PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 15-1587
PAUL SCINTO, SR.,
Plaintiff - Appellant,
v.
WARDEN PATRICIA STANSBERRY, FCI - Butner-Low; SUSAN
MCCLINTOCK, Camp Administrator, FPC-Butner; R. HOLT, Senior
Officer Specialist; DR. PHILLIPS; OFFICER COORS,
Defendants - Appellees,
and
FEDERAL BUREAU OF PRISONS, a division of the U.S. Department
of Justice; HARLEY G. LAPPIN, Director, Bureau of Prisons;
KIM WHITE, Mid Atlantic Regional Director,
Defendants.
Appeal from the United States District Court for the Eastern
District of North Carolina, at Raleigh. James C. Dever III,
Chief District Judge. (5:10-ct-03165-D)
Argued: September 23, 2016 Decided: November 4, 2016
Before NIEMEYER, MOTZ, and WYNN, Circuit Judges.
Affirmed in part and reversed in part by published opinion.
Judge Wynn wrote the opinion, in which Judge Niemeyer and Judge
Motz joined.
ARGUED: Adam H. Farra, COHEN MILSTEIN SELLERS & TOLL PLLC,
Washington, D.C., for Appellant. Robert J. Dodson, OFFICE OF
THE UNITED STATES ATTORNEY, Raleigh, North Carolina, for
Appellees. ON BRIEF: Paul J. Zidlicky, SIDLEY AUSTIN LLP,
Washington, D.C., for Appellant. John Stuart Bruce, Acting
United States Attorney, G. Norman Acker, III, Assistant United
States Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Raleigh,
North Carolina, for Appellees.
2
WYNN, Circuit Judge:
Plaintiff Paul Scinto, Sr. (“Plaintiff”), a former federal
prisoner, sued several federal prison officials pursuant to
Bivens v. Six Unknown Named Agents of Federal Bureau of
Narcotics, 403 U.S. 388 (1971), alleging a number of violations
under the Fourth, Fifth, Eighth, and Fourteenth Amendments.
Defendants are Dr. Derick Phillip (“Dr. Phillip”); Patricia
Stansberry, former Federal Prison Camp Butner Warden (“Warden
Stansberry”); and Susan McClintock, former Butner Camp
Administrator (“Administrator McClintock”). Collectively, these
Defendants successfully moved for summary judgment on all of
Plaintiff’s claims.
On appeal, Plaintiff limits his arguments to the district
court’s dismissal of three claims that Defendants were
deliberately indifferent to his medical needs, in violation of
the Eighth Amendment. Plaintiff argues that, in dismissing
these claims, the district court made credibility determinations
and weighed the parties’ evidence, thus violating the summary
judgment standard.
For the reasons that follow, we reverse the district
court’s disposition of the two Eighth Amendment claims against
Dr. Phillip and Administrator McClintock but affirm its
resolution of the claim against Warden Stansberry.
3
I.
The Eighth Amendment prohibits the infliction of “cruel and
unusual punishments.” U.S. Const. amend. VIII. This
prohibition “proscribes more than physically barbarous
punishments.” Estelle v. Gamble, 429 U.S. 97, 102 (1976). It
also encompasses “the treatment a prisoner receives in prison
and the conditions under which he is confined.” Helling v.
McKinney, 509 U.S. 25, 31 (1993). In particular, the Eighth
Amendment imposes a duty on prison officials to “provide humane
conditions of confinement . . . [and] ensure that inmates
receive adequate food, clothing, shelter, and medical care.”
Farmer v. Brennan, 511 U.S. 825, 832 (1994). To that end, a
prison official’s “deliberate indifference to serious medical
needs of prisoners constitutes the unnecessary and wanton
infliction of pain proscribed by the Eighth Amendment.”
Estelle, 429 U.S. at 104 (internal quotation marks and citation
omitted). Prisoners alleging that they have been subjected to
unconstitutional conditions of confinement must satisfy the
Supreme Court’s two-pronged test set forth in Farmer v. Brennan,
511 U.S. 825 (1994).
First, Farmer’s “objective” prong requires plaintiffs to
demonstrate that “the deprivation alleged [was], objectively,
‘sufficiently serious.’” Farmer, 511 U.S. at 834 (quoting
Wilson v. Seiter, 501 U.S. 294, 298 (1991)). To be
4
“sufficiently serious,” the deprivation must be “extreme”--
meaning that it poses “a serious or significant physical or
emotional injury resulting from the challenged conditions,” or
“a substantial risk of such serious harm resulting from . . .
exposure to the challenged conditions.” De’Lonta v. Angelone,
330 F.3d 630, 634 (4th Cir. 2003) (internal quotation marks and
citation omitted). In medical needs cases, like the case at
bar, the Farmer test requires plaintiffs to demonstrate
officials’ deliberate indifference to a “serious” medical need
that has either “been diagnosed by a physician as mandating
treatment or . . . is so obvious that even a lay person would
easily recognize the necessity for a doctor’s attention.” Iko
v. Shreve, 535 F.3d 225, 241 (4th Cir. 2008).
Second, under Farmer’s “subjective” prong, plaintiffs must
show that prison officials acted with a “sufficiently culpable
state of mind.” Farmer, 511 U.S. at 834 (internal quotation
marks omitted) (quoting Wilson, 501 U.S. at 297). In conditions
of confinement cases, the requisite state of mind is deliberate
indifference. Id. To prove deliberate indifference, plaintiffs
must show that “the official kn[ew] of and disregard[ed] an
excessive risk to inmate health or safety.” Id. at 837. Put
differently, the plaintiff must show that the official was
“aware of facts from which the inference could be drawn that a
substantial risk of serious harm exist[ed], and . . . dr[ew]
5
th[at] inference.” Id. (emphasis added). Deliberate
indifference is “more than mere negligence,” but “less than acts
or omissions [done] for the very purpose of causing harm or with
knowledge that harm will result.” Id. at 835. It “lies
somewhere between negligence and purpose or knowledge: namely,
recklessness of the subjective type used in criminal law.”
