Opinion ID: 5097344
Heading Depth: 2
Heading Rank: 1

Heading: Claims against Dr. Mesrobian and Wexford

Text: In the case of a claim of deliberate indifference against a medical professional, a prisoner must demonstrate that the medical professional’s response was “so inadequate that it demonstrated an absence of professional judgment.” Johnson v. Dominguez, 5 F.4th 818, 826 (7th Cir. 2021) (quoting Collignon v. Milwaukee Cnty., 163 F.3d 982, 989 (7th Cir. 1998)). A difference of opinion among doctors is not sufficient evidence to establish deliberate indifference. Pyles v. Fahim, 771 F.3d 403, 409 (7th Cir. 2014). “A medical professional is entitled to deference in treatment decisions unless ‘no minimally competent professional would have so responded under those circumstances.’” Id. (quoting Sain v. Wood, 512 F.3d 886, 894–95 (7th Cir. 2008)). “To infer deliberate indifference on the basis of a physician’s treatment decision, the decision must be so far afield of accepted professional standards as to raise the inference that it was not actually based on a medical judgment.” Norfleet v. Webster, 439 F.3d 392, 396 (7th Cir. 2006). The use of a black box restraint does not, in and of itself, violate the Eight No. 19-2994 9 amendment. Knox v. McGinnis, 998 F.2d 1405, 1412 (7th Cir. 1993). Therefore the only question is whether the prison and the medical providers were deliberately indifferent to Stewart’s specific medical needs when they refused to give him an exemption to the use of the black box based on his personal medical history. In this case we can assume, for the sake of this appeal, that Stewart had a serious medical condition and that Dr. Mesrobian was aware of Stewart’s condition. Consequently, we need only look to see whether any minimally competent professional would have made the same decision. When Stewart requested a black box exemption, Dr. Mesrobian responded in various ways including by evaluating Stewart’s complaints of pain, examining his shoulder and wrists, prescribing pain medication, and referring Stewart to physical therapy. We cannot say that no minimally competent doctor could have made the same assessment or that Dr. Mesrobian’s response was “so far afield of accepted professional standards as to raise the inference that it was not actually based on a medical judgment.” Norfleet, 439 F.3d at 396. Nor does Dr. Mesrobian’s conduct rise to the level of criminal recklessness that an Eighth Amendment violation requires. Farmer, 511 U.S. at 839–40 (equating criminal recklessness with deliberate indifference). The fact that different medical providers did provide Stewart a medical exemption at various points in time does not force us to conclude that Dr. Mesrobian’s course of action was not based on medical judgment. “[A] difference of opinion among physicians on how an inmate should be treated cannot support a finding of deliberate indifference.” Norfleet, 439 F.3d at 396. For this reason, the fact that Stewart’s oncologist at an outside facility recommended leather restraints does 10 No. 19-2994 not support a claim for deliberate indifference. Dr. Shah was Stewart’s oncologist and not his orthopedic surgeon. And as an outside provider, Dr. Shah was not in a position to assess the security concerns of the prison. Dr. Mesrobian followed up with Dr Shah regarding his recommendation and investigated the need for the exemption. Unlike Dr. Shah, Dr. Mesrobian was balancing Stewart’s subjective reports of pain, his own assessment of Stewart’s medical conditions, and an assessment of the institution’s security concerns and policies. The balance between security and medical concerns adds an additional layer for us to consider. Ordinarily a court need not balance penological and security concerns against medical treatment. See Whitley v. Albers, 475 U.S. 312, 320 (1986). For example, whether a doctor recommends surgery or medication does not ordinarily impact prison security. But as the Supreme Court noted in Whitley, when the safety and security of other prisoners, staff, administrative personnel, and visitors is at issue, “a deliberate indifference standard does not adequately capture the importance of such competing obligations.” Id. Instead, the Supreme Court announced that a court must ask, “whether force was applied in a good faith effort to maintain or restore discipline or maliciously and sadistically for the very purpose of causing harm,” while considering “such factors as the need for the application of force, the relationship between the need and the amount of force that was used, [and] the extent of injury inflicted.” Id. at 320–21 (internal citations omitted). “From such considerations inferences may be drawn as to whether the use of force could plausibly have been thought necessary, or instead evinced such wantonness with respect to the unjustified infliction of harm as is tantamount to a knowing willingness that it occur.” Id. at 321. In Whitley, the facts involved the use of force to subdue a No. 19-2994 11 prison riot—a situation in which the threat was not hypothetical but real and imminent. This case is not one in which prison officials must make spur-of-the moment decisions about the use of force in order to stop an imminent security breach. At the same time, it does not present a situation in which the decision of the medical practitioner has no effect on external security and safety concerns. Prisoners who are taken to outside medical providers can pose a security threat to the transporting staff, to other inmates, to medical providers and to members of the public at the hospitals and doctors’ offices to which they are taken. And as the court explained in Whitley, a court should give deference to prophylactic or preventative security measures just as it does in cases with rioting inmates. Id. at 322. In this case, it is certainly true that the use of a black box restraint “could plausibly have been thought necessary.” Id. at 321. The amount of force involved in the wearing of the black box is minimal, as it is merely a passive restraint. Generally, the harm in terms of the discomfort it causes is also minimal, although in Stewart’s case it inflicted significant discomfort and pain. Nevertheless, there is no evidence that Dr. Mesrobian approved that use of force “maliciously or sadistically for the very purpose of causing harm.” Id. at 320–21. The black box is a security measure and not a medical treatment. It makes sense, therefore, for a medical provider to default to the security needs of the prison unless the medical professional determines that an exemption is required for medical reasons. Taking the facts in the light most favorable to Stewart, Dr. Mesrobian recognized that the measure inflicted discomfort and pain but concluded, in his medical judgment, that an exemption was not necessary. The amount of force used was minimal and the security concerns significant. 