Opinion ID: 760210
Heading Depth: 2
Heading Rank: 1

Heading: Summary Judgment for the County Defendants

Text: 10 Our review of the district court's grant of summary judgment is de novo, and we must apply the now familiar standard to determine whether the County defendants are entitled to a judgment as a matter of law. The plaintiffs base their claims against Milwaukee County and Dr. Downing on 42 U.S.C. § 1983, which provides that [e]very person who, under color of statute, ordinance, regulation, custom, or usage, of any State ... subjects, or causes to be subjected, any citizen of the United States ... to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in an action at law.... The plaintiffs claim that Dr. Downing and Milwaukee County deprived Jonathan, a pre-trial detainee, of his rights under the Fourteenth Amendment, which prohibits a state from depriv[ing] any person of life, liberty, or property, without due process of law. It is now well settled that pre-trial detainees are protected by the Fourteenth Amendment's Due Process Clause rather than the Eighth Amendment's prohibition against cruel and unusual punishment, which applies only to convicted persons. See Estate of Cole v. Fromm, 94 F.3d 254, 259 n. 1 (7th Cir.1996). But the precise scope of the due process protections are not well settled. Thus, we first must determine what the appropriate test under the Fourteenth Amendment is. 11 The plaintiffs do not assert that Jonathan received inadequate procedural safeguards before Dr. Downing or Milwaukee County deprived him of life or liberty. Their claims are under the substantive component of the Due Process Clause, that is, they assert that the actions (or inactions) of Dr. Downing and Milwaukee County were in themselves unconstitutional. See, e.g., Collins v. City of Harker Heights, 503 U.S. 115, 125, 112 S.Ct. 1061, 117 L.Ed.2d 261 (1992). In DeShaney v. Winnebego County Dept. of Social Servs., 489 U.S. 189, 195, 109 S.Ct. 998, 103 L.Ed.2d 249 (1989), the Court stated that 12 [t]he [Due Process] Clause is phrased as a limitation on the State's power to act, not as a guarantee of certain minimum levels of safety and security. It forbids the State itself to deprive individuals of life, liberty, or property without due process of law, but its language cannot fairly be extended to impose an affirmative obligation on the State to ensure that those interests do not come to harm through other means. 13 The Court held that [a]s a general matter, then, we conclude that a State's failure to protect an individual against private violence simply does not constitute a violation of the Due Process Clause. Id. at 197, 109 S.Ct. 998. Thus, the plaintiffs cannot base their claims on the assertion that Dr. Downing or Milwaukee County had an obligation to stop Jonathan from committing suicide once he had been released from the jail. Cf. Archie v. City of Racine, 847 F.2d 1211, 1221 (7th Cir.1988) (en banc) ([T]he Due Process Clause does not require the state to imprison [insane persons] or protect its citizens from them.) (discussing Bowers v. DeVito, 686 F.2d 616 (7th Cir.1982)). Similarly, the plaintiffs cannot claim that the County defendants should have involuntarily committed Jonathan to a mental health facility: Due process protects people from being unlawfully restrained; it provides no right to be restrained, lawfully or otherwise. Wilson v. Formigoni, 42 F.3d 1060, 1066 (7th Cir.1994) ([T]here is no constitutional right to be deprived of liberty....). And this case does not present a situation in which the County, by releasing Jonathan on bail, placed him in a position of danger. See Wallace v. Adkins, 115 F.3d 427, 429 (7th Cir.1997) (state creates special relationship and an obligation to provide protection when it affirmatively places the individual in a position of danger the individual would not have otherwise faced). It would present a much different situation than we have here if a state actor released a pre-trial detainee by, for example, dumping him in the wilderness. Cf. Bowers v. DeVito, 686 F.2d 616, 618 (7th Cir.1982) (abandoning a person in a position of danger is no less a tort than to throw him into a snake pit). That, of course, is a far cry from what happened here. So whatever liability might attach to the County defendants must be based on actions or inactions taken while Jonathan was in custody. 