Court Opinion

ID: 9396412
Source: CourtListenerOpinion
Date Created: 2023-05-22 16:00:59.356819+00
Date Added: 2024-06-11T17:19:16.760097
License: Public Domain

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                                                              [PUBLISH]
                                    In the
                 United States Court of Appeals
                          For the Eleventh Circuit

                           ____________________

                                  No. 21-14275
                           ____________________

        BETTY WADE,
        in her capacity as Personal Representative of the Estate of David
        Henegar,
                                                       Plaintiﬀ-Appellant,
        versus
        CINDY MCDADE, et al.,

                                                   Defendants-Appellees.

                           ____________________

                  Appeal from the United States District Court
                     for the Northern District of Georgia
                      D.C. Docket No. 4:18-cv-00192-AT
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        2                      Opinion of the Court                21-14275

                             ____________________

        Before NEWSOM, LUCK, and TJOFLAT, Circuit Judges.
        NEWSOM, Circuit Judge:
               Over a four-day stretch during his incarceration at Walker
        State Prison in Georgia, David Henegar failed to receive his pre-
        scribed seizure medication. On the fourth night, Henegar had two
        seizures that he claimed caused permanent brain damage. Pro-
        ceeding under 42 U.S.C. § 1983, Henegar sued five prison employ-
        ees—Lieutenant John Stroh and Sergeant Jerome Scott Keith, as
        well as nurses Sherri Lee, Julie Harrell, and Cindy McDade—alleg-
        ing that they were deliberately indifferent to his medical needs in
        violation of the Eighth Amendment.
               The district court granted summary judgment to all five de-
        fendants on the ground that they were entitled to qualified immun-
        ity. Shortly thereafter, Henegar died from causes unrelated to the
        seizures that he suffered while in prison. His sister, Betty Wade,
        now pursues his claims on appeal as the personal representative of
        his estate.
               Before us, Wade asserts that the district court improperly
        accorded the defendants qualified immunity. In order to address
        that question, we find that we must first decide, by reference to our
        existing precedent, what mens rea a plaintiff has to prove to make
        out an Eighth Amendment deliberate-indifference claim. Must she
        show, as some of our decisions have said, that the defendant whose
        conduct she challenges acted with “more than mere negligence,” or
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        21-14275               Opinion of the Court                        3

        must she go further, as others have held, and show that the defend-
        ant acted with “more than gross negligence”? Applying our prior-
        panel-precedent rule—and, in particular, following the first of two
        decisions that squarely addressed and purported to resolve the ten-
        sion in our case law—we conclude, for reasons that we will explain,
        that a deliberate-indifference plaintiff must prove (among other
        things) that the defendant acted with “more than gross negligence.”
               Applying that standard to each of the five defendants here,
        we conclude that none of them was deliberately indifferent to
        Henegar’s medical needs and, accordingly, that none of them vio-
        lated the Eighth Amendment—and, accordingly, that the district
        court was correct to grant all of them summary judgment.
                                          I
                                         A
                Because this case comes to us on appeal from a decision
        granting summary judgment, “we must view all the evidence and
        all factual inferences reasonably drawn from the evidence in the
        light most favorable to the nonmoving party.” Stewart v. Happy
        Herman’s Cheshire Bridge, Inc., 117 F.3d 1278, 1285 (11th Cir. 1997).
        We therefore construe the facts in Wade’s favor, noting factual dis-
        putes—overwhelmingly here, between and among the various de-
        fendants—where necessary.
               While serving his sentence at Walker State Prison, Henegar
        was diagnosed with epilepsy. Initially, his condition was well-con-
        trolled with a daily anticonvulsant called Dilantin. The epileptic
        episode at issue here followed a four-day period—from Sunday,
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        4                     Opinion of the Court                 21-14275

        August 28, to Wednesday, August 31, 2016—during which Henegar
        didn’t receive his medication.
               First, a brief introduction of the ﬁve defendants: Nurses Ju-
        lie Harrell and Sherri Lee worked the day shift on weekdays in the
        prison medical unit. As relevant here, both were on duty from
        Monday, August 29, through Thursday, September 1. Lieutenant
        John Stroh and Sergeant Jerome Scott Keith worked the night shift
        on Sunday, August 28, when Henegar missed his ﬁrst dose of Di-
        lantin, and then didn’t return to work until the evening of Wednes-
        day, August 31. Nurse Cindy McDade was the nursing manager;
        the parties agree that she neither treated Henegar nor saw or spoke
        to him during the four days in question.
               In August 2016, Nurse Mary Ann Melton, who isn’t a party
        to this litigation, was responsible for ordering inmates’ medica-
        tions. She worked at the prison until Thursday, August 25, at which
        point she went on medical leave for several months. Nurse Melton
        usually ordered reﬁlls of inmates’ medications from the Georgia
        Department of Corrections’ pharmacy shortly before they ran out.
               On Tuesday, August 23—just before going on leave—Nurse
        Melton ordered Henegar’s Dilantin. Medications ordinarily arrived
        within one to two business days, and almost always within three.
        For reasons still unknown, Henegar’s Dilantin wasn’t delivered un-
        til sometime after Wednesday, August 31. Typically, if a prisoner’s
        medicine didn’t arrive as expected, Nurse Melton would follow up
        with the pharmacy. In Nurse Melton’s absence, Nurse Harrell or-
        dered medications, recorded them in a binder when they arrived,
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        21-14275               Opinion of the Court                         5

        cross-checked to ensure all orders had been delivered, and invento-
        ried and stocked the prison’s “pill cart.” Nurse McDade occasion-
        ally helped order and stock medicines, but it typically fell to Nurse
        Harrell to cover Nurse Melton’s duties.
               As it turns out, despite the delay in the delivery of Henegar’s
        Dilantin, the prison had the medication on hand; there was a
        backup supply in the medical department’s “standard ward inven-
        tory.” All nurses had access to that supply, and any nurse could also
        obtain Dilantin on short notice from a local pharmacy. Corrections
        oﬃcers, by contrast, didn’t have access to the backup supply and
        couldn’t order new medicines.
               There were four “pill calls” each day at regular intervals—
        5:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. Henegar was as-
        signed to receive his medication at the 9:00 p.m. call. During regu-
        lar hours on weekdays, nurses administered inmates’ medicines;
        Nurse Lee, for instance, conducted the 5:00 a.m. pill call each
        morning. At night and on weekends, though, no medical person-
        nel were onsite, so corrections oﬃcers distributed medications.
        During those pill calls, an oﬃcer would review a prisoner’s medi-
        cation administration record (“MAR”) to determine what medicine
        he needed and then retrieve it from the pill cart. If there was an
        issue with distributing or administering an inmate’s medication,
        the oﬃcer was supposed to make a notation to that eﬀect in his
        MAR. Standard notations included “A” for “administered,” “N” for
        “no-show,” “R” for “refused,” and “A/W” for “accepted but
        wasted.”
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        6                      Opinion of the Court                 21-14275

               When Henegar attended the 9:00 p.m. pill call on Sunday,
        August 28, his Dilantin wasn’t on the cart. Lieutenant Stroh was
        supervising that night, and Sergeant Keith, who was administering
        the pill call, made an “unidentiﬁable marking” in Henegar’s MAR.
        It wasn’t one of the four standard notations that oﬃcers had been
        trained to use in MARs.
               Having missed his August 28 dose, Henegar returned to the
        9:00 p.m. pill calls on August 29 and 30, to no avail. As already ex-
        plained, both Lieutenant Stroh and Sergeant Keith were oﬀ those
        days. The corrections oﬃcers who conducted those pill calls put
        “question marks” in Henegar’s MAR. It is undisputed that “it
        would be unusual for [a question mark] to appear in the medication
        [b]inder.” Although we don’t know who, someone also put a post-
        it note on Henegar’s ﬁle to indicate that there had been a problem
        with administering his medication—the parties agree that it
        “st[uck] out . . . like a ﬂag” from Henegar’s ﬁle in the pill cart.
               At some point on either August 29, 30, or 31, Henegar also
        attended a daytime pill call but still didn’t receive his Dilantin. He
        spoke to a nurse at the time, although he couldn’t remember ex-
        actly when or which one. The only nurses working daytime pill
        calls on those days were Nurses Harrell and Lee. Nurse Harrell
        admits having inventoried the pill cart at least once during the days
        when Henegar went without his medication and checking the
        binder of prescription deliveries daily. Nonetheless, she insists that
        she didn’t know that Henegar was out of his Dilantin.
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        21-14275               Opinion of the Court                          7

