Court Opinion

ID: 9838534
Source: CourtListenerOpinion
Date Created: 2023-09-06 18:01:27.944318+00
Date Added: 2024-06-11T18:02:37.693861
License: Public Domain

Case: 21-11258   Document: 00516884650     Page: 1     Date Filed: 09/06/2023

          United States Court of Appeals
               for the Fifth Circuit
                                                                   United States Court of Appeals
                                                                            Fifth Circuit

                            ____________                                  FILED
                                                                   September 6, 2023
                              No. 21-11258                           Lyle W. Cayce
                            ____________                                  Clerk

   Berman De Paz Gonzalez, individually and as heir and on behalf of
   the Estate of Berman De Paz-Martinez; Emerita
   Martinez-Torres, individually and as heir and on behalf of the
   Estate of Berman De Paz-Martinez,

                                                     Plaintiffs—Appellants,

                                  versus

   Therese M. Duane; Acclaim Physician Group,
   Incorporated; Tarrant County Hospital District, doing
   business as JPS Health Network,

                                                  Defendants—Appellees,

                         consolidated with
                           _____________

                              No. 22-11019
                            _____________

   Berman De Paz Gonzalez, individually and as heir and on behalf of
   the Estate of Berman De Paz-Martinez; Emerita
   Martinez-Torres, individually and as heir and on behalf of the
   Estate of Berman De Paz-Martinez,

                                                     Plaintiffs—Appellants,

                                  versus
Case: 21-11258         Document: 00516884650             Page: 2     Date Filed: 09/06/2023

   Therese M. Duane, Medical Doctor,

                                                Defendant—Appellee.
                      ______________________________

                      Appeal from the United States District Court
                          for the Northern District of Texas
                                USDC No. 4:20-CV-72
                      ______________________________

   Before Haynes and Engelhardt, Circuit Judges, and Saldaña,
   District Judge.*
   Per Curiam:†
          Berman De Paz-Martinez, Jr., a twenty-one-year-old, was severely
   injured after he jumped out of a moving vehicle. He was hospitalized, and
   later died after Dr. Theresa Duane disconnected him from a ventilator,
   allegedly without his parents’ consent. Berman De Paz Gonzalez, Sr. and
   Emerita Martinez-Torres (“Plaintiffs”), claim Dr. Duane’s actions violated
   their and their son’s procedural due process rights under the Fourteenth
   Amendment and the Texas Advance Directives Act (“TADA”). They filed
   a wrongful death and survival action under 42 U.S.C. § 1983 against Dr.
   Duane, Acclaim Physician Group, Inc. (“Acclaim”), and JPS Health
   Network (“JPS”) (collectively, “Defendants”).                    The district court
   dismissed Plaintiffs’ claims against JPS and Acclaim in full, and against Dr.
   Duane, in part. After discovery, the district court granted Dr. Duane’s
   summary judgment motion. Plaintiffs timely appealed both judgments in two
   separate appeals, now consolidated. For the reasons set forth below, we
   AFFIRM.

          _____________________
          *
             United States District Judge for the Southern District of Texas, sitting by
   designation.
          †
              This opinion is not designated for publication. See 5th Cir. R. 47.5.

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                                    No. 21-11258
                                  c/w No. 22-11019