Brice v. Va. Beach Corr. Ctr., 58 F.3d 101, 105 (4th Cir. 1995)
(citing Farmer, 511 U.S. at 835). Under this standard, mere
“[d]isagreements between an inmate and a physician over the
inmate’s proper medical care” are not actionable absent
exceptional circumstances. Wright v. Collins, 766 F.2d 841, 849
(4th Cir. 1985) (citing Gittlemacker v. Prasse, 428 F.2d 1, 6
(3d Cir. 1970)).
In deliberate indifference to medical needs cases, Farmer’s
subjective prong requires proof of the official’s “actual
subjective knowledge of both the inmate’s serious medical
condition and the excessive risk posed by [the official’s]
action or inaction.” Jackson v. Lightsey, 775 F.3d 170, 178
(4th Cir. 2014) (citing Farmer, 511 U.S. at 837–39). A
plaintiff can meet the subjective knowledge requirement through
direct evidence of a prison official’s actual knowledge or
circumstantial evidence tending to establish such knowledge,
including evidence “that a prison official knew of a substantial
risk from the very fact that the risk was obvious.” Makdessi v.
6
Fields, 789 F.3d 126, 133 (4th Cir. 2015) (quoting Farmer, 511
U.S. at 842).
A plaintiff also makes out a prima facie case of deliberate
indifference when he demonstrates “that a substantial risk of
[serious harm] was longstanding, pervasive, well-documented, or
expressly noted by prison officials in the past, and the
circumstances suggest that the defendant-official . . . had been
exposed to information concerning the risk and thus must have
known about it . . . .” Parrish ex rel. Lee v. Cleveland, 372
F.3d 294, 303 (4th Cir. 2004) (first alteration in original)
(internal quotation marks omitted) (quoting Farmer, 511 U.S. at
842). Similarly, a prison official’s “[f]ailure to respond to
an inmate’s known medical needs raises an inference [of]
deliberate indifference to those needs.” Miltier v. Beorn, 896
F.2d 848, 853 (4th Cir. 1990), overruled in part on other
grounds by Farmer, 511 U.S. at 837. However, even officials who
acted with deliberate indifference may be “free from liability
if they responded reasonably to the risk.” Farmer, 511 U.S. at
844.
7
II.
Plaintiff entered federal custody at Federal Prison Camp
Seymour Johnson in October 2002. 1 At that time, he suffered from
myriad medical conditions, including hepatitis C, a knee
infection, insulin-dependent diabetes, and high blood pressure.
In the years that followed, Plaintiff was confined in various
federal prison facilities. In particular, from June 2005 to
March 2006, Plaintiff was incarcerated at Federal Prison Camp
Butner in Butner, North Carolina. During that time, several
incidents purportedly occurred and gave rise to a number of
constitutional claims. Following a circuitous journey through
the federal judicial system, the present appeal addresses only a
subset of these claims.
On February 28, 2008, Plaintiff filed a Bivens action pro
se in the United States District Court for the District of
Columbia. Plaintiff’s original complaint sought relief for
alleged violations of his rights under the Fourth, Fifth,
Eighth, and Fourteenth Amendments, naming as defendants various
federal officials, including the Bureau of Prisons, then-Bureau
Director Harley Lappin, Regional Director Kim White, Warden
1After pleading guilty to maintaining a place for the
purpose of manufacturing, distributing, or using phencyclidine,
Plaintiff was sentenced to 78 months’ imprisonment. The nature
of his conviction and sentence are irrelevant to this appeal.
8
Stansberry, Administrator McClintock, and Butner Correctional
Officer Richard Holt (“Officer Holt”). After dismissing a
number of these claims on jurisdictional and sovereign immunity
grounds, the district court transferred Plaintiff’s remaining
claims against Warden Stansberry, Administrator McClintock, and
Officer Holt to the United States District Court for the Eastern
District of North Carolina. Scinto v. Fed. Bureau of Prisons,
608 F. Supp. 2d 4, 10 (D.D.C.), aff’d, 352 F. App’x 448 (D.C.
Cir. 2009). Following a second appeal in this Circuit,
Plaintiff successfully amended his complaint to include
additional Eighth Amendment claims against defendants Dr.
Phillip and Butner Correctional Officer Lawrence Coor (“Officer
Coor”). Scinto v. Stansberry, 507 F. App’x 311 (4th Cir. 2013)
(per curiam). Cross-motions for summary judgment followed and,
on September 9, 2014, the district court denied Plaintiff’s
motion for summary judgment and granted summary judgment to the
defendants on each of Plaintiff’s claims.
Plaintiff appeals only three of the claims dismissed on
summary judgment, each arising under the Eighth Amendment.
These include: (1) Plaintiff’s claim against Dr. Phillip for
allegedly denying Plaintiff insulin to treat his diabetes; (2)
Plaintiff’s claims against Dr. Phillip and Administrator
McClintock for allegedly failing to provide aid in a medical
emergency; and (3) Plaintiff’s claim against Warden Stansberry
9
for her alleged failure to provide Plaintiff with a diabetic
diet during Plaintiff’s incarceration in administrative
segregation (the “Special Housing Unit”). We address the facts
relevant to each claim below.
III.
