                                In the

     United States Court of Appeals
                   For the Seventh Circuit
                      ____________________ȱ
No.ȱ15Ȭ2562ȱ
CRAIGȱJ.ȱCESAL,ȱ
                                                   PlaintiffȬAppellant,ȱ

                                   v.ȱ

SCOTTȱMOATS,ȱ
                                                  DefendantȬAppellee.ȱ
                      ____________________ȱ

          AppealȱfromȱtheȱUnitedȱStatesȱDistrictȱCourtȱforȱtheȱ
                      CentralȱDistrictȱofȱIllinois.ȱ
            No.ȱ1:12ȬcvȬ01524ȬSLDȱ—ȱSaraȱDarrow,ȱJudge.ȱ
                      ____________________ȱ

   ARGUEDȱNOVEMBERȱ8,ȱ2016ȱ—ȱDECIDEDȱMARCHȱ20,ȱ2017ȱ
                      ____________________ȱ

   BeforeȱWOOD,ȱChiefȱJudge,ȱandȱPOSNERȱandȱROVNER,ȱCircuitȱ
Judges.ȱ
    WOOD,ȱChiefȱJudge.ȱWhileȱliftingȱaȱheavyȱdoorȱatȱhisȱprisonȱ
jobȱ atȱ theȱ Pekinȱ Correctionalȱ Institutionȱ onȱ Marchȱ 21,ȱ 2008,ȱ
CraigȱJ.ȱCesalȱheardȱaȱ“snap”ȱinȱhisȱbackȱandȱfeltȱpainȱinȱhisȱ
legȱandȱhip.ȱHeȱpromptlyȱsoughtȱtreatmentȱfromȱtheȱprison’sȱ
medicalȱstaě,ȱbutȱheȱwasȱdissatisęedȱwithȱtheirȱresponse.ȱHeȱ
allegesȱthatȱheȱreceivedȱonlyȱaȱthreeȬyearȱlongȱmedicalȱrunaȬ
2ȱ                                                     No.ȱ15Ȭ2562ȱ

roundȱduringȱwhichȱhisȱpainȱwasȱignored.ȱWorse,ȱheȱsays,ȱPeȬ
kin’sȱClinicalȱDirector,ȱDr.ȱScoĴȱMoats,ȱcanceledȱCesal’sȱinsuȬ
linȱprescriptionȱinȱretaliationȱforȱCesal’sȱęlingȱofȱaȱcomplaintȱ
aboutȱtheȱinadequateȱcareȱforȱhisȱback.ȱWithoutȱtheȱprescripȬ
tion,ȱ Cesal—anȱ insulinȬdependentȱ diabetic—wasȱ unableȱ toȱ
controlȱhisȱbloodȱsugarȱandȱconsequentlyȱsuěeredȱadditionalȱ
unnecessaryȱpainȱandȱphysicalȱharm.ȱHeȱęledȱaȱsecondȱcomȬ
plaintȱwithȱtheȱprisonȱaboutȱtheȱinsulinȱdeprivation.ȱ
     CesalȱultimatelyȱsuedȱDr.ȱMoatsȱandȱDr.ȱAndreasȱMolina,ȱ
anotherȱPekinȱphysician,ȱallegingȱthatȱtheyȱexhibitedȱdeliberȬ
ateȱ indiěerenceȱ inȱ theȱ careȱ theyȱ gaveȱ him.ȱAtȱ theȱ screeningȱ
phase,ȱseeȱ28ȱU.S.C.ȱ§ȱ1915A,ȱtheȱdistrictȱcourtȱidentięedȱtwoȱ
claimsȱinȱCesal’sȱproȱseȱcomplaint:ȱanȱEighthȱAmendmentȱdeȬ
liberateȬindiěerenceȱclaimȱregardingȱhisȱbackȱtreatment,ȱandȱ
aȱFirstȱAmendmentȱretaliationȱclaimȱrelatedȱtoȱtheȱwithholdȬ
ingȱofȱinsulin.ȱTheȱdistrictȱcourtȱgrantedȱsummaryȱjudgmentȱ
forȱtheȱdefendantsȱonȱbothȱissues,ȱreasoningȱthatȱtheȱstatuteȱ
ofȱ limitationsȱ onȱ hisȱ complaintsȱ hadȱ runȱ andȱ that,ȱ inȱ anyȱ
event,ȱthereȱwasȱnoȱquestionȱofȱmaterialȱfactȱthatȱwouldȱjusȬ
tifyȱallowingȱhisȱcaseȱtoȱmoveȱforward.ȱCesalȱappealsȱonlyȱtheȱ
judgmentȱinȱfavorȱofȱDr.ȱMoats,ȱandȱsoȱweȱlargelyȱdisregardȱ
Dr.ȱMolina’sȱroleȱinȱtheseȱevents.ȱAlthoughȱCesal’sȱallegationsȱ
areȱ troublesome,ȱ weȱ concludeȱ inȱ theȱ endȱ thatȱ theȱ districtȱ
court’sȱjudgmentȱmustȱbeȱaĜrmed.ȱȱ
                                 Iȱ
    BecauseȱthisȱisȱanȱappealȱfromȱtheȱgrantȱofȱsummaryȱjudgȬ
ment,ȱourȱreviewȱisȱdeȱnovo.ȱConleyȱv.ȱBirch,ȱ796ȱF.3dȱ742,ȱ746ȱ
(7thȱCir.ȱ2015).ȱAtȱthisȱstageȱofȱtheȱlitigation,ȱweȱassumeȱthatȱ
theȱfactsȱallegedȱbyȱCesalȱareȱtrue,ȱandȱweȱdrawȱallȱreasonableȱ
inferencesȱinȱhisȱfavor.ȱDixonȱv.ȱCnty.ȱofȱCook,ȱ819ȱF.3dȱ343,ȱ346ȱ
(7thȱCir.ȱ2015).ȱSummaryȱjudgmentȱisȱappropriateȱwhenȱthereȱ
No.ȱ15Ȭ2562ȱ                                                          3