14 When a state actor such as Milwaukee County deprives a person of his ability to care for himself by incarcerating him, detaining him, or involuntarily committing him, it assumes an obligation to provide some minimum level of well-being and safety. DeShaney, 489 U.S. at 198-200, 109 S.Ct. 998 (discussing Estelle v. Gamble, 429 U.S. 97, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976) (Eighth Amendment requires medical care for prisoners)); Youngberg v. Romeo, 457 U.S. 307, 102 S.Ct. 2452, 73 L.Ed.2d 28 (1982) (substantive due process requires State to provide reasonable safety for involuntarily committed person); Revere v. Massachusetts General Hospital, 463 U.S. 239, 244, 103 S.Ct. 2979, 77 L.Ed.2d 605 (1983) (substantive due process requires State to provide needed medical care for suspect in police custody). In Youngberg, the Court held that the test for determining whether an involuntarily committed person had been provided reasonable safety is whether professional judgment in fact was exercised [by the State actors]. It is not appropriate for the courts to specify which of several professionally acceptable choices should have been made. 457 U.S. at 321, 102 S.Ct. 2452 (internal quotation omitted). The Court explained that 15 there certainly is no reason to think judges or juries are better qualified than appropriate professionals in making such decisions. For these reasons, the decision, if made by a professional, is presumptively valid; liability may be imposed only when the decision by the professional is such a substantial departure from accepted professional judgment, practice, or standards, as to demonstrate that the person responsible actually did not base the decision on such a judgment. 16 Id. at 322-23, 102 S.Ct. 2452 (citations and footnotes omitted). We have applied this same standard to the decisions of professionals in the setting at issue here, that is, treatment of a pre-trial detainee's medical needs. See, e.g., Fromm, 94 F.3d at 262. 17 The substantive due process standard (in this context we'll call it the professional judgment standard) is at least as demanding as the Eighth Amendment deliberate indifference standard. Fromm, 94 F.3d at 259 n. 1. The plaintiffs urge us to hold that it is more demanding, but they do not articulate what, as a practical matter, this more demanding standard requires. The plaintiffs correctly note that the deliberate indifference standard and the professional judgment standard arise in substantially different contexts: deliberate indifference analysis looks to identify what conduct amounts to unlawful punishment of convicted persons, while the professional judgment analysis looks to identify what conduct falls below a minimum level of care that must be provided to persons such as pre-trial detainees whom the state may not punish at all. But there is minimal difference in what the two standards require of state actors. 18 Both the Eighth Amendment and this limited form of substantive due process require the state to provide to detained, committed, or incarcerated persons minimum levels of the basic human necessities: food, clothing, shelter, medical care, and reasonable safety. See Farmer v. Brennan, 511 U.S. 825, 832, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994) (Eighth Amendment); DeShaney, 489 U.S. at 200, 109 S.Ct. 998 (discussing substantive due process and Eighth Amendment); Youngberg, 457 U.S. at 324, 102 S.Ct. 2452 (substantive due process). The standard for liability under the Eighth Amendment is deliberate indifference, which is more than negligence and approaches intentional wrongdoing. Farmer, 511 U.S. at 835, 114 S.Ct. 1970 (While Estelle establishes that deliberate indifference entails something more than mere negligence, the cases are also clear that it is satisfied by something less than acts or omissions for the very purpose of causing harm or with knowledge that harm will result.). A comparable standard is applicable to substantive due process' professional judgment standard for detained or committed persons. Estate of Porter v. Illinois, 36 F.3d 684, 688 (7th Cir. 1994) ( '[p]rofessional judgement, like recklessness and gross negligence, generally falls somewhere between simple negligence and intentional misconduct' ) (quoting Shaw v. Strackhouse, 920 F.2d 1135, 1146 (3d Cir.1990) (alternation by quoting court)). In Farmer, the Court concluded that deliberate indifference was essentially a criminal recklessness standard, that is, ignoring a known risk, 511 U.S. at 837, 114 S.Ct. 1970. Although when discussing the professional judgement standard in Porter we referred to either recklessness or gross negligence--the terms used by the Third Circuit--we have concluded that gross negligence, while more egregious, is still negligence and thus below the standard needed to impose constitutional liability. Salazar v. City of Chicago, 940 F.2d 233, 238 (7th Cir.1991). Only the criminal recklessness standard provides adequate notice of what conduct is or is not permitted; degrees of negligence vary considerably with the facts of each case. Id; Archie 847 F.2d at 1219 (A line that cannot be policed is not worth drawing in constitutional law). As a practical matter, then, there is little difference between the Eighth Amendment standards regarding the conduct of prison medical professionals' treatment of prisoners' medical needs, and substantive due process' standards regarding the conduct of other medical professionals' treatment of detained or committed persons' medical needs. And certainly the plaintiffs have not tried to articulate any material difference between the two standards. Indeed, the principal difference between the two standards lies with the type