               On Wednesday night, August 31, Lieutenant Stroh and Ser-
        geant Keith were back on duty together, and Sergeant Keith once
        again conducted the 9:00 p.m. pill call. When Henegar showed up
        and his Dilantin still wasn’t on the pill cart, Sergeant Keith recorded
        another question mark in the MAR. One of the two oﬃcers told
        Henegar to go to the sick bay the following morning.
                At 10:50 p.m. that same day, having been without his Dilan-
        tin for four days, Henegar suﬀered a nearly 20-minute seizure that
        induced status epilepticus—a condition that can cause brain dam-
        age. The resulting injury usually centers in the hippocampus,
        which regulates memory and mood. The on-call doctor didn’t an-
        swer Lieutenant Stroh’s call, so he phoned Nurse McDade, who in-
        structed him to call 911. Henegar was transported to the emer-
        gency room, treated, and returned to the prison at around 2:30 a.m.
        on September 1.
               Just two hours later, Henegar suﬀered another seizure that
        left him oxygen-deprived for about 20 minutes. When Lieutenant
        Stroh and Sergeant Keith arrived at Henegar’s cell, his seizure had
        subsided. Lieutenant Stroh called Nurse McDade again at home to
        report the incident, and she told him to have Nurse Lee examine
        Henegar when she arrived.
               When Nurse Lee got to the prison around 5:00 a.m., she
        took Henegar to the medical unit, examined him, and found that
        his oxygen level was 81%—a low but not critical level—and that his
        pupils were slow to dilate but otherwise functioning correctly. She
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        8                      Opinion of the Court                  21-14275

        determined that he needed supplemental oxygen and additional
        seizure-prevention measures, so she sent him back to the hospital.
               Later that day, Nurse McDade investigated the incident and
        contacted the pharmacy to ensure that Henegar’s Dilantin was de-
        livered. She also switched administration of all anti-seizure medi-
        cations from the 9:00 p.m. pill call to the 4:00 p.m. pill call so that
        nurses, rather than corrections oﬃcers, would be in charge of dis-
        tribution. Nurse McDade reports that a similar situation had never
        occurred before.
                Following the August 2016 incident, Henegar regularly re-
        ceived his medication until his release a year later. The defendants
        all but acknowledge that a breakdown in communication between
        nurses, the pharmacy, and corrections oﬃcers caused Henegar’s
        injuries. After his release, Henegar began to struggle with his
        short-term memory, ﬁnding himself unable to remember everyday
        conversations and keep up with his welding job. He came to rely
        on his mother, with whom he lived, to remind him about medical
        appointments, and he suﬀered strained relationships because he
        was no longer able to regulate his emotions.
                                       * * *
                One last “factual” issue: There’s a fair amount of ﬁnger-
        pointing among the defendants. For instance, Nurse McDade in-
        sists that she trained corrections oﬃcers to communicate with
        nurses about an inmate’s medication both “through the MAR and
        verbally.” (For her part, Wade likewise alleges that the oﬃcers had
        been trained to contact the on-call nurse immediately when a
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        21-14275                Opinion of the Court                          9

        question about medication arose.) And it is undisputed that neither
        Lieutenant Stroh nor Sergeant Keith called a nurse immediately
        when Henegar initially missed his medication on August 28.
                Lieutenant Stroh and Sergeant Keith respond in three ways.
        First, they say—and all agree about this much—that they believed
        (even if incorrectly) that the medical staﬀ reviewed their notations
        in the MARs every morning, although Nurse McDade rejoins that
        she didn’t train them to think that. Second, the oﬃcers assert that
        they considered it an inmate’s responsibility to notify the medical
        staﬀ if his medicine was unavailable and that oﬃcers were sup-
        posed to communicate with the medical staﬀ exclusively through
        MARs. Sergeant Keith, in particular, testiﬁed that his practice was
        to contact the on-call nurse only when there were discrepancies
        with a prisoner’s medication—say, if a pill on the cart didn’t match
        the prisoner’s prescription—not when medication was missing en-
        tirely. Finally, Sergeant Keith claims (1) that he did tell at least one
        nurse verbally about the problem either late on August 28 or early
        on August 29, (2) that it must have been Nurse Lee because she was
        the only one whose shift overlapped with his, and (3) that, in any
        event, the nurse with whom he spoke told him that Henegar’s Di-
        lantin was “on order.”
              In return, the nurses seek to shift blame back to the oﬃcers.
        For instance, Nurse Lee denies that Sergeant Keith ever told her
        about Henegar’s missing Dilantin. And more generally, all of the
        nurses deny that either Lieutenant Stroh or Sergeant Keith told
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        10                     Opinion of the Court                 21-14275

        them anything—they insist that they were completely unaware
        that Henegar was out of Dilantin.
                The nurses also point ﬁngers at one another. Nurse Melton,
        for instance, testiﬁed that it was Nurse Lee’s responsibility to check
        the MARs from the previous night’s 9:00 p.m. pill call to determine
        whether there had been medication-related problems. Wade
        agrees that Nurse Lee was supposed to check the MARs and, ac-
        cordingly, that she either knew or should have known that Henegar
        had been missing his Dilantin doses. Nurse Lee, naturally, denies
        that it was her responsibility either (1) to review the previous
        night’s or weekend’s MARs or (2) to communicate with corrections
        oﬃcers or solicit reports on the nighttime pill call. For her part,
        Nurse McDade testiﬁed that she didn’t double-check to ensure that
        line nurses were reviewing the nighttime MARs or the medication-
        order binder because she didn’t want to “micromanage” them.
                                          B
               Henegar sued Lieutenant Stroh, Sergeant Keith, and Nurses
        Harrell, Lee, and McDade under 42 U.S.C. § 1983, alleging that
        each of them had been deliberately indiﬀerent to his serious medi-
        cal needs in violation of the Eighth Amendment. The district court
        granted summary judgment to all defendants on the ground that
        they were entitled to qualiﬁed immunity. In particular, the court
        held that even if one or more of the defendants had violated the
        Constitution, the law in August 2016 was insuﬃciently “clearly es-
        tablished” to give them fair notice of the unlawfulness of their con-
        duct: “Assuming Defendants’ conduct here constituted deliberate
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        21-14275                  Opinion of the Court                             11

        indiﬀerence to a serious medical need in violation of Plaintiﬀ’s
        Eighth Amendment rights, Plaintiﬀ has failed to point to any law
        applicable to the circumstances presented in this case that clearly
        established the alleged violation of Plaintiﬀ’s rights.”
                Henegar’s sister, Betty Wade, assumed responsibility for his
        suit following his death, and on appeal she contends that the district
        court erred in granting the defendants summary judgment.1
                                              II
                 A government oﬃcial sued under § 1983 may defend on the
        ground that he or she has qualiﬁed immunity from suit. Qualiﬁed
        immunity protects oﬃcials “from liability for civil damages insofar
        as their conduct does not violate clearly established statutory or
        constitutional rights of which a reasonable person would have
        known.” Pearson v. Callahan, 555 U.S. 223, 231 (2009) (quoting Har-
        low v. Fitzgerald, 457 U.S. 800, 818 (1982)). Because it is undisputed
        that the defendants here were at all relevant times performing dis-
        cretionary functions of their oﬃces, see Glasscox v. City of Argo, 903
        F.3d 1207, 1213 (11th Cir. 2018), Wade has the burden both (1) to
        “make out a violation of a constitutional right” and (2) to show that
        the right that she claims the defendants violated was “clearly estab-
        lished at the time of [their] alleged misconduct.” Pearson, 555 U.S.
        at 232 (quotation omitted).

