Court Opinion

ID: 6963229
Source: CourtListenerOpinion
Date Created: 2022-07-24 01:49:12.412197+00
Date Added: 2024-06-11T16:08:22.163466
License: Public Domain

BOGGS, Circuit Judge,
concurring in pari;, and dissenting in part.
The issue on appeal in this case is whether the district court properly denied the appellants’ motion for summary judgment on the grounds of qualified immunity as to the Eighth Amendment deliberate indifference claim underlying the plaintiffs section 1983 action. I agree with the majority’s disposition of this case as to Dr. Mehra. However, I must dissent as to the other appellants because I believe that under the facts of this ease and existing law all three appellants should be granted summary judgment for the simple reason that the conduct alleged by the plaintiff does not satisfy the threshold condition of stating facts that constitute a violation of the Eighth Amendment’s prohibition against deliberate indifference to the serious medical needs of a prisoner.
The short and simple synopsis of this case is this: Wade had attempted suicide eight months before coming to SPSM, by hoarding pills, apparently a common practice at Wayne County jail. After he came to SPSM, he was seen at least 12 times in 3 months by a number of psychiatric and medical professionals. They clearly recognized that he was depressed, and at some risk of suicide, though his condition varied, and he specifically denied wanting to commit suicide before this appeal was finished. His medication was changed twice, and individual psychotherapy sessions were scheduled and carried out.
It is true that medication was ordered in pill form, but under a regimen where pills were to be consumed under the observation of the dispensing nurse, exactly to prevent the hoarding of pills. The only constitutional violation alleged against Doctors Cabrera and Rodriguez is that they did not shift Wade’s medication away from pills to liquid. (Pills had been originally prescribed by Dr. Mehra, who is correctly found to have committed no violation.)
In short, today’s decision only makes sense if there were some evidence, even by inference and in the light most favorable to the plaintiff, that Drs. Cabrera and Rodriguez, while seeing the patient, adjusting his medication, scheduling treatment sessions, and otherwise appearing by all indications as though they were doing their best to control and improve Williams’s medical problems, actually were also saying to themselves, “What the hell, we know he may commit suicide and that we could stop it by switching to liquid, but we just don’t give a damn.” There is absolutely no evidence to create any genuine issue of material fact, in my opinion, as to such an attitude, and I accordingly respectfully dissent.
I
The majority is affirming the denial of qualified immunity for two prison psychiatrists on the Outpatient Health Team at SPSM, Doctors Cabrera and Rodriguez. The majority’s analysis, however, is troubling for several reasons. To begin with, it misstates the first step in the well-established framework for analyzing qualified immunity claims. The threshold inquiry is “whether, based on the applicable law, a constitutional violation occurred.” Dickerson v. McClellan, 101 F.3d 1151, 1157 (6th Cir.1996). It is not, as the majority claims in Part IV of its opinion, simply determining what constitutional right has allegedly been violated. Of course, identifying the right allegedly violated is a necessary step in determining whether a constitutional violation has occurred. But this court’s case law makes clear that it is not enough to merely identify the right that was allegedly violated.
Judge Jones’s opinion in Centanni v. Eight Unknown Officers properly defines “[t]he threshold issue” as determining “whether a constitutional right has been violated.” 15 F.3d 587, 589 (6th Cir.1994) (emphasis added). That opinion also illustrates that making this threshold determination requires an appellate court to consider in a light most favorable to the plaintiff the facts alleged by the complaining party and the undisputed facts in the record and analyze these facts in accordance with the applicable *1117substantive law to see if a violation occurred on those facts.
II
