Opinion ID: 4548568
Heading Depth: 2
Heading Rank: 2

Heading: Dr. Butler

Text: Next, Pulera argues that it was unreasonable for Dr. Butler to deny him his prescription medications without taking some alternative step. If she really believed he had abused his medications, he suggests, she should have implemented the facility’s detoxiﬁcation or withdrawal protocols. Pulera, however, falls short with the medical and causation evidence. The record contains no evidence from which a factﬁnder could infer that, had Pulera received his medications, he would not have attempted suicide. His own expert denied such a theory. Dr. Butler’s expert—Dr. Keith Ness, M.D.—declared in his aﬃdavit that cutting a patient oﬀ either clonazepam or tramadol, even “cold turkey,” was not known to make that patient suicidal, whereas giving either drug to someone who had consumed them in excess within the past few days could have been dangerous. Pulera oﬀered nothing to rebut this medical opinion. Dr. Butler made a reasonable decision on imperfect information. She knew only that many of Pulera’s pills were missing. Putting aside the facility’s policy directing her not to set up his medications in this situation, there was at least some chance that he had taken those pills and giving him more could have been harmful, even deadly. Between the option with some risk of death and the option with no apparent risk (according to the only medical evidence in the record), Dr. Butler chose the latter. That choice was objectively reasonable as a matter of law, regardless of whether Pulera had, in fact, abused his medications. A jury could not infer that depriving Pulera of his medications might be deadly from the mere fact that a physician had 18 No. 19-2291 prescribed them to him. Pulera insists a prescription is evidence of a “serious medical need.” See Gutierrez v. Peters, 111 F.3d 1364, 1373 (7th Cir. 1997) (deﬁning term to include a need “that has been diagnosed by a physician as mandating treatment”). Whether a medical need is serious, though, is just a threshold requirement before the state has a duty under the Eighth Amendment to provide medical care to a prisoner. Id. at 1369, 1372. We have held that there is no such threshold under the Fourth Amendment, as the “reasonableness analysis operates on a sliding scale, balancing the seriousness of the medical need with the third factor—the scope of the requested treatment.” Williams v. Rodriguez, 509 F.3d 392, 403 (7th Cir. 2007). From what Dr. Butler and the nurses knew, Pulera’s need for his medications was not serious relative to the risks of his receiving them. Pulera likens his situation to that of a diabetic deprived of insulin. Egebergh v. Nicholson, 272 F.3d 925, 928 (7th Cir. 2001). But a diabetic needs insulin to live. No evidence suggest that Pulera depended on his medications to stay alive; he needed them only to treat his pain and anxiety. Undoubtedly, a jury could infer that the defendants knew Pulera might become anxious or suﬀer chronic pain without his medications, but he points to nothing that would inform them that this anxiety or pain might lead him to attempt suicide or otherwise cause harm comparable to a risk of overdose. His reliance on Gil v. Reed, 381 F.3d 649 (7th Cir. 2004), is misplaced. We held in Gil that a jury could infer a prison doctor’s deliberate indiﬀerence when a specialist prescribed certain medications noting the risks of alternative treatments, No. 19-2291 19 the doctor ignored that warning, and the prisoner suﬀered as predicted. Id. at 662–64. If Pulera’s primary care physician prescribed him clonazepam and tramadol because he was known to be suicidal without them, that fact is missing from the record. Based on the evidence that is in the record and of which she was made aware, Dr. Butler reasonably concluded the only foreseeable risk of depriving Pulera of his prescriptions was a few days’ discomfort—a small price to pay compared to even a low chance of overdose. All four nurses were entitled to defer to Dr. Butler’s medical judgment weighing the costs and beneﬁts of these two choices. See McCann, 909 F.3d at 887 (aﬃrming summary judgment for nurse who deferred to doctor’s prescription that led to overdose). Pulera makes much of the fact that Dr. Butler never implemented a withdrawal or detoxiﬁcation protocol, despite her asserted belief that he was abusing his medications. But, as Pulera himself emphasizes, Dr. Butler knew only that it was possible that Pulera had abused his medications. We agree with the district court that Dr. Butler could reasonably have awaited a nurse or correctional oﬃcer’s report of concrete symptoms before making further treatment decisions. When Nurse Reed did report symptoms, on Sunday evening, Dr. Butler asked that someone check Pulera’s vitals and call her if any abnormalities arose. She heard nothing back, so it was reasonable for her to infer (correctly) that all objective signs showed Pulera was ﬁne and not suﬀering withdrawal. She never had the opportunity to take this new information into account and reassess Pulera’s medication regimen because of his attempt a few hours later. 20 No. 19-2291