        1 We review a district court’s grant of summary judgment de novo. See Stewart
        v. Happy Herman’s Cheshire Bridge, Inc., 117 F.3d 1278, 1284 (11th Cir. 1997).
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        12                      Opinion of the Court                   21-14275

               A reviewing court may consider the two prongs of the qual-
        iﬁed-immunity standard in either order. Id. at 236. As already ex-
        plained, the district court here bypassed the ﬁrst prong—“[a]ssum-
        ing” that the defendants had violated the Eighth Amendment—in
        favor of deciding the case on the ground that Wade hadn’t shown
        that applicable law was “clearly established.” We think it best—and
        ﬁnd that we are able—to resolve the case on the ﬁrst, “violation”
        prong.
                                        * * *
               In relevant part, the Eighth Amendment forbids the “in-
        ﬂict[ion]” of “cruel and unusual punishments.” U.S. Const. amend
        VIII. The Supreme Court ﬁrst held in Estelle v. Gamble that the
        Cruel and Unusual Punishments Clause should be understood to
        prohibit “deliberate indiﬀerence to serious medical needs of pris-
        oners.” 429 U.S. 97, 104–05 (1976). As it has evolved in the years
        since Estelle, a deliberate-indiﬀerence claim has come to entail both
        an objective and a subjective component. See Keohane v. Florida
        Dep’t of Corr. Sec’y, 952 F.3d 1257, 1266 (11th Cir. 2020). As an initial
        matter, the plaintiﬀ-inmate must establish an “objectively serious
        medical need.” Id. It is undisputed, as relevant here, that an un-
        medicated seizure disorder satisﬁes that objective threshold.
                A deliberate-indiﬀerence claim’s subjective component en-
        tails three subparts: The plaintiﬀ must prove that the defendant (1)
        actually knew about a risk of serious harm; (2) disregarded that
        risk; and (3) acted with more than ______ negligence. See Hoﬀer v.
        Secretary, Fla. Dep’t of Corr., 973 F.3d 1263, 1270 (11th Cir. 2020). To
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        21-14275               Opinion of the Court                         13

        be clear, the blank in our paraphrase is intentional. For more than
        25 years now, our case law regarding a deliberate-indiﬀerence
        claim’s mens rea element has been hopelessly confused, resulting
        in what we’ll charitably call a “mess.” We’ve tried to clean up that
        mess at least twice, but seemingly to no avail, as panels continue to
        ﬂip-ﬂop between two competing formulations: “more than mere
        negligence” and “more than gross negligence.” We ﬁnd it necessary
        to address the mens rea issue once again—this time, we hope more
        deﬁnitively—because, as it turns out, the standard is dispositive
        with respect to two of our defendants.
               In the discussion that follows, we will explain the dissonance
        in our precedent and our resolution of it, and then, having done so,
        apply the governing deliberate-indiﬀerence standard to each of our
        ﬁve defendants.
                                          A
                The confusion in our case law arose in the wake of the Su-
        preme Court’s decision in Farmer v. Brennan, 511 U.S. 825 (1994).
        Farmer was a successor to Estelle and, for the ﬁrst time, set out to
        explain the term “deliberate indiﬀerence.” Id. at 829. In particular,
        the Farmer Court said that “[w]hile 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.” Id. at 835. The Court thus likened deliberate
        indiﬀerence to “subjective recklessness as used in the criminal law.”
        Id. at 839.
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        14                      Opinion of the Court                  21-14275

                Our post-Farmer decisions are a jumble, with diﬀerent panels
        adopting one of two diﬀerent mens rea standards at diﬀerent times.
        On the one hand, some have interpreted Estelle and Farmer to re-
        quire a deliberate-indiﬀerence plaintiﬀ to show only that the de-
        fendant acted with “more than mere negligence.” See, e.g., Adams v.
        Poag, 61 F.3d 1537, 1543 (11th Cir. 1995); McElligott v. Foley, 182 F.3d
        1248, 1255 (11th Cir. 1999); Brown v. Johnson, 387 F.3d 1344, 1351
        (11th Cir. 2004); Mann v. Taser Int’l, Inc., 588 F.3d 1291, 1307 (11th
        Cir. 2009); Bingham v. Thomas, 654 F.3d 1171, 1176 (11th Cir. 2011);
        Jackson v. West, 787 F.3d 1345, 1353 (11th Cir. 2015); Melton v. Abston,
        841 F.3d 1207, 1223 (11th Cir. 2016); Mitchell v. Nobles, 873 F.3d 869,
        876 (11th Cir. 2017); Swain v. Junior, 961 F.3d 1276, 1285 (11th Cir.
        2020); Keohane, 952 F.3d at 1266. On the other hand, just as many
        (if not more) of our opinions have said that a deliberate-indiﬀer-
        ence plaintiﬀ must prove that the defendant acted with “more than
        gross negligence.” See, e.g., Cottrell v. Caldwell, 85 F.3d 1480, 1490
        (11th Cir. 1996); Bozeman v. Orum, 422 F.3d 1265, 1272 (11th Cir.
        2005); Burnette v. Taylor, 533 F.3d 1325, 1330 (11th Cir. 2008); Town-
        send v. Jeﬀerson Cnty., 601 F.3d 1152, 1158 (11th Cir. 2010); Harper v.
        Lawrence Cnty., Ala., 592 F.3d 1227, 1234 (11th Cir. 2010); Youmans v.
        Gagnon, 626 F.3d 557, 564 (11th Cir. 2010); Pourmoghani-Esfahani v.
        Gee, 625 F.3d 1313, 1317 (11th Cir. 2010); Liese v. Indian River Cnty.
        Hosp. Dist., 701 F.3d 334, 344 (11th Cir. 2012); Goodman v. Kimbrough,
        718 F.3d 1325, 1332 (11th Cir. 2013); Keith v. DeKalb Cnty., Ga., 749
        F.3d 1034, 1047 (11th Cir. 2014); Valderrama v. Rousseau, 780 F.3d
        1108, 1116 (11th Cir. 2015); Patel v. Lanier Cnty., Ga., 969 F.3d 1173,
        1188 (11th Cir. 2020); Hoﬀer, 973 F.3d at 1270; Wade v. Daniels, 36
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        21-14275                   Opinion of the Court                                15

        F.4th 1318, 1326 (11th Cir. 2022); Ireland v. Prummell, 53 F.4th 1274,
        1293 (11th Cir. 2022). As the dates in our string cites attest, we have
        pitched back and forth—and back and forth and back and forth—
        between the “more than mere negligence” and “more than gross
        negligence” standards for the better part of the last three decades.
                As already noted, on at least two separate occasions, panels
        of this Court have squarely confronted the mere-vs.-gross issue
        and attempted to set circuit law straight. First, in 2010, the panel
        in Townsend v. Jeﬀerson County expressly adopted the “more than
        gross negligence” standard. A deliberate-indiﬀerence plaintiﬀ, it
        held, must prove, among other things, that the defendant engaged
        in conduct that amounted to “more than [gross] negligence.” 601
        F.3d at 1158 (alteration in original). 2 In doing so, the Townsend
        panel acknowledged that some opinions had “occasionally stated,
        in dicta, that a claim of deliberate indiﬀerence requires proof of
        ‘more than mere negligence,’” citing for that proposition McElligott
        v. Foley, 182 F.3d at 1255. Townsend, 601 F.3d at 1158. Importantly,
        though, the Townsend panel concluded that the “earlier holding in
        Cottrell [v. Caldwell], 85 F.3d at 1490, made clear that, after Farmer v.
        Brennan, 511 U.S. 825 (1994), a claim of deliberate indiﬀerence