The task of making the threshold determination of whether the plaintiff states an Eighth Amendment claim of deliberate indifference to the decedent’s serious medical needs is complicated by defects in the statements of fact provided in Parts I and VI of the majority opinion. Viewing the facts in a light most favorable to the plaintiff does not mean that we ignore undisputed facts in the record that are not favorable to her claim of a constitutional violation.
One problem with the majority’s statement of facts appears in its discussion of Ms. Alea-la-Cardew’s assessment of the decedent on August 30, 1993. The portion of her report quoted by the majority in the text at page six omits the next two sentences, which state: “He [decedent] denies being suicidal currently stating that he has his mother, his brothers and sisters, his fiancee, and his daughter who are in support of him. He is also currently on Sinequin and being followed by the Outpatient Mental Health Team here at RCC.”
By skillfully redacting other portions of Ms. Aleala-Cardew’s report, the majority is able to make her assessment that “the decedent’s adjustment “within his community’ and ‘to his incarceration’ was ‘guarded’ ” and that he was a “moderate potential risk for suicide” 1 appear to be an ominous and obvious signal portending his ultimate fate. These statements, however, lose their effect as harbingers of tragedy when one considers the portion of Ms. Aleala-Cardew’s assessment stating that the decedent “is not suicidal, but is depressed; and he is being treated for this by the Outpatient Mental Health Team.” (emphasis added). Furthermore, the majority makes no mention of Ms. Aleala-Cardew’s final recommendation that “[a] referral is being made to the Outpatient Team to continue his being followed by them.”
Another significant omission from the majority’s summary of facts is the undisputed testimony of a psychiatrist from the Wayne County Jail confirming that there had been a “number of instances in the Wayne County Jail where inmates would be able to hoard medication by not taking the medication they were prescribed.” This is especially significant in view of other undisputed facts pertaining to the method used to dispense drugs at SPSM, which were also omitted from the majority’s recitation of facts. At SPSM, prisoners had to line up in front of a window. They would receive their prescribed medication from a nurse as their names were called, and they were required to take the medication in front of the nurse.
A reader of the majority’s statement of facts would also not be aware that it was upon Doctor Rodriguez’s recommendation following his October 13, 1993 session with decedent that the decedent’s treatment regimen was enhanced to include bi-weekly individual psychotherapy with Mr. Little. In his first session with Mr. Little, the decedent did, as the majority notes, say that some days he would “rather be dead.” The majority, however, omits that in his first session the decedent also acknowledged that he “had a good support system in the world.” Although in his second session with Little the decedent admitted that he was “still feeling really down,” this statement is less ominous when it is viewed in the context of the decedent’s entire sentence that he was “still feeling really down but [that he] want[ed] to work on [his] appeal.” Furthermore, although Little did note that the decedent had suicidal ideation2, he also observed that he had “no immediate suicide plans.” Mr. Lit-*1118tie’s observations are also redacted in the majority’s discussion of his last session with the decedent to reinforce the impression that the decedent had a definite plan to commit suicide. The majority, despite its discussion at note 11, simply ignores Mr. Little’s undisputed testimony that the decedent said he would commit suicide if he did not prevail on his appeal. Although the majority refers to this statement as “wishful thinking” and the statement turned out to be false, there is no dispute that the statement was recorded by Mr. Little, and available to Drs. Cabrera and Rodriguez. The statement indicates that suicide was a contingency the decedent was considering sometime in the future if he did not win his appeal, not “a definite plan” he was intent on carrying out immediately. This omission is particularly important in light of the majority’s emphasizing at page five that Wade said in August 1993 that he would “wait until after sentencing on Thursday” to commit suicide and did not attempt to do so until four months later.3