“We review the district court’s grant of summary judgment
de novo, viewing the facts and the reasonable inferences
therefrom in the light most favorable to the nonmoving party.”
Bonds v. Leavitt, 629 F.3d 369, 380 (4th Cir. 2011). Summary
judgment must be granted “if the movant shows that there is no
genuine dispute as to any material fact and the movant is
entitled to judgment as a matter of law.” Fed. R. Civ. P.
56(a). To survive summary judgment, “there must be evidence on
which the jury could reasonably find for the [nonmovant].”
Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252 (1986).
A.
1.
Plaintiff’s first claim alleges that Dr. Phillip violated
Plaintiff’s Eighth Amendment rights by denying Plaintiff insulin
to treat his diabetes. Dr. Phillip was Plaintiff’s prison
doctor at Federal Prison Camp Butner and treated several of
Plaintiff’s medical conditions, including his diabetes. On
June 5, 2005, shortly after Plaintiff’s arrival at Butner, Dr.
Phillip prescribed Plaintiff morning and evening insulin
10
injections, as well as supplemental insulin injections based
upon a “sliding scale” keyed to his blood sugar. According to
that sliding scale, Plaintiff was prescribed two units of
insulin when his blood sugar was between 141 and 150 milligrams
(“mg”) per deciliter (“dL”), four units when his blood sugar was
between 151 and 200mg/dL, and so on.
On June 14, 2005, Plaintiff requested from Dr. Phillip and
other medical personnel at Federal Medical Camp Butner a
supplemental insulin injection because his blood sugar was
200mg/dL. Based on the sliding scale Dr. Phillip prescribed,
Plaintiff should have received four units of insulin. At the
time of his request, Plaintiff admits that he was “angry”--at
least in part because his blood sugar was high. The parties
agree that, rather than providing four units of insulin as
dictated by Plaintiff’s prescription, Dr. Phillip terminated
Plaintiff’s visit to the medical clinic and declined to provide
him with insulin. Instead, Dr. Phillip developed an alternative
plan to monitor Plaintiff’s blood sugar levels at mealtimes and
to “cover each meal with short acting insulin” if Plaintiff
desired. J.A. 521. 2
2
Citations to “J.A. __” refer to the Joint Appendix filed
by the parties in this appeal.
11
According to Plaintiff’s evidence, the June 14 incident was
not the first time Dr. Phillip denied Plaintiff prescribed
insulin injections. Nor, according to Plaintiff, was it the
last. Although medical records reflect Dr. Phillip’s plan to
monitor Plaintiff’s blood sugar and provide supplemental insulin
at mealtimes, Plaintiff filed two Inmate Request to Staff forms
(“cop-outs”) that suggest this plan was never followed. First,
on June 22, 2005, Plaintiff directed a cop-out to Dr. Phillip
“request[ing] insulin coverage whenever my blood glucose levels
rise above 200mg/dl.” J.A. 88. And on July 27, 2005, Plaintiff
addressed another cop-out to Dr. Phillip referencing his June 22
request for supplemental insulin (along with several other,
unrelated requests for medical attention) and stating that his
conditions “remain untreated [and] uncured.” J.A. 82. Dr.
Phillip admits that he did not provide Plaintiff with insulin
during the June 14 appointment, but asserts that the denial was
justified based on Plaintiff’s threatening behavior and that his
treatment of Plaintiff’s diabetes before and after this incident
was appropriate.
Plaintiff claims that Dr. Phillip’s alleged repeated
denials of supplemental insulin resulted in an unhealthy
increase in Plaintiff’s blood sugar and his hemoglobin A1C
levels, which rose from approximately 7 (within the normal range
for diabetics) to 9.8 (an unhealthy level for diabetics) from
12
January to September 2005. More generally, Plaintiff claims
that the inadequate treatment of his diabetes resulted in
“unnecessary exacerbation of his serious diabetic . . .
condition[], causing serious harm to the Plaintiff [that]
resulted in damage to the Plaintiff’s kidney’s [sic], eyesight,
nervous system, . . . and psychological well being.” J.A. 165.
2.
Contrary to the district court’s holding, Plaintiff adduced
sufficient evidence to establish a genuine dispute of fact as to
both Farmer’s objective and subjective prongs.
Regarding the objective prong, Plaintiff’s evidence
established that he suffers from a serious medical condition:
insulin-dependent diabetes. This medical condition was
diagnosed by a medical professional, and Dr. Phillip provided
treatment for the condition by prescribing Plaintiff’s insulin
regimen. Moreover, Plaintiff has created a genuine issue of
material fact regarding whether Dr. Phillip’s failure to provide
him with insulin was an “extreme deprivation” resulting in “a
serious or significant physical or emotional injury” or “a
substantial risk” thereof actionable under the Eighth Amendment.
See De’Lonta, 330 F.3d at 634. Dr. Phillip admits that he
denied Plaintiff a supplemental dose of insulin on June 14,
2005, at a time when Plaintiff’s blood sugar was 200mg/dL. This
may be sufficient alone to meet the objective test set forth in
13
Farmer. See, e.g., Lolli v. Cty. of Orange, 351 F.3d 410, 420
(9th Cir. 2003) (“Leaving a diabetic . . . without proper food
or insulin when it is needed creates an objectively,
sufficiently serious risk of harm.” (internal quotation marks
omitted)).
Even without drawing this conclusion, however, Plaintiff
raises a genuine dispute of material fact as to whether the
deprivation of his prescribed insulin caused serious injury or a
substantial risk of serious injury as required by the objective
prong. He does so by pointing to his deposition testimony and
medical records showing an increase in his blood sugar and
hemoglobin A1C values from January to September 2005, which
encompasses the period from June to August 2005 during which Dr.