        2 To be clear, the Townsend panel didn’t insert the word “gross” into its recita-
        tion of the governing standard. Rather, it quoted Bozeman v. Orum, 422 F.3d
        at 1272, which in turn quoted Brown v. Johnson, 387 F.3d at 1351, but substi-
        tuted the word “gross” for Brown’s “mere” on the ground that the decisions in
        Miller v. King, 384 F.3d 1248, 1261 (11th Cir. 2004), and Cottrell v. Caldwell, 85
        F.3d at 1491, had recognized that “after [Farmer], gross negligence fails to sat-
        isfy [the] state-of-mind requirement for deliberate indifference.” Bozeman, 422
        F.3d at 1272.
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        16                     Opinion of the Court                  21-14275

        requires proof of more than gross negligence.” Id. (parallel cita-
        tions omitted).
                Notwithstanding Townsend’s embrace of Cottrell and the
        “more than gross negligence” standard, within a few years some
        panels reverted to the “more than mere negligence” formulation.
        See, e.g., Bingham, 654 F.3d at 1176; West, 787 F.3d at 1353. So in
        2016, another three-judge panel re-engaged the mere-vs.-gross is-
        sue. In Melton v. Abston, the panel held that “[a] plaintiﬀ claiming
        deliberate indiﬀerence to a serious medical need must prove,” inter
        alia, that the defendant engaged in conduct that amounted to
        “more than mere negligence.” 841 F.3d at 1223 (emphasis added).
        The Melton panel acknowledged Townsend’s earlier conclusion that
        “under [Cottrell] and [Farmer], ‘a claim of deliberate indiﬀerence re-
        quires proof of more than gross negligence.’” Id. at 1223 n.2 (quot-
        ing Townsend, 601 F.3d at 1158). But the Melton panel “disagree[d]”
        with Townsend “for three main reasons.” Id. First, the Melton panel
        expressed the view that “the ‘more than mere negligence’ standard
        in McElligott” was “more consistent with Farmer than the ‘more
        than gross negligence’ standard in Townsend.” Id. Second, and re-
        latedly, it observed that the phrase “more than gross negligence”
        didn’t appear (at least in so many words) in either Cottrell or Farmer.
        Id. And ﬁnally, the Melton panel said that Cottrell’s adoption of the
        “more than gross negligence” standard came only in dicta: “[T]he
        panel in Cottrell,” it said, “found no deliberate indiﬀerence where
        the plaintiﬀ failed to prove ‘the subjective intent element prescribed
        in Farmer,’ and therefore, did not reach whether Farmer requires
        ‘more than mere negligence’ or ‘more than gross negligence.’” Id.
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        21-14275                  Opinion of the Court                               17

        (quoting Cottrell, 85 F.3d at 1491–92). Accordingly, the Melton panel
        held that the 1999 decision in McElligott—rather than the 1996 de-
        cision in Cottrell—was the “earliest Eleventh Circuit case after
        Farmer to directly address” the mens rea issue, that the McElligott
        panel’s determination of the mens rea issue was not dicta, as Town-
        send had said, and, therefore, that the “more than mere negligence”
        standard controlled. Id.
                What to do with Townsend’s and Melton’s dueling attempts
        to answer the mere-vs.-gross question? The short answer is that
        our prior-panel-precedent rule binds us to Townsend’s earlier reso-
        lution. “When there is no method for reconciling an intracircuit
        conﬂict of authority”—as there isn’t here, given the Melton panel’s
        explicit “disagree[ment]” with and rejection of Townsend—“the ear-
        liest panel opinion resolving the issue in question binds this circuit
        until the court resolves the issue en banc.” United States v. Dailey,
        24 F.3d 1323, 1327 (11th Cir. 1994) (quoting Clark v. Housing Auth. of
        Alma, 971 F.2d 723, 726 n.4 (11th Cir. 1992)); see also United States v.
        Archer, 531 F.3d 1347, 1352 (11th Cir. 2008) (emphasizing “the
        strength of the prior panel precedent rule in this circuit”). 3

        3 To be clear, the “issue in question” with respect to which we apply the prior-
        panel-precedent rule here, see Dailey, 24 F.3d at 1327 (quoting Clark, 971 F.2d
        at 726 n.4), isn’t whether “more than mere negligence” or “more than gross
        negligence” is the proper mens rea standard as an initial matter. If that were
        the proper object of our prior-panel-precedent-rule inquiry, then we would
        seek out the “earliest panel opinion” addressing that issue, whatever that opin-
        ion might be. Id. But that’s not our task; rather, the prior-panel-precedent
        issue that we confront now, in the wake of Townsend and Melton, is which of
        those two previous efforts to clarify circuit law controls our decision. Cf.
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        18                          Opinion of the Court                        21-14275

                To summarize the key points about Townsend and Melton: In
        2010, Townsend held that our then-existing decisions could be read
        consistently (and in any event were best read) to impose a “more
        than gross negligence” standard. In particular, Townsend held (1)
        that the existing decisions did not embody conﬂicting holdings on
        the mere-vs.-gross issue, (2) that McElligott’s adoption of the “more
        than mere negligence” standard was mere “dicta,” and (3) that the
        “earlier holding” in Cottrell was clear that the “more than gross neg-
        ligence” standard applied. Townsend, 601 F.3d at 1158. Six years
        later, the Melton panel expressly “disagree[d] with” Townsend on the
        grounds (1) that in fact (and contra Townsend) there was a split in
        our cases that required resolving, (2) that in fact (and contra Town-
        send) Cottrell had not “h[eld]” that a “more than gross negligence”
        standard applied, and (3) that in fact (and contra Townsend) McElli-
        gott’s adoption of the “more than mere negligence” standard was
        not just “dicta” but instead a binding holding.
               With all due respect to the Melton panel, under our prior-
        panel-precedent rule, it had no authority to “disagree with” Town-
        send—either Townsend’s treatment of McElligott as “dicta,” its treat-
        ment of Cottrell as a “holding,” or its resulting conclusion that cir-
        cuit precedent, properly understood, embraces a “more than gross

        Offshore of the Palm Beaches, Inc. v. Lynch, 741 F.3d 1251, 1256–57 (11th Cir. 2014)
        (applying the prior-panel-precedent rule not to the first case to decide the un-
        derlying question—there, whether the court had appellate jurisdiction over
        interlocutory admiralty-related orders under 28 U.S.C. § 1292(a)(1)—but, ra-
        ther, to the first of several conflicting cases to determine whether an interven-
        ing Supreme Court decision had abrogated contrary circuit precedent).
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        21-14275                  Opinion of the Court                               19

        negligence” mens rea standard. We too are bound by Townsend.
        Whatever we might think about the confusion surrounding the
        mens rea issue or its resolution, Townsend settled matters by em-
        bracing Cottrell and the “more than gross negligence” standard.
        The Melton panel was powerless to decide otherwise, and so are
        we. 4
               Filling in the blank, then: To make out the subjective com-
        ponent of an Eighth Amendment deliberate-indiﬀerence claim, a
        plaintiﬀ must establish that the defendant (1) had subjective
        knowledge of a risk of serious harm, (2) disregarded that risk, and
        (3) acted with more than gross negligence.
                                               B
             Having resolved the standard that governs our analysis, we
        now proceed to apply it to each of our ﬁve defendants.
                                               1
              We consider the corrections oﬃcers ﬁrst. Our analysis of
        Wade’s claim against Lieutenant Stroh is straightforward, as it
        founders on the subjective component’s ﬁrst subpart: Lieutenant
        Stroh didn’t have “subjective knowledge of a risk of serious harm.”

