Court Opinion

ID: 9927039
Source: CourtListenerOpinion
Date Created: 2024-01-26 00:00:36.610468+00
Date Added: 2024-06-11T09:23:45.922973
License: Public Domain

In the

    United States Court of Appeals
                For the Seventh Circuit
                    ____________________
No. 22-1585
VICTOR R. BROWN,
                                                 Plaintiff-Appellant,
                                v.

DANIEL LAVOIE,
                                                Defendant-Appellee.
                    ____________________

        Appeal from the United States District Court for the
                  Eastern District of Wisconsin.
           No. 2:20-cv-00319 — Lynn Adelman, Judge.
                    ____________________

  ARGUED SEPTEMBER 19, 2023 — DECIDED JANUARY 23, 2024
              AMENDED JANUARY 25, 2024
                ____________________

   Before EASTERBROOK, WOOD, and KIRSCH, Circuit Judges.
   WOOD, Circuit Judge. Victor Brown, an inmate in the Wis-
consin Department of Corrections, has a history of self-harm.
One morning while he was particularly upset, Brown forced
a two-inch metal screw into his own ﬂesh by his left elbow.
The screw was embedded so deeply that it could not be seen
without manipulating the skin, and so a prison nurse called
the prison doctor, Daniel LaVoie, to extract it.
2                                                 No. 22-1585

    Dr. LaVoie twice tried, and twice failed, to extract the
screw using a pair of metal-ring forceps. He did so without
using any anesthetic to deaden the site. When he ﬁrst in-
formed Brown that this would be his approach, Brown pro-
tested by attempting to head-butt him. During the second at-
tempt, Dr. LaVoie again refused to apply an anesthetic, even
though Brown’s pain was obvious. The doctor poked at
Brown’s arm and tried to pull on the screw for several
minutes as Brown shouted in pain. He paused only to make
dismissive comments, such as telling Brown that he needed to
change his attitude. Eventually Brown was taken to a local
hospital, where staﬀ administered an anesthetic and removed
the screw painlessly and quickly.
    In this lawsuit, Brown claims that Dr. LaVoie was deliber-
ately indiﬀerent to his serious medical condition in violation
of the Eighth Amendment. The district court granted sum-
mary judgment to Dr. LaVoie. Although it was willing to as-
sume that Brown had a serious medical condition, it con-
cluded that Dr. LaVoie was not deliberately indiﬀerent to that
condition and thus did not violate Brown’s Eighth Amend-
ment rights. For good measure, the court added that in any
event Dr. LaVoie was entitled to qualiﬁed immunity. We see
things diﬀerently. When we view the record in the light most
favorable to Brown, as we must, there is a genuine dispute of
material fact about Dr. LaVoie’s state of mind. We therefore
reverse and remand for further proceedings.
                               I
   A closer look at the record helps to explain why summary
judgment on both those grounds was premature. Brown al-
leges that around noon on August 21, 2019, two prison super-
visors were called to his cell after he had an altercation with
No. 22-1585                                                   3

an oﬃcial. The cell window was covered with a towel when
they arrived. Brown informed them that he had removed the
mirror from the cell wall; he banged it against the door as
proof. The supervisors asked Brown to remove the towel from
his window, but he did not immediately do so. Instead,
Brown swallowed six pieces of metal and inserted a two-inch
metal screw from the mirror into his ﬂesh at the crook of his
left elbow. He then removed the towel and told the supervi-
sors what he had done.
    More prison oﬃcials arrived after Brown agreed to come
out of his cell. They handcuﬀed Brown, placed a spit-guard
over his mouth, strapped him into a restraint chair, and took
him to a nurse’s station in the prison. The nurse inspected
Brown’s inner left elbow and determined that Brown needed
to see a doctor. In a video recording of the incident, the nurse
can be heard saying, “I gotta call a doctor. … I can feel it in
there … but I can’t even see it.”
    Still strapped into the restraint chair, Brown was brought
to a hearing room, where he sat for over half an hour. Several
oﬃcials approached him during that time. Brown indicated to
the ﬁrst that he would not allow the prison doctor to remove
the screw. A second oﬃcial told Brown that he would be kept
in restraints until the screw was removed. This oﬃcial sug-
gested that Brown should permit the doctor to remove it so
that he could go to bed. Brown eventually agreed to see the
doctor, at which point he was carted back to the nurse’s sta-
tion.
   Dr. LaVoie was waiting at the station when Brown arrived.
He studied Brown’s inner elbow from a short distance and
then drew a pair of metal-ring forceps from a sterile bag. As
Dr. LaVoie bent down to extract the screw with the tool,
4                                                 No. 22-1585