12 No. 19-2994 Consequently, on this record, even with the facts taken in the light most favorable to Stewart, no reasonable jury could find that Dr. Mesrobian acted with deliberate indifference to a substantial risk to Stewart’s health. As for the defendant Wexford Health Services, private entities acting to fulfill government duties are not vicariously liable for the conduct of their employees. Monell v. Dep't of Soc. Servs. of City of New York, 436 U.S. 658, 694 (1978). Instead, a plaintiff must demonstrate direct liability by showing that the constitutional violation was “caused by (1) an express municipal policy; (2) a widespread, though unwritten, custom or practice; or (3) a decision by a municipal agent with final policymaking authority.” Milestone v. City of Monroe, Wis., 665 F.3d 774, 780 (7th Cir. 2011). In this case, Stewart claims that Wexford had a widespread custom or practice of not granting black box exemptions to inmates with conditions similar to that of Stewart. In order to succeed on this claim, Stewart must present evidence of an “unconstitutional practice by the [prison’s] staff that is so well settled that it constitutes a custom or usage with the force of law.” Palmer v. Marion Cnty., 327 F.3d 588, 596 (7th Cir. 2003). As part of its contract with IDOC, Wexford must follow IDOC’s administrative and institutional directives, including the requirement that all inmates wear black box restraints when they leave prison. The directive allows a medical doctor to issue an exemption when a medical condition so warrants. Therefore, it is IDOC policy that creates the presumption that an inmate will wear a black box outside of the prison unless medically contraindicated. Some Wexford physicians found that Stewart qualified for the exemption at some times, and others did not. Stewart has not provided any evidence that No. 19-2994 13 Wexford had a widespread custom or practice of disallowing all exemptions for his condition. In fact, the evidence of Stewart’s own experience indicates that the medical providers do as instructed and issue black box exemptions on a case-bycase basis based on the clinical facts before them, as Stewart himself sometimes received the exemption and sometimes did not. Stewart argues that the evidence that he was denied a medical exemption on multiple occasions and by multiple providers is a sufficient pattern of repeated behavior to create a factual question regarding a widespread pattern or practice. Although he was denied an exemption and forced to wear a black box on many occasions (twenty-three, by his count, (see Stewart Brief at 7, and Reply brief at 8)), by his own admission he also received medical exemptions from wearing the black box, sometimes for years at a time. See Stewart Brief at 10–11. He does not enumerate the times he received medical treatment but was not forced to wear a black box, but based on his many medical appointments and the years in which he was exempt, we can assume these were many, too. “To prove an official policy, custom, or practice within the meaning of Monell, [a prisoner] must show more than the deficiencies specific to his own experience.” Daniel v. Cook Cnty., 833 F.3d 728, 734 (7th Cir. 2016). But in this case, even Stewart’s own experience indicates the lack of a per se policy against black box exemptions. Stewart also claims that Wexford had a policy of inaction, and that a lack of policy or obvious gaps in policy created the constitutional violation. It is true that “the absence of a policy might reflect a decision to act unconstitutionally, but the Supreme Court has repeatedly told us to be cautious about drawing that inference.” Calhoun v. Ramsey, 408 F.3d 375, 380 (7th Cir. 2005) (citing Bd. of the Cnty. Comm'rs of Bryan Cnty. v. 14 No. 19-2994 Brown, 520 U.S. 397, 409–10 (1997) and City of Canton v. Harris, 489 U.S. 378, 388–89 (1989)). In this case, Wexford did have a policy that required medical providers to evaluate each prisoner on a case-by-case basis to assess the medical risks in light of the security concerns and according to medical standards. Wexford medical providers followed this policy, and at times granted Stewart an exemption even if, more often, they did not grant an exemption. This is not a case in which a prison allowed individual guards to make decisions as to whether a prisoner would wear a black box or not, without any guiding principles. In this case, the prison asked medical professionals to rely on their extensive medical training and judgment to evaluate complex and individualized medical conditions in light of prevailing security concerns. Even assuming the truth of all of Stewart’s facts, Wexford did not have a policy or practice of per se denials of black box exemptions or of failing to perform assessments to determine whether an exemption was warranted. Finally, a word on what we have not decided. As we noted earlier, the Wexford defendants spend several pages describing, for example, a lack of medical evidence that the black box position is harmful to carpal tunnel syndrome, shoulder bursitis or impingement, or that the black box would actually prevent aggravation to Stewart’s shoulders. See Wexford brief at 31–33, 35. The Wexford defendants state that “the uncontroverted medical evidence described … [is] that use of the black box restraint would not require the placement of Stewart’s shoulders or wrists in a position that would induce pain or aggravate his underlying conditions.” Wexford brief at 35. As we noted earlier, these and similar descriptions and arguments impermissibly take the facts in the light most favorable to the Wexford defendants. See Payne, 337 F.3d at 770. In any No. 19-2994 15 event, the factual determination is not necessary, as we have found that even if we credit Stewart’s accounts of the pain he suffered from the use of the black box, we cannot say that no reasonable medical doctor, considering those complaints in light of the prison policy on black box restraints, could have made the same medical decision.