Phillip was assigned to treat Plaintiff’s diabetes. Viewing
these facts in the light most favorable to Plaintiff, there are
genuine disputes of material fact as to whether (1) this
increase is itself a serious injury and (2) the act of
withholding insulin from an insulin-dependent diabetic alone
creates a serious injury or a substantial risk of such injury.
Plaintiff’s evidence also created a genuine dispute of
material fact as to Farmer’s subjective prong. As Plaintiff’s
prison doctor, Dr. Phillip knew of Plaintiff’s serious medical
condition. Indeed, Dr. Phillip prescribed the insulin regimen
under which Plaintiff was to receive supplemental insulin
14
injections when his blood sugar was above 140mg/dL. This
evidence establishes that Dr. Phillip was aware of facts--
Plaintiff’s diabetes and his blood sugar value at the time of
his request for insulin--giving rise to an inference that
failing to provide insulin could result, at least, in a
substantial risk of serious harm.
Moreover, viewed in the light most favorable to Plaintiff,
Plaintiff’s lengthy prison medical records show that his
diabetes diagnosis was “longstanding, pervasive, well-
documented, [and] expressly noted by prison officials,” Parrish,
372 F.3d at 303--including by Dr. Phillip himself. This is
sufficient to prove a prima facie case of deliberate
indifference. Id. Furthermore, as in Miltier, Dr. Phillip knew
of Plaintiff’s medical need for insulin at the time of the
request and failed to respond to that known need, raising an
inference of deliberate indifference. 896 F.2d at 853,
overruled in part on other grounds by Farmer, 511 U.S. at 837.
The district court erred in failing to apply the Parrish
presumption and infer deliberate indifference from Dr. Phillip’s
knowledge of Plaintiff’s diabetes and disregard of his own
prescription designed to manage that condition.
Notwithstanding the factual disputes outlined above, the
district court granted Dr. Phillip’s motion for summary judgment
for two principal reasons. First, the court found fault with
15
Plaintiff’s failure to offer medical expert testimony (a) that
his blood sugar level during the June 14 appointment “created a
substantial harm” under the objective prong of Farmer and (b)
that Dr. Phillip’s failure to provide insulin during the
appointment “resulted in some substantial harm” sufficient to
satisfy the objective prong. 3 J.A. 956. Second, the district
court concluded that Dr. Phillip had no obligation under the
Eighth Amendment to provide Plaintiff, “an angry and hostile
patient,” with the requested insulin. J.A. 956. Accordingly,
the district court held, Dr. Phillip satisfied his
constitutional burden by ordering staff to monitor Plaintiff’s
condition and provide supplemental insulin at mealtimes. We
disagree with both conclusions.
Regarding the absence of expert medical testimony,
plaintiffs alleging deliberate indifference must, “[a]t a
3
We emphasize that the correct standard to apply when
considering the objective prong of deliberate indifference
claims is whether there is an “extreme deprivation” and “a
serious or significant physical or emotional injury resulting
from the challenged conditions or . . . a substantial risk of
such serious harm resulting from . . . exposure to the
challenged conditions.” De’Lonta, 330 F.3d at 634. The
district court’s reference to a “substantial harm” requirement
does not change this analysis substantively, but does alter
unnecessarily the language set forth in Fourth Circuit
precedent. We caution that the “serious or significant” injury
or “substantial risk” standard, not the district court’s
“substantial harm” standard, should be used when instructing the
jury on the objective prong of the Farmer test.
16
minimum, . . . specifically describe not only the injury but
also its relation to the allegedly unconstitutional condition.”
Strickler v. Waters, 989 F.2d 1375, 1381 n.9 (4th Cir. 1993).
There is no requirement, however, that a plaintiff alleging
deliberate indifference present expert testimony to support his
allegations of serious injury or substantial risk of serious
injury. Rather, the Federal Rules of Evidence apply, and expert
testimony is necessary--indeed, permissible--only when it will
“help the trier of fact to understand the evidence or to
determine a fact in issue.” Fed. R. Evid. 702(a). When
laypersons are just “as capable of comprehending the primary
facts and of drawing correct conclusions from them” as are
experts, expert testimony may properly be excluded. Salem v.
U.S. Lines Co., 370 U.S. 31, 35 (1962). As a result, when the
seriousness of an injury or illness and the risk of leaving that
injury or illness untreated would be apparent to a layperson,
expert testimony is not necessary to establish a deliberate
indifference claim. See, e.g., Blackmore v. Kalamazoo Cty., 390
F.3d 890, 899–900 (6th Cir. 2004); Boring v. Kozakiewicz, 833
F.2d 468, 473 (3d Cir. 1987).
Recognizing that it is a “[w]ell-known” fact that diabetes
is a “common yet serious illness that can produce harmful
consequences if left untreated for even a short period of time,”
several of our Sister Circuits have denied defendants summary
17
judgment on Eighth Amendment claims alleging that prison
officials deprived diabetic inmates of insulin, even when those
claims were not supported by expert testimony. Lolli, 351 F.3d
at 419–20 (concluding, based on the plaintiff’s testimony, that
a diabetic person who is “unable to take insulin . . .
regularly” suffers a sufficiently serious risk of harm); Natale
v. Camden Cty. Corr. Facility, 318 F.3d 575, 582–83 (3d Cir.
2003) (holding, in the absence of expert testimony, that a
reasonable jury could conclude that prison officials who knew
the inmate was diabetic and needed insulin regularly were
deliberately indifferent in denying insulin for nonmedical
reasons). We agree: a jury is capable of understanding,
unaided, the risks of failing to provide insulin to a diabetic
and of a trained doctor’s denial of a diabetic’s known need for
insulin. Accordingly, we reject the district court’s contention
that Plaintiff was required to adduce expert testimony to
demonstrate an objectively serious deprivation giving rise to a
claim under the Eighth Amendment.