        4 Were the rule otherwise—such that any panel was free to re-decide what it
        thought the first-in-time case actually was, even in the face of intervening de-
        cisions resolving that very issue—there could, by definition, be no closure.
        Every day would be a new day. That is precisely the situation that our prior-
        panel-precedent rule is designed to prevent.
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        20                          Opinion of the Court                        21-14275

        Hoﬀer, 973 F.3d at 1270. 5 “Whether a prison oﬃcial had the requi-
        site knowledge of a substantial risk is a question of fact subject to
        demonstration in the usual ways, including inference from circum-
        stantial evidence.” Farmer, 511 U.S. at 842. Here, Lieutenant Stroh
        testiﬁed—without contradiction—that he didn’t “have a sense of
        urgency” about Henegar’s missing Dilantin because (1) he had a
        son with epilepsy and (2) his son could miss doses of his seizure
        medication without incident. So while Lieutenant Stroh acknowl-
        edged that he knew that an unmedicated seizure disorder consti-
        tuted a serious health risk, he didn’t know that missing medication
        for just a few days could produce that risk. Because he lacked the
        requisite subjective knowledge, Lieutenant Stroh was not deliber-
        ately indiﬀerent to Henegar’s medical needs, and the district court
        correctly granted him summary judgment.
               Next, Sergeant Keith. It’s undisputed that Sergeant Keith
        made MAR notations on the ﬁrst and fourth nights that Henegar
        missed his Dilantin, a fact from which one could reasonably (if un-
        charitably) infer that he had a subjective awareness of a serious risk
        to Henegar’s health. Construing the facts in Wade’s favor vis-à-vis
        Sergeant Keith, one could also reasonably infer that he had been

        5 Although Lieutenant Stroh was Sergeant Keith’s supervisor, “[i]t is well es-
        tablished in this circuit that supervisory officials are not liable under § 1983 for
        the unconstitutional acts of their subordinates on the basis of respondeat su-
        perior or vicarious liability.” Hartley v. Parnell, 193 F.3d 1263, 1269 (11th Cir.
        1999) (internal quotation and citation omitted). Accordingly, our review is
        limited to the question whether Lieutenant Stroh himself exhibited deliberate
        indifference to Henegar’s serious medical needs.
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        21-14275               Opinion of the Court                        21

        trained not only to convey medication-administration problems
        through MAR notations, but also to communicate them directly to
        nurses. All agree that Sergeant Keith made notations in Henegar’s
        MAR in an attempt to signal problems with administering his Di-
        lantin and that he believed (even if incorrectly) that the nurses gen-
        erally reviewed MAR notations. The defendants dispute among
        themselves, though, whether Sergeant Keith ever told a nurse.
        Construing the facts in the light most favorable to Wade—again,
        vis-à-vis Sergeant Keith—we must assume that he never verbally
        told a nurse about the problem as he had been told to do. Based on
        the facts as thus understood, we conclude that Wade has shown not
        only that Sergeant Keith was subjectively aware of a risk of serious
        harm but also that he at least partially disregarded that risk. Hoﬀer,
        973 F.3d at 1270.
                But was he more than grossly negligent? We hold, especially
        in light of his attempt to communicate with the prison’s medical
        staﬀ through notations in Henegar’s MAR, that he was not. In Cot-
        trell, we described the “more than gross negligence” standard as
        “‘the equivalent of recklessly disregarding’ a substantial risk of se-
        rious harm to the inmate.” Cottrell, 85 F.3d at 1490–91 (quoting
        Farmer, 511 U.S. at 836). Sergeant Keith’s partial disregard of (what
        we will assume to be) his training doesn’t satisfy that high standard.
        Accordingly, the district court correctly granted him summary
        judgment.
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        22                     Opinion of the Court                21-14275

                                         2
              Nurses Harrell and Lee are closer calls. The subjective
        prong’s ﬁrst subpart is pretty easily satisﬁed. Circumstantial evi-
        dence, which Farmer says we may consider and from which we may
        draw reasonable inferences, indicates that both knew that Henegar
        wasn’t getting his Dilantin, and we may further assume that, as
        medical professionals, both knew that he faced a risk of serious
        harm.
                Nurse Harrell, in particular, doesn’t dispute either that she
        staﬀed the daytime pill calls on three of the four days that Henegar
        missed his medication or that he attended at least one daytime pill
        call during those days. She also admits that she inventoried the pill
        cart at least once during those days—on either Monday, August 29,
        or Wednesday, August 31—and that an unusual post-it note had
        been attached to and was protruding from Henegar’s MAR during
        that period. Beyond her conclusory testimony, Nurse Harrell has
        done nothing to demonstrate that she was unaware of the serious
        risk that Henegar faced.
                So, too, with respect to Nurse Lee. We must assume that
        she was supposed to check the previous night’s MARs to determine
        whether there were problems with administering an inmate’s med-
        ications. And taking the facts in the light most favorable to Wade
        vis-à-vis Nurse Lee, we must also assume that Sergeant Keith actu-
        ally told her early on Monday that Henegar was missing his medi-
        cation.
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        21-14275                Opinion of the Court                         23

               Construing the facts in Wade’s favor, we further conclude
        that Nurses Harrell and Lee “disregarded th[e] risk” of a serious
        health concern. Hoﬀer, 973 F.3d at 1270. The parties agree that
        they knew about the backup Dilantin supply, had access to it, and
        had the ability to order medications from either the prison-system
        pharmacy or a local pharmacy. And yet no one suggests that either
        attempted to order or obtain backup Dilantin for Henegar. Based
        on the totality of the circumstances, we can reasonably infer not
        only that both knew Henegar was out of Dilantin, but also that at
        least one of them—and perhaps both—did little to remedy the sit-
        uation. Henegar testiﬁed that when he told the daytime-pill-call
        nurse that he was out—he couldn’t remember who it was—she
        simply responded that his Dilantin was “on order” from the prison
        system’s pharmacy. And Sergeant Keith, of course, said that Nurse
        Lee responded the same way—that the medicine was “on order”—
        when he told her that Henegar’s Dilantin had run out.
                Even so, we hold that both Nurses Harrell and Lee are enti-
        tled to summary judgment because their conduct was not more
        than grossly negligent. The nurses’ responses—replying that
        Henegar’s Dilantin was “on order” rather than obtaining a substi-
        tute dose from the supply closet or a local pharmacy—was regret-
        table, and we think it was likely more than merely negligent. But it
        is axiomatic that simple medical malpractice does not rise to the
        level of a constitutional violation. Estelle, 429 U.S. at 106. If (as we
        assume for present purposes) Nurses Harrell and Lee were told ver-
        bally that Henegar was missing his Dilantin, the facts show that
        they both checked to ensure that it would be arriving soon and
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        24                      Opinion of the Court                   21-14275

        reported that it was “on order.” We cannot say that their actions in
        that respect constitute the sort of “reckless[ ] disregard[ ]” that we
        have held characterizes conduct that is more than grossly negli-
        gent. Cottrell, 85 F.3d at 1490–91; see also Poag, 61 F.3d at 1543 (stat-
        ing, even in what appears to be a “more than mere negligence”
        case, that “it is obduracy and wantonness, not inadvertence or er-
        ror in good faith, that violates the Eighth Amendment in supplying
        medical needs” (alteration in original) (internal quotations omit-
        ted) (quoting Whitley v. Albers, 475 U.S. 312, 319 (1986))).
               Our decisions imposing deliberate-indiﬀerence liability have
        typically involved egregious circumstances, often involving prison
        oﬃcials denying inmates medication for no reason at all. Nothing
        like that happened here. See Goebert v. Lee Cnty., 510 F.3d 1312, 1330
        (11th Cir. 2007) (applying a more-than-gross-negligence standard
        and observing that “an oﬃcial acts with deliberate indiﬀerence
        when he intentionally delays providing an inmate with access to
        medical treatment, knowing that the inmate has a life-threatening
        condition or an urgent medical condition that would be exacer-
        bated by delay” (quoting Lancaster v. Monroe Cnty., Ala., 116 F.3d
        1419, 1425 (11th Cir. 1997))); compare, e.g., Lawrence Cnty., 592 F.3d
        at 1234–35 (holding that the complaint plausibly alleged that prison
        oﬃcials were more than grossly negligent when they failed to treat
        an alcoholic suﬀering from severe withdrawal and obvious delir-
        ium for four days until he eventually died), with, e.g., Burnette, 533
        F.3d at 1328–31 (holding that oﬃcers were not more than grossly
        negligent when they failed to obtain medical attention for a lucid
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        21-14275               Opinion of the Court                         25