Brown asked whether anesthetics would be used to numb the
site. Dr. LaVoie said “No.” Frightened, Brown immediately
reacted by attempting to head-butt the doctor. Dr. LaVoie
quickly backed away, but before leaving the station, he said
to Brown: “Well, maybe you deserve to be strapped down in
the bed.”
    Video from the incident shows that the oﬃcials next took
Brown to a cell and strapped him into a restraint bed. They
secured Brown’s torso with belts across his chest and legs, and
restricted his limbs by fastening his upper arms, wrists, and
ankles to the bed. Brown believed that he would remain
strapped down until the screw was removed, and so he even-
tually agreed to see the doctor again. When Dr. LaVoie en-
tered the cell to make a second attempt at removal, Brown
speciﬁcally said, through the spit-guard, “I want you to use
anesthesia.” Dr. LaVoie replied, “No. You stuck a screw in
your arm, not me, and this is a consequence of your actions.”
    This time, Dr. LaVoie worked at Brown’s arm for nearly
ﬁve minutes. Prison oﬃcials stood around Brown to help the
doctor; some of them prevented Brown from raising his neck
so that he could see his arm. Brown had several dissociative
experiences, and within 90 seconds, his arm started bleed-
ing—so much so that an oﬃcial requested a trash can “for the
bloody stuﬀ.” The video recording of the incident shows that
as Brown shouted in pain, Dr. LaVoie responded with dis-
missive comments, and a tone of annoyance, perhaps even
sarcasm. The following is a partial transcription of what was
said:
      Brown: Alright, I need a break. I need a break.
      Break. Ow, you fucker! I need a break!
No. 22-1585                                                5

      Dr. LaVoie: This is—this is not something I did.
      Do you understand that—Mr. Brown?
      Brown: You got a real slick attitude, huh?
      Dr. LaVoie: Yeah, well, your attitude is the one
      that needs to change.
      …
      Brown: Can’t you just—pull it out?
      Dr. LaVoie: Well, you didn’t put it in right.
      Brown: Ow!
      Dr. LaVoie: You put it in so it’s hard to get out.
      So next time, don’t do that.
      …
      Brown: I don’t like that. I don’t want [indiscern-
      ible]
      Dr. LaVoie: You don’t want what?
      Brown: I can’t go—I can’t keep going on like
      that.
      Prison Oﬃcial: He’s close.
      Brown: No, he’s not! It’s not even on the surface!
      Dr. LaVoie: I thought he was agreeing to have
      this done.
      Prison Oﬃcial: He did agree.
      …
      Brown: Stop! STOP! STOP!! You bitch! I’m re-
      fusing!
6                                                 No. 22-1585

   Even after Brown begged Dr. LaVoie to stop, the doctor
persisted in poking in Brown’s arm for another few seconds.
Brown then shouted, “Why do you keeping digging in my
arm?” Dr. LaVoie ﬁnally gave up, stood, and said to Brown:
“No. You know what? It can stay there. That’s ﬁne.” He wiped
the ring forceps and left the cell.
    Brown fell asleep in the restraint bed, where he remained
(still strapped in) for nearly four hours until he was taken to
a local hospital, accompanied by three oﬃcials. The hospital
staﬀ “deemed it obvious” that local anesthesia was required
for the procedure, and after administering an anesthetic they
painlessly removed the screw in under three minutes.
                              II
    Invoking 42 U.S.C. § 1983, Brown ﬁled this lawsuit against
Dr. LaVoie, who, he asserted, had acted with deliberate indif-
ference toward Brown’s serious medical condition in viola-
tion of the Eighth Amendment. Brown also contended that
several other prison oﬃcials had violated the Eighth Amend-
ment by failing to intervene to stop Dr. LaVoie. The latter
claims have all been resolved, and so we say no more about
them.
    Along with his complaint, Brown ﬁled a motion to recruit
counsel pursuant to 28 U.S.C. § 1915(e)(1). The district court
denied this request, both initially and on reconsideration. Af-
ter the district court issued a screening order, Brown renewed
his request for counsel. This time he attached to the motion
the letters he sent to 24 attorneys seeking assistance with his
case. In the motion itself, Brown explained that he suﬀers
from several mental illnesses and a documented learning dis-
ability, all of which aﬀect his ability to engage in this
No. 22-1585                                                    7

