Court Opinion

ID: 9481340
Source: CourtListenerOpinion
Date Created: 2023-08-05 08:15:49.392288+00
Date Added: 2024-06-11T17:48:14.763879
License: Public Domain

PELL, Senior Circuit Judge,
concurring in part, dissenting in part.
I concur in the majority’s affirmance of the district court’s judgment dismissing the plaintiffs’ state-law tort claims, but being satisfied that the localized scenario presented by the record in this case fails to present an antitrust claim under either the Sherman or Clayton Acts, I respectfully dissent from that part of the majority opinion.
To put this case in context, I think it helpful to note the following. The position of the plaintiffs, of course, evokes sympathy. They are apparently unable to consult a doctor for non-emergency reasons in their home area. They have been regularly, as needed, receiving medical attention in Madison, the state capital, where the medical practitioners, if not providing more competent service, are at least equal to those in Monroe. They complain that traveling to Madison occasions some inconvenience and additional expense, although the time and mileage involved resembles what many people in outlying suburban areas of Chicago will incur in receiving medical services at facilities in the central city. But sympathy, which should not be an element in this case, in any event, is even-handed between the litigants.
The present litigation arises out of the fact that plaintiff’s claim that their failure to be able to secure medical services in Green County, Wisconsin, is because of action of the defendant barring any non-emergency treatment. This is described as retaliatory on the part of the Monroe Clinic because of a malpractice suit filed in April 1986 against it and also a Dr. Raettig, who had been a treating physician of plaintiff Darci Anne Bowman, the slightly retarded daughter of her co-plaintiff Judith Nelson. Whether or not it is against public policy under certain circumstances to compel a physician to continue to serve a patient who has filed a malpractice action against him, is not involved in the present situation, although perhaps it should be.
The undisputed facts are that the malpractice action was begun without consultation with a single medical expert, without consultation with the treating physician, and without having obtained the medical records of the Monroe Clinic. Dr. Raettig *1569was understandably shocked by the filing of the suit as he had had no contact with the plaintiffs concerning the urinary tract infection which formed the basis of their malpractice action. In addition to the fact that no medical expert had been consulted prior to plaintiffs’ filing suit, discovery developed that not even the physician who corrected the supposed medical error had been consulted. The suit remained pending for sixteen months. Finally after consulting medical experts, the attorney for the plaintiffs concluded he could not make out a case against the Clinic and Dr. Raettig and he dismissed the action. In a few words, the malpractice action was frivolous from the beginning and never achieved any other status.
In an antitrust or any other context, it appears obvious that the action taken by the Clinic in refusing to provide medical services to Nelson or her daughter could not be the basis of recovering damages single compensatory or tripled. The mere fact that the clinic apparently included all of the doctors in Green County should not alter the situation. The principle is made clearer if in a sparsely populated area in the northwest of this country there were only two physicians in a county who were in partnership in practice and one was sued in a suit as frivolous as the one with which we are dealing. Both he and his partner declined any further medical services which would mean many miles of travel for one who needed non-emergency treatment. Can it be doubted even though they constituted a monopoly that this was not within the ambit of the antitrust statute?
Judith Nelson was distressed by having some minor travel and by job problems. We should not overlook that Dr. Raettig’s distress must have been more acute. One of the most priceless attributes of a practitioner of a profession is that of high quality and effective use of that ability. Holding these attributes up to doubt by the filing of a malpractice suit can be most hurtful.
Monroe is not a large community but one which by its size suggests that not everything that is known to most of the residents needs be in the written or spoken media. Yet for sixteen months Dr. Raettig was smeared by the brush of having committed malpractice. Often the effect of such an accusation lingers in the minds of some even though proved not to be correct. It may be many years before the falsely imposed blemish on his reputation completely disappears.
In considering this appeal, I would be perfectly content just to affirm across the board, however, I recognize that to the extent the district judge opined that the facts were sufficient to require an examination of the antitrust phase of the action, a straight affirmance would be approving that part of his decision. Because I do not believe that antitrust has any place in this action, I think it necessary for us to consider it but I do not agree with the majority that it is necessary to remand for further consideration by the district court.
The Clinic has cross-appealed the district court’s rejection of three of its contentions, namely that (a) the defendant’s alleged illegal conduct did not involve multiple actions as required by the antitrust statutes, (b) the alleged illegal conduct bore no connection to interstate commerce, and (c) the defendant did not possess market power in a relevant market as required by federal antitrust statutes.
These three, of course, can be raised and considered here on the basis of the whole record for the purpose of defending the judgment under attack.
Section 1 of the Sherman Act requires, as a fundamental prerequisite, a contract, combination or conspiracy — a concerted action by a plurality of actors. Section 1 does not prohibit independent business actions or decisions by a single entity. This central concept has been stated most succinctly by this court:
[sjection 1 of the Sherman Act prohibits contracts, combinations, or conspiracies unreasonably restraining trade or commerce. The fundamental prerequisite is unlawful conduct by two or more parties pursuant to an agreement, explicit or implied. Solely unilateral conduct, regardless of its anti-competitive effects *1570is not prohibited by Section 1. Rather, to establish an unlawful combination or conspiracy, there must be evidence that two or more parties have knowingly participated in a common scheme or design to accomplish an anti-competitive purpose.