                                 I.    Background
          A. Facts
          On March 29, 2018, De Paz-Martinez, Jr. was taken to the JPS
   Emergency Department after he sustained serious injuries by jumping from
   a moving vehicle that was traveling at approximately 45 miles per hour. On
   arrival, De Paz-Martinez, Jr. was in a coma and required intubation. JPS staff
   told Plaintiffs that their son’s prognosis was extremely poor, and he likely
   would not survive.
          Two days later, Plaintiffs met with a nurse practitioner for a physician
   and pastoral care conference. During this conversation, Plaintiffs indicated
   that they wished to continue treatment.           Early the next morning, Dr.
   Duane—a Medical Director for JPS and a member of Acclaim’s board of
   directors—told Mr. De Paz Gonzalez that his son would be disconnected
   from the ventilator. Shortly after De Paz-Martinez, Jr. was taken off the
   ventilator, he died.
          Later that year, a political advocacy group called Direct Action Texas
   published an article claiming that a medical director at JPS had been
   terminating life-sustaining treatment for patients, in violation of the TADA.
   An anonymous JPS surgical resident subsequently verified the article’s
   allegations, indicating that on three different occasions, Dr. Duane had
   improperly withdrawn medical treatment without familial consent. This,
   along with allegations of other questionable conduct by Dr. Duane, caused
   ICU nurses to make a report to JPS’s CEO. After an investigation, Dr.
   Duane agreed to dismissal from her position in lieu of JPS filing a formal
   complaint against her with the Texas Medical Board.

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                                      No. 21-11258
                                    c/w No. 22-11019

          B. Procedural History
          Plaintiffs sued under § 1983 asserting, among other claims, that
   Defendants violated their Fourteenth Amendment procedural due process
   rights when Defendants allegedly failed to comply with the TADA. See Tex.
   Health & Safety Code §§ 166.001–.053. Plaintiffs brought their
   claims individually, as heirs, and on behalf of their son’s estate. Shortly
   thereafter, Plaintiffs voluntarily dismissed, and the district court entered final
   judgment on, the claims on behalf of their son’s estate. Defendants then
   moved to dismiss the remaining claims, which the district court granted. We
   vacated the judgment on appeal and remanded, concluding Plaintiffs had
   standing to assert a wrongful death and survival action under § 1983. De Paz
   v. Duane, 858 F. App’x 734, 738 (5th Cir. 2021) (mem.).
          On remand, Plaintiffs reasserted their § 1983 claims, individually and
   as heirs. Specifically, Plaintiffs claimed that Defendants violated their
   constitutional rights by depriving: (1) their son of his life and liberty interests
   inherent in the United States Constitution; (2) their son of his life, liberty,
   and property interests created by the TADA; and (3) them of their own
   liberty and property interests created by the TADA.
          Defendants renewed their motions to dismiss, which the district court
   granted in part. It dismissed all § 1983 claims against JPS and Acclaim on the
   ground that Plaintiffs failed to plausibly plead municipal liability and entered
   a final judgment as to them under Rule 54(b). It also dismissed Plaintiffs’
   § 1983 claim against Dr. Duane that was based on the alleged deprivation of
   their and their son’s due process rights created by the TADA. Plaintiffs
   timely appealed this partial, final judgment under Case No. 21-11258.
          Thereafter, discovery proceeded as to the sole surviving claim—
   whether Dr. Duane violated § 1983 by depriving Plaintiffs of their Fourteenth
   Amendment due process rights that are inherent in the Constitution. Dr.

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                                       No. 21-11258
                                     c/w No. 22-11019

   Duane moved for summary judgment, which the district court granted. The
   district court reasoned that Plaintiffs could not recover damages because De
   Paz-Martinez, Jr.’s preexisting injuries were the proximate cause of his
   death, not Dr. Duane’s conduct. Plaintiffs timely appealed under Case No.
   22-11019. The two appeals were initially consolidated only for oral argument
   purposes, but we hereby consolidate them in full.1
                      II.    Jurisdiction & Standard of Review
          The district court had jurisdiction under 28 U.S.C. § 1331. We in turn
   have appellate jurisdiction under 28 U.S.C. § 1291 because the district
   court’s order granting Dr. Duane’s motion for summary judgment was a final
   judgment. Likewise, because the prior “prejudicial adverse interlocutory
   rulings” merged with the final judgment, we have jurisdiction over the
   district court’s orders granting JPS’s and Acclaim’s motions to dismiss in full
   and Dr. Duane’s motions to dismiss in part. Dickinson v. Auto Ctr. Mfg. Co.,
   733 F.2d 1092, 1102 (5th Cir. 1983).
          We review a district court’s dismissal of a complaint under Rule
   12(b)(6) de novo. Gen. Elec. Cap. Corp. v. Posey, 415 F.3d 391, 395 (5th Cir.
   2005). To determine whether a plaintiff has stated a plausible claim for relief,
   “the well-pleaded facts alleged in [the] complaint are accepted as true and
   the allegations are construed in the light most favorable to” the plaintiff.
   Arias-Benn v. State Farm Fire & Cas. Ins. Co., 495 F.3d 228, 230 (5th Cir.
   2007). “A claim has facial plausibility when the plaintiff pleads factual
   content that allows the court to draw the reasonable inference that the

