Limitations to Qualified Immunity for Physicians

Facts of the Case

Mr. Brown was an inmate in the Wisconsin Department of Corrections with a history of self-injurious behavior. Around midday on August 21, 2019, Mr. Brown had an altercation with a prison official, and two prison supervisors were called to his cell. Mr. Brown informed the supervisors that he had removed the mirror from the cell wall, swallowed six pieces of metal, and “inserted a two-inch metal screw from the mirror into his flesh at the crook of his left elbow” (Brown, p 1209). Mr. Brown was subsequently placed into restraints. He was evaluated by a nurse, who determined that Mr. Brown required the attention of a physician. Mr. Brown told prison officials that he would not allow the prison doctor (Dr. LaVoie) to remove the screw but changed his mind after he was told that he would be kept in restraints until the screw was removed.

When Dr. LaVoie arrived, Mr. Brown asked him if he planned to use an anesthetic and Dr. LaVoie replied, “No.” Mr. Brown attempted to headbutt Dr. LaVoie, who backed away and said, “Well, maybe you deserve to be strapped down in the bed” (Brown, p 1209). Mr. Brown was then taken to another room where more extensive restraints were applied. Mr. Brown agreed to allow Dr. LaVoie another attempt to remove the screw and specifically requested anesthesia. Dr. LaVoie replied, “No. You stuck a screw in your arm, not me, and this is a consequence of your actions” (Brown, p 1209).

Dr. LaVoie attempted to remove the screw for almost five minutes while prison officials prevented Mr. Brown from raising his head to observe. Mr. Brown had “several dissociative experiences,” and a garbage can was required for “the bloody stuff.” A video of the encounter showed that Dr. LaVoie responded to Mr. Brown’s shouts with “dismissive comments, and a tone of annoyance, perhaps even sarcasm,” replying to Mr. Brown’s protests with such comments as “This is not something I did,” “Next time, don’t do that,” and “Your attitude is the one that needs to change” (Brown, p 1210). Mr. Brown again shouted for Dr. LaVoie to stop and stated, “I’m refusing!” Dr. LaVoie continued to work at Mr. Brown’s arms for several seconds before Mr. Brown again shouted his protests. Dr. LaVoie then stood up and said, “No. You know what? It can stay there. That’s fine,” and left the cell (Brown, p 1210). Mr. Brown was later transported to a local hospital where the screw was removed painlessly using local anesthetic.

Mr. Brown filed a 42 U.S.C. § 1983 lawsuit against Dr. LaVoie asserting that Dr. LaVoie had acted with deliberate indifference toward Mr. Brown’s serious medical condition. Dr. LaVoie moved for summary judgment, arguing that Mr. Brown could not succeed on the merits of his case. Dr. LaVoie also argued that, even if Mr. Brown could succeed on the merits, Dr. LaVoie was entitled to qualified immunity as a government employee. Dr. LaVoie submitted a short declaration supporting the motion but did not explain his chosen treatment approach, why he continued as Mr. Brown made his pain known, or what he meant when he made a statement implying that Mr. Brown deserved the pain.

The district court granted summary judgment in favor of Dr. LaVoie, basing their conclusion on a prior decision by the Seventh Circuit in Snipes v. DeTella, 95 F.3d 586 (7th Cir. 1996). In Snipes, the Seventh Circuit held that a prison doctor did not violate the Eight Amendment when removing a broken toenail without topical anesthesia. The district court acknowledged that removal of the screw was more invasive than the removal of a toenail but that, because it was not a “major surgery,” it did not “obviously” require anesthetic. The district court also concluded that Dr. LaVoie was entitled to qualified immunity. Mr. Brown appealed this decision to the U.S. Court of Appeals for the Seventh Circuit.

Ruling and Reasoning

The U.S. Court of Appeals for the Seventh Circuit found that fact problems remained regarding Dr. LaVoie’s motivation and therefore reversed and remanded for further proceedings.

In reviewing Mr. Brown’s claim, the court of appeals examined whether Dr. LaVoie displayed deliberate indifference to the serious medical needs of Mr. Brown. The court of appeals employed a two-step analysis, first examining whether Mr. Brown experienced a serious medical condition and then determining whether a reasonable trier of fact could conclude that Dr. LaVoie was deliberately indifferent to the condition. The first arm was uncontested; both parties agreed that Mr. Brown experienced a serious medical condition.

The court of appeals’s analysis hinged on whether the record contained evidence of a “culpable mental state” on Dr. LaVoie’s part, specifically whether Dr. LaVoie failed to act despite his knowledge of a substantial risk of serious harm. The analysis offered several possible interpretations of Dr. LaVoie’s actions that would support a finding of deliberate indifference, including that they were intended as punishment, retaliation, the result of “personal hostility” or “personal prejudices or animosity,” or to deter Mr. Brown from engaging in further acts of self-harm. The court of appeals declined to make a conclusory judgment on the basis that Dr. LaVoie’s state of mind remained a question for a jury, which could equally reject the above interpretations.

The court of appeals concluded that the district court erred in their interpretation that Snipes meant a prison doctor “need not apply” anesthetic when performing a “minor surgery.” The court determined that Snipes did not establish a rigid rule about the use of anesthesia or a line between “major” and “minor” surgery. The court wrote that the problem was not the nonapplication of anesthetic but whether Dr. LaVoie exercised any medical judgment whatsoever in his treatment of Mr. Brown.

The court then analyzed whether Dr. LaVoie was entitled to qualified immunity. Qualified immunity protects government officials from liability when their conduct “does not violate clearly established statutory or constitutional rights of which a reasonable person would have known,” (Brown, p 1214, citing Pearson v. Callahan, 555 U.S. 223 (2009), p 231). If Dr. LaVoie’s motivation was to punish Mr. Brown or to inflict or prolong pain, then he would no longer be entitled to qualified immunity, as these motivations constitute a violation of the Eighth Amendment. Therefore, if a jury were to determine that Dr. LaVoie was deliberately indifferent to Mr. Brown’s serious medical condition, he would no longer be entitled to qualified immunity.

Discussion

This case highlights two important concepts: first, the pronounced difficulties that incarcerated individuals face when attempting to prove deliberate indifference in a civil action and second, the limitations to qualified immunity for government officials, including physicians.

The descriptions of Dr. LaVoie’s behavior raise important concerns. The Seventh Circuit declined to conclude deliberate indifference, holding Dr. LaVoie’s state of mind, specifically whether he acted out of a desire to punish Mr. Brown or inflict pain upon him, “[remained] a question for the jury” (Brown, p 1213). Dr. LaVoie’s actions, combined with his comments, would lay fertile ground for civil and criminal sanctions in any noncarceral setting. And yet Mr. Brown’s claim remains unresolved because of the taxing deliberate indifference standard outlined in Estelle v. Gamble, 429 U.S. 97 (1976).

No less relevant are the limitations to qualified immunity enjoyed by government officials, including physicians. In determining that deliberate indifference toward serious medical needs constitutes a violation of the Eighth Amendment, the Seventh Circuit opens the door to civil claims against prison physicians. Nevertheless, the high bar of the deliberate indifference standard makes it unlikely that this holding will result in a dramatic increase in findings against prison physicians.