Court Opinion

ID: 771241
Source: CourtListenerOpinion
Date Created: 2012-04-18 10:47:46+00
Date Added: 2024-06-11T17:55:56.172943
License: Public Domain

233 F.3d 494 (7th Cir. 2000)
CLARA WALKER, Plaintiff-Appellant,v.HOWARD PETERS, SALVADOR GODINEZ,  RICHARD GRAMLEY, et al., Defendants-Appellees.
No. 97-4058
In the  United States Court of Appeals  For the Seventh Circuit
Argued December 10, 1999Decided November 30, 2000

Appeal from the United States District Court  for the Northern District of Illinois, Eastern Division.  No. 93 C 5831--James B. Moran, Judge.
Before EASTERBROOK, ROVNER and DIANE P. WOOD, Circuit  Judges.
ROVNER, Circuit Judge.

1
Dwayne Walker was a  prisoner who suffered from a variety of serious  illnesses. He sued a number of prison officials  and doctors for violating his Eighth Amendment  right to be free from cruel and unusual  punishment, claiming these various individuals  were deliberately indifferent to his serious  medical needs. The district court granted summary  judgment in favor of the defendants, finding  that, at most, Walker's complaints amounted to a  malpractice action and not a constitutional  deprivation. We affirm.

I.

2
Dwayne Walker suffered from hemophilia,  avascular necrosis of his right hip, arthritis,  retinoschisis, a partially fused right ankle, a  partially fused left elbow, a pinched nerve in  his back, and AIDS. He suffered from mental  problems as well, including anti-social  personality disorder. He was incarcerated by the  Illinois Department of Corrections ("IDOC") from  June 1984 until his death in August 1999.1  Because of his hemophilia, Walker required  infusions of a substance known as "Factor VIII,"  a clotting protein that occurs naturally in the  blood of persons who do not suffer from  hemophilia. Factor VIII, marketed under the trade  name "Factorate," is a concentrate derived from  donor blood. In the early 1980s, donor blood was  not yet tested for the presence of HIV, and  consequently, a large percentage of hemophiliacs  contracted HIV and, subsequently, AIDS, as a  result of taking Factor VIII. The defendants do  not dispute Walker's statement that 90% of  hemophiliacs taking Factor VIII during this time  period eventually contracted AIDS.

3
Walker exhibited a number of symptoms consistent  with HIV infection and AIDS from the beginning of  his incarceration. In particular, he exhibited  generalized lymphadenopathy and an inverted T-4  helper cell/T-8 suppressor cell ratio, and these  symptoms were noted in medical records  transferred to the prison within a few months of  the date of his incarceration. Because he was in  a high risk group for contracting AIDS, and  because he exhibited these symptoms, certain  prison doctors assumed Walker was HIV positive,  or strongly suspected that he had HIV infection  and/or AIDS. One of the prison doctors noted in  Walker's record that he "received so much Factor  VIII [that he is] assumed to be HIV positive."  Another health summary in Walker's prison records  indicated that Walker was at high risk for AIDS  because of his hemophilia, and another indicated  that he had repeatedly refused to take a blood  test to confirm or rule out HIV infection. Walker  does not deny that he refused to take the  confirmatory blood test, but explained that the  results would have stigmatized him in prison.

4
Although he exhibited these symptoms and fell  into this high risk group, and although some  prison officials and physicians assumed he was  HIV positive, Walker received no treatment for  this condition until 1993. The parties agree that  the appropriate treatment for a person infected  with HIV and possibly suffering from AIDS was  AZT, an anti-viral drug that became generally  available in 1987, and Bactrim, a widely  available antibiotic that is effective in  preventing certain opportunistic infections  associated with AIDS. The defendants contend that  they did not prescribe these medications for  Walker because he would not take the confirmatory  test. It would have been malpractice, they  maintain, to administer the potent and dangerous  drug AZT without confirmation that Walker was in  fact HIV positive. They maintain that they were  merely following the Centers for Disease Control  ("CDC") criteria when they required a positive  HIV test before prescribing AZT. Walker contends  they did not provide the proper treatment for  more sinister reasons. He argues that the CDC  guidelines did not require a positive HIV test  for an AIDS diagnosis beginning in 1987. He also  points to the IDOC AIDS Manual, which he claims  allows AZT treatment for inmates with a CD4 count  below 300, whether or not HIV infection has been  confirmed. Moreover, upon his transfer to another  prison in the Illinois system in late 1993, he  began receiving AZT and Bactrim even though he  continued to refuse to take the confirmatory HIV  test. Finally, Walker maintains that if the HIV  test was required before treatment, the  defendants could have forced him, under Illinois  law, to take the test at any time. The defendants  are not allowed, Walker argues, to avoid learning  the true nature of his condition once they have  reason to believe he is seriously ill.