Once the gaps in the majority’s statement of facts are corrected, what the record clearly indicates is: 1) that the decedent attempted suicide by overdosing on anti-depressants in December 19924 while at Wayne County Jail — a place where prisoners were frequently able to hoard drugs; 2) that the decedent continued to have suicidal ideations (i.e., thoughts about killing himself), but he never articulated a specific plan while at SPSM5; 3) the decedent’s medication was switched from liquid back to tablets when he was transferred to SPSM, where inmates were required to take each dosage of their medication in the presence of a nurse; 4) Ms. Alcala-Cardew reported that the decedent was “not suicidal” but “depressed” and classified him as a “moderate potential6 risk for suicide.” (emphasis added); 5) the decedent himself made ambiguous and varying statements as to his condition, some of which, especially towards the end of his life, indicated that he was improving and intent on seeing his ease through the appellate process 7; 6) between August 20, 1993 and No*1119vember 28,1993, the decedent had at least 12 sessions ■with seven different members of the staff at SPSM; 7) during these sessions his medication was supplemented and altered in response to his condition on more than one occasion, individual psychotherapy was added to his treatment regimen, and the effect of these changes in treatment were monitored and appeared to be helping as late as November 15, 1993; and 8) on November 28, 1993, approximately eleven months after his attempted suicide at Wayne County, the decedent killed himself by overdosing on medication he somehow managed to hoard despite safeguards intended to ensure that he actually ingested his medication.8
Ill
I do not believe that these facts establish that any of the defendants were deliberately indifferent to the decedent’s serious medical needs. It is well established that something more than negligence or medical malpractice is required for a claim of deliberate indifference. Estelle, 429 U.S. at 107, 97 S.Ct. at 292-93. This is not to say that conduct that violates the Eighth Amendment could not also be medical malpractice. Rather, conduct in violation of the Eighth Amendment’s prohibition against deliberate indifference would provide an egregious instance of medical malpractice or be an intentional tort. This is because for the acts or omissions of a doctor to rise to the level of an Eighth Amendment violation, it is not enough that a reasonable person in the defendant’s position reasonably should have known facts from which he reasonably should have drawn the inference that a substantial risk of serious harm exists. See Farmer v. Brennan, 511 U.S. 825, 837-38, 114 S.Ct. 1970, 1979, 128 L.Ed.2d 811 (1994) (rejecting objective standard for deliberate indifference). Rather, the Supreme Court has adopted a more exacting subjective standard for deliberate indifference which includes a showing that the official “must both be aware of facts from which the inference could be drawn that a substantial risk of serious harm exists, and he must also draw the inference.” Ibid. This subjective standard is appropriate because the Eighth Amendment “outlaws cruel and unusual punishment.” Ibid, (emphasis added). It leaves to tort law “an official’s failure to alleviate a risk that he should have perceived but did not” because under existing Eighth Amendment jurisprudence such tragedies cannot be “condemned as the infliction of punishment.” Ibid, (emphasis added).
The problem with the majority’s conclusion becomes more apparent when this case is analyzed in a meaningful way against eases factually analogous to this one, in which this court has held that there was no evidence of deliberate indifference as a matter of law. For example, in McKee v. Turner, No. 96-3446,1997 WL 525680 at *1, (6th Cir. August 25,1997), which the majority cites, the mother of a prisoner who committed suicide by hanging himself brought a section 1983 claim against the prison psychiatrist who was treating her son at the time of his suicide. She alleged that the doctor was deliberately indifferent to her son’s serious medical needs. Six weeks before he was transferred to the Ohio Correctional Facility where he committed suicide by hanging himself, the decedent had attempted to hang himself at the Hamilton County Jail. Id. at *2. The psychiatrist treating him at the state facility, Dr. Morcos, knew of this prior suicide attempt. Ibid. Dr. Morcos had concluded that the decedent was suffering from “hallucinations,” “delusions” and severe “depression” and that he had a personality disorder that made him impulsive and aggressive. Ibid. Despite these problems and the prior suicide attempt, Dr. Morcos never felt that the decedent appeared “to be at imminent risk of *1120suicide.” Ibid. The doctor was, however, wrong, because after three months at the state facility, the decedent succeeded in taking his own life by hanging himself.9