litigation; that although he is 28 years old, he has completed
school through only the eighth grade and has not earned a
GED; and that he relies on the assistance of other prisoners to
conduct his case. The district court denied this request as well.
    Dr. LaVoie then moved for summary judgment. He ar-
gued that Brown could not succeed on the merits of his Eighth
Amendment claim and that even if Brown cleared that hurdle,
Dr. LaVoie was entitled to qualiﬁed immunity. The doctor
submitted a short declaration to support his motion. His ac-
count was similar to the one from Brown that we have de-
scribed above, but there are some diﬀerences. Dr. LaVoie
stated that when he ﬁrst tried to remove the screw, Brown
asked whether he would use an anesthetic, and Dr. LaVoie
said no. Brown’s version to this point is the same. Brown then
attempted to head-butt him—something Brown concedes that
he did. Dr. LaVoie said that in response to the head-butt, he
paused the treatment; Brown agrees that the doctor backed
oﬀ then. Brown adds, however, that as Dr. LaVoie left, he
commented that “maybe [Brown] deserve[d] to be strapped
down in the bed.”
    Both parties agree that Dr. LaVoie tried again to remove
the screw. Brown adds that he speciﬁcally asked Dr. LaVoie
to use anesthesia before the second attempt, but that Dr. La-
Voie refused. The only explanation he gave, according to
Brown, was that Brown had “stuck a screw in [his] arm” and
that “this [was] a consequence of [his] actions.” Both sides
agree that Dr. LaVoie stopped after about ﬁve minutes,
shortly after Brown shouted that he revoked his consent. Dr.
LaVoie did not explain his chosen course of treatment, why
he continued it as Brown shouted in pain, or what he meant
by saying essentially that Brown deserved the pain.
8                                                         No. 22-1585

    The district court granted summary judgment in favor of
Dr. LaVoie. In so doing, it found that no rational trier of fact
could conclude that Dr. LaVoie’s decision not to use anesthe-
sia and his wielding of the forceps inside Brown’s ﬂesh
amounted to deliberate indiﬀerence. The court thought that
this conclusion followed from Snipes v. DeTella, 95 F.3d 586
(7th Cir. 1996), a case in which we held that a prison doctor
did not violate the Eighth Amendment by removing a broken
toenail without applying topical anesthesia. The court
acknowledged that the removal of a screw “may have been
more invasive than the removal of a toenail,” but it reasoned
that the attempted screw removal “was not a ‘major surgery’
that ‘obviously’ required some form of anesthetic.” As an al-
ternative basis for summary judgment, the district court con-
cluded that Dr. LaVoie was entitled to qualiﬁed immunity.
This was so, the court said, because in light of Snipes, Brown
had no clearly established right to an anesthetic.
   At this stage of the appeal, Brown challenges the district
court’s judgment in favor of Dr. LaVoie. In an earlier order,
we aﬃrmed the district court’s rulings on other aspects of the
case, but we recruited counsel to assist with Brown’s claim
against Dr. LaVoie. * See Brown v. LaVoie, No. 22-1585, 2023 WL
154798 (7th Cir. Jan. 11, 2023). The remaining issues before us
are whether Dr. LaVoie was entitled to summary judgment
and whether the district court abused its discretion by not re-
cruiting counsel to assist Brown with this claim. Because we
reverse on the ﬁrst ground, we have no need to reach the sec-
ond.