5
Walker's treatment for hemophilia also proved to  be troublesome. Construing the facts in favor of  Walker as we must on summary judgment,  hemophiliacs are able to sense their need for  Factor VIII, and should be infused with the  substance when they ask for it. Apparently  hemophiliacs can learn to recognize the signs  that they are having an internal bleed, and that  clotting factor is needed. Factor VIII should be  infused as soon as possible after the patient  senses the need. The consequences for an  untreated bleed can be severe and permanent.  Untreated bleeds in joints can lead to extreme  pain and limitation of the movement of that joint  in the future. A delay of even an hour can have  dire consequences. Walker states that on many  occasions when he requested Factor VIII, prison  officials refused to give it to him. Other times,  he was offered Factor VIII which had been  improperly prepared, and he refused to take it.  The defendants counter that Walker was an  unreliable indicator of his need for Factor VIII,  that he often asked for it when he did not need  it, and that he then refused to take it without  good reason after it had been mixed. Because the  substance must be discarded three hours after it  is prepared, Walker's refusals led to repeated  spoilage of the expensive substance. Rather than  preparing the substance every time Walker  requested it, a prison doctor would examine him  and determine whether Walker actually needed the  Factor VIII before dispensing it. The defendants  claim that Walker was not harmed by this policy  and that his own actions made appropriate  treatment nearly impossible.

6
Walker sued a number of prison officials and  doctors for deliberate indifference to his  serious medical needs, in violation of the Eighth  Amendment proscription against cruel and unusual  punishment. Count I of his complaint alleged that  the defendants failed to take the medically  necessary steps to determine whether he was  infected with HIV or whether he had AIDS, that  they failed to timely inform him of his HIV or  AIDS status, and that they failed to treat him  for HIV infection and AIDS. Count II alleged that  the defendants failed to provide Walker  appropriate treatment for his hemophilia by  routinely refusing to give him Factor VIII, and  by not informing non-medical prison staff of the  greater risk of physical injury to Walker  inherent in his hemophilia. Walker also complains  in Count II that the defendants failed to provide  adequate pain management for his hemophilia and  that even when they began treating him for AIDS,  the treatment was not medically appropriate.

7
The defendants moved for summary judgment and  the district court granted judgment in favor of  the defendants on both counts. The court found  that the defendants' failure to treat Walker for  HIV or AIDS could not constitute deliberate  indifference because Walker could have obtained  treatment by agreeing to the HIV confirmatory  test. The court also held that a refusal to  provide AZT without a confirmatory test was a  matter of medical judgment, and that action based  on medical judgment could never rise to the level  of a constitutional violation. The court found  that, contrary to Walker's claim, Illinois law  did not give the defendants authority to test  Walker for HIV against his will unless he had  otherwise consented to treatment. Because the  record was replete with Walker's refusal to  consent to treatment in a variety of contexts, and because he had expressly refused to consent  to the HIV test, the district court held that  Illinois law did not grant authority to the  defendants to test Walker for HIV against his  will. As for Walker's complaint that the  defendants sometimes refused to give him Factor  VIII when he requested it, the court found that  requiring clinical observation before dispensing  Factor VIII could not constitute deliberate  indifference because it was, once again, action  based on medical judgment. Finally, the court  granted summary judgment in favor of the non-  medical defendants because Walker could not  demonstrate that they were personally responsible  for any decisions regarding his medical care. The  court therefore granted summary judgment in favor  of all of the defendants and against Walker on  Counts I and II. Walker appeals.

II.

8
On appeal, Walker contends that the defendants  were deliberately indifferent to his serious  medical needs because they failed to take the  medically necessary steps to determine whether he  was HIV positive or had AIDS, failed to timely  inform him of his HIV or AIDS status, and failed  to timely provide the medical treatment necessary  for a person with HIV disease or AIDS. He also  maintains that the defendants were deliberately  indifferent to his serious medical needs when  they routinely failed to provide appropriate  treatment for his hemophilia. Finally, he argues  that even when the defendants did begin to treat  him for AIDS, they did not provide treatment in  a medically appropriate manner.