The plaintiff proffered two affidavits by another psychiatrist, who served as her expert witness. One of these affidavits stated that Dr. Morcos’s conduct “in light of the above circumstances, constituted, at a minimum, a significant departure from the accepted standards of psychiatric care.” The other stated that in view of the decedent’s “recent suicide attempt” and that given Dr. Morcos’s diagnosis of “psychotic depression,” providing the decedent with “no meaningful psychiatric treatment other than low dose triavil, without special monitoring” constituted “deliberate indifference to a substantial risk to [the decedent’s] safety.” Despite these affidavits and the undisputed facts of the case, a panel of this court held that “summary judgment in favor of Dr. Morcos was appropriate as a matter of law.” Id. at *5.
The panel in McKee reasoned that disputed issues of fact pertaining to “whether the medication being given was appropriate, and whether this suicide could have been predicted and prevented” were “immaterial.” Ibid. This was because “[a]t most, these facts demonstrate that there is a difference of opinion among professionals as to what the accepted practice within the psychiatric community is.” Apd such a difference of opinion, the panel observed, “constituted negligence or medical malpractice” but, as a matter of law, not deliberate indifference.
Although McKee is an unpublished opinion, and therefore only persuasive to the extent that its reasoning is persuasive, I find this reasoning persuasive and directly applicable to the present case. In each case the plaintiffs claim boiled down to: 1) the doctor provided the wrong medication; 2) they should have realized that it was imminent that prisoners they had diagnosed as severely depressed would again attempt to commit suicide by the same means they had attempted to kill themselves while at a county jail; and 3) greater precautions should have been taken to prevent the decedents’ suicides. As the panel in McKee explained, even when assumed to be true, such allegations do not amount to deliberate indifference — that the defendant doctors “had knowledge of faets about [the decedent] from which [they] could draw the inference that [the decedent’s] present course of treatment presented a substantial risk of serious harm to [the decedent], and that [the doctors] actually drew that inference, but persisted in the course of treatment anyway.” Ibid. The majority attempts to distinguish the McKee case by stating (at note 12) that McKee only involved a difference of opinion among medical professionals and here there is no such dispute. In fact, in McKee there was at least an affidavit by a doctor that stated in conclusory language that the actions there constituted deliberate indifference. In this case, plaintiff’s expert said no more (J.A. 413), and perhaps even less. He mainly claimed that the doctors’ actions “represented significant deviations from the standard of care” and constituted “intentional disregard of the principles of treatment,” not of Wade’s rights.
The soundness of this reasoning is further demonstrated by comparing the present case to cases in which this court has found the facts sufficient to raise a claim of deliberate indifference resulting from a lack of medical care. In Boretti v. Wiscomb, 930 F.2d 1150 (6th Cir.1991), a prisoner’s Eighth Amendment deliberate indifference claim against a prison nurse was permitted to go to a jury. The prisoner had just undergone surgery for a gunshot wound to his leg. Contrary to the prison doctor’s express orders, the nurse repeatedly refused to change the prisoner’s bandages, or give him pain medication. Id. at 1151. When the prisoner told the nurse that he had been using toilet paper and soap to clean his wound, the muse responded that she did not have time for him and “could not be bothered with his petty excuses.” Id. at 1152. On another occasion when the prisoner told the nurse that his leg was hurting badly and that his bandages were filthy, she *1121informed him that “she had no intention of contacting the doctor and that he could see the doctor in five days and then walked away.” Ibid. This obdurate refusal to provide any care for the prisoner, even the care prescribed by the doctor, persisted for five days.