Contractor Utility Sales Co. v. Certain-Teed, Products Corp., 638 F.2d 1061, 1074 (7th Cir.1981). See also Albrecht v. The Herald Co., 390 U.S. 145, 149, 88 S.Ct. 869, 871, 19 L.Ed.2d 998 (1968); Weit v. Continental Illinois Nat’l Bank & Trust Co., 641 F.2d 457, 468-69 (7th Cir.1981), cert. denied, 455 U.S. 988, 102 S.Ct. 1610, 71 L.Ed.2d 847 (1982); Trabert & Hoeffer, Inc. v. Piaget Watch Cory., 633 F.2d 477, 480 (7th Cir.1980). The plaintiffs must demonstrate that the Monroe Clinic plus at least one other independent entity knowingly participated in an unlawful scheme to achieve an anticompetitive purpose. Despite the Motion for Summary Judgment of the Monroe Clinic raising the issue, the district court did not consider this fundamental requirement in its dismissal Order. Had it done so, it would certainly have found no such plurality.
The district court did find that there was no relationship between the act of monopolization and the decision to deny care. That act, however, of denying non-emergency medical service was an act by the Monroe Clinic alone. There simply were no other actors — so there could be no Section 1 violation. By finding no direct relationship between the action to deny care on January 22, 1988, and the merger of the Medical Center of Monroe Clinic, the court was finding in effect that the Monroe Clinic acted alone in its decision to deny care.
The Monroe Clinic is a medical partnership organized pursuant to Chapters 178 and 448 of the Wisconsin Statutes. Section 178.03 of the Wisconsin Statutes defines a partnership as “an association of two or more persons to carry on as co-owners of a business for profit.” The partnership and every individual acting in the ordinary course of the business of the partnership is liable for partnership actions. Wis.Stat. § 178.10; see also Wis.Stat. §§ 178.11 and 178.12. That the Monroe Clinic was a single legal and economic entity at the time care was denied (January 22, 1988) was never contested. As such, it was entirely incapable, as a matter of law, of contracting, combining, or conspiring with itself. The Monroe Clinic could not possess monopoly power “[b]ecause the essential element of agreement or understanding is missing, [the plaintiff] has failed to establish a violation of § 1 of the Sherman Act_” Sargent-Welch Scientific Co. v. Ventron Corp., 567 F.2d 701, 709 (7th Cir.1977), cert. denied, 439 U.S. 822, 99 S.Ct. 87, 58 L.Ed.2d 113 (1978).
To survive the Rule 12(b)(6) motion to dismiss, plaintiffs were required to allege, and to survive the motion for summary judgment, they were required to present sufficient evidentiary facts to establish that the defendant’s allegedly illegal conduct either was “in interstate commerce” or had a “substantial and adverse effect” upon interstate commerce. McLain v. Real Estate Bd. of New Orleans, Inc., 444 U.S. 232, 241-42, 100 S.Ct. 502, 509-10, 62 L.Ed.2d 441 (1980); Hospital Bldg. Co. v. Trustees of Rex Hosyital, 425 U.S. 738, 743, 96 S.Ct. 1848, 1851-52, 48 L.Ed.2d 338 (1976). The “allegedly unlawful conduct itself must be shown to ‘infect’ those general business activities of the defendant which do, or are likely to, effect interstate commerce.” Stone v. William Beaumont Hosy., 782 F.2d 609, 613-14 (6th Cir.1986).
Under the law in this circuit the “plaintiff must allege sufficient facts concerning the alleged violation and its likely effect on interstate commerce to support an inference that the defendants’ activities infected by illegality either have had or can reasonably be expected to have a not insubstantial effect on commerce.” Seglin v. Esau, 769 F.2d 1274, 1280 (1985).
As this court has noted, even denial of a physician’s staff privileges, which is certainly more 'far reaching than denial of non-emergency services to two patients, is insufficient to meet the interstate commerce requirement. Doe ex rel. Doe v. St. Joseph’s Hosp., 788 F.2d 411, 417 (7th Cir.1986); Seglin, 769 F.2d at 1280. The allegations of the plaintiffs’ complaint (and *1571their proof) of equipment purchases, insurance, and government payments and even travel by patients do not meet the interstate commerce standard. Indeed, such facts have been expressly rejected by this court as insufficient:
[w]e held that plaintiffs allegations that “the defendants provide psychiatric services to patients who travel in interstate commerce to receive such services, purchase equipment in interstate commerce, and receive insurance payments through interstate commerce ...” were “insufficient to establish the required nexus with interstate commerce.”
Doe ex rel. Doe, 788 F.2d at 417 (quoting Seglin, 769 F.2d at 1279-80).
The plaintiffs present no more than a recast Seglin case, with the single physician of Seglin now the Nelson family. The reasoning of Seglin requires the dismissal of the plaintiffs’ antitrust complaint. If they are permitted to proceed, then:
[virtually every physician [every patient] who is ever temporarily denied hospital privileges [non-emergency clinic care] for whatever reason could drag the hospital [clinic] ... into costly antitrust litigation merely by alleging that the defendant receives payments, goods, or equipment in interstate commerce.
Doe ex rel. Doe, 788 F.2d at 417 (quoting Seglin, 769 F.2d at 1283-84).
In Seglin, the plaintiff physician was denied hospital privileges. Although his hospital purchased and participated in a wide variety of activities in interstate commerce, this court’s inquiry focused not on the ordinary and common activities of a large medical facility, but rather on the conduct which formed the genesis of that lawsuit — the denial of staff privileges. This court acknowledged that in the 1980’s it is inconceivable that a major medical facility does not participate in interstate commerce. The Monroe Clinic is no different than any relatively large business with customers, suppliers, and outlets in different states. The inquiry must focus not on the general activities of the defendant, but on the conduct “infected by illegality.” In Seglin that conduct was the denial of staff privileges, and in this case that conduct is the denial of non-emergency medical services.
