Opinion ID: 173302
Heading Depth: 2
Heading Rank: 2

Heading: Clinical Director Nafziger

Text: Before we get to the nub of Mr. Arocho’s claim against Nafziger, we wish to clear away two meritless points advanced against it. First, defendants seize and expand upon the district court’s characterization of the case as involving nothing more than a difference of medical opinion in light of the more recent October 2008 blood tests that, in the testing physician’s opinion, disqualified Mr. Arocho for treatment. Aplee. Br. at 20-23. What we have just said about this procedurally improper and substantively inadequate line of argument in connection with the claim against Lappin, see supra page 20, note 12, is equally pertinent here. Second, to the extent Nafziger is included in appellees’ indiscriminate statement that “there is no allegation that the Defendants were aware of any emergent need for Interferon/Ribavirin,” Aplee. Br. at 20, the contention borders on the frivolous. Nafziger allegedly recommended the Interferon/Ribavirin treatment because his testing revealed that Mr. Arocho’s Hepatitis C was causing liver damage. The general theme of the complaint, attributing primary responsibility for the denial of treatment to Lappin, appears to supply Nafziger with grounds for exoneration rather than liability: Nafziger discovered the immediate threat posed 12 (...continued) such an interval itself may give rise to cognizable harm. See generally Erickson v. Pardus, 551 U.S. 89, 92 (2007) (recognizing sufficiency of claim that prisoner “will suffer irreparable damage if his [Hepatitis C] disease goes untreated”). -21- by the Hepatitis C, concluded that Interferon/Ribavirin treatment was appropriate, and recommended that Lappin approve the treatment. As the district court concluded, this “does not evidence the degree of neglect sufficient to find that Defendant Nafziger was deliberately indifferent to Plaintiff’s medical needs. Indeed, it evidences no neglect at all.” R. vol. 4 at 148-49 (citation omitted). But there is a second, counter-theme evident, though less prominent, in the claim directed specifically at Nafziger. Mr Arocho attributes the continuing delay in obtaining the recommended treatment, at least in part, to Nafziger’s own inaction and indifference. He alleges that since his favorable psychological assessment for the treatment in September 2007, he has “contact[ed] . . . the health care service, S. Nafsinger [sic], requesting the treatment – medication – status of his case and complaint about symptoms of the Hepatitis C as pain and other symptoms and they answered to be patient and in other oc[c]asions have ignored [his] complaints and request[s] – intentionally – with deliberate indifference.” R. vol. 1 at 269. And, though Nafziger recommended the Interferon/Ribavirin regimen, he then “failed to act for plaintiff’s im[m]ediate treatment” and is at least partially responsible for the subsequent delay, which he “did nothing to prevent.” Id. These are factually thin allegations. Indeed, the only facts stated concern the insensitive response given to Mr. Arocho’s inquiries about the status of his recommended treatment. But complaints about poor patient-communication do -22- not, at least standing alone, evince deliberate indifference to a serious medical need. So long as Nafziger adequately pursued the treatment recommended for Mr. Arocho’s medical condition, an Eighth Amendment claim cannot be made out on the basis that he simply neglected to keep Mr. Arocho fully apprised of the status of the recommendation. Of course, Mr. Arocho also considers Nafziger partly to blame for the delay and ultimate denial of the recommended treatment, as the more general allegations quoted above reflect. But he offers no suggestion, much less a plausible factual specification, as to what Nafziger failed to do in making and medically supporting his recommendation or in prompting a more appropriate response to its exigency. “[T]he pleading standard Rule 8 [of the Federal Rules of Civil Procedure] announces does not require detailed factual allegations, but it demands more than an unadorned, the-defendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 129 S. Ct. 1937, 1949 (2009) (internal quotation omitted). A complaint must include “factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged,” and where its allegations “are merely consistent with a defendant’s liability, it stops short of the line between possibility and plausibility of entitlement to relief.” Id. (internal quotations omitted). Here, the most that can be said about Nafziger’s alleged actions–recommending the Interferon/Ribavirin treatment upon discovering that Hepatitis C was damaging Mr. Arocho’s liver, and then waiting on approval of the -23- treatment by the authorities–is that they do not necessarily preclude his liability for the alleged delay and denial of medical treatment. But such liability is nothing more than a theoretical possibility in the absence of other, unnamed acts about which the court can only speculate at this point. We therefore agree with the district court that Mr. Arocho has not stated a claim for relief against Nafziger. But there are additional considerations here, particularly given our reinstatement of the case against BOP Director Lappin, that weigh in favor of providing Mr. Arocho an opportunity to cure this pleading deficiency. While the conclusory allegations regarding Nafziger’s role in the delay/denial of treatment fall short of stating a claim, when viewed in light of the litigation position espoused by BOP Director Lappin, they nevertheless warrant the exercise of some caution in foreclosing the possibility of liability on Nafziger’s part. The claims against these two defendants are to some degree in direct opposition, creating a “zero-sum game” of liability: the stronger the claim that Nafziger failed to properly support or press for treatment, the weaker the claim that Lappin should be held liable for not approving it; conversely, the more Nafziger did to satisfy his duty to secure the necessary treatment, the stronger the claim against Lappin for denying it. And the litigation positions separately advanced by these defendants do seem to exploit (however innocently) this situation. Nafziger notes that he recommended Interferon/Ribavirin and insists his “efforts to gain approval -24- of this medication for Mr. Arocho are not indicative of negligence, but rather of diligence.” Aplee. Br. at 20. But, as we have seen, Lappin’s position is that he was not aware that this particular treatment was needed, or that the need for treatment was urgent, or that Mr. Arocho could suffer serious and irreparable harm if Lappin failed to approve it. See id. at 23. All of which begs the crucial question: what did Nafziger convey to Lappin about Mr. Arocho’s condition, the need for Interferon/Ribavirin, and the harm involved if the treatment was denied or delayed? Obviously, the facts known to and alleged by Mr. Arocho cannot settle that question. He knows only what he has experienced and what he has been told by defendants, i.e., that Hepatitis C is causing him pain and damaging his liver, that Nafziger recommended he be treated with Interferon/Ribavirin, and that Lappin refused to approve the treatment. The nature and extent of the exchange between Nafziger and Lappin, which may exonerate one (or both) while implicating the other (or both), is known only by defendants. In such circumstances, to dismiss the claim against Nafziger without one more chance at amendment following the reinstatement of the claim against Lappin could lead to a real injustice: after the dismissal, Lappin could oppose the claim against him by submitting evidence on summary judgment indicating that all of the fault lay, rather, with Nafziger who, having been dismissed with prejudice from the case, could not be brought back in to answer for his now-demonstrated liability. -25- Under the unique circumstances here, and particularly given our reinstatement of the case against BOP Director Lappin, we deem it appropriate to afford Mr. Arocho an opportunity to amend his pleadings on remand to state a claim, if possible, against Nafziger. See Reynoldson v. Shillinger, 907 F.2d 124, 127 (10th Cir. 1990) (affirming dismissal of pro se prisoner complaint, but remanding “with instructions that the dismissal be without prejudice to plaintiff's filing an amended complaint.”).