These allegations were sufficient to create a triable issue as to whether the nurse was deliberately indifferent to the prisoner’s serious medical needs. The panel reasoned that the facts alleged demonstrated “unnecessary suffering” resulting from the “denial of medical care” under circumstances where relief was readily available. Id. at 1155 (emphasis added). Thus the nurse’s conduct was “not inadvertence or error in good faith,” rather it exhibited the kind of “obduracy and wantonness” necessary to establish deliberate indifference. Id. at 1154.
A similar claim of an obdurate and wanton refusal to provide care for a prisoner’s serious medical needs caused this court to permit a deliberate indifference claim against a doctor to proceed to trial in Weeks v. Chaboudy, 984 F.2d 185 (6th Cir.1993). The prisoner was paralyzed from the waist down but was placed in a portion of the prison where he was not permitted to have a wheelchair. Id. at 187. Wheelchairs were only permitted in the prison infirmary. The doctor, who had been treating the prisoner throughout his incarceration, could have authorized the prisoner’s transfer to the infirmary. Ibid. It was undisputed that it “was accepted practice to keep paralyzed inmates in the infirmary” since “it was the only area of the prison equipped to cater to their needs” and that the doctor knew the prisoner “would not have access to a wheelchair if not admitted to the infirmary.” The doctor did not, however, admit the prisoner to the infirmary. He simply concluded that the prisoner is “presently locked in J Block so this negates the use of a wheelchair in his particular area. We will pursue other avenues of consultation and see if we can’t derive some disposition of this man other than here in the infirmary.” No other “disposition was found or attempted” by the doctor. Ibid.
As a result of being denied the use of a wheelchair, the prisoner was unable to take advantage of his limited out-of-cell time, or to shower himself. He could not care for his person or clean his cell from May 3, 1983 to February 4, 1985. Ibid. This court found that these facts stated a claim of deliberate indifference since the doctor knew of Weeks’s paraplegia, knew that he could not have a wheelchair outside of the infirmary, could have admitted Weeks to the infirmary, and refused to do so or take any other steps to help the prisoner from May 3, 1983 to February 4,1985. Ibid.
While it is indeed tragic that a young man took his life, I do not believe that the facts of this tragedy demonstrate the kind of obduracy and wantonness on the part of doctors Cabrera and Rodriguez necessary to state a claim of deliberate indifference to the serious medical needs of the decedent. The decedent was not denied medical care. The doctors did not refuse to see him. They did not sit by passively when his fluctuating condition appeared to worsen. To the contrary, they reacted. They supplemented the dosage of his medication, placed him on another anti-depressant to make his medication more effective, and placed him in individual psychotherapy. They did not take away or refuse to provide the decedent with medication. They did not simply give the decedent a bottle of pills and tell him to take two at bedtime. Rather, they had him receiving individual dosages from a nurse who watched him until she believed he had ingested the pills.10
*1122In hindsight, it is clear that this safeguard failed and that a different course of treatment may have been better than the one selected. But that is not enough. Even when viewed in a light most favorable to the plaintiff, the facts of this tragedy do not provide grounds from which a jury could conclude that the doctors at SPSM knew the course of treatment they were following had a substantial risk of leading to the decedent’s death by suicide uncompensated for by any gain and nevertheless “persisted in the course of treatment anyway.” McKee, at *5. Thus the plaintiffs allegations do not establish a violation of the Eighth Amendment’s prohibition against deliberate indifference to the serious medical needs of a prisoner. Accordingly, the defendants are entitled to judgment as a matter of law and I dissent from the majority’s conclusion to the contrary.