The district court apparently overlooked this court’s Seglin standard. (Compare the district court’s first decision, (“plaintiffs’ allegations that out of state patients, supplies and employees will be affected ... are sufficient”), the district court’s second decision, and the district court’s third decision (“defendant has clinics in Illinois and a large percentage of out-of-state patients, thus placing its conduct in interstate commerce.”)).
The relevant inquiry is whether the effect on interstate commerce of the alleged unlawful activity — denying medical care to the plaintiffs — is, as a matter of practical economics, not insubstantial. Seglin, 769 F.2d at 1280. Discovery revealed no effect whatsoever on interstate commerce. The plaintiffs concede that their requirements for medical services have not changed since the action of the Monroe Clinic. They will now travel to Madison, Wisconsin, to obtain the medical care they are unable to receive in Monroe, Wisconsin. Plaintiffs have insurance coverage from Blue Cross and Blue Shield United of Wisconsin and whether the insurance payments go to the Monroe Clinic in Green County, Wisconsin, or the Dean Clinic in Madison at Dane County, Wisconsin, will not effect interstate commerce. As to the few dollars these plaintiffs might spend on medicine and supplies, there is no evidence that using physicians in Madison rather than those in Monroe will impact the volume of medicine and supplies in interstate commerce. See Litman v. A. Barton Hepburn Hosp., 679 F.Supp. 196, 202 (N.D.N.Y.1988).
The trial court’s finding that the Monroe Clinic’s conduct was “in interstate commerce” misses the basic standard of this court. The general conduct of the Monroe Clinic is not relevant but rather the specific conduct is at issue — and that is combining for the purpose of denying non-emergency medical services. As to the effect of that conduct on interstate commerce, the record is abundantly clear that there is no effect at all. As one court observed in a similar case rejecting a claim of interstate com*1572merce when a physician was denied cardiology privileges,
the gravamen of [plaintiffs’] complaint was that defendants illegally excluded him from using a local facility two or three times a month. This court cannot ascertain how such a deprivation has anymore than a de minimus impact on interstate commerce. Consequently, the Sherman Act prerequisites simply have not been satisfied.
Stone, 782 F.2d at 614. The plaintiffs have failed to demonstrate a not insubstantial effect on interstate commerce.
On the last of the three points here involved, ultimately any federal antitrust action must rest upon a showing of “market power.” Will v. Comprehensive Accounting Corp., 776 F.2d 665, 671 (7th Cir.1985), cert. denied, 475 U.S. 1129, 106 S.Ct. 1659, 90 L.Ed.2d 201 (1986) (“This failure [to demonstrate market power] makes every other element of this antitrust case irrelevant.”). While that ultimate question of market power may not be reached before a showing of a relevant market, (both product and geographic), Brown Shoe Co. v. United States, 370 U.S. 294, 325, 82 S.Ct. 1502, 1523-24, 8 L.Ed.2d 510 (1962); Collins v. Associated Pathologists, Ltd., 844 F.2d 473, 480 (7th Cir.), (“It is impossible to monopolize a market that does not exist.”), cert. denied, 488 U.S. 852, 109 S.Ct. 137, 102 L.Ed.2d 110 (1988); Kayser Aluminum & Chemical Corp. v. FTC, 652 F.2d 1324, 1330-31 (7th Cir.1981), ultimately the power to control prices or exclude competition is the object addressed by antitrust laws, United States v. E.I. du Pont de Nemours & Co., 351 U.S. 377, 391, 76 S.Ct. 994, 1004-05, 100 L.Ed. 1264 (1956); Juneau Square Corp. v. First Wisconsin Nat’l Bank, 624 F.2d 798, 813 (7th Cir.), cert. denied, 449 U.S. 1013, 101 S.Ct. 571, 66 L.Ed.2d 472 (1980). The district court in this instance apparently found sufficient basis to believe there was a factual dispute concerning the relevant market and relevant market power without explicitly so stating. The difficulty with examining this apparent conclusion is caused by the district court’s failure to state and find whether the relevant product and geographic markets were what the plaintiff contended existed.
The plaintiffs contended variously that it was “medical care”; “primary care” consisting of internal medicine, family practice, general practice, OB/GYN and pediatric medicine; and “primary care” consisting of pediatric, OB/GYN and family practice services. Similarly, they variously considered the geographic market to be Green County, the City of Monroe, the three county zip code area surrounding Monroe, Wisconsin, and a seventeen zip code area. The district court’s and the plaintiffs’ difficulty in describing the relevant market was to a great measure the result of the plaintiffs’ reliance on Harold Luft, Ph.D. as their sole economic analyst/expert. Dr. Luft is the sole qualified source cited by the plaintiffs supporting their allegation of the Clinic’s market power. Yet, Dr. Luft conceded that he was “not an expert,” that he had no background in antitrust markets, either geographic or product, and that he had no background in “primary care” markets. Dr. Luft further stated that he was not a member of any associations or industrial organization groups which form the bulwark of economists specializing in antitrust law and economics. Where supposed experts have admitted that they are “not experts,” courts have had little difficulty in excluding their testimony. See Dawsey v. Olin Corp., 782 F.2d 1254, 1264 (5th Cir.1986); Gates v. United States, 707 F.2d 1141, 1145 (10th Cir.1983); Will v. Richardson Merrell, Inc., 647 F.Supp. 544 (S.D.Ga.1986). Moreover, affidavits which supply faulty analyses do nothing to assist the court in resolving the difficult inquiries and ought to be stricken:
[t]he importance of safeguarding the integrity of [judicial] process requires the trial [or appellate] judge, when he believes that an expert’s testimony has fallen below professional standards, to say so, as many judges have done.
