Court Opinion

ID: 6986020
Source: CourtListenerOpinion
Date Created: 2022-07-24 03:09:26.339858+00
Date Added: 2024-06-11T16:09:27.383091
License: Public Domain

MESKILL, Circuit Judge,
dissenting:
The Eighth Amendment is violated when prison officials act with “deliberate indifference to serious medical needs.” Estelle v. Gamble, 429 U.S. 97, 104, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976). Today, the Court holds that deliberate indifference to a dental cavity violates the Eighth Amendment. I respectfully disagree.
The standard governing Harrison’s claim is well established. For Harrison to avoid summary judgment, he must show a material question of fact as to whether Dr. Hoehn or the other defendants acted with “ ‘deliberate indifference to [his] serious medical needs.’ ” Chance v. Armstrong, 143 F.3d 698, 702 (2d Cir.1998) (quoting Estelle, 429 U.S. at 104, 97 S.Ct. 285) (alteration in original). The standard includes subjective and objective components: “First, the alleged deprivation must be, in objective terms, sufficiently serious. Second, the defendant must act with a sufficiently culpable state of mind. An official acts with the requisite deliberate indifference when that 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.’ ” Id. (quoting Farmer v. Brennan, 511 U.S. 825, 837, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994)) (other cita*141tions and internal quotation marks omitted).
Harrison stated in an affidavit that he had been subjected to “unbearable pain and suffering since September of 1994, until the painful cavity was filled ... on June 7, 1995.” Assuming that this assertion creates a material issue of fact as to whether the deprivation was, objectively, “sufficiently serious,” it says nothing about whether the defendants knew that Harrison faced “a substantial risk of serious harm.” Indeed, there is no allegation, nor evidence of record, indicating that the defendants were aware of Harrison’s “unbearable pain and suffering.”
On June 31[sic], 1994, Harrison filed a “Dental Request Slip” on which he checked the box “Need Filling.” He made no additional notations on the form. On August 24 he filed a second such slip, on which he wrote “tooth pain” next to the box marked “OTHER.” On September 11, he filed a third slip, again complaining of “tooth pain” next to the box marked “OTHER.”
On September 15, Harrison was seen by Dr. Hoehn. There is no indication that Harrison complained to Dr. Hoehn of “unbearable pain and suffering.” Dr. Hoehn refused to fill Harrison’s cavity (tooth # 26) because a different tooth (tooth # 18), although asymptomatic, presented the more serious and immediate medical need and required extraction. Nine months later, when Harrison’s cavity was filled by Dr. Mirza, the dentist observed only “a small cavity” in tooth #26 that “was not deep.” Dr. Mirza stated in an affidavit:
8. The tooth’s dentin, or underlayer of sensitive calcified tissue was, not exposed. No nerve was exposed by the cavity. There was no sign of visible decay.
9. While the patient may have experienced slight sensitivity in this tooth, there was nothing revealed during my examination of the patient to indicate a condition in tooth # 26 which would produce tooth pain.
In other words, Dr. Hoehn would not have known from his examination of Harrison’s teeth that Harrison was experiencing anything more than “slight sensitivity” in the tooth.1
Dr. Hoehn noted in Harrison’s record that Harrison refused treatment. On September 23, Dr. Hoehn added a memorandum explaining that Harrison “has a carious non-restorable tooth which needs to be extracted prior to further treatment.”
On September 16, Harrison filed a grievance complaining that “Dentist R. Hoehn refused to fill a cavity unless I allowed him to extract a tooth.” The complaint did not mention pain. The Inmate Grievance Resolution Committee denied Harrison’s grievance, stating that it did not “have the power to ... over ride [sic] the decision of the Dentist.” The accompanying investigative report also echoed Dr. Hoehn’s memorandum of September 28, informing Harrison, “You have a carious non-restora-ble tooth which needs to be extracted prior to further treatment.” Harrison appealed, first to the prison superintendent, and then to the Central Office Review Committee (CORC). Harrison did not complain of pain on either occasion, and both appeals *142were denied. The superintendent, after repeating that “you have a carious non-restorable tooth which needs to be extracted prior to further dental treatment,” further explained, “It is the dentist’s policy to take care of the most serious dental problems first.” The CORC additionally advised: “[I]n accordance with the Health Services Policy Manual an infection is considered a class 4 treatment priority and takes precedence over a routine cleaning [sic], classified as a 2 in priority.”