          _____________________
          1
            Accordingly, the issue in Case No. 21-11258 as to whether Dr. Duane’s partial
   summary judgment was appealable in that case is now moot. As discussed below, given the
   consolidation, all the relevant rulings are before us.

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                                           No. 21-11258
                                         c/w No. 22-11019

   defendant is liable for the misconduct alleged.” Ashcroft v. Iqbal, 556 U.S.
   662, 678 (2009).
           Likewise, we review a district court’s order granting summary
   judgment de novo, applying the same standard as the district court. Brand
   Servs., L.L.C. v. Irex Corp., 909 F.3d 151, 155–56 (5th Cir. 2018) (quotation
   omitted). “Summary judgment is proper only when it appears that there is
   no genuine issue of material fact and that the moving party is entitled to
   judgment as a matter of law.” Id. at 156 (quotation omitted). We view the
   facts in the light most favorable to the non-movant and draw all inferences in
   his favor. Id. (quotation omitted).
                                      III.     Discussion
           Plaintiffs contend the district court erred when it granted JPS’s and
   Acclaim’s motions to dismiss in full and Dr. Duane’s motion to dismiss in
   part. Likewise, Plaintiffs also contend the district court erred in granting Dr.
   Duane’s motion for summary judgment. We examine each challenge in turn,
   but none warrant reversal.2

           _____________________
           2
              In addition to those discussed in this opinion, Plaintiffs raise several other
   challenges to the district court’s orders granting Defendants’ motions to dismiss and
   motions for summary judgment—including, whether they have procedural due process
   rights under the Fourteenth Amendment for end-of-life decisions, whether Dr. Duane is
   entitled to qualified immunity, whether Dr. Duane’s removal of the ventilator implicates
   Plaintiffs’ liberty interest in end-of-life decisions, etc. We need not reach these issues,
   however, because we are affirming on the grounds stated above. Thus, we express no
   judgment on the merits of the district court’s conclusions regarding these issues other than
   to note in De Paz v. Duane, 858 F. App’x 734 (5th Cir. 2021) (mem.), we addressed
   Plaintiffs’ standing to sue under § 1983, not whether they had a procedural due process
   right to end-of-life decisions inherent in the United States Constitution. Id. at 736 n.9, 738.

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                                         No. 21-11258
                                       c/w No. 22-11019