of decisions that each addresses: the professional judgment standard only applies to decisions made by professionals such as physicians, psychiatrists, and nurses within their area of professional expertise, see Youngberg, 457 U.S. at 323 n. 30, 102 S.Ct. 2452, while the deliberate indifference standard applies to a variety of decisions made by prison officials, including when to segregate a prisoner to protect him from the violence of others. See Farmer, 511 U.S. at 831, 114 S.Ct. 1970; Soto v. Johansen, 137 F.3d 980, 981 (7th Cir.1998). But significantly, the deliberate indifference standard also applies to the decisions of prison medical personnel as to what medical care a prisoner requires. See Estelle v. Gamble, 429 U.S. at 104, 97 S.Ct. 285; Gutierrez v. Peters, 111 F.3d 1364, 1365 (7th Cir.1997). 19 In the context of a claim for inadequate medical care, the professional judgment standard requires essentially the same analysis as the Eighth Amendment standard. First, the plaintiff's medical needs must have been objectively serious. Cf. Gutierrez, 111 F.3d at 1369. The inadequate treatment of minor medical needs simply does not rise to the level of a constitutional wrong. See Snipes v. DeTella, 95 F.3d 586, 591 (7th Cir.1996). Second, in order for the plaintiff to show that the state actor's decision was such a substantial departure from accepted professional judgment, practice, or standards, as to demonstrate that the person responsible actually did not base the decision on such a judgment, Youngberg, 457 U.S. at 323, 102 S.Ct. 2452, the plaintiff must show: (1) that the professional knew of the serious medical need, and (2) disregarded that need. Cf. Farmer, 511 U.S. at 837, 114 S.Ct. 1970. A trier of fact can conclude that the professional knew of the need from evidence that the serious medical need was obvious. Farmer, 511 U.S. at 842, 114 S.Ct. 1970. And we can assume that what might not be obvious to a lay person might be obvious to a professional acting within her area of expertise. A plaintiff can show that the professional disregarded the need only if the professional's subjective response was so inadequate that it demonstrated an absence of professional judgment, that is, that no minimally competent professional would have so responded under those circumstances. Cf. Steele v. Choi, 82 F.3d 175, 179 (7th Cir.1996) (under Eighth Amendment analysis, evidence that some medical professionals would have chosen a different course of treatment is insufficient to make out a constitutional claim). 20 With this standard in mind, we now turn to the merits of the plaintiffs' claims against Dr. Downing and Milwaukee County. Although the plaintiffs make a passing argument regarding the County's policies and practices in an effort to set forth § 1983 liability under Monell v. Department of Social Servs. of the City of New York, 436 U.S. 658, 98 S.Ct. 2018, 56 L.Ed.2d 611 (1978), the plaintiffs' arguments do not articulate what policies or practices they believe violated Jonathan's substantive due process rights. Rather, their arguments against the County merely rely on the assertion that the policies and training inadequacies (whatever they were) caused Jonathan to receive constitutionally inadequate medical treatment while at the jail. Thus, our primary analysis must be whether the conduct of Dr. Downing--who was principally responsible for deciding the course of Jonathan's medical care at the jail--violated Jonathan's constitutional rights. If her treatment was not constitutionally inadequate, the plaintiffs' claims fail against both Dr. Downing and the County. 21 The threshold requirement is that the plaintiffs show that Jonathan had an objectively serious medical need, and they have met that burden here. From our after-the-fact vantage point, we now know that Jonathan's mental illness was very serious; it not only had caused him to attempt suicide in the past but ultimately caused him to make another attempt that killed him. The second requirement is that the plaintiffs show that Dr. Downing was subjectively aware of Jonathan's serious medical need. In hindsight, we know that Jonathan's condition placed him on the verge of suicide; but hindsight is not the measure of Dr. Downing's conduct. The critical question is what Dr. Downing knew of Jonathan's medical needs and whether she exercised professional judgment in that face of those known needs. 22 Clearly Dr. Downing knew from her initial conversation with Jonathan that he had a serious mental illness and posed some risk for suicide. We have no doubt that such knowledge was enough to trigger a constitutional obligation to provide some level of care and treatment while he was a pre-trial detainee. She also knew, however, that Jonathan had an aversion to powerful, effective anti-psychotic medications. She prescribed a nontherapeutic dosage of an anti-psychotic drug (Thorazine) with the intention of forming a therapeutic alliance with Jonathan and slowly increasing the dosage so that he could gradually overcome his aversion to the side effects of the medication. The plaintiffs' expert did not dispute that this treatment plan was one that a professional might use in such a situation. But he disagreed with the treatment plan, opining that it would have been better had Dr. Downing ordered Jonathan to be intra-muscularly injected with a large dosage of a powerful anti-psychotic drug, which would have had a therapeutic effect for a period of time. For two reasons (at least) this opinion is simply not enough to overcome summary judgment. 