9
The defendants contend that Walker's refusal to  cooperate in his own diagnosis is fatal to his  claim of deliberate indifference in the diagnosis  and treatment of HIV infection and AIDS.  Similarly, in the treatment of his hemophilia,  the defendants maintain that Walker's repeated  wasting of Factor VIII led the prison officials  to refuse to provide the substance to him on  demand. Moreover, the defendants claim that  Walker cannot show that he was damaged by any of  the refusals to give him Factor VIII on any  particular occasion. Finally, the non-medical  defendants contend that Walker cannot demonstrate  that they were aware of his medical conditions or  treatment much less that they were involved in  the decision-making. Without personal  involvement, the non-medical defendants claim  they cannot be held liable under 42 U.S.C. sec.  1983.

A.

10
We turn first to the standard for deliberate  indifference. In a case involving an attack on a  prisoner by other inmates, the Supreme Court set  forth the following definition

11
We hold instead that a prison official cannot be  found liable under the Eighth Amendment for  denying an inmate humane conditions of  confinement unless the official knows of and  disregards an excessive risk to inmate health or  safety; 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. . . . [A]n  official's failure to alleviate a significant  risk that he should have perceived but did not,  while no cause for commendation, cannot under our  cases be condemned as the infliction of  punishment.

12
Farmer v. Brennan, 511 U.S. 825, 837-38 (1994).  The Court further explained that an inmate need  not show that a prison official acted or failed  to act believing that harm would actually befall  the inmate; rather it is enough for the inmate to  show that the official acted or failed to act  despite his knowledge of a substantial risk of  serious harm. 511 U.S. at 842. Moreover, whether  a prison official had the requisite knowledge of  a substantial risk is a fact question that could  be demonstrated by drawing an inference from  circumstantial evidence. For example, a fact finder could conclude that the official was aware  of the substantial risk from the very fact that  the risk was obvious. Id.

13
As we noted above, Farmer was a case in which a  prisoner was assaulted by other inmates, and we  subsequently expanded on the theme of obviousness  in the medical treatment context. We first noted  that people are not always conscious of what  reasonable people would be conscious of. Steele  v. Choi, 82 F.3d 175, 178 (7th Cir. 1996), cert.  denied, 519 U.S. 897 (1996). We do not consider  what a reasonable doctor would have done. That is  an objective test, and Farmer dictated a  subjective analysis. 82 F.2d at 179. Nor is it  enough to show that a prison doctor committed  malpractice. At the very least, a prison official  must act or fail to act despite his knowledge of  a substantial risk of serious harm. 82 F.3d at  178. Thus, in Choi, we noted that where there was  no evidence that the inmate's symptoms were  consistent only with a single diagnosis, and  where there is no evidence that the doctor was  ignoring the inmate's medical needs, it is not  enough to show that a reasonable doctor would  have made the correct diagnosis and treatment. 82  F.3d at 179. "If the symptoms plainly called for  a particular medical treatment--the leg is  broken, so it must be set; the person is not  breathing so CPR must be administered--a doctor's  deliberate decision not to furnish the treatment  might be actionable under sec. 1983." Id. A  doctor might be careless in not appreciating the  need to investigate several possible explanations  for a particular prisoner's symptoms, and this  carelessness may constitute malpractice. But  malpractice alone is not enough to meet the  constitutional standard. Id.

14
Walker believes that his symptoms were obvious  and plainly called for a particular medical  treatment. Walker's generalized lymphadenopathy  and inverted T4 helper cell/T8 suppressor cell  ratio, together with his hemophilia at a time  when hemophiliacs were contracting HIV at an  alarming rate all led a number of doctors to  strongly suspect, even assume, that he was HIV  positive. Indeed, a notation on his medical  records indicates that he had received so much  Factor VIII that he was presumed to be HIV  positive. The defendants agree that they strongly  suspected Walker was HIV positive and had  contracted AIDS. Thus, Walker presented enough  evidence from which an inference could be drawn  that at least some of the defendants knew of a  substantial risk of serious harm. The question  remains, however, whether Walker has any evidence  that the defendants' response to this knowledge  was inadequate. Under Farmer, prison officials  who are aware of a substantial risk of serious  harm may not be held liable if they responded  reasonably to the risk, even if the harm was not  ultimately averted. 511 U.S. at 844; Reed v.  McBride, 178 F.3d 849, 854 (7th Cir. 1999)  ("[t]he remaining question is whether the  defendants' response can be characterized either  as inaction or woefully inadequate.").