In sum, Dr. Hoehn knew at most that Harrison had a cavity, causing him “tooth pain.” It is not clear that the defendants other than Dr. Hoehn reviewed Harrison’s dental request slips during the course of his administrative appeals, and Harrison made no allegation and made no showing that they knew he was experiencing tooth pain. Nevertheless, the majority holds that, “because a tooth cavity will degenerate with increasingly serious implications if neglected over sufficient time, it presents a ‘serious medical need’ within the meaning of our case law.” Majority Op. at 137 (citation omitted). I do not believe that a mere cavity amounts to a “serious medical need.”
Indeed, the majority admits as much: “Ordinarily, a tooth cavity is not a serious medical condition.” See Majority Op. at 137. However, the majority then asserts that “a tooth cavity is a degenerative condition, and if it is left untreated indefinitely, it is likely to produce agony and to require more invasive and painful treatments, such as root canal therapy or extraction.” See Majority Op. at 137. The majority concludes that “a degenerative condition” — even if not ordinarily considered a serious medical condition- — amounts to a serious medical condition if it “tends to cause acute infections, debilitating pain and tooth loss if left untreated.” See Majority Op. at 137 - 38. In short, the Estelle standard “deliberate indifference to serious medical needs” has metamorphosed to include “deliberate indifference to non-serious medical needs if they might become serious in the face of deliberate indifference.”
The majority’s misreading of Estelle ignores entirely the reason why denial of medical treatment is cognizable only with respect to serious medical needs: “[S]oci-ety does not expect that prisoners will have unqualified access to health care, [so] deliberate indifference to medical needs amounts to an Eighth Amendment violation only if those needs are ‘serious.’” Hudson v. McMillian, 503 U.S. 1, 9, 112 S.Ct. 995, 117 L.Ed.2d 156 (1992) (citing Estelle, 429 U.S. at 103-04, 97 S.Ct. 285). Society’s “evolving standards of decency,” id. at 8, 112 S.Ct. 995 (internal quotation marks omitted), do not require that a prisoner be entitled to treatment for a small cavity, having refused treatment for a different, life-threatening dental condition.
The Supreme Court’s decision in Helling v. McKinney, 509 U.S. 25, 113 S.Ct. 2475, 125 L.Ed.2d 22 (1993), is not to the contrary. Although the Court recognized that exposure to second-hand tobacco smoke might “unreasonably endanger[]” a prisoner’s future health and that therefore an Eighth Amendment violation could be proven, id. at 35, 113 S.Ct. 2475, the Court emphasized that it would still be necessary for the prisoner to prove that involuntary exposure to second-hand smoke was “contrary to current standards of decency.” Id. Thus, the Court in no way sanctioned the wholesale extension of Estelle adopted here.