Mid-State Fertilizer Co. v. Exchange Nat’l Bank, 877 F.2d 1333, 1340 (7th Cir.1989) (quoting Deltak, Inc. v. Advanced Systems, Inc., 574 F.Supp. 400, 406 (N.D.*1573Ill.1983), vacated on other grounds, 767 F.2d 357 (7th Cir.1985)).
Since the plaintiffs have conceded or cannot demonstrate that there was an effect on the generalized market or an effect on prices or output, it is not difficult to imagine that an analysis of the market would demonstrate the lack of market power by the Monroe Clinic. It is precisely that conclusion to which the evidence leads.
As the fundamental inquiry of antitrust law focuses upon market power, so too a discussion of market power (i.e., the ability to control price or output) inevitably leads to a consideration of the barriers those entering a market must face. It is fundamental that in order to establish market power, the plaintiffs must show a barrier to entry that prevents competition. “[W]ithout a barrier there is no market power.” Will, 776 F.2d at 672. As this court observed:
[t]he use of barriers to entry as a proxy for market power is familiar in the law of mergers. Unless barriers to entry prevent rivals from entering the market at the same cost of production, even a very large market share does not establish market power.
Id. at 672 n. 3. Of course, “[u]nless the defendants possess market power, it is unnecessary to ask whether their conduct may be beneficial to consumers. Firms without power bear no burden of justification.” Ball Memorial Hosp., Inc. v. Mutual Hosp. Ins., Inc., 784 F.2d 1325, 1334-35 (7th Cir.1986).
In this instance, the provision of medical care (whether primary or specialized) by medical doctors is the sole “product market” at issue. As a result, it is necessary to investigate what barriers might exist to a medical doctor’s entry into the Monroe geographic market. The evidence is overwhelming and unchallenged that the barriers to the entry of physicians into this market are virtually nonexistent. More than 40 physicians not associated with the Monroe Clinic have in recent years been granted privileges at St. Clare Hospital (the sole hospital in Monroe, Wisconsin). The chairman of the board and the president of the hospital emphatically noted that any qualified physician, regardless of other affiliations or lack thereof, can obtain privileges if qualified. Indeed, the board chairman and chief administrator both noted that the hospital’s economic motivations require it to “encourage” new physicians to join in order to increase patient volume, and they do so. In view of both the economic motivations of the St. Clare Hospital and the actual number of physicians who have entered into some form of practice in Monroe, it is not surprising that Dr. Harold Luft is the plaintiffs’ sole support for the proposition that barriers exist. Contrary to the most fundamental professional standards, Luft concludes that barriers to entry may exist for physicians, though he has “no direct evidence” of any disinclination of other medical doctors to enter this marketplace. Though the plaintiffs hypothesize that the non-availability of staff privileges at St. Clare Hospital is a significant barrier, as “typical medical staff privileges are controlled by the medical staff,” this assumption of what is “typical” is wrong; staff privileges are granted at St. Clare Hospital by the Board of Directors not the staff. The supposed plaintiffs’ expert had not spoken with a single physician who sought and was denied privileges; indeed, “no licensed medical doctor has been denied privileges_” at St. Clare Hospital.
It is fundamental that the court must find that there are barriers to entry into a market to determine that the Monroe Clinic may have market power. Having failed to find such barriers, the Monroe Clinic simply could not possess “market power” in any legal or economic sense.
In order to determine what product is sold, one must examine “the reasonable interchangeability of use of the cross-elasticity of demand between the product itself and substitutes for it.” Brown Shoe, 370 U.S. at 325, 82 S.Ct. at 1523-24. As the Supreme Court has noted:
[t]he “market” which one must study to determine when a producer has monopoly power will vary with the part of commerce under consideration. The tests are constant. That market is com*1574posed of products that have reasonable interchangeability for the purposes for which they are produced....
du Pont de Nemours, 351 U.S. at 404, 76 S.Ct. at 1012. Following these reasonable economic definitions, the plaintiffs first considered the product or service provided to be “medical care.” Later, however, the plaintiffs altered this definition to allow for “primary care,” though it still remains unclear exactly what that “primary care” is. The plaintiffs’ failure to define the relevant product market itself is a basis for dismissal of their complaint.
The plaintiffs defined the product market as “all out-patient health care” and “all in-patient health care” and, consistent with those general statements, addressed the concept of “medical care” as their product in answers to interrogatories. In the plaintiffs’ Brief in Opposition to a Motion to Dismiss, they described their complaint as one addressing “health care services,” and that product definition was apparently understood by the district court as well as by the defendant as encompassing medical care. Of course, in answers to interrogatories the plaintiffs considered medical care to be the “relevant product of service.” The deadline for dispositive motions having passed, and the Monroe Clinic having demonstrated the futile nature of the plaintiffs’ case in a motion for summary judgment, the plaintiffs then changed their definition during an expert’s deposition to “primary care” which definition included internal medicine, family practice, general practice, OB/GYN and pediatric medicine.