        arrestee who had “glassy eyes and dilated pupils” and died hours
        later of an overdose).
               Because neither Nurse Harrell nor Nurse Lee was more than
        grossly negligent, neither exhibited deliberate indiﬀerence to
        Henegar’s medical needs. The district court properly granted them
        summary judgment.
                                          3
               Wade’s claim against Nurse McDade is different in that it
        names her in her supervisory capacity. Where, as here, there is no
        allegation that a supervisor “personally participated” in any wrong-
        doing, she can be held liable only if she “instigated or adopted a
        policy that violated [the plaintiff’s] constitutional rights.” Poag, 61
        F.3d at 1544. We have emphasized that “[t]he standard by which a
        supervisor is held liable in her individual capacity for the actions of
        a subordinate is extremely rigorous.” Braddy v. Florida Dep’t of Lab.
        & Emp. Sec., 133 F.3d 797, 802 (11th Cir. 1998).
               Policy-based supervisory liability can result either where a
        challenged policy is unconstitutional on its face or where it is im-
        plemented in an unconstitutional manner. See Goebert, 510 F.3d at
        1332. To succeed on an implementation-based challenge, a plain-
        tiff must show, among other things, that the supervisor “had actual
        or constructive notice of a flagrant, persistent pattern of viola-
        tions.” Id.
               Wade challenges two of Nurse McDade’s policies. First, she
        targets the MAR policy. Nurse McDade, of course, insists that she
        trained the officers to call a nurse immediately if a problem arose
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        26                      Opinion of the Court                   21-14275

        dispensing an inmate’s medication; Lieutenant Stroh and Sergeant
        Keith deny that she did so. Construing the facts in the light most
        favorable to Wade vis-à-vis Nurse McDade, we will assume that
        she didn’t train the officers to contact a nurse if they encountered
        medication-related issues and that her system relied entirely on
        MAR notifications. Even so, an MAR-only policy—while not
        ideal—is not deliberately indifferent on its face. It would not, as
        Wade asserts, necessarily “fail[ ] to ensure that Lieutenant Stroh
        and Sergeant Keith had an effective mechanism to communicate
        with medical at times when there were no medical staff on duty.”
        Br. of Appellant at 30–31; see Goebert, 510 F.3d at 1332 (holding that
        a “policy of not permitting inmates to lie down at their leisure dur-
        ing the daytime” was “certainly [ ] not facially unconstitutional” in
        a case involving a pregnant woman who, when denied an exemp-
        tion, suffered a miscarriage). That is especially true given the un-
        disputed fact that there was a medical staff member on call.
                Second, Wade alleges that Nurse McDade was deliberately
        indifferent for “failing to properly ensure her subordinates, Nurses
        Lee and Harrell, searched the MARs daily for communications
        from security, or otherwise check to be sure all medications were
        on the pill cart.” Br. of Appellant at 31. To the extent that Wade
        assails that policy on its face, her challenge fails. It was not facially
        deliberately indifferent for Nurse McDade to expect subordinates
        to check MARs daily without looking over their shoulders, espe-
        cially given that she had established an elaborate system of order-
        ing, cross-checking, and inventorying the pill cart to ensure that
        each inmate received his medicine. Cf. Goebert, 510 F.3d at 1332.
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        21-14275                Opinion of the Court                          27

               We likewise reject any implementation-based challenge, alt-
        hough doing so requires a bit more explanation. For implementa-
        tion-related deliberate-indifference claims,
               [w]e apply a three-prong test to determine a supervi-
               sor’s liability: (1) whether the supervisor’s failure to
               adequately train and supervise subordinates consti-
               tuted deliberate indiﬀerence to an inmate’s medical
               needs; (2) whether a reasonable person in the super-
               visor’s position would understand that the failure to
               train and supervise constituted deliberate indiﬀer-
               ence; and (3) whether the supervisor’s conduct was
               causally related to the subordinate’s constitutional vi-
               olation.

        Poag, 61 F.3d at 1544. Here, for reasons we will explain, Wade can-
        not meet the third, causation element; accordingly, her challenge
        fails.
               For our purposes, a causal connection is shown when: (1) “a
        history of widespread abuse puts the responsible supervisor on no-
        tice of the need to correct the alleged deprivation, and he fails to
        do so”; (2) “a supervisor’s custom or policy . . . results in deliberate
        indifference to constitutional rights”; or (3) “facts support an infer-
        ence that the supervisor directed the subordinates to act unlawfully
        or knew that the subordinates would act unlawfully and failed to
        stop them from doing so.” Cottone v. Jenne, 326 F.3d 1352, 1360
        (11th Cir. 2003), abrogated in part on other grounds by Randall v. Scott,
        610 F.3d 701 (11th Cir. 2010) (alteration accepted) (internal
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        28                      Opinion of the Court                  21-14275

        citations and quotations omitted). None of those requirements is
        satisfied here.
                First, Wade hasn’t alleged any facts to indicate that there
        was a “history of widespread abuse” sufficient to put Nurse
        McDade on “actual or constructive notice of a flagrant, persistent
        pattern of violations.” Goebert, 510 F.3d at 1332. It is undisputed
        (1) that Henegar’s condition was well-controlled before the inci-
        dent that underlies this case and (2) that he received his medication
        regularly thereafter until his release. And Wade has pointed to no
        evidence of a pattern of similar violations with respect to other in-
        mates, either. See Reply Br. of Appellant at 19 (“[T]hose cases in-
        volve allegations of widespread patterns of policy violation, which
        is not an issue here.”).
                Second, and for similar reasons, there is no evidence that a
        policy of trusting subordinates to monitor the MARs and manage
        the pill cart generally “results in deliberate indifference to constitu-
        tional rights.” Cottone, 326 F.3d at 1360. Lieutenant Stroh testified
        that in 23 years at the prison, it was not “typical” for medication to
        be missing, McDade testified that no comparable situation had ever
        occurred, and Wade has alleged no facts to the contrary. Though
        failing to double-check subordinates’ work might open cracks in
        the system to accidents and oversights, “[m]edical malpractice does
        not become a constitutional violation merely because the victim is
        a prisoner.” Estelle, 429 U.S. at 106. Compare, e.g., Doe v. School Bd.
        of Broward Cnty., Fla., 604 F.3d 1248, 1266 (11th Cir. 2010) (holding
        that allegations that supervisors had been aware of “two instances
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        21-14275               Opinion of the Court                       29

        of sexual harassment” were insufficient to “show the requisite
        causal connection” for deliberate-indifference purposes), with, e.g.,
        Valdes v. Crosby, 450 F.3d 1231, 1243–44 (11th Cir. 2006) (holding
        that a prison warden was deliberately indifferent when he had re-
        ceived at least 13 complaints and inquiries in 13 months before the
        plaintiff’s son’s death at the hands of prison guards).
               Finally, there have been no allegations that Nurse McDade
        directed subordinates to act unlawfully or knew that subordinates
        would do so and failed to stop them. At worst, perhaps she should
        have assumed that mistakes might occur if she didn’t review
        nurses’ work on the MARs. That is not enough.
                                         IV
               We echo the district court’s lament that the defendants’
        “careless actions and their systemic communication failures caused
        Mr. Henegar serious suffering” and “irreparably altered his life.”
        And we reiterate that “while engaged in the business of prison med-
        icine”—no less so than on the outside, so to speak—“the essential
        command of the Hippocratic Oath is ‘first, do no harm.’” Even so,
        the bar to proving an Eighth Amendment deliberate-indifference
        claim is appropriately high, and we conclude that Wade hasn’t met
        it. We therefore affirm the district court’s order granting all five
        defendants summary judgment.
              AFFIRMED.
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        21-14275              Newsom, J., Concurring                        1