Regarding Dr. Phillip’s response to Plaintiff’s request for
insulin, we agree that--even when both Farmer prongs are
satisfied--a prison official who responds reasonably in the face
of a known, serious risk of harm to an inmate may be “free from
liability” under the Eighth Amendment even if harm is not
avoided. Farmer, 511 U.S. at 844. But even assuming arguendo
18
that it was reasonable for Dr. Phillip to decline to provide
Plaintiff insulin in the face of his “angry” demands and,
instead, to plan to monitor Plaintiff’s blood sugar and provide
supplemental insulin at mealtimes, Plaintiff nonetheless has
established a genuine dispute of fact as to whether Dr. Phillip
followed through with that plan. In particular, Plaintiff’s
June 22 and July 27, 2005, cop-outs raise a reasonable inference
that Dr. Phillip failed to provide supplemental insulin as
proposed by his alternative plan. Therefore, the district court
erred in concluding that there was no genuine dispute of fact as
to whether Dr. Phillip reasonably responded to Plaintiff’s
medical needs.
B.
1.
We now turn to Plaintiff’s second Eighth Amendment claim,
which arises out of Dr. Phillip’s and Administrator McClintock’s
alleged failure to provide aid to Plaintiff during a medical
emergency. On August 24, 2005, Plaintiff was locked in his
housing unit while prison officials conducted a “census count.” 4
During that time, the flow of water to Plaintiff’s unit was
discontinued because maintenance workers were repairing the
4
During a census count, inmates must remain in place while
prison officials conduct a count to ensure that all inmates are
in their assigned locations.
19
unit’s showers. While locked down and unable to access water,
Plaintiff began experiencing “extreme [stomach] pain . . . was
throwing up vomit and blood . . . [and] became incontinent.”
J.A. 846. In this state, Plaintiff used an emergency phone in
the unit to call for help by dialing a “deuces alarm” (2-2-2).
The parties dispute Plaintiff’s reason for using the
emergency phone. Plaintiff claims that he used the phone to
report his illness, saying “I’m sick. The water is off. I
can’t get anything to drink. I can’t wash up. I’ve got blood
all over me.” J.A. 848–49. By contrast, in a now-expunged
incident report arising from the phone use, prison officials
recorded that Plaintiff used the phone to complain about the
lack of water. According to prison officials, Plaintiff
complained that he “ha[d] to get a shower” before reporting to
his work shift that afternoon. J.A. 327. Plaintiff asserts
that the officials’ explanation is unfounded since prison
records show that he worked only the morning shift on the day in
question.
When prison officials responded to Plaintiff’s emergency
call, they offered no assistance even though Plaintiff points to
several “outward signs” of his need for medical attention,
including that his cell “reeked to high heaven” and that his
20
face was covered with partially wiped-up vomit and blood. 5 J.A.
867–68. Despite his distressed state, Plaintiff claims that Dr.
Phillip simply “looked at [Plaintiff] in disgust and turned his
head and started to walk away,” providing no medical aid. J.A.
858. According to Plaintiff’s evidence, Administrator
McClintock also failed to provide Plaintiff with treatment or
call for medical assistance, instead ordering prison guards to
“lock him up” in the Special Housing Unit. J.A. 858–59.
Thereafter, prison officials removed Plaintiff to the Special
Housing Unit, where he was confined for six months.
Plaintiff’s evidence indicates he did not receive medical
attention until at least two days after the August 24 incident,
with the only related entry in his medical record appearing on
August 29, 2005--five days after the purported emergency. In
court documents, Plaintiff attributes his emergency to acute
cholelithiasis (gallstones), signs of which were first
documented in his medical record on July 20, 2005, over one
month prior to the incident.
5
In recounting their version of events, prison officials
make no mention of Plaintiff’s physical appearance or medical
condition.
21
2.
Again, Plaintiff’s evidence establishes genuine disputes of
material fact as to both Farmer prongs. First, there is a
genuine dispute regarding whether Dr. Phillip’s and
Administrator McClintock’s failure to provide aid to Plaintiff
after he used the emergency phone constituted an “objectively,
sufficiently serious” deprivation. Viewing the facts in the
light most favorable to Plaintiff, as we must, Plaintiff was
suffering from a serious, visible medical need at the time Dr.
Phillip and Administrator McClintock responded to his emergency
call. In particular, Plaintiff was experiencing “extreme pain
in [his] stomach, . . . throwing up vomit and blood[, and]
became incontinent.” J.A. 846. This is the sort of serious
medical condition “so obvious that even a lay person would
easily recognize the necessity for a doctor’s attention.” Iko,
535 F.3d at 241 (internal quotation marks omitted) (quoting
Henderson v. Sheahan, 196 F.3d 839, 846 (7th Cir. 1999)).
Further, Plaintiff’s evidence creates a genuine dispute of
fact as to whether the denial of medical attention during this
emergency resulted in serious injury or a substantial risk of
serious injury. A juror could reasonably infer that failing to
treat, for two to five days, an inmate who is vomiting blood and
experiencing evident physical distress creates a substantial
risk that serious bodily injury will result or has already
22
occurred. This conclusion is supported by Plaintiff’s medical
records, which indicate that, at the time of the alleged
emergency, he may have been experiencing complications arising
from an earlier gallstone diagnosis.