15
Everyone agrees that the defendants refused to  treat Walker unless and until he took a  confirmatory HIV test. They disagree on the  reason why prison officials insisted on this  step, and on the reason why Walker refused to  submit to the blood test. Even Walker does not  deny that at any point, he could have received a  confirmatory blood test, and if found positive,  would have been treated with AZT and Bactrim.  Walker argues that neither prison policy nor  medical standards at the time required a positive  HIV test before treatment could begin, and that  even if the HIV test was the only barrier to  obtaining treatment, the defendants could have,  indeed should have, forced him to undergo the  test. Walker points out that prison officials had  forced treatment on him in the past, requiring  him to take psychotropic medications. Walker  objected to that treatment, and sued prison  officials there for violating his Eighth  Amendment rights. See Walker v. Shansky, 28 F.3d 666 (7th Cir. 1994). He points also to the  Illinois AIDS Confidentiality Act, which  provides, in relevant part, that written informed  consent to the HIV test is not required where, in  the judgment of the physician, the testing is  medically indicated to provide appropriate  diagnosis and treatment, provided that the  subject of the test has otherwise consented to  medical treatment. See 410 ILCS 305/8. Although  the defendants disagree on the applicability of  this section, we will assume, in this summary  judgment context, that prison officials could  have forced Walker to undergo an HIV test, and  knew that they had the legal authority to do so.

16
That does not answer the question, however. The  question is whether a reasonable jury could find  that prison officials were deliberately  indifferent to Walker's serious medical needs  because they required the HIV test as a  prerequisite to treatment and then did not force  him to take it. Walker claims that officials are  now hiding behind the test as the reason for  their inaction when in fact no such test was ever  really required before treatment could be  dispensed. His evidence for this proposition is  thin. Although CDC criteria for counting AIDS  cases at that time did not include a requirement  of a positive HIV blood test, Walker has no  evidence that CDC criteria for treating (as  opposed to simply counting) AIDS patients did not  include a requirement for an HIV positive blood  test before AZT could be dispensed. Walker also  presents a 1989 memorandum from Dr. Ronald  Shansky, a defendant in this case, to all medical  directors and physicians in the Illinois  Department of Corrections. That memo, which has  a subject line of "Treatment of HIV Infection,"  states, in relevant part

17
All individuals, whether confirmed with the  diagnosis of AIDS or ARC or with asymptomatic HIV  infection (T4 counts below 300), should be given  the same dose of AZT--that dose being 600 mg per  day. . . . All confirmed cases of AIDS should be  on this dose. In addition, I am recommending that  all individuals who have T4 counts of less than  300 and whose T4 cells are less than 20 percent  of the total T-cells be started on this dosage.

18
Walker cites this memo as evidence that no HIV  blood test was necessary as of 1989 in order to  begin treatment with AZT. Rather, all that was  needed was a T4 cell count of less than 300,  which prison doctors knew he had. Walker's  reading of the memo is strained past the limits  of reasonableness. His best evidence that  requiring an HIV test was simply a ploy to deny  him treatment is that as soon as he was  transferred to another prison within the same  system, and subject to the same policies, he was  given AZT without taking an HIV test.

19
This, however, is merely evidence that, in  another physician's judgment, treatment could  begin in some cases without an HIV blood test.  Even so, requiring an HIV test before dispensing  a dangerous drug used to treat HIV positive  persons and persons with AIDS is so clearly  within the realm of reasonable conduct by the  prison that no reasonable jury could find that  the prison was deliberately indifferent to  Walker's serious medical needs for requiring that  test, even though he had many of the symptoms of  the disease. Like the plaintiff in Choi, there is  no evidence tending to suggest that Walker's  symptoms were consistent only with AIDS or HIV  infection, and there is no evidence that the  prison was ignoring Walker's needs. Rather, they  required him to take a test confirming what they  suspected to be the case before they would begin  treatment. Nor are we persuaded by the fact that  the prison officials chose not to force the  needed test on Walker. Walker does not claim to  be incompetent or to have displayed any signs of  an inability to make medical decisions for  himself. As a competent adult, he was free to  refuse treatment. Here he impliedly refused  treatment by refusing to take the one test he  knew would lead to a confirmed diagnosis and  treatment with AZT. If there had been any  evidence that the defendants were aware he was  mentally ill and incompetent to make his own  medical decisions, or perhaps suffering from  AIDS-related dementia, for example, this might  well be a different case. Without evidence of  incompetence, no reasonable jury could find the  defendants were deliberately indifferent to  Walker's serious medical needs simply because  they required an HIV confirmatory test before  dispensing a powerful and dangerous drug. The  district court correctly granted summary judgment  in favor of the defendants.