If this unending string of changes were not enough, the plaintiffs again changed their definition of the product market to “pediatric, OB/GYN and family practice services, commonly referred to in health care context as ‘primary care.' ” Product market definition in an antitrust lawsuit is as central as the identity of a product in a product liability lawsuit. Defendants cannot be expected to defend against an ever-changing case.
The plaintiffs nevertheless continued to make changes in the definition. Nothing prior to the summary judgment deadline put the Monroe Clinic on notice that it was to defend against a “primary care” product market definition. Without regard to the numerous problems the plaintiffs have in demonstrating that “primary care” is a relevant product market, all of which are sufficient to sustain the district court, “notice” to a defendant is the single most fundamental principle of a relevant product market in the district court. See Fed.R.Civ.P. 7, 8, 12(e); Globig v. Johns-Manville Sales Co., 486 F.Supp. 735, 739 (E.D.Wis.1980); 1 Wright & Miller, Federal Practice and Procedure, §§ 12, 15-16 (1982).
The record established by plaintiffs also clearly, as the defendant points out, fails to demonstrate any geographic market. Whichever view is accepted, either by number of doctors or by number of patients, the findings are far below any accepted standard to establish market power.
It also should be noted that belatedly, and over the objection of the defendant, plaintiffs sought to rely on Section 7 of the Clayton Act. 15 U.S.C. § 18. Whether or not the issue is properly before this court is immaterial, as the issues of antitrust injury, interstate commerce and market power are also dispositive of the Section 7 claims.
Turning now to the position taken by the district court that the antitrust statutes are involved but here are not to be applied, it should first be noted that “federal courts have been ‘virtually unanimous in concluding that Congress did not intend the antitrust laws to provide a remedy in damages for all injuries that might conceivably be traced to an antitrust violation.’ ” Associated General Contractors of Cal. v. California State Council of Carpenters, 459 U.S. 519, 534, 103 S.Ct. 897, 906-07, 74 L.Ed.2d 723 (1983) (quoting Hawaii v. Standard Oil Co., 405 U.S. 251, 263 n. 14, 92 S.Ct. 885, 891-92 n. 14, 31 L.Ed.2d 184 (1972)). No matter how broadly one views the potential reach of the antitrust laws it must be conceded “that despite the broad wording of § 4 there is a point beyond which the wrongdoer should not be held liable.” Illinois Brick Co. v. Illinois, 431 U.S. 720, 760, 97 S.Ct. 2061, 2082, 52 L.Ed.2d 707 (1977) (Brennan, J., dissent*1575ing). Section 4 of the Clayton Act, 15 U.S.C. § 15 provides:
[a]ny person who shall be injured in his business or property by reason of anything forbidden in the antitrust laws may sue....
This provision is the operative provision for purposes of the plaintiffs, or any other complainant as they seek damages under the antitrust laws. Recognizing the practical limitations of applying the broad wording of Section 4, our courts have developed two separate, but overlapping, concepts limiting the reach of that section. (Each concept is often referred to as a matter of “standing.”) The injury complained of must “be of a type that the antitrust laws were designed to guard against ... and further that the antitrust violation [must] be the direct cause of plaintiffs injury.” Havoco of America, Ltd. v. Shell Oil Co., 626 F.2d 549, 556 (7th Cir.1980). See Lupia v. Stella D’Oro Biscuit Co., 586 F.2d 1163, 1168 (7th Cir.1978), cert. denied, 440 U.S. 982, 99 S.Ct. 1791, 60 L.Ed.2d 242 (1979) (“[n]ot only must the injury be direct, but it must be of the kind the antitrust laws were written to guard against.”). These requirements of standing are applicable regardless of the federal antitrust provision upon which relief is sought. Ball, 784 F.2d at 1334 (“the ‘antitrust injury’ rule applies to requests for damages and injunctions alike”) (a Section 1 or 2 claim); Havoco, 626 F.2d at 556 (“as with all antitrust claims”); see also In re Industrial Gas Antitrust Litigation, 681 F.2d 514, 515 (7th Cir.1982), cert. denied, 460 U.S. 1016, 103 S.Ct. 1261, 75 L.Ed.2d 487 (1983) (a Section 1 claim); Brunswick Corp. v. Pueblo Bowl-O-Mat, Inc., 429 U.S. 477, 97 S.Ct. 690, 50 L.Ed.2d 701 (1977) (a Section 7 claim).
An injury suffered by a plaintiff must be a “direct” result of the illegal antitrust act. Repp v. F.E.L. Publications, Ltd., 688 F.2d 441, 445 (7th Cir.1982). This standard of “directness,” which referred to an issue of “standing” — as here by the district court — or as a “more general requirement” of Section 4 of the Clayton Act, 15 U.S.C. § 15, embodies the same requirement “that plaintiffs establish a sufficient nexus between the defendant’s alleged [anticompeti-tive] actions and an injury to plaintiffs.” Weit, 641 F.2d at 469. Similar to the concept of proximate cause in tort law, the allowance of damages in an antitrust matter “despite the broad wording of § 4,” Illinois Brick, 431 U.S. at 760, 97 S.Ct. at 2082 (Brennan, J., dissenting), is fundamentally limited by the rule that the damages flow out and relate to the anticompetitive act. The injuries must be direct, not “fortuitous,” Brunswick, 429 U.S. at 487, 97 S.Ct. at 696-97, as “Congress did not intend to allow every person tangentially affected by an antitrust violation to maintain an action....” Associated General, 459 U.S. at 535, 103 S.Ct. at 907.