Plaintiff also has raised a genuine issue of material fact
on the subjective prong of Farmer--whether Dr. Phillip and
Administrator McClintock acted with deliberate indifference in
failing to provide assistance in the face of Plaintiff’s alleged
medical emergency. In particular, there is sufficient
circumstantial evidence to suggest that Defendants were aware of
facts giving rise to an inference that their decision to send
Plaintiff to the Special Housing Unit without providing medical
aid created a substantial risk of serious injury.
Plaintiff’s testimony that his cell “reeked” and his face
exhibited visible signs of illness, as well as his
contemporaneous account of his symptoms create a genuine factual
dispute about whether his need for medical attention was so
obvious that an official observing the scene would have both
known of the facts giving rise to a risk of serious harm
resulting from failure to provide medical attention and inferred
that such a substantial risk was present. In addition, these
outward signs of Plaintiff’s need for medical attention and
Defendants’ contemporaneous failure to offer aid give rise to an
inference of deliberate indifference sufficient for Plaintiff’s
23
claim to survive summary judgment. See Miltier, 896 F.3d at 853
(“Failure to respond to an inmate’s known medical needs raises
an inference [of] deliberate indifference to those needs.”).
C.
1.
Plaintiff’s final Eighth Amendment claim is against Warden
Stansberry and alleges a denial of a proper diabetic diet during
his six-month confinement in the Special Housing Unit.
According to Plaintiff’s evidence, the only meals available to
Plaintiff in the Special Housing Unit were those served to every
other inmate in the unit--meals high in sugar and accompanied by
a sugary drink.
Plaintiff used several channels of communication to
complain to Warden Stansberry about the unavailability of a
diabetic diet. First, Plaintiff complained to the Warden during
her weekly rounds in the unit. Second, Plaintiff submitted cop-
outs to Warden Stansberry seeking redress for his complaints.
Third, Plaintiff wrote to his congressman, asking him to inquire
with prison officials about the deficiencies in his diet. After
the congressman forwarded this correspondence to the Bureau of
Prisons, Warden Stansberry addressed the allegations in a reply
letter. She acknowledged that inmates in the Special Housing
Unit did not receive special diets but maintained that inmates
24
were educated about how to select foods appropriate for their
medical conditions.
Because of the alleged deficiencies in the diet offered in
the Special Housing Unit, Plaintiff claims to have suffered an
increase in his blood sugar and A1C levels. Prison medical
officials sought to combat these symptoms by increasing his
insulin dosage. This treatment purportedly “resulted in the
loss of . . . diabetic control . . . and severe painful and
destructive episodes of diabetic hypoglycemia and . . .
hyperglycemia.” J.A. 626.
The district court assumed without deciding that Plaintiff
raised a genuine issue of material fact on Farmer’s objective
prong: that the lack of a diabetic diet constituted a
sufficiently serious deprivation. The court went on to
conclude, however, that there was no genuine dispute regarding
whether Warden Stansberry knew of and disregarded Plaintiff’s
need for a special diet. The court based its conclusion on
Plaintiff’s log of interactions with prison officials, which
revealed that Plaintiff was “mainly focused on pursuing a
collateral attack on his criminal conviction and on defending
against his disciplinary charge, rather than on informing
Stansberry of the conditions” he considered unconstitutional.
J.A. 964. The court went on to note that even if there were a
genuine dispute of material fact on this subjective prong,
25
Plaintiff’s acknowledgement that he otherwise received adequate
medical treatment for his diabetes while confined in the Special
Housing Unit rendered a finding of deliberate indifference
untenable.
2.
We affirm the district court’s award of summary judgment in
favor of Warden Stansberry on this claim, but for a different
reason. Viewing the record in the light most favorable to
Plaintiff, we conclude that Plaintiff failed to raise a genuine
dispute of material fact regarding whether, in this case, the
lack of a diabetic diet was a sufficiently serious deprivation
to be actionable under the Eighth Amendment. Warden Stansberry
conceded in her deposition and in her letter to Plaintiff’s
congressman that there was no diabetic diet provided to inmates
in the Special Housing Unit. Even so, Warden Stansberry stated
on at least two occasions that all inmates were educated about
how to select from the available meals foods appropriate for
their medical conditions.
In Farmer, the Supreme Court stated that the Eighth
Amendment imposes a duty on prison officials to provide inmates
with “adequate food.” Farmer, 511 U.S. at 832. Several of our
Sister Circuits have reasoned, albeit in unpublished decisions,
that this duty includes an obligation to provide a medically
appropriate diet when necessary. For instance, the Tenth
26
Circuit has stated that the Eighth Amendment “requires officials
to provide inmates with a special diet if such an accommodation
is medically necessary.” Frazier v. Dep’t of Corr., No. 97-
2086, 1997 WL 603773, at *1 (10th Cir. Oct. 1, 1997) (citing
Byrd v. Wilson, 701 F.2d 592, 595 (6th Cir. 1983)). Similarly,
the Seventh Circuit has noted that the Amendment “assures
prisoners a medically and nutritionally sound diet.” Jackson v.
Hanlon, Nos. 89-2144, 89-2368, 1991 WL 3056, at *1 (7th Cir.
Jan. 14, 1991). Likewise, the Sixth Circuit has concluded that
“officials must provide inmates with a special diet if such an
accommodation is obviously medically necessary.” Miller v.
Cleek, No. 99-5145, 1999 WL 1045156, at *2 (6th Cir. Nov. 9,
1999) (citing Byrd, 701 F.2d at 594–95). We agree.