           A.      Motion to Dismiss
           In their appeal of the motion to dismiss, Plaintiffs urge that they have
   plausibly pled municipal liability against JPS and Acclaim, and that the
   TADA creates a life, liberty, or property interest for them and their son. We
   disagree.
                1. Municipal Liability
           To establish municipal liability under § 1983, Plaintiffs “must
   identify: (1) an official policy (or custom), of which (2) a policymaker can be
   charged with actual or constructive knowledge, and (3) a constitutional
   violation whose moving force is that policy or custom.” Valle v. City of
   Houston, 613 F.3d 536, 541–42 (5th Cir. 2010) (internal quotation marks and
   citation omitted). Plaintiffs falter on the first requirement.3
           Plaintiffs’ first theory is that Dr. Duane was delegated policymaking
   authority by virtue of her positions as “Vice Chair,” “Department Chair,”
   and “Medical Director” of JPS and because she allegedly “overs[aw] and
   assume[d] responsibility for her department.” But this is not enough by itself
   for us to infer that Dr. Duane has been delegated final policymaking
   authority, especially when for JPS, the medical executive committee sets the
   policy for medical decisions, and for Acclaim, its board of directors sets the
   policies. See Tex. Health & Safety Code § 281.0286(e), (f)(1)(F);
   Tex. Bus. Orgs. Code §§ 22.201, 22.202. Thus, the most we can infer
           _____________________
           3
             Plaintiffs also request that we adopt Texas’s “vice principal” doctrine as a proxy
   for the “policymaker” standard when the defendant is a private corporation, like Acclaim,
   instead of a municipal corporation. We respectfully decline Plaintiffs’ request as it
   completely misapplies the “vice principal” doctrine. See, e.g., Austin v. Paramount Parks,
   Inc., 195 F.3d 715, 727–28 (4th Cir. 1999); see also Kennemer v. Parker Cnty., No. 21-10467,
   2022 WL 2610239, at *1 n.1 (5th Cir. July 8, 2022) (per curiam); Kimble v. Correcthealth
   Jefferson, L.L.C., No. 22-30388, 2023 WL 3946437, at *1 (5th Cir. June 12, 2023) (per
   curiam); Olivas v. Corr. Corp. of Am., 215 F. App’x 332, 333 (5th Cir. 2007) (per curiam).

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                                     No. 21-11258
                                   c/w No. 22-11019

   is that Dr. Duane has been delegated decision-making authority, which is not
   enough. Sweetin v. City of Tex. City, 48 F.4th 387, 393 (5th Cir. 2022).
          Plaintiffs’ second theory is that their allegations create an inference
   that Acclaim and JPS had a policy of granting physicians discretion to make
   unilateral end-of-life decisions. To support their second theory, Plaintiffs
   contend JPS’s and Acclaim’s arguments before the district court and in the
   first appeal that the TADA is optional constitute judicial admissions. Not so.
   Judicial admissions are inapplicable to questions of law. See Blankenship v.
   Buenger, 653 F. App’x 330, 335 & n.15 (5th Cir. 2016) (per curiam).
          What Plaintiffs are left to argue then is that the anonymous email and
   article from the advocacy group demonstrates a widespread practice or
   custom. This too fails. They, at most, allege isolated incidents by a single
   doctor within a one-month period. See Bennett v. City of Slidell, 728 F.2d
   762, 768 n.3 (5th Cir. 1984); Connick v. Thompson, 563 U.S. 51, 61 (2011)
   (explaining that for § 1983 liability, a practice must be “so persistent and
   widespread as to practically have the force of law”).
          Nor can we reasonably infer that Dr. Duane acted pursuant to an
   official policy when Plaintiffs’ other allegations—that other personnel
   reported Dr. Duane’s conduct to JPS’s CEO, resulting in her dismissal—are
   inconsistent with this inference. Without more—such as allegations that
   other doctors engaged in the same type of conduct—Plaintiffs fail to plausibly
   plead facts suggesting an official municipal policy. See Fraire v. City of
   Arlington, 957 F.2d 1268, 1278 (5th Cir. 1992) (holding “[a]llegations of an
   isolated incident are not sufficient to show the existence of a custom or
   policy”).
          Plaintiffs’ last theory is the converse of the second—Acclaim and JPS
   were deliberately indifferent to the need for a policy prohibiting unilateral
   termination decisions either by failing to adopt a policy or by failing to train