        NEWSOM, Circuit Judge, concurring:
                As the majority opinion explains, our precedent has for years
        bobbed and weaved between two competing views regarding the
        mens rea that underlies an Eighth Amendment deliberate-indiﬀer-
        ence claim: Must an inmate prove that the prison oﬃcial whose
        conduct he challenges acted with “more than gross negligence,” or
        is it enough to show “more than mere negligence”? Applying our
        prior-panel-precedent rule, the Court holds today—correctly, un-
        der existing law—that the former, “more than gross negligence”
        standard governs. See Maj. Op. at 13–19.
               I’d like to explore a more foundational question: Is any neg-
        ligence-based standard consistent with the plain language and orig-
        inal understanding of the Eighth Amendment, which by its terms
        applies only to “punishments”? The answer, I think, is pretty
        clearly no. Just as a parent can’t accidently punish his or her child,
        a prison oﬃcial can’t accidentally—or even recklessly—“punish[]”
        an inmate.
                                          I
               The Eighth Amendment states that “[e]xcessive bail shall not
        be required, nor excessive ﬁnes imposed, nor cruel and unusual
        punishments inﬂicted.” U.S. Const. amend. VIII. To my mind, it is
        fairly well-established that, as originally understood, the Amend-
        ment’s Cruel and Unusual Punishments Clause prohibited only cer-
        tain particularly objectionable methods of punishment imposed in
        conjunction with a criminal defendant’s judgment of conviction. It
        did not, for instance, entail a proportionality principle that
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        2                      Newsom, J., Concurring                   21-14275

        empowered judges to determine that a particular penalty was ex-
        cessive in relation to a particular crime, nor did it purport to regu-
        late the conditions of a prisoner’s conﬁnement. I won’t reinvent
        the wheel; I’ll simply say that I ﬁnd myself persuaded by Justice
        Scalia’s thorough analysis in Harmelin v. Michigan, 501 U.S. 957, 961–
        85 (1991) (Scalia, J.); see also, e.g., Anthony F. Granucci, Nor Cruel and
        Unusual Punishments Inﬂicted: The Original Meaning, 57 Calif. L. Rev.
        839, passim (1969). Be that as it may, the Supreme Court has moved
        on. It has read the Clause more broadly, not only to embrace a
        proportionality criterion, see Gre v. Georgia, 428 U.S. 153, 172
        (1976), but also to “appl[y] to some deprivations that were not spe-
        ciﬁcally part of the sentence but were suﬀered during imprison-
        ment,” see Wilson v. Seiter, 501 U.S. 294, 297 (1991), and, even more
        generally, to embody a fuzzy, eye-of-the-beholder “evolving stand-
        ards of decency” criterion, see Trop v. Dulles, 356 U.S. 86, 101 (1958)
        (plurality opinion).
                It remains the case, though, that the Eighth Amendment, by
        its plain terms, applies only to “punishments.” And whatever the
        proper understanding of the phrase-of-art “cruel and unusual pun-
        ishments,” the word “punishment[]” had—and has—a settled
        meaning. Samuel Johnson’s 1785 English dictionary, for instance,
        deﬁned it as “[a]ny inﬂiction or pain imposed in vengeance of a
        crime.” 2 Samuel Johnson, Dictionary of the English Language 424
        (6th ed. 1785). And nearly two centuries later, Americans were still
        using the term in fundamentally the same way to mean a “[p]enalty
        [or a] retributive suﬀering, pain, or loss.” Punishment, Webster’s
        New International Dictionary (2d ed. 1934). It seems plain to me
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        21-14275              Newsom, J., Concurring                        3

        that both of those deﬁnitions—and others like them—denote an
        element of intentionality. And that seems all the more plain in the
        speciﬁc context of the Eighth Amendment, which addresses not
        just “punishments” simpliciter, but their “inﬂiction,” a term that
        likewise indicates purposeful, directed conduct. See 1 Samuel John-
        son, Dictionary of the English Language 1040 (6th ed. 1785) (deﬁning
        “inﬂict” to mean “[t]o put in act or impose as punishment”); accord
        Noah Webster, An American Dictionary of the English Language 444
        (1828) (“Inﬂict, verb transitive: To lay on; to throw or send on; to
        apply; as, to inﬂict pain or disgrace; to inﬂict punishment on an of-
        fender.”).
                To be clear, I’m hardly the ﬁrst person to make this observa-
        tion about the Cruel and Unusual Punishments Clause’s text. Writ-
        ing for the Second Circuit in Johnson v. Glick, Judge Friendly empha-
        sized that “[t]he thread common to all [Eighth Amendment] cases
        is that ‘punishment’ has been deliberately administered for a penal
        or disciplinary purpose.” 481 F.2d 1028, 1032 (2d Cir. 1973). Even
        more directly to the point, Judge Posner has explained, pointing to
        what he called “normal meaning[],” that “[t]he inﬂiction of punish-
        ment is a deliberate act intended to chastise or deter.” Duckworth
        v. Franzen, 780 F.2d 645, 651–52 (7th Cir. 1985). “That,” he correctly
        said, “is what the word means today; it is what it meant in the eight-
        eenth century.” Id. at 652 (citing Samuel Johnson, Dictionary of the
        English Language (1755)). And Justice Scalia, writing for the Su-
        preme Court in Wilson v. Seiter—citing and quoting, among others,
        Judges Friendly’s and Posner’s observations and adding his own
        emphasis for good measure—indicated that the Eighth
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        Amendment entails an “intent requirement” and clariﬁed that
        “[t]he source of t[hat] requirement is not the predilections of this
        Court, but the Eighth Amendment itself, which bans only cruel and
        unusual punishment.” 501 U.S. at 300 (emphasis in original).1
                 The undeniable linguistic fact that the term “punishment”
        entails an intentionality element would seem to preclude any legal
        standard that imposes Eighth Amendment liability for uninten-
        tional conduct, no matter how negligent—whether it be only
        “mere[ly]” so or even “gross[ly]” so. Negligence and recklessness,
        after all, are expressly deﬁned in contradistinction to intentional con-
        duct. See, e.g., Negligence, Black’s Law Dictionary (10th ed. 2015)
        (“[A]ny conduct that falls below the legal standard established to
        protect others against unreasonable risk of harm, except for conduct
        that is intentionally, wantonly, or willfully disregardful of others’ rights.”
        (emphasis added)); Recklessness, id. (“Recklessness involves a