As the district court here concluded:
[i]f the damage was merely incidental or consequential, or if the defendants’ antitrust acts are so removed from the injury as to be only remotely causative, the plaintiffs have not been injured “by reason of anything forbidden in the antitrust laws” as contemplated by the Clayton Act.
The importance of this fundamental requirement has been emphasized by this court:
[i]t would appear the circuits all view the treble damages suit as too lethal a cannon to put in the hands of anyone who has suffered only an “indirect,” “secondary,” or “remote” injury.
Lupia, 586 F.2d at 1168.
Even assuming, as the district court assumed here, that there existed a potential anticompetitive act in the creation of a monopoly by the Monroe Clinic, the district court was unable to find any support in the record for the proposition that the injury— the denial of care — had any relationship with the anticompetitive act. “The [plaintiffs] have provided no affidavit, answer to interrogatory, deposition or other evidence supporting a relationship between the alleged creation of a monopoly and the decision to terminate plaintiff Bowman’s care.” The plaintiffs apparently misunderstand their obligations under Rule 56. As in Celotex Corp. v. Catrett, 477 U.S. 317, 106 *1576S.Ct. 2548, 91 L.Ed.2d 265 (1986), the Monroe Clinic discharged its obligations under the Rule by showing an absence of evidence supporting the plaintiffs’ claim. Id. at 325, 106 S.Ct. at 2553-54. The plaintiffs may no longer rest upon the allegations of their Complaint, or the speculation that the two acts — monopolization and denial of care — are related. They must present something in this record which ties the events together.
Unlike Williams v. St. Joseph Hospital, 629 F.2d 448 (7th Cir.1980), where (a) the courts examined the matter under a Motion to Dismiss; (b) the very objective of a conspiracy between the doctors was the denial of care; and (c) this court did not address the issue of antitrust injuries, In re Stegall, 865 F.2d 140, 142 (7th Cir.1989) (“A point of law merely assumed in an opinion, not discussed is not authoritative.”), here the matter comes to this court under Rule 56 so that the purported anticompetitive objective must be supported by much more than simple allegation. See Williams, 629 F.2d at 453 n. 7. Dr. Raetigg, the Clinic director, and the Medical Center physician involved deny any relationship, and even the plaintiffs are unable to cite to a single document, deposition testimony or other item of proof to demonstrate a tie. The plaintiffs are unable to present any evidence, much less evidence sufficient to create a “genuine issue of material fact,” relating the act of the Executive Committee of the Monroe Clinic on January 21, 1988, to choose not to treat the plaintiffs, to the allegedly antitrust act of creating a monopoly.
Certainly obtaining medical care may be more inconvenient here but that inconvenience and its related costs to the plaintiffs are at best remote, and the indirect result of the prior conduct (monopolization) to which the antitrust laws apply. Those added costs, resulting in part because the plaintiffs travel farther than they would have traveled had the Medical Center of Monroe, not been acquired, are not themselves sufficient to justify a cause of action. The existence of real damages is not the issue, see Associated General, 459 U.S. at 523, 103 S.Ct. at 900-01 ($25 million damages); Brunswick, 429 U.S. at 481, 97 S.Ct. at 693-94 ($2.3 million lost profits); Repp, 688 F.2d at 441 (money losses for music licensing); Lupia, 586 F.2d at 1168 (lost revenues), it is the- relationship of these damages to the illegal act which may make them antitrust injuries. The plaintiffs’ damages simply “did not result from the defendant’s acquisition or exploitation of market power.” Industrial Gas, 681 F.2d at 519.
As stark as the failure of the plaintiffs to demonstrate a relationship of an anticom-petitive act of the cost associated with the denial of care, is the relentless repetition by the plaintiffs describing what they view as the heinous character of the result of the Clinic’s action. The plaintiffs’ outrage, however, does not translate into anticom-petitive conduct; on the contrary, as the Supreme Court admonished:
[t]he injury should reflect the anticom-petitive effect either of the violation or of anticompetitive acts made possible by the violation. It should, in short, be “the type of loss that the claimed violations ... would be likely to cause.”
Brunswick, 429 U.S. at 489, 97 S.Ct. at 697-98 (citing Zenith Radio Corp. v. Hazeltine Research, Inc., 395 U.S. 100, 125, 89 S.Ct. 1562, 1577-78, 23 L.Ed.2d 129 (1969)). The plaintiffs’ claim fails to recognize the most fundamental of all issues in antitrust law that, an antitrust injury “means injury from higher prices or lower output, the principal vices proscribed by the antitrust laws.” Ball, 784 F.2d at 1334. See also Associated General, 459 U.S. at 538, 103 S.Ct. at 908 (“The Sherman Act was enacted to assure customers the benefits of price competition_”). The plaintiffs have yet to explain how the denial of care might plausibly be considered related to anticompetitive price and output decisions. Simply to restate that the plaintiffs must go farther for their care than they would if another physician group existed in Monroe does not relate the denial by the Clinic to pricing or output decisions. The relationship is at most “fortuitous.” Brunswick, 429 U.S. at 487, 97 S.Ct. at 696-97.
*1577The admonition that the antitrust laws are intended to encourage competition is often restated.
Antitrust laws in general, and the Sherman Act in particular, are the Magna Carta of free enterprise.... And the freedom guaranteed each and every business, no matter how small, is the freedom to compete — to assert with vigor, imagination, devotion, and ingenuity whatever economic muscle it can muster.