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   their personnel. This theory fails for being too conclusory. Spiller v. City of
   Tex. City, Police Dep’t, 130 F.3d 162, 167 (5th Cir. 1997) (explaining “[t]he
   description of a policy or custom and its relationship to the underlying
   constitutional violation, moreover, cannot be conclusory; it must contain
   specific facts”). Accordingly, we affirm the district court’s dismissal of
   Acclaim and JPS.
              2. Texas Advance Directives Act
          Plaintiffs contend that the TADA creates a life, liberty, or property
   interest for their son to receive life-sustaining treatment and for them to make
   medical decisions on his behalf. We disagree.
          State-created substantive interests arise when a state places
   “‘substantive limitations on official discretion.’” See Ridgely v. FEMA, 512
   F.3d 727, 735 (5th Cir. 2008) (quoting Olim v. Wakinekona, 461 U.S. 238, 249
   (1983)). A state law substantively limits official discretion when it establishes
   “substantive predicates to govern official decision-making” and also
   “mandate[es] the outcome to be reached” when the substantive predicates
   are met. Ky. Dep’t of Corr. v. Thompson, 490 U.S. 454, 462 (1989) (internal
   quotation marks and citation omitted).         The state law must also use
   “explicitly mandatory language” and require a particular substantive
   outcome. Id. at 463.
          Under the TADA, when a terminally ill patient has not executed an
   advanced directive and is incapable of communicating, the attending
   physician and the patient’s parents “may make a treatment decision that may
   include a decision to withhold or withdraw life-sustaining treatment.” See
   Tex. Health & Safety Code § 166.039(a), (b). If the parents make a
   decision regarding life-sustaining treatment and the treating physician
   refuses to comply with the treatment decision, the physician must follow the
   procedure set forth in § 166.046 in order to remain within the aegis of the

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                                           No. 21-11258
                                         c/w No. 22-11019

   TADA. See id. § 166.045(d). Under § 166.046, the physician’s refusal to
   honor the treatment decision made by the patient’s parents is “reviewed by
   an ethics or medical committee,” and the patient must be “given life-
   sustaining treatment during th[is] review.” Id. § 166.046(a-1). Importantly,
   the procedures set forth in § 166.046 do not mandate a particular substantive
   outcome—that is, the committee is free to affirm or reverse the physician’s
   decision. See id. § 166.046.
           Based on these provisions, we conclude the TADA does not create a
   substantive interest for Plaintiffs or their son. While the TADA may contain
   substantive predicates—like a parent’s decision regarding life sustaining
   treatment and a doctor’s refusal to comply with that decision—no particular
   substantive outcome is guaranteed.4 Rather, the TADA guarantees only that
   a review of the physician’s decision by an ethics or medical committee will
   take place, and the committee has largely unfettered discretion to either
   affirm or reverse the physician’s decision. See id.; see also T.L. v. Cook
   Children’s Med. Ctr., 607 S.W.3d 9, 80, 85 (Tex. App.—Fort Worth 2020,
   pet. denied) (explaining “[§] 166.046 makes no provision whatsoever for how
   the committee will review or otherwise consider the attending physician’s
   decision” and that “[b]y giving the deciding ‘vote’ to [the]
   committee, . . . [§] 166.046(e) unquestionably trumps the . . . surrogate
   decision maker’s decision”). Thus, at most, Plaintiffs and their son have an

           _____________________
           4
              To be clear, when the process under § 166.046 is invoked, there is an entitlement
   to life-sustaining treatment for a limited period of time. See Tex. Health & Safety
   Code § 166.046(a-1). However, this limited, mandatory right does not dictate that a
   particular outcome follow from the procedures at issue, but “rather[] . . . simply sets the rules
   [for life-sustaining treatment] pending that outcome.” Cf. Elwell v. Byers, 699 F.3d 1208,
   1215 (10th Cir. 2012) (concluding a foster-care statute did not create a liberty interest
   despite it requiring a temporary substantive result—that a child could not be removed from
   a foster home upon request of a hearing—because the statute did not mandate any
   particular outcome from the hearing and procedures).