        1 Tellingly, even those who contend that the constitutional term “cruel”
        should be understood by reference to a punishment’s effect on the punished,
        rather than to the punisher’s particular motivation, acknowledge my funda-
        mental point—that, by definition, “all punishment involves intent.” John F.
        Stinneford, The Original Meaning of “Cruel”, 105 Geo. L.J. 441, 479 (2017). They
        admit that under “the Eighth Amendment’s intent requirement,” “[t]o violate
        the Cruel and Unusual Punishments Clause, some government official must
        intend to punish”; they just deny that the Clause requires the further proof
        that the official “intend[ed] to punish cruelly.” Id. at 493. Accord, e.g., John F.
        Stinneford, Is Solitary Confinement a Punishment?, 115 Nw. L. Rev. 9, 17 (2020)
        (reviewing historical and modern definitions of “punishment” and concluding
        that the term “involves intent to inflict pain or suffering, [just] not necessarily
        culpable intent”).
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        21-14275              Newsom, J., Concurring                        5

        greater degree of fault than negligence but a lesser degree of fault
        than intentional wrongdoing.” (emphasis added)).
              So on a plain reading, the Cruel and Unusual Punishments
        Clause applies only to penalties that are imposed intentionally and
        purposefully.
                                          II
                How is it, then, that we ﬁnd ourselves debating which of two
        negligence-based standards governs a particular species of Eighth
        Amendment claim? When and where did things go so wrong? It
        started innocently enough, with Estelle v. Gamble, 429 U.S. 97 (1976),
        in which the Supreme Court minted what it dubbed (and we still
        call) a “deliberate indiﬀerence” claim under the Eighth Amend-
        ment. There, the Court was pretty good about minding the line
        between intentional and negligent conduct—but it sowed seeds
        that would later ﬂower into a clean break from the text’s intention-
        ality criterion. On the one hand, the Estelle Court made clear that
        ordinary negligence does not constitute “punishment” within the
        meaning of the Eighth Amendment: Neither “[a]n accident” nor
        “an inadvertent failure to provide adequate medical care,” it said—
        even one that would give rise to a “medical malpractice” claim—
        crosses the constitutional line. Id. at 105–06. And, in fact, in de-
        scribing the types of conduct that could “manifest” suﬃciently cul-
        pable conduct, the Court twice adverted to purposeful actions:
        prison guards “intentionally denying or delaying access to medical
        care or intentionally interfering with the treatment once pre-
        scribed.” Id. at 104–05 (emphasis added). On the other hand,
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        6                     Newsom, J., Concurring                 21-14275

        though, the Court also repeated language from its “evolving stand-
        ards of decency” line of decisions asserting that the “unnecessary
        and wanton inﬂiction of pain” could give rise to an Eighth Amend-
        ment claim. Id. at 103 (emphasis added) (quoting Gre, 428 U.S. at
        173). “Wanton”-ness is a heightened mental state, to be sure, but
        it is not the same thing as intent or purpose.
                Next came Wilson v. Seiter, to which I’ve already referred. Re-
        spectfully, Wilson is an odd opinion. The question there was
        whether an ordinary conditions-of-conﬁnement claim should be
        decided under Estelle’s “deliberate indiﬀerence” standard, whatever
        its precise parameters—or instead under a higher standard that ap-
        plies when “oﬃcials act in response to a prison disturbance,” in
        which the complaining inmate must prove that oﬃcers acted “ma-
        liciously and sadistically for the very purpose of causing harm.”
        501 U.S. at 302 (quoting Whitley v. Albers, 475 U.S. 312, 320–21
        (1986)). In the course of its opinion, the Court nodded strongly
        toward a true intentionality criterion. As already noted, the Court
        stated that the source of what it called “the intent requirement”
        was “the Eighth Amendment itself, which bans only cruel and un-
        usual punishment,” id. at 300, and went on to quote favorably Judge
        Posner’s deﬁnition of the term “punishment” as “a deliberate act
        intended to chastise or deter,” as well as Judge Friendly’s observa-
        tion that “punishment” is “deliberately administered for a penal or
        disciplinary purpose,” id. (quoting Duckworth, 780 F.2d at 652, and
        Glick, 481 F.2d at 1032, respectively).
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                Strangely, though, having made the case—and a convincing
        one—that “[a]n intent requirement is . . . implicit in the word ‘pun-
        ishment,’” id. at 301, the Wilson Court then pivoted, in the second
        part of its opinion, to decide what it (somewhat inconsistently) pre-
        sented as an open question: “[I]t remains for us to consider what
        state of mind applies in cases challenging prison conditions” as vi-
        olative of the Eighth Amendment. Id. at 302. And in answer to
        that question, the Court deferred to language in its earlier decisions
        (including Estelle) rather than the language of the Constitution it-
        self: “[O]ur cases say that the oﬀending conduct must be wanton.”
        Id. (emphasis in original). In particular, the Wilson Court said that
        the form of wantonness to which Estelle had adverted was suﬃ-
        cient: In the ordinary prison-conditions “context, as Estelle held,
        ‘deliberate indiﬀerence’ would constitute wantonness.” Id.
               Lastly—in the Supreme Court, anyway—came Farmer v.
        Brennan, 511 U.S. 825 (1994). There, the Court set out to specify
        “the proper test for deliberate indiﬀerence,” as adopted in Estelle
        and seconded in Wilson. Id. at 834. Canvassing its earlier decisions,
        the Court opted for a standard “lying somewhere between the
        poles of negligence at one end and purpose or knowledge at the
        other,” settling on one that it loosely called “recklessness.” Id. at
        836. More precisely, the Court embraced a criminal-recklessness
        standard, which, it explained, requires a complaining prisoner to
        prove that the prison oﬃcial whose conduct he challenges subjec-
        tively “kn[ew] of and disregard[ed] an excessive risk to inmate
        health or safety.” Id. at 837. In justifying its choice, the Court
        brieﬂy adverted to the Eighth Amendment’s language, noting that
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        8                     Newsom, J., Concurring                21-14275

        it “does not outlaw cruel and unusual ‘conditions’” but only “cruel
        and unusual ‘punishments.’” Id. It never explained, though, how
        even a criminal-recklessness standard followed from the text itself.
        Rather, the most the Court could muster was that “subjective reck-
        lessness as used in the criminal law is a familiar and workable stand-
        ard that is consistent with the Cruel and Unusual Punishments
        Clause as interpreted in our cases”—that is, as glossed in decisions
        like Estelle and Wilson. Id. at 839–40 (emphasis added). Having said
        so, the Farmer Court “adopt[ed]” criminal recklessness “as the test
        for ‘deliberate indiﬀerence’ under the Eighth Amendment.” Id. at
        840.
                With Farmer, the retreat from the Eighth Amendment’s
        “punishment” requirement—and the intentionality criterion that it
        indicates—was complete. And our own post-Farmer decisions have
        only widened the gap between text and doctrine. As today’s ma-
        jority opinion explains, at times we have stated that a deliberate-
        indiﬀerence plaintiﬀ need only prove that an oﬃcial acted with a
        mental state of “more than mere negligence.” See, e.g., Melton v.
        Abston, 841 F.3d 1207, 1223 n.2 (11th Cir. 2016). At others, we’ve
        insisted that a plaintiﬀ prove a mens rea of “more than gross negli-
        gence.” Townsend v. Jeﬀerson Cnty., 601 F.3d 1152, 1158 (11th Cir.
        2010). Notably, even the higher gross-negligence standard seems
        to set a lower bar than Farmer’s criminal-recklessness criterion. See
        Farmer, 511 U.S. at 837 (rejecting a standard grounded in reckless-
        ness as used in civil tort law). And in any event, neither of our
        competing negligence-based standards—whether “mere” or
        “gross”—has any foundation in, or even connection to, the Eighth
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        Amendment’s “punishment” requirement, which, as a matter of
        both language and logic, demands proof of intentionality.
                                        III
               Maybe it makes sense to hold prison oﬃcials liable for negli-
        gently or recklessly denying inmates appropriate medical care.
        Maybe not. But any such liability, should we choose to recognize
        it, must ﬁnd a home somewhere other than the Eighth Amend-
        ment. We—by which I mean the courts generally—have been ig-
        noring that provision’s text long enough. Whether we like it or
        not, the Cruel and Unusual Punishments Clause applies, as its mon-
        iker suggests, only to “punishments.” And whether we like it or
        not, “punishment[]” occurs only when a government oﬃcial acts
        intentionally and with a speciﬁc purpose to discipline or deter.