Aside from my disagreement with the majority’s misreading of Estelle, I find the majority’s conclusion untenable as a matter of fact and reason. The majority asserts that a tooth cavity is a degenerative condition “likely” to produce agony and other serious consequences, so that the refusal to treat amounts to an Eighth Amendment violation. To support its view, the majority cites Toward Improving the Oral Health of Americans, a government report whose bias is evident from its title. Cf. Rhodes v. Chapman, 452 U.S. 337, 348 n. 13, 101 S.Ct. 2392, 69 L.Ed.2d *14359 (1981) (observing that “opinions of experts ... simply do not establish the constitutional minima; rather, they establish goals recommended by the organization in question” (internal quotation marks omitted)). The majority’s view, however, has been characterized as “ignorant” by respected medical authority. See Textbook of Cariology 295 (Anders Thylstrup & Ole Fejerskov eds., 1986) (discussing hypothetical dentist who “is ignorant of current knowledge of dental caries and accordingly regards surgical treatment [such as filling of dental caries] as the most realistic way of stopping caries progression”). To the contrary, it may be perfectly reasonable for a dentist not to fill a cavity, especially where it is “not deep” and the dentin is not involved. See id. at 294 (“[I]t seems justified for the regular dental visitor to expect that dental health delivery as provided by the dentist in principle is aimed at control of caries progression without surgical treatment.”); see also Lloyd Baum et al., Textbook of Operative Dentistry 15 (2d ed.1985) (noting that surgical intervention is usually required “after the enamel has been penetrated and dentin is involved” (emphasis added)).
I am also unmoved by the majority’s ipse dixit assertion that the risk here “was particularly serious because the plaintiff had few teeth to spare.” Majority Op. at 137. I suspect that dentistry cannot be reduced so easily to a numbers game, and that the medical significance of any given tooth depends heavily on the condition of the patient’s adjacent and opposing teeth and on the availability of dental prosthet-ics. To be sure, I am not an expert in the field of dentistry, and I assume that the proper treatment of dental caries is a debatable point among dentists of reason. But, as a consequence, I think it imprudent for this Court to hold that the defendants can be liable for violating Harrison’s Eighth Amendment rights, knowing only that Harrison’s cavity was not filled promptly.
Even if this Court had a bevy of experts — which it does not now have — proclaiming in unison that “dental cavities degenerate and must be filled, or they are likely to produce agony,” I still would not agree with the majority’s conclusion because it interferes unjustifiably with the prison dentist’s judgment and decision-making.
The majority assumes a niggardly view of the dentist’s role and the deference that courts owe to a treating dentist’s medical judgment and decision-making. The majority assumes that Harrison has two separate dental problems and implies that they ought to have been addressed independently by Dr. Hoehn: “It appears to be uncontested that the indicated treatment for the cavity was a filling, and that the indicated treatment for the non-restorable tooth was extraction.” See Majority Op. at 140. However, a dentist should be allowed to formulate a patient’s treatment plan based on the patient’s overall dental health, not only on the health of individual teeth. See Robert B. Morris, Strategies in Dental Diagnosis and Treatment Planning 129 (1999) (basing treatment planning on the establishment of a “healthy oral environment”). Indeed, “[i]t is a careful and wise dentist who protects the oral health' of his patients rather than serving only as a repairman for damaged teeth.” Textbook of Operative Dentistry, supra, at 1. “Even when a patient presents on an emergency basis for diagnosis and treatment of one problem tooth, treatment must be harmonized with the findings and needs of the total oral cavity and of the patient as a whole.” Norman K. Wood & Gerard Byrne, Treatment Planning in Dentistry 6, in 1 Clark’s Clinical Dentistry (Jefferson F. Hardin ed., rev. ed.1996).