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                                         c/w No. 22-11019

   expectation in receiving a certain process, which is not, by itself, enough. See
   Olim, 461 U.S. at 250 n.12 (“[A]n expectation of receiving process is not,
   without more, a liberty interest protected by the Due Process Clause.”).
   Accordingly, we affirm the district court’s dismissal of Plaintiffs’ claims
   against Dr. Duane based on the TADA.
           B. Motion for Summary Judgment
           Plaintiffs contend the district court erred when it (1) concluded there
   was no genuine dispute of material fact regarding § 1983 causation, and
   (2) rejected application of the “loss of chance” doctrine. Neither argument
   has merit.5
           “[A] plaintiff seeking to recover on a wrongful death claim under
   § 1983 must prove both the alleged constitutional deprivation required by
   § 1983 and the causal link between the defendant’s unconstitutional acts or
   omissions and the death of the victim, as required by the state’s wrongful
   death statute.” Slade v. City of Marshall, 814 F.3d 263, 264 (5th Cir. 2016)
   (quotation omitted). Under Texas’s Wrongful Death Act, “liability may be
   predicated only on an injury that causes an individual’s death.”                             Id.
   (quotation omitted).          It is not sufficient to show that the defendant’s
   wrongful actions “reduced the decedent’s chance of survival by some lesser
   degree.” Id. at 265.

           _____________________
           5
              Recall that Plaintiffs voluntarily dismissed their claims brought on behalf of De
   Paz-Martinez, Jr.’s estate under Texas’s survival statute. See Tex. Civ. Prac. & Rem.
   Code § 71.021. Claims under the survival statute are effectively derivative claims.
   Schaefer v. Gulf Coast Reg’l Blood Ctr., 10 F.3d 327, 330 (5th Cir. 1994) (per curiam). Thus,
   when Plaintiffs voluntarily dismissed these claims, their son’s rights were no longer in play.
   In fact, Plaintiffs do not even contest the district court’s conclusion to that effect. Naturally
   then, our holding regarding causation only applies to Plaintiffs’ wrongful death action
   asserted under § 1983.

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                                     No. 21-11258
                                   c/w No. 22-11019

          Plaintiffs argue there is a genuine dispute of material fact regarding the
   “causal link” between the alleged deprivation of due process and their son’s
   death because after Dr. Duane removed their son’s ventilator (and did not
   reintubate him), he died. However, Plaintiffs fail to create a fact issue by
   providing evidence rebutting Dr. Duane’s medical evidence which
   establishes that the actual cause of their son’s death was his underlying
   injuries, not Dr. Duane’s removal of the ventilator. Put differently, Plaintiffs
   have not offered any competent evidence which demonstrates that
   “[D]efendant’s wrongful actions more likely than not caused [De Paz-
   Martinez, Jr.’s] death—not just that they reduced [his] chance of survival by
   some lesser degree.” See id. at 264–65. Indeed, Plaintiffs’ separate lawsuit
   against the driver of the moving vehicle, in which they claimed that the
   driver’s conduct caused their son’s death, directly contradicts their
   argument that this is not a “loss of chance” case. As such, we conclude there
   is no genuine dispute of material fact regarding causation.
          Plaintiffs’ second argument is similarly foreclosed by Slade. See id. at
   267. Plaintiffs argue it is inconsistent with policies underlying § 1983 to reject
   application of the “loss of chance” doctrine because most victims who have
   had life-support withdrawn without consent are terminally ill, and therefore,
   if the “loss of chance” doctrine did not apply, these victims could never
   recover. We rejected this argument in Slade. See id. (noting “[t]he fact that
   employing the Texas rule . . . denies compensation to appellants does not
   suffice to render the borrowing impermissibly inconsistent with federal law”
   (alteration in original) (quotation omitted)). As such, in the context of this
   case, rejection of the “loss of chance” doctrine is not inconsistent with the
   policies underlying § 1983. Accordingly, we affirm the district court’s grant
   of summary judgment in favor of Dr. Duane.

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                              IV.    Conclusion
         For the reasons set forth above, we AFFIRM the district court’s
   orders granting JPS’s and Acclaim’s motions to dismiss, partially granting
   Dr. Duane’s motion to dismiss, and granting Dr. Duane’s motion for
   summary judgment.

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