Yet the Eighth Amendment’s requirement that prisoners
receive special diets when medically appropriate is not without
limit. Courts have consistently held that prison officials
comply with this mandate when they provide some food that the
complaining prisoner is able to eat without compromising his
health. For instance, in Frazier, the Tenth Circuit rejected a
prisoner’s deliberate indifference claim when he “d[id] not
contend that he [wa]s unable to eat any of the food provided by
the correctional facility” and conceded that he was “able to eat
certain items on the facility’s menu.” Frazier, 1997 WL 603773,
at *1. The same was true in Miller, where the Sixth Circuit
27
affirmed dismissal of an inmate’s inadequate diet claim based in
part on the lack of “evidence that [he] could not maintain his
health based on the diet provided and [the fact that he] d[id]
not contend that he was unable to eat any of the food provided
by the jail.” Miller, 1999 WL 1045156, at *2.
Likewise, courts have found that inmates who are denied
special diets suffer no constitutional harm so long as they are
instead given instruction on how to eat the available meals in a
way that satisfies their medical needs. For example, the Tenth
Circuit has found that an inmate who was served a universal,
cafeteria-style diet but could use “nutritional break down
cards” to determine what foods were amenable to his medical
condition could not claim deliberate indifference based on the
lack of a special diet. Moore v. Perrill, No. 94-1377, 1995 WL
139407, at *1 (10th Cir. Mar. 31, 1995); see also Williams v.
Hartz, 43 F. App’x 964, 966 (7th Cir. 2002) (affirming the
district court’s award of summary judgment when the complaining
prisoner was not given a special diet, but was “instructed” on
medically appropriate food choices and given “snacks” when
necessary to raise his blood sugar).
And a California district court held that a prisoner who
received the “Heart Healthy” diet provided to all inmates in the
state prison system and failed to present evidence that he could
not eat certain menu items or that the “overall percentage” of
28
such items in each meal was significant could not survive
summary judgment on his deliberate indifference claim. Baird v.
Alameida, 407 F. Supp. 2d 1134, 1140–41 (C.D. Cal. 2005).
We find these decisions persuasive. Only an “extreme
deprivation” is actionable under the Eighth Amendment.
According to Plaintiff, the meals in the Special Housing Unit
included “a bread, a meat product[,] a vegetable[,] and a sweet
dessert.” J.A. 279. Plaintiff has not offered evidence that
there was no combination of foods in each meal that would have
provided him with adequate sustenance without causing adverse
medical consequences, instead asserting only that the meals were
high in sugar and accompanied by a sugary drink. Plaintiff also
does not contradict prison officials’ claims that he was
educated on how to eat the available meals (which were from the
“national diet” “approved for all” inmates, J.A. 462, 539) in a
way that would not exacerbate his diabetic condition. 6
Accordingly, the district court properly awarded Warden
6
Because Plaintiff has not raised a genuine issue of
material fact as to whether there was a sufficiently serious
deprivation, we need not consider whether he has sufficiently
established the subjective, deliberate indifference prong. See
Celotex Corp. v. Catrett, 477 U.S. 317, 322–23 (1986) (requiring
the nonmovant to “make a sufficient showing on” every essential
element to survive summary judgment).
29
Stansberry summary judgment on Plaintiff’s diet and nutrition
claim. 7
IV.
Having determined that Plaintiff’s claims against Dr.
Phillip and Administrator McClintock should go forward, we must
address Defendants’ argument that they are entitled to qualified
immunity. Defendants raised qualified immunity before the
district court, but because the court ruled for Defendants on
the merits, it did not reach the question of Defendants’
entitlement to qualified immunity. Qualified immunity may
provide a basis for affirming the district court. R.R. ex rel.
R. v. Fairfax Cty. Sch. Bd., 338 F.3d 325, 332 (4th Cir. 2003)
(“[W]e may affirm the district court’s judgment on any ground
properly raised below.”) (citing Nw. Airlines, Inc. v. Cty. of
Kent, 510 U.S. 355, 364 (1994)).
Qualified immunity shields “government officials performing
discretionary functions . . . from liability for civil damages
7Though we affirm the district court’s award of summary
judgment on Plaintiff’s diet and nutrition claim, we reject the
district court’s reasoning that because Plaintiff received some
adequate treatment for his diabetes while in the Special Housing
Unit he cannot complain about other aspects of that treatment.
To the contrary, this court has held that “just because [prison
officials] have provided [an inmate] with some treatment . . .
it does not follow that they have necessarily provided h[im]
with constitutionally adequate treatment.” See De’lonta v.
Johnson, 708 F.3d 520, 526 (4th Cir. 2013).
30
insofar as their conduct does not violate clearly established
statutory or constitutional rights of which a reasonable person
would have known.” Harlow v. Fitzgerald, 457 U.S. 800, 818
(1982). In determining whether defendant government officials
are protected by qualified immunity, the court considers both
“whether a constitutional right [was] violated on the facts
alleged” and “whether the right was clearly established” at the
time of the conduct in question. Saucier v. Katz, 533 U.S. 194,
200 (2001), overruled in part by Pearson v. Callahan, 555 U.S.
223 (2009).
As explained previously, Plaintiff has alleged facts
sufficient for a reasonable jury to conclude that his
constitutional rights were violated when Dr. Phillip denied
Plaintiff his prescribed insulin and when Dr. Phillip and
Administrator McClintock failed to aid Plaintiff during a
medical emergency. See supra Parts III.A, B. Although a jury
may ultimately decide that Defendants’ version of events is more
credible, we are barred from making such a determination when
deciding whether to grant summary judgment based on qualified
immunity. See Meyers v. Balt. Cty., 713 F.3d 723, 733 (4th Cir.
2013).