B.

20
We turn next to Walker's claim that the  defendants were deliberately indifferent to his  serious medical needs by routinely refusing to  give him Factor VIII on demand, and by giving him  inadequate treatment for AIDS once they did begin  to treat him for that condition. In particular,  he complains that the prison officials did not  provide adequate nutrition, exercise, living  conditions or psychological counseling for a  person with AIDS, and that prison staff were not  properly trained on how to handle a person with  hemophilia. His complaints relating to his  treatment for AIDS and his handling as a  hemophiliac are not supported by any evidence in  the record other than his own personal opinion  given in deposition testimony. No medical  testimony supports the proposition that his  treatment for AIDS was inadequate once the prison  officials began to treat him. Nor does he cite  any medical evidence in the record that he was  mishandled as a hemophiliac. No reasonable jury  could conclude based on his personal testimony  that his medical treatment was inadequate without  any competent evidence in the record to support  these claims. The district court therefore  correctly entered summary judgment on those  claims.

21
Walker's complaint about the administration of  Factor VIII is a closer call. Some of the prison  doctors agreed that hemophiliacs in general can  learn to recognize the signs of an internal bleed  and that they should be administered Factor VIII  on demand when they request it. Walker does not  dispute that he sometimes requested Factor VIII  and then refused to take it because he believed  it had been prepared improperly. Because the  substance can be used for only a few hours after  it is prepared, his refusals resulted in the  wasting of Factor VIII on occasion. Prison  officials have a different explanation for why  Walker refused to take Factor VIII after  requesting it. According to them, Walker often  requested narcotic pain medication at the same  time and refused to take the Factor VIII unless  he was also given the pain medication, even when  doctors believed the pain medication was not  needed. On summary judgment, we will give Walker  the benefit of the doubt and assume that he  refused to take Factor VIII because he thought it  had been improperly prepared. There is no  evidence in the record that it had, in fact, been  improperly prepared but we will assume Walker had  a good faith belief that it had been. That still  left the prison in the position of having to  decide whether to prepare Factor VIII every time  Walker requested it. Some doctors gave Walker  Factor VIII on demand, and others decided to  examine him to determine if he needed it before  preparing it and potentially wasting it. There  was clearly a difference of medical opinion on  how to treat Walker's hemophilia, but there is no  evidence that the prison officials were  deliberately indifferent to Walker's condition.  We examine the totality of an inmate's medical  care when determining whether prison officials  have been deliberately indifferent to an inmate's  serious medical needs. See Reed, 178 F.3d at 855.  Viewing the totality of the care Walker received  for his hemophilia, isolated incidents of delay  or even refusals to administer Factor VIII after  clinical determinations that none was needed  cannot be construed to be deliberate  indifference.

22
The decisive factor, however, is that Walker  has no evidence that he was injured by the  defendants' refusal on some occasions to provide  him Factor VIII. Although it is true that the  defendants admitted that a hemophiliac could be  harmed by delays or refusals in providing Factor  VIII, there is no evidence that Walker actually  was harmed by these decisions. In support of this  alleged harm, he cites the deposition of his  hematologist. She states that Walker's inability  to walk could be the result of untreated joint  bleeds, or could be the result of muscle weakness  from lack of use. Because she is speculating as  to the cause of his difficulties, nothing in her  testimony supports Walker's claim that he was  actually injured by the occasional refusals to  infuse him with Factor VIII when he requested it.  Because he cannot show injury, he cannot make out  a claim of deliberate indifference relating to  his treatment as a hemophiliac. The district  court was correct to grant summary judgment on  that claim as well.

III.

23
Because Walker refused to take a reasonably  requested confirmatory test that would have led  to appropriate treatment, we conclude that he  cannot make out a claim for deliberate  indifference to his serious medical needs.  Likewise, we affirm the grant of summary judgment  on his claim of inappropriate treatment for  hemophilia because he cannot show that he was  injured by the defendants' policies or practices.  Finally, we affirm summary judgment in favor of  the defendants on Walker's remaining claims  because there is no competent evidence in the  record to support claims that he was not treated  appropriately once prison officials did begin  treating him for AIDS.

24
AFFIRMED.

Notes:

1
 Dwayne Walker died while this appeal was pending.  By order of this Court, his mother, Clara Walker,  was allowed to substitute as plaintiff. When we  refer herein to "Walker," we are referring to  Dwayne Walker.