. Ms. Alcala-Cardew expressly noted that Wade was "not suicidal.” (JA 94). Several of the medical professionals who testified in this case, including Ms. Alcala-Cardew, explained the significant difference in the risk posed by a prisoner who is potentially suicidal, as opposed to actually suicidal. The majority seems to ignore this distinction.

. A psychiatrist from Wayne County gave undisputed testimony that “suicidal ideation” is distinct from a "suicide plan” and that a "suicide plan” is distinct from a "suicidal intent.” "Suicidal ideation” refers to "an individual who is having thoughts about killing him or herself, but hasn't formulated a specific plan, or may not have the requisite intent or motive to actually carry out any urges or feelings of suicide.”

. The record does not appear to support an inference that this delay resulted from the need to hoard massive quantities of medication for a suicide attempt. Williams’s own expert stated that "a three to five day supply of this medication would be lethal in overdose.”

. The record contains undisputed testimony by a psychiatrist that "recent suicide attempts” are a factor to be considered in determining the mode of treatment for a patient. However, this same testimony defines a "recent” suicide attempt as "anything within the previous three months.”

. The record does establish that the decedent informed the medical staff at Wayne County that he would wait and see what happened in court before he decided what he "was going to do.” The Wayne County staff interpreted this statement to mean that the decedent was "still holding some suicidal thoughts.” This, however, is far from being an articulable suicide plan that the staff at SPSM could thwart. An illustration of such a "suicide plan” may be found in Matje v. Leis, 571 F.Supp. 918, 922-23 (S.D.Ohio 1983), where prison officials were told that an inmate planned to commit suicide by overdosing on drugs that she planned to smuggle into the jail under a diaphragm. Prison officials subsequently strip searched the inmate, but in a manner that they admitted could not reveal the presence of a diaphragm. /Md.Instead of searching for a diaphragm and contraband medication under it, the prison officials simply relied on the inmate’s statement that she did not have a diaphragm. Ibid..She was then placed in general population and,' on her first night in jail, she committed suicide by overdosing on drugs. Id. at 923.

. In her undisputed deposition testimony, Ms. Alcala-Cardew explained the difference between prisoners who are deemed “potentially suicidal” and those who are actually "deemed to be suicidal” and the difference in treatment for these two classes of prisoners. (JA217)

. On September 14, 1993 the decedent told Dr. Cabrera that he had no suicidal ideas. On October 6, 1993, decedent told Dr. Cabrera he felt he was getting worse and that he did not want to live but did not believe he had "the heart” to kill himself. During this same meeting the decedent relayed his three prior suicide attempts to Cabrera. In response, Dr. Cabrera altered his medication. On October 13, the decedent indicated to Dr. Rodriguez that his new medication was helping him and that he would not "harm himself because he care[d] about his family.” At this session the decedent also agreed to address his long-term depression by engaging in individual psychotherapy with Mr. Little. In his first session with Little on October 18, 1993, the decedent said "somedays I’d rather be dead” but also stated that he "had a good support system in the world.” On November 1, 1993, the decedent told Mr. Little that he was "still feeling really down, but ... wantfed] to work on [his] appeal.” During this session, Little also noted that the decedent still had some suicidal ideation, but had *1119"no immediate suicide plan.” When the decedent met with Dr. Cabrera on November 2, 1993, he indicated that the addition of the second medication he had been prescribed by Dr. Cabrera on October 6, 1993 was helping. When Dr. Rodriguez met with the decedent on November 15, 1993 he was also led to believe that the combination of the two medications was helping the decedent and that the decedent had "no suicidal thoughts” at that time. During his last interaction with an SPSM staff member, Mr. Little, on November 22, 1993, the decedent said he would commit suicide if he did not prevail on his appeal, but had no “suicide plan” at that time. Six days later, he killed himself, his appeal still unresolved.

. The plaintiff's own expert stated that "a three to five day supply of [Sinequin] would be lethal in overdose.”

. This obviously means that the decedent was left with the means to carry out his second and successful attempt to hang himself.

. The majority emphasizes, at notes 6 and 11, that pills were given rather than liquids simply because liquids "would take a longer amount of time.” The only evidence for this consideration is Doctor Cabrera’s statement that liquids are not given in the pill line, only in the hospital, for this reason (JA 285), but there is no indication that this was a policy of the doctors, rather than of the institution. Read in context, Dr. Cabrera’s testimony makes clear that the pill line was deemed an alternative means of assuring that Williams could not again hoard medication and actually strengthens the case in favor of qualified immunity. Similarly, the majority’s emphasis on Ms. Cardew’s statements about not giving psychotherapy after intake because of "limited resources” (see note 5) actually strengthens the case for qualified immunity on behalf of these doctors. Whatever might be the case as to the liability of the institutional or political leadership *1122of the Michigan Prison System (cf. Birrell v. Brown, 867 F.2d 956, 959-60 (6th Cir.1989)) for any harm caused by lack of resources, that lack of resources, and reasonable policies to cope with it, cannot be a constitutional violation by these doctors. In any event, individual psychotherapy was indeed added to the treatment regimen.