This is not an over-idealized, ivory tower view of the patient-dentist relationship that bears no application to the nitty gritty world of prison health care and the Eighth Amendment. To the contrary, it is rooted in the Eighth Amendment and the “deliberate indifference” standard itself. The *144Eighth Amendment “bans only cruel and unusual punishment. If the pain inflicted is not formally meted out as punishment by the statute or the sentencing judge, some mental element must be attributed to the inflicting officer before it can qualify.” Wilson v. Seiter, 501 U.S. 294, 300, 111 S.Ct. 2321, 115 L.Ed.2d 271 (1991). A prison health care provider simply does not have the requisite “mental element” to be guilty of an Eighth Amendment violation when he or she acts, motivated by the best interests of the patient. In this case, Dr. Hoehn refused to treat a small cavity, motivated by a medically justified concern that a different dental condition was life threatening and required immediate treatment. Dr. Hoehn cannot be said to have disregarded “an excessive risk to inmate health or safety,” and consequently he is not guilty of deliberate indifference. See Farmer, 511 U.S. at 837, 114 S.Ct. 1970.2
Of course, a private patient has the right to reject a proposed plan of treatment and may demand that elective procedures be performed first, even before other, urgently needed procedures. After all, it is the patient’s time and money that are at stake. See Strategies in Dental Diagnosis and Treatment Planning, supra, at 11-12. That calculus changes when the patient is a prisoner. In that case, the patient is entitled to basic medical care, but he has no right to dictate the “type or scope” of care that he receives. United States ex rel. Hyde v. McGinnis, 429 F.2d 864, 867 (2d Cir.1970) (internal quotation marks omitted). Dr. Hoehn examined Harrison and determined that Harrison’s dental well-being required treatment of one tooth before the other. We ought not impose our understanding of sound dental practices over Dr. Hoehn’s exercise of professional judgment.
For the foregoing reasons, I believe the defendants are entitled to summary judgment on Harrison’s Eighth Amendment claim, and I would therefore affirm the district court. Also, as noted earlier, the majority’s reading of Estelle is novel, inasmuch as it extends “serious medical needs” to include non-serious medical needs that are “likely” to degenerate and to result in pain or serious complications if left untreated. Defendants cannot be expected to foresee novel extensions of existing law. See Harlow v. Fitzgerald, 457 U.S. 800, 818, 102 S.Ct. 2727, 73 L.Ed.2d 396 (1982). Therefore, it cannot be said that the defendants were violating Harrison’s “clearly established constitutional rights,” see Weyant v. Okst, 101 F.3d 845, 857 (2d Cir.1996). I would also affirm on the grounds that the defendants are entitled to qualified immunity.

. The majority disparages Dr. Mirza's affidavit without explanation, stating that it “minimizes the extent of decay” in tooth # 26. See Majority Op. at 138. The only evidence to the contrary, however, is an affidavit submitted by Harrison, in which he stated that “the cavity had plainly and clearly pierced the tooth enamal [sic]” and that “nerve ending[s] were exposed.” Assuming that Harrison’s self-diagnosis is competent and based on personal knowledge, which is highly unlikely, it is belied by his failure to complain of tooth pain through three levels of administrative appeals or during the course of the proceedings in state court. See In re Harrison, # 94-R-1722, at 3 (N.Y.Sup.Ct. May 31, 1995) (“Petitioner's submissions are silent with respect to pain.”). In any event, as discussed later in this opinion, the majority does not base its decision on the severity of Harrison’s cavity but on its mere existence.

. The majority denies that Dr. Hoehn's medical judgment is at issue here, asserting instead that Harrison was denied treatment solely “based on the purported requirement of an administrative guideline that he first consent to the extraction of another tooth.” Majority Op. at 137 n. 2; see also id. at 134 (“Hoehn refused, claiming that Riverview policy required the non-restorable tooth to go before the cavity could be filled.”). However, the record is to the contrary. Dr. Hoehn never claimed that an administrative policy required denial of treatment; he only stated that Harrison “has a non-restorable tooth which needs to be extracted prior to further treatment.” The Inmate Grievance Resolution Committee denied Harrison's grievance, stating that it did not "have the power to ... over ride [sic] the decision of the Dentist" (emphasis added), and the superintendent additionally observed that it was “the dentist’s policy to take care of the most serious dental problems first” (emphasis added). To be sure, the CORC subsequently cited the Health Services Policy Manual, but to say that a dentist’s medical judgment is consistent with an administrative policy is not to say that no medical judgment was ever involved. See also In re Harrison, # 94-R-1722, at 2 (referring to defendants’ argument that “the dentist's professional judgment was not inconsistent with the Department's policy manual”).