United States v. Topco Associates, Inc., 405 U.S. 596, 610, 92 S.Ct. 1126, 1134-35, 31 L.Ed.2d 515 (1972). The “ruthless” process of competition, Ball, 784 F.2d at 1338, is a natural byproduct of that free market system, as is the conclusion that “the intent to preserve or expand one’s market share is presumptively lawful.” MCI Communications Corp. v. American Telephone and Telegraph Corp., 708 F.2d 1081, 1113 (7th Cir.), cert. denied, 464 U.S. 891, 104 S.Ct. 234, 78 L.Ed.2d 226 (1983).
It is the public injury to competition, not the private injury to single individuals, that is addressed by the antitrust laws. Only those injured by anticompetitive conduct affecting the marketplace are compensated under these laws. Car Carriers, Inc. v. Ford Motor Co., 745 F.2d 1101, 1107 (7th Cir.1984), cert. denied, 470 U.S. 1054, 105 S.Ct. 1758, 84 L.Ed.2d 821 (1985) (“Thus, the plaintiff must allege, not only an injury to himself, but an injury to the market as well.”); Havoco, 626 F.2d at 558-59. Despite the unanimous requirement of our courts that there be a generalized injury to the marketplace before an individual may recover damages, the plaintiffs concede that they can prove no deleterious effect on the market. As this court noted, “it is the function of § 1 to compensate the unfortunate only when their demise is accompanied by a generalized injury to the market.” Car Carriers, 745 F.2d at 1109.
The sole known result of their supposed unlawful anticompetitive action of monopolization is the denial to the plaintiffs of non-emergency medical care. Yet, the very essence of a claim under the Sherman Act is the requirement that the plaintiff prove a significant adverse impact on competition in the relevant market of the activities violating the antitrust laws, and not simply effect on a single consumer. United States Trotting Ass’n v. Chicago Downs Ass’n, 665 F.2d 781 (7th Cir.1981) (“[Ojur cases consistently hold that a plaintiff ... must prove adverse impact in the relevant market_”); Contractor, 638 F.2d at 1078; Juneau, 624 F.2d at 811; Lektro-Vend Corp. v. Vendo Co., 660 F.2d 255, 268 (7th Cir.1981), cert. denied, 455 U.S. 921, 102 S.Ct. 1277, 71 L.Ed.2d 461 (1982) (“It is now well established that any rule of reason analysis requires a showing of anti-competitive market effect. To hold otherwise would ignore the very purpose of the antitrust laws which were enacted for the protection of competition, not competitors.”). America’s Best Cinema Corp. v. Fort Wayne Newspapers, Inc., 347 F.Supp. 328, 333 (N.D.Ind.1972).
When faced with a single disgruntled plaintiff affected by the acts of a defendant in an antitrust action this court has concluded that, “a loss by the plaintiff of a single contract with a single purchaser is simply not equivalent to a deleterious effect on the market.” Havoco, 626 F.2d at 558. Nonetheless, it is precisely that single event which the plaintiffs asked the district court to find sufficient to meet the requirements of injury to the marketplace. Absent other proof, the plaintiffs failed to carry their burden.
The conduct of the Monroe Clinic is, if anything, typical of a group of doctors faced with increased competition. It is certainly expected, and businesses are encouraged by the courts, to take steps -to improve efficiency, profitability, and sales, Sargent-Welch, 567 F.2d at 712. Viewed from a purely economic perspective, the actions of the Monroe Clinic, as the district court judge found in this instance, were not indicative of an anticompetitive marketplace.
Professional malpractice actions present a perceived economic threat to the physicians’ businesses. “Medical Malpractice— 1985: Reflections of a Health Care Provider,” Journal of the Kansas Medical Society, Vol. LXXXV, No. XII, December 1984, *1578p. 323-29. (“The malpractice problem is again approaching crisis proportions, impacting upon patients, competent providers, law, the insurance industry, the economy, government and society”); “Response of the American Medical Association to the Association of Trial Lawyers of America Statements Regarding the Professional Liability Crisis,” American Medical Association Special Task Force on Professional Liability Insurance, August 1985, p. 4; “Doctors and Lawyers Spar Over State Malpractice Litigation,” The Business Journal (Milwaukee, Wisconsin), October 7, 1985; “Malpractice Premium Expenses: Another ‘Crisis’ and its Implications,” Journal of Medical Practice Management, Vol. 3, No. 3, page 163, ("There is a sense that another malpractice insurance ‘crisis’ is either upon the medical profession or quickly developing. Rapid increases in the frequency and severity of claims experience are once again being cited by those concerned.”) Though a variety of groups may argue about the extent of the cost of malpractice actions, there can be no doubt that they affect the profitability of a medical practice. As a consequence it makes good business sense to choose not to treat patients who are more likely than not to file a frivolous medical malpractice case. The Monroe Clinic does not terminate care to all malpractice litigants; on the contrary, these plaintiffs represent a single case in the history of the Monroe Clinic. This particular malpractice case was unique in the view of the Monroe Clinic, because it was entirely meritless and because it was pursued beyond the point where its lack of merit should have been obvious. Viewed from an economic standpoint, no matter how well it conducts its practice by providing highest quality care, the Monroe Clinic has no ability to prevent meritless litigation of the type previously pursued by the plaintiffs. Viewed from this perspective the Monroe Clinic’s action was consistent with a competitive market decision to lower its potential economic risks.