    * We thank Madeline Clark and the firm of Jones Day for their assis-

tance to Brown and to the court.
No. 22-1585                                                   9

                              III
   As we already have noted, we review the district court’s
order awarding summary judgment de novo, construing the
record in the light most favorable to Brown and drawing all
reasonable inferences in his favor. See Burton v. Downey, 805
F.3d 776, 783 (7th Cir. 2015).
    The Eighth Amendment to the United States Constitution
lies at the center of this case. Among other things, it protects
prisoners from being subjected to “unnecessary and wanton
inﬂiction of pain.” Gregg v. Georgia, 428 U.S. 153, 173 (1976).
That proscription includes “deliberate indiﬀerence to serious
medical needs of prisoners.” Estelle v. Gamble, 429 U.S. 97, 104
(1976). “To determine if the Eighth Amendment has been vi-
olated in the prison medical context, we perform a two-step
analysis, ﬁrst examining whether a plaintiﬀ suﬀered from an
objectively serious medical condition, and then determining
whether the individual defendant was deliberately indiﬀerent
to that condition.” Petties v. Carter, 836 F.3d 722, 727–28 (7th
Cir. 2016) (en banc). The parties do not dispute that Brown suf-
fered from an objectively serious medical condition, and so
we need only determine whether a reasonable trier of fact
could conclude that Dr. LaVoie was deliberately indiﬀerent to
Brown’s condition.
                   A. Deliberate Indiﬀerence
    The deliberate-indiﬀerence standard of the Eighth
Amendment mirrors the recklessness standard of the criminal
law. See Rivera v. Gupta, 836 F.3d 839, 842 (7th Cir. 2016). In
order to state a deliberate-indiﬀerence claim against a prison
doctor, it is thus not enough to show “mere” negligence in
treating a serious medical condition. See Estelle, 429 U.S. at
10                                                   No. 22-1585

105–06. At the same time, a plaintiﬀ does not bear the burden
of showing that a doctor intentionally denied necessary treat-
ment. See Jones v. Simek, 193 F.3d 485, 490 (7th Cir. 1999).
    The key question is whether the record contains the requi-
site evidence of a culpable mental state on the doctor’s part.
“[T]he prison oﬃcial must act or fail to act despite his
knowledge of a substantial risk of serious harm.” Gil v. Reed,
382 F.3d 649, 664 (7th Cir. 2004) (citing Farmer v. Brennan, 511
U.S. 825, 837 (1994)). We apply this standard both when a
plaintiﬀ claims that a doctor provided no medical treatment,
and when the claim is that the doctor provided inadequate
treatment. Indeed, we have stressed that “[a] doctor who pro-
vides some treatment may still be held liable if he possessed
a suﬃciently culpable mental state.” Zaya v. Sood, 836 F.3d
800, 805 (7th Cir. 2016) (citing Petties, 836 F.3d at 729–30) (em-
phasis omitted).
    We also have emphasized the importance of deferring to
the professional judgment of medical personnel. See, e.g., Sain
v. Wood, 512 F.3d 886, 894–95 (7th Cir. 2008). This is because
“[a] doctor who claims to have exercised professional judg-
ment is eﬀectively asserting that he lacked a suﬃciently cul-
pable mental state.” Zaya, 836 F.3d at 805. Even then, however,
a doctor is entitled to summary judgment only “if no reason-
able jury could discredit that claim.” Id.
    We have identiﬁed several prototypical situations in
which a jury might discredit a prison doctor’s proﬀered justi-
ﬁcation for his chosen course of treatment. See generally Pet-
ties, 836 F.3d at 729–31. It is not necessary to restate each of
them here; it is enough to note just one. Where a plaintiﬀ puts
forward evidence that a doctor failed to exercise medical
judgment, it is for the jury to decide whether the doctor had a
No. 22-1585                                                      11