23 First, this demonstrates a disagreement about which of many professionally acceptable treatment plans should have been implemented. While such a dispute might state a negligence cause of action, it cannot make out a substantive due process claim. Youngberg, 457 U.S. at 321, 102 S.Ct. 2452. Second, the plaintiffs' expert conceded that there is no evidence in the record that Jonathan would have voluntarily submitted to such a treatment or would have tolerated the side effects. Thus, the opinion that such an alternative treatment plan would have been more beneficial or even acceptable to Jonathan is pure speculation. 1 24 This case would present a different factual setting if Dr. Downing--or anyone else--had somehow known that Jonathan was on the verge of committing suicide. But the plaintiffs' expert conceded that no one could have predicted Jonathan was about to attempt suicide. Of course a medical professional need not be certain that an individual is about to commit suicide before a constitutional obligation to act is triggered, but the obligation to take some action is not triggered absent a substantial risk of suicide. See, e.g., Haley v. Gross, 86 F.3d 630, 641 (7th Cir.1996) (under the Eighth Amendment, liability is imposed for ignoring actual knowledge of a substantial risk of serious harm). The plaintiffs rely heavily on the fact that Jonathan was placed on the highest level of suicide watch at the jail. This reliance is misplaced. The substantial risk Jonathan faced was not from a violent third person; rather it was from himself. His jailers prudently eliminated that risk by closely scrutinizing his behavior while he was in custody. Placing him on a high level of suicide watch does not automatically impose on those responsible for the precaution a constitutional obligation to devise a treatment plan premised on the probability that Jonathan was on the verge of suicide. No one can predict suicide with any level of certainty; medical professionals at jails, based on limited information, must decide whether a person is little, some, or a serious risk of suicide. Placing a pre-trial detainee on some level of suicide watch, even the highest level, does not demonstrate a subjective awareness of a substantial risk of imminent suicide. See Fromm, 94 F.3d at 261 (expert's disagreement with treating psychiatrist's conclusion regarding the likelihood that a patient would commit suicide does not amount to evidence of deliberate indifference). Suicide watch is not a treatment for a suicidal person: it is a preventative safety measure that may be part of a state actor's constitutional obligation to provide reasonable safety to a detainee. Being placed on suicide watch may save a suicidal person's life not by preventing the desire to attempt suicide, but by preventing the attempt from succeeding. At least from the standpoint of the Due Process Clause, it is acceptable for a medical professional to take the safety measure of placing an individual on the highest level of suicide watch while at the same time devising a treatment plan that does not presuppose the person is highly likely to attempt suicide as soon as he is released to his parents. That is the sort of treatment plan the plaintiffs' expert opined should have been put in place for Jonathan. Such an opinion falls far short of showing a violation of Jonathan's substantive due process rights. 2 The County had a duty to provide reasonable safety to Jonathan while he was a pre-trial detainee and to provide for his basic medical needs. In the context of a chronically mentally ill person like Jonathan, that duty is principally one of maintenance rather than cure because, as the plaintiffs' expert explained, Jonathan's schizophrenia could not be cured, only treated in the long term without any guarantee of success. And once Jonathan was released, the County's duty was cut off. DeShaney, 489 U.S. at 195, 109 S.Ct. 998. 25 Because we have concluded that Dr. Downing's treatment of Jonathan did not violate his constitutional rights, we need not consider for purposes of her qualified immunity from suit whether her conduct violated a right clearly established at the time. See Siegert v. Gilley, 500 U.S. 226, 232, 111 S.Ct. 1789, 114 L.Ed.2d 277 (1991). And because the plaintiffs' claims against the County are premised on the same claim that Jonathan received constitutionally inadequate treatment, we need not address the plaintiffs' Monell issues. Nor need we address the various causation arguments raised by the County defendants. 26