Moreover, it could be argued that as the profitability of a clinic narrows the economic incentives increase on the clinic to reduce risks by denying care to potential malpractice litigants. Even the plaintiffs’ purported economic expert agreed when asked, “[i]t would be more likely in a competitive market, rather than an uncompetitive market from an economic standpoint to turn down the person [malpractice litigant] for care, wouldn’t it? Answer: “[PJrobably true.” Ironically even if the plaintiffs are correct in believing they pose no economic risks to medical care providers, then the denial of care may itself be a “pro-competitive” act by encouraging others to enter the market to treat the plaintiffs. The plaintiffs failed to present to the district court any evidence that the conduct alleged was anything but consistent with a competitive market. As one court has observed, “an antitrust plaintiff opposing a motion for summary judgment must present evidence that tends to exclude the possibility that the defendant’s conduct was as consistent with competition as with illegal conduct. Indiana Grocery, Inc. v. Super Value Stores, Inc., 864 F.2d 1409, 1412-13 (7th Cir.1989).
The plaintiffs’ sole attempt to address the purposes of the denial by the Monroe Clinic certainly support the proposition that no anticompetitive effect has occurred or was intended. To the plaintiffs this case is about a “doctor with a vendetta,” “revenge,” and “a bully.” They theorize that Dr. James Raettig, one of the defendants in the 1986 malpractice action, carried out a plan of “punishment” by waiting for the Monroe Clinic to become large enough before denying care so that the “punishment” could be more extreme. Forgetting for the moment the preposterous character of this theory in light of the nearly 174,000 doctor/patient visits annually, and lack of any citation to supportive proof in the record, the plaintiffs have yet to explain how that motivation is even within hailing distance of the purposes of the antitrust laws. Such “evil” motivations have nothing whatsoever to do with the pernicious anticom-petitive conduct addressed by our antitrust statutes.
The act of choosing to serve patients certainly deserves the same protection af*1579forded other rights of contract. United States v. Colgate & Co., 250 U.S. 300, 39 S.Ct. 465, 63 L.Ed. 992 (1919). The refusal to treat a particular patient is not, itself, an antitrust violation as courts have uniformly upheld the right of a single entity to refuse to deal with customers, even when the refusal has been in retaliation for a customer’s non-conforming conduct. See, e.g., Lamb’s Patio Theater v. Universal Film Exchanges, Inc., 582 F.2d 1068 (7th Cir.1978). Contrary to the plaintiffs’ assertion that a refusal to provide care as a response to use of the courts to enforce their rights, courts have specifically upheld unilateral refusals to deal imposed in response to antitrust and other lawsuits. See, e.g., House of Materials, Inc. v. Simplicity Pattern Co., 298 F.2d 867 (2d Cir.1962); Zoslaw v. CBS, Inc., 1978-2 Trade Cas. (CCH), ¶ 62,269 (N.D.Cal. Sept. 26, 1978). Even a monopolistic entity may unilaterally refuse to deal. Sargent-Welch, 567 F.2d at 701; America’s Best, 347 F.Supp. at 328. The motives attributed by the plaintiffs to the acts of the Monroe Clinic are simply not intended for redress under our antitrust statutes.
The record is replete with motivation consistent with a single physician group’s — the Monroe Clinic’s — common sense view of medical malpractice litigation. Where a patient pursues a malpractice action, particularly one that is meritless (as this 1986 case was viewed from the start by the Monroe Clinic) it must be conceded that the patient has voluntarily terminated the professional relationship of doctor and patient. The plaintiffs’ attorney in the malpractice case, after nearly two years of discovery, conceded he had no case against the Monroe Clinic. See Williams, 629 F.2d at 450. (“It might be against public policy as involving something akin to a conflict of interests to compel a physician to continue to serve a patient who has filed a malpractice suit against him.”) That doctor/patient relationship is based, at the very least upon trust, and the patient’s election to accuse the medical group and doctor of violating that trust terminates the relationship. The Executive Committee of the Monroe Clinic considered the matter at length under an established “policy and procedure for withdrawal from care.” The denial then followed under established professional guidelines, and the clinic made a judgment as professionals to decline care as a clinic. The plaintiffs seem consistently to forget that the Monroe Clinic itself was one of the defendants in their malpractice action.
Consistent with their professional obligations, each malpractice or patient misconduct incident (i.e., threats to staff, refusal to take medicine, failure to arrive for appointments) brought to the Executive Committee is an individual case considered with a policy emphasizing the individual character of that case. Despite the plaintiffs’ indignation, they can point to no support in this record that would find a general policy to deny care to malpractice litigants. This case is a case of one. Having been accused of malpractice, the clinic chose to terminate services because it believed the doctor/patient professional relationship had been breached. Certainly, doctors retain the right, as a matter of law, to terminate relationships with patients.
Such terminations, when not the part of any overall plan of market control, are clearly not indicative of anticompetitive conduct. This is certainly not the “bold, relentless, and predatory commercial behavior” to suppress competition at which the antitrust laws are aimed. Lorain Journal Co. v. United States, 342 U.S. 143, 149, 72 S.Ct. 181, 184, 96 L.Ed. 162 (1951). The district court, faced with overwhelming proof, properly entered judgment against the plaintiffs whose “unsubstantiated speculation” simply is not sufficient to create a genuine issue of fact.
For the reasons I have stated, perhaps at too great length, I strongly feel that the judgment of the district court should be affirmed.