suﬃciently culpable mental state. See Rasho v. Elyea, 856 F.3d
469, 476 (7th Cir. 2017) (citing Petties, 836 F.3d at 730). A plain-
tiﬀ may show a lack of professional judgment by introducing
evidence of some other motive for the doctor’s chosen course
of action, such as hostility or ill-will towards the plaintiﬀ. See
Rivera, 836 F.3d at 842; Rasho, 856 F.3d at 476.
    Brown has put forward suﬃcient evidence to raise a ma-
terial question about Dr. LaVoie’s state of mind. Both Dr. La-
Voie’s own statements and his troublesome course of treat-
ment could support a ﬁnding of deliberate indiﬀerence. The
record shows that Dr. LaVoie viewed the procedure as a “con-
sequence” of Brown’s behavior, and that he persisted in his
eﬀorts to remove the screw without applying anesthesia as
Brown shouted in pain and pleaded for an end to it. As Dr.
LaVoie continued to root around with the ring forceps in an
eﬀort to grab the screw embedded in Brown’s arm, he told
Brown that he needed a change of attitude, reminded him that
it was his own fault the screw was in his arm, and blamed him
for inserting it in a way that made removal more challenging.
These comments could be interpreted as signs of annoyance,
if not hostility. Some of them come across as sarcastic (or so a
jury could ﬁnd). And in addition to Dr. LaVoie’s behavior
throughout the procedure, the record shows that Dr. LaVoie
persisted in his unsuccessful eﬀorts to remove the screw
(which took longer than the hospital’s successful procedure)
and thereby callously prolonged Brown’s pain.
    Taking the record evidence in the light most favorable to
Brown, a jury could ﬁnd that medical judgment did not moti-
vate Dr. LaVoie’s chosen course of treatment. First, the fact
that Brown had tried to head-butt Dr. LaVoie supports the in-
ference that the doctor wanted to inﬂict pain upon Brown in
12                                                  No. 22-1585

retaliation for Brown’s action; similarly, a jury could see the
doctor’s response as based on “personal hostility,” Rivera, 836
F.3d at 842, or “personal prejudices or animosity,” Rasho, 856
F.3d at 476. In addition, a reasonable jury could infer from the
content and tone of his comments that Dr. LaVoie chose not
to use anesthesia because he intended to punish Brown for
inserting the screw into his elbow in the ﬁrst place. Looking
at Dr. LaVoie’s statement to Brown that he needed to change
his attitude, a jury might infer that the doctor persisted with-
out anesthesia to deter Brown from engaging in similar acts
of self-harm in the future. If any non-medical reasons of this
kind motivated the doctor’s judgment, then that would be a
basis for a ﬁnding of deliberate indiﬀerence. (It should go
without saying, but we add in the interest of completeness,
that a rational jury might equally reject these inferences and
ﬁnd in Dr. LaVoie’s favor.)
    Our conclusion is reinforced by the fact that Dr. LaVoie
has oﬀered no evidence that he did exercise medical judgment
in attempting to remove the screw from Brown’s arm. His
declaration in support of summary judgment was limited to a
brief statement of what happened. Nothing in it suggests that
he exercised professional judgment either in his assessment of
the need for anesthesia or in his decision to use the forceps for
a screw buried so far in the ﬂesh that the nurse could not even
see it. While the failure to present such evidence is not neces-
sarily dispositive at the summary judgment stage, its absence
here is striking because it is “common sense” that pulling a
screw from Brown’s ﬂesh without anesthesia could carry a
substantial risk of harm. Gil, 385 F.3d at 662; see also Petties,
836 F.3d at 729. But even if Dr. LaVoie were to introduce evi-
dence that he exercised medical judgment, his state of mind
would remain a question for the jury. Evidence to that eﬀect
No. 22-1585                                                    13

would merely contribute to the existing dispute about Dr. La-
Voie’s motivation, and so his credibility and the weight to as-
sign his testimony would be matters for the jury to decide. See
Rasho, 856 F.3d at 476–77 (citing Anderson v. Liberty Lobby, Inc.,
477 U.S. 242, 255 (1986)).
    As we noted earlier, the district court felt itself bound by
our decision in Snipes, where we held that a prison doctor who
decided not to anesthetize an inmate’s toe before removing a
partially torn-oﬀ toenail did not act with deliberate indiﬀer-
ence. See 95 F.3d at 591. The district court took Snipes to mean
that a prison doctor need not apply an anesthetic when per-
forming a minor surgery. And because removing a screw
from the arm is not major surgery, the court reasoned, Dr. La-
Voie did not act with deliberate indiﬀerence when he chose
not to anesthetize Brown’s arm. Dr. LaVoie, both in the dis-
trict court and on appeal, relies on the same understanding of
Snipes.
    But Snipes does not establish a rigid rule about the use of
anesthesia, much less a rule about the line between major and
minor surgery. As an initial matter, it is a far cry between the
removal of a torn toenail and the extraction of a two-inch
screw embedded beneath the surface of the arm. And once we
look beyond the nature of the injury to the reasoning that sup-
ported Snipes, that case becomes increasingly inapposite. In
Snipes, there was no question about the doctor’s motivation;
the doctor was understood to have exercised his medical
judgment, and the only issue before us was whether his deci-
sion not to administer an anesthetic conformed to contempo-
rary medical expertise and practices. As we have noted be-
fore, Snipes was based on the determination that “reasonable
medical minds may diﬀer over the appropriate treatment for”
14                                                 No. 22-1585