To determine whether the right was clearly established, we
first must define the right at issue. Occupy Columbia v. Haley,
738 F.3d 107, 118 (4th Cir. 2013). Dr. Phillip maintains that
31
we should frame our analysis of qualified immunity as to
Plaintiff’s insulin claim as whether it is “clearly established
that a prison medical provider runs afoul of the Eighth
Amendment when he does not give one single dose of insulin to a
federal inmate, after the inmate becomes angry and hostile
. . ., and the doctor implements a plan to monitor the inmate
thereafter.” Appellees’ Br. at 44. Similarly, Dr. Phillip and
Administrator McClintock assert that we should consider their
qualified immunity as to Plaintiff’s medical emergency claim
based on whether a reasonable official would have known it
violated a clearly established constitutional right to follow
protocol by placing an inmate in administrative detention after
he receives an incident report.
But “[f]or a constitutional right to be clearly
established, its contours ‘must be sufficiently clear that a
reasonable official would understand that what he is doing
violates that right.’” Hope v. Pelzer, 536 U.S. 730, 739 (2002)
(quoting Anderson v. Creighton, 483 U.S. 635, 640 (1987)).
There is no requirement that the “very action in question [must
have] previously been held unlawful” for a reasonable official
to have notice that his conduct violated that right. Id.
Accordingly, we reject Dr. Phillip’s and Administrator
32
McClintock’s invitations to define the rights at issue in
accordance with the “very action[s] in question.” 8
Rather, we define the right in question as the right of
prisoners to receive adequate medical care and to be free from
officials’ deliberate indifference to their known medical needs.
This definition is consistent with previous deliberate
indifference cases from this Circuit. For example, in Iko v.
Shreve--a case in which a prisoner alleged government officials
failed to conduct a medical evaluation after pepper-spraying him
to compel compliance during a cell removal--this Court defined
the right at issue as “the right to adequate medical care.” 535
F.3d at 243 n.12. This definition also accords with Supreme
Court jurisprudence, which has long dictated that the Eighth
Amendment confers a duty upon prison officials to ensure that
prisoners “receive adequate . . . medical care.” Farmer, 511
U.S. at 832.
A prisoner’s right to adequate medical care and freedom
from deliberate indifference to medical needs has been clearly
established by the Supreme Court and this Circuit since at least
1976 and, thus, was clearly established at the time of the
8We reject Dr. Phillip’s and Administrator McClintock’s
framing of the right at issue in Plaintiff’s medical emergency
claim for the additional reason that it would require us to make
a credibility determination inappropriate at the summary
judgment stage of litigation.
33
events in question. See, e.g., Estelle, 429 U.S. at 104–05 (“We
therefore conclude that deliberate indifference to serious
medical needs of prisoners constitutes the ‘unnecessary and
wanton infliction of pain’ proscribed by the Eighth Amendment.”
(citation omitted) (quoting Gregg v. Georgia, 428 U.S. 153, 182–
83 (1976))); Farmer, 511 U.S. at 832 (“[P]rison officials must
ensure that inmates receive adequate food, clothing, shelter,
and medical care.”); Bowring v. Godwin, 551 F.2d 44, 47 (4th
Cir. 1977) (“This circuit has consistently adhered to the
prevailing view in requiring reasonable medical treatment [for
inmates].”) (citing authorities).
Because we conclude that there is sufficient evidence that
Plaintiff’s Eighth Amendment right to adequate medical care and
freedom from officials’ deliberate indifference to his medical
needs was violated and that the right was clearly established,
Dr. Phillip and Administrator McClintock are not entitled to
qualified immunity. 9
9
Although we need not reach the issue here, we note once
again the “special problem” of “‘applying an objective qualified
immunity standard in the context of an Eighth Amendment claim
that is satisfied only by a showing of deliberate indifference’-
-that is, a knowing violation of the law.” Cox v. Quinn, 828
F.3d 227, 238 n.4 (4th Cir. 2016) (quoting Rish v. Johnson, 131
F.3d 1092, 1098 n.6 (4th Cir. 1997)).
Some Circuits have resolved this problem by concluding that
qualified immunity is unavailable when the plaintiff presents a
genuine dispute of material fact regarding the defendant’s
(Continued)
34
V.
For the foregoing reasons, we affirm the district court’s
disposition of Plaintiff’s deliberate indifference claim against
Warden Stansberry, reverse its resolution of the claims against
Dr. Phillip and Administrator McClintock, and reject Dr.
Phillip’s and Administrator McClintock’s invocations of
qualified immunity.
AFFIRMED IN PART AND REVERSED IN PART
deliberate indifference. The Seventh Circuit, for example, has
held that the subjective prong of the Farmer test and the
objective, clearly established prong of the qualified immunity
test “effectively collapse into one” when the plaintiff raises
genuine factual disputes regarding the defendant’s deliberate
indifference. Walker v. Benjamin, 293 F.3d 1030, 1037 (7th Cir.
2002). That court explained that when a plaintiff raises
genuine disputes of fact on Farmer’s subjective prong, “a
defendant may not avoid trial on the grounds of qualified
immunity” even though qualified immunity protects covered
government officials from suit, not merely from liability. Id.;
see also, e.g., Beers-Capitol v. Whetzel, 256 F.3d 120, 142 n.15
(3d Cir. 2001) (“[T]o the extent that the plaintiffs have made a
showing sufficient to overcome summary judgment on the merits
[of their deliberate indifference claim], they have also made a
showing sufficient to overcome any claim to qualified
immunity.”). But see Estate of Ford v. Ramirez-Palmer, 301 F.3d
1043, 1049–50 (9th Cir. 2002) (rejecting the view that the
deliberate indifference and clearly established inquiries
merge).
35