Why would he? Did he possess some malevolent 

temperament? Did he bear some grudge against Pfaller? The majority does not and cannot 

suggest any such thing. Given the dearth of evidence of deliberateness in the record, no 

reasonable person could conclude that this element of the deliberate-indifference standard 

was met. 

Far from deliberately ignoring Pfaller’s needs, the undisputed facts show that Dr. 

Wang tried to treat Pfaller’s HCV and made, at worst, honest mistakes about the FIB-4 

threshold for fibroscan testing. Dr. Wang did not order a fibroscan when Pfaller’s FIB-4 

scores were below what he believed to be the threshold, but he did order one as soon as 

Pfaller received a score above that value. See J.A. 1958. Once again, when Pfaller presented 

with symptoms of liver disease in June 2018, Dr. Wang prescribed him seven different 

types of medication. Id. at 1958–59. And when VCU had not scheduled Pfaller’s fibroscan 

after two months, Dr. Wang demanded that he receive the test “asap.” Id. at 1959. A 

deliberately indifferent doctor would not have done any of this. 

The majority repeatedly concedes that Dr. Wang provided Pfaller with medical care 

for his HCV but contends that this fact is irrelevant to whether he was deliberately 

indifferent. See Maj. Op. at 23–24. The majority’s position raises the unknowable question 

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of how much medical care is enough and abandons this whole area of law to indeterminacy. 

Often the best medical care lies in monitoring and observation, not in disturbing patient 

stasis. But given the majority’s rule, physicians will be tempted to overprescribe and 

overtest to avoid Eighth Amendment claims—the easiest path for minimizing liability. The 

majority ultimately substitutes judicial judgment for medical judgment. But our chambers 

are not a doctor’s office. We cannot don our white coats and apply our own preferred 

diagnostic and treatment regimens in place of physicians’ medical judgment. By forsaking 

Estelle’s high standard for deliberate-indifference claims, the majority encourages courts 

to venture into medical judgments that we are woefully unqualified to make. 

Indeed, the majority’s opinion reads like a routine negligence case and of course, in 

such a case, the inferences at the summary-judgment stage belong to the non-moving party. 

What the majority neglects, however, is the fact that the value of any immunity and 

heightened standard of proof lies in resolving claims at an earlier rather than later stage of 

litigation. This whole dimension of the problem is ignored by my good colleagues. In 

addition to being wrong on the outcome, the majority is wrong on the process. By 

embracing routine full-dress litigation even in the face of so many undisputed material 

facts, it has doubled down on the difficulties of its position and further undermined the

value that the deliberate-indifference standard was intended to have. 

III.

A.

When federal courts gratuitously interfere with state prison administration, we 

damage the Constitution’s differentiation between the enumerated powers of the federal 

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government and the residual powers of the states. It is true that Article I, section 8 is a great 

charter of federal enumerated power, including the national economic engine that is the 

Commerce Clause. See U.S. Const., art. I, § 8. But at the same time, the “powers not 

delegated to the United States by the Constitution, nor prohibited by it to the States, are 

reserved to the States respectively, or to the people.” U.S. Const. amend. X. These residual 

powers must include something of meaning if our system of dual sovereignty is to be 

preserved and the states not relegated to the position of lesser sovereigns or inferior 

partners. As Justice Iredell noted long ago, “[e]ach State in the Union is sovereign as to all 

the powers reserved. . . . [T]he United States have no claim to any authority but such as the 

States have surrendered to them.” Chisholm v. Georgia, 2 U.S. (2 Dall.) 419, 435 (1793). 

The often salutary growth of federal power since must not obscure the democratic 

virtues that state decision-making still retains. If the residual power of the states is to mean 

anything, it would seem to preserve a good amount of state autonomy over state institutions 

like schools and prisons. The administration of schools, for example, implicates highly 

local, policy-driven judgments about how the state “provides for the education of its 

children”—“an area in which [the Court] has traditionally deferred to state legislatures.” 

San Antonio Indep. Sch. Dist. v. Rodriguez, 411 U.S. 1, 40 (1973). State prisons and their 

medical facilities implicate the same basic local policy concerns. “[C]ourts are ill equipped 

to deal with . . . problems of prison administration,” which “require expertise, 

comprehensive planning, and the commitment of resources.” Procunier v. Martinez, 416 

U.S. 396, 405 (1974). For this reason, “[t]raditionally, federal courts have adopted a broad 

hands-off attitude toward problems of prison administration.” Id. at 404. Operating prisons 

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and providing medical care to inmates are among the residual powers most clearly reserved 

to the states. The majority’s granular intrusion is, yet once again, exactly what Estelle v. 

Gamble sought to avoid. 