removing a busted toenail. King v. Kramer, 680 F.3d 1013, 1019
(7th Cir. 2012). The doctor had to weigh the risks of using an-
esthesia (including the possibility “that an injection of anes-
thetic would have hurt more than quickly removing the nail”)
in light of the beneﬁts of doing so. Snipes, 95 F.3d at 591–92.
Given the prevailing medical practices of that time, we deter-
mined that the balance could tip either way. Here, by contrast,
the issue is whether Dr. LaVoie exercised any medical judg-
ment, and there was no evidence at all indicating that he
weighed the risks and beneﬁts of using anesthesia for the ex-
traction procedure. Our decision here is thus entirely con-
sistent with Snipes.
                   B. Qualiﬁed Immunity
   Dr. LaVoie argues that even if he was deliberately indiﬀer-
ent to Brown’s condition, he is nonetheless entitled to sum-
mary judgment on qualiﬁed-immunity grounds. The district
court agreed. But qualiﬁed immunity is not a basis for sum-
mary judgment here.
    “The doctrine of qualiﬁed immunity protects government
oﬃcials ‘from liability for civil damages insofar as their con-
duct does not violate clearly established statutory or constitu-
tional rights of which a reasonable person would have
known.’” Pearson v. Callahan, 555 U.S. 223, 231 (2009) (quoting
Harlow v. Fitzgerald, 457 U.S. 800, 818 (1982)). We already have
noted that Brown’s Eighth Amendment claim turns on Dr. La-
Voie’s state of mind. If, in attempting to remove the screw as
he did, Dr. LaVoie was motivated by a desire to punish Brown
or otherwise inﬂict or prolong pain, then his conduct violated
clearly established law under the Eighth Amendment. See,
e.g., Gil, 381 F.3d at 661–62. Whether that (or something else)
No. 22-1585                                                    15

was Dr. LaVoie’s motive, is a question that only a jury may
resolve.
                               IV
    As we noted at the outset, Brown also challenges the dis-
trict court’s denial of his second motion for recruited counsel.
Given our decision on the deliberate-indiﬀerence element, we
need not decide whether that denial amounted to an abuse of
discretion. But on remand we encourage the district court to
consider whether it might now be appropriate to recruit coun-
sel to assist Brown. Cases involving state-of-mind require-
ments may be diﬃcult for pro se litigants, see, e.g., Pruitt v.
Mote, 503 F.3d 647, 655–56 (7th Cir. 2007) (en banc), and the
considerations that inform whether to recruit counsel often
change as a case progresses toward discovery or a trial, see,
e.g., Perez v. Fenoglio, 792 F.3d 768, 785 (7th Cir. 2015). We are
conﬁdent that the district court will revisit that decision on
remand with Brown’s circumstances in mind.
   The judgment of the district court is REVERSED and
Brown’s case against Dr. LaVoie is REMANDED for further
proceedings consistent with this opinion.
16                                                  No. 22-1585

   KIRSCH, Circuit Judge, concurring in the judgment. I agree
with the result. In reaching that result, the majority focuses on
Dr. LaVoie’s comments to Brown, which a jury could view as
dismissive, annoyed, or sarcastic. But we need not look to
these comments at all. Instead, I would ﬁnd a genuine dispute
of material fact because the hospital staﬀ “deemed it obvious”
that Brown required anesthesia for the screw removal, and
Dr. LaVoie has oﬀered no explanation whatsoever for his re-
fusal to administer anesthesia. Considering only this evi-
dence, a jury could ﬁnd that Dr. LaVoie was deliberately in-
diﬀerent to Brown’s serious medical needs because his treat-
ment decision was “so far aﬁeld of accepted professional
standards as to raise the inference that it was not actually
based on a medical judgment.” Arnett v. Webster, 658 F.3d 742,
751 (7th Cir. 2011) (quotation omitted). For this reason, I agree
that the district court’s grant of summary judgment should be
reversed.