Those who control the levers of federal power—be they legislators or judges—risk 

arrogating to themselves powers that our Constitution never meant them to have. I am 

disappointed that my esteemed colleagues in the majority have joined the company of 

federal overlords who view the states as little more than junior varsity sovereigns. 

B.

This case is a perfect example of how a federal court can undermine a state’s policy 

decisions by allowing a suit for a constitutional violation to go forward where no such 

violation exists. The plaintiff in this case brought, in addition to his federal deliberateindifference claim, a state medical-malpractice claim based on Dr. Wang’s alleged 

negligence in treating Pfaller’s HCV. J.A. 80–81. All members of this panel rightly agree 

that in light of the Virginia Supreme Court’s decision in Patterson v. City of Danville, 875 

S.E.2d 65 (Va. 2022), Pfaller’s malpractice claim is barred by state sovereign immunity. I 

readily join in the majority’s fine opinion on this point. See Maj. Op. Part III.

Patterson is important because it demonstrates how Virginia conceives of its own 

interest in determining how to provide medical care to its prisoners. Virginia applies a fourfactor test to determine whether a government employee is protected by sovereign 

immunity. Id. at 70. These factors are “(i) the nature of the function performed by the 

employee; (ii) the extent of the [state’s] interest and involvement in the function; (iii) the 

degree of control and direction exercised by the [government employer] over the employee; 

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and (iv) whether the act complained of involved the use of judgment and discretion.” Id. 

(quotation marks omitted). Crucially, the Patterson Court held that the state’s 

“governmental interest and involvement” in “provid[ing] medical care to incarcerated 

patients . . . is at its apogee.” Id. at 72 (quotation marks omitted). Given this fact, along 

with the discretionary nature of medical care and the degree of governmental control over 

the doctor, the Court held that the medical-malpractice suit was barred by state sovereign 

immunity. Id. at 73. 

The Virginia Supreme Court has thus determined that medical-malpractice suits 

alleging a doctor’s negligence implicate the state’s weighty interest in providing medical 

care to prisoners and are therefore barred by sovereign immunity. One might disagree with 

Virginia’s invocation of sovereign immunity in these circumstances, but mere 

disagreement with a state policy does not license a federal court to cavalierly supersede it 

in the name of enforcing a federal right. 

That is precisely what the majority does today. In one breath, the majority rejects 

Pfaller’s state medical-negligence claim on the basis of sovereign immunity. With the next, 

the majority allows a federal claim predicated only on negligent acts to proceed in the guise 

of a deliberate-indifference claim. The majority effectively supersedes the state’s judgment 

that sovereign immunity ought to bar medical-negligence suits. It accomplishes the precise 

end that the state sought to avoid: subjecting state prison doctors to suit for what are 

essentially negligence allegations. This case, like all too many others, is a classic example 

of how federal constitutional activism has wrested from the states control over their own 

institutions.

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The consequences will be severe. Virginia’s interest in claiming sovereign 

immunity from medical-malpractice suits is grounded in legitimate concerns about its 

prison doctors being inundated with such claims. The majority invites a big increase in 

lawsuits that threaten to lodge in federal judges the power to second-guess state prison 

doctors’ exercise of “medical judgment.” Estelle, 429 U.S. at 107. Under the majority’s 

rule, a plaintiff offering nothing more than mere speculation that a doctor was deliberately 

indifferent can overcome the doctor’s immunity and force him to stand trial.

It does not take an economist to predict what will happen when a state’s prison 

doctors are hauled into federal court for any perceived deficiency in medical care and 

branded with the stigma of deliberate indifference for honest mistakes: Good doctors will 

be strongly discouraged from providing their services in state prisons. Thus, unwarranted 

federal interference with state prisons works not only to the detriment of our federal system, 

but to the well-being of prisoners themselves. 

IV.

The moral of this case is simple. In the words of the great Scottish poet Robert 

Burns, “The best-laid schemes o’ Mice an’ Men gang aft agley.” Robert Burns, To a Mouse

(1785). The Supreme Court, with the best of intentions, sought to crack the door a little bit 

to a limited category of prisoner medical-mistreatment claims where the high standard of 

deliberate indifference was met. But those best intentions have gone badly awry. Over time, 

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what the Supreme Court intended as a small crack of the door has been flung wide by the 

lower federal courts. This case and Estelle v. Gamble bear scant resemblance. 

Not only that. The “best-laid” plans of the majority will “gang aft agley” as well, as 

its admirable desire for adequate medical care for inmates will likely occasion just the 

opposite. 

This did not need to be. That the majority bumps so squarely against both 

constitutional law and the law of unintended consequences should have given it pause. I 

do concur in Parts II.C and III of its opinion. I respectfully dissent in part and would reverse 

the judgment below in its entirety and remand with instructions to dismiss the complaint.

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