areȱnoȱgenuineȱdisputesȱofȱmaterialȱfactȱandȱtheȱmovantȱisȱenȬ
titledȱtoȱjudgmentȱasȱaȱmaĴerȱofȱlaw.ȱFed.ȱR.ȱCiv.ȱP.ȱ56;ȱCelotexȱ
Corp.ȱv.ȱCatreĴ,ȱ477ȱU.S.ȱ317,ȱ322ȱ(1986).ȱ
    BetweenȱMarchȱ21,ȱ2006,ȱandȱMarchȱ28,ȱ 2011,ȱ Cesalȱ wasȱ
servingȱaȱlifeȱsentenceȱatȱtheȱPekinȱFederalȱCorrectionalȱInstiȬ
tution,ȱwhichȱisȱrunȱbyȱtheȱBureauȱofȱPrisonsȱ(BOP).ȱThere,ȱheȱ
workedȱ asȱ aȱ welder—aȱ physicallyȱ demandingȱ jobȱ thatȱ reȬ
quiredȱhimȱtoȱmoveȱ320Ȭpoundȱdoors.ȱHeȱwasȱliftingȱoneȱsuchȱ
doorȱonȱFriday,ȱMarchȱ21,ȱ2008,ȱwhenȱheȱheardȱaȱ“snap”ȱinȱ
hisȱbackȱandȱfeltȱsharpȱpainȱinȱhisȱleftȱhipȱandȱknee.ȱHeȱimȬ
mediatelyȱsoughtȱcareȱatȱtheȱmedicalȱunit,ȱbutȱwasȱtoldȱthatȱ
theȱ facilityȱ wasȱ closingȱ andȱ insteadȱ toȱ reportȱ toȱ sickȬcallȱ onȱ
Monday,ȱMarchȱ24.ȱHeȱdidȱso,ȱmeetingȱwithȱaȱnurseȱthatȱday.ȱ
Byȱthen,ȱCesalȱhadȱbeenȱgivenȱaȱwheelchairȱandȱwasȱtempoȬ
rarilyȱexcusedȱfromȱhisȱjob.ȱDr.ȱMoatsȱgaveȱhimȱaȱverbalȱorderȱ
forȱ Motrinȱ (theȱ activeȱ ingredientȱ ofȱ whichȱ isȱ ibuprofen)ȱ butȱ
wasȱnotȱotherwiseȱinvolvedȱinȱhisȱtreatmentȱthatȱday.ȱ
    CesalȱwasȱnextȱseenȱbyȱaȱphysicianȱassistantȱonȱMarchȱ27.ȱ
Cesalȱ reiteratedȱ hisȱ reportȱ ofȱ painȱ andȱ numbnessȱ inȱ hisȱ legȱ
andȱhip.ȱAlthoughȱheȱstillȱwasȱusingȱtheȱwheelchair,ȱtheȱphyȬ
sicianȱ assistantȱ notedȱ thatȱ Cesalȱ hadȱ “noȱ diĜcultiesȱ geĴingȱ
upȱtoȱsitȱonȱexamȱtable”ȱandȱthatȱCesalȱdisplayedȱnormalȱgaitȱ
andȱ posture.ȱ Duringȱ theȱ exam,ȱ theȱ physicianȱ assistantȱ reȬ
viewedȱxȬraysȱofȱCesal’sȱback.ȱTheseȱxȬraysȱhadȱbeenȱtakenȱonȱ
Marchȱ12,ȱ2008—beforeȱCesal’sȱliftingȱaccident—inȱresponseȱ
toȱhisȱearlierȱreportsȱofȱhipȱpainȱandȱnumbnessȱinȱhisȱkneeȱandȱ
thigh.ȱTheȱphysicianȱassistantȱprescribedȱCesalȱibuprofenȱforȱ
anotherȱtenȱdays.ȱ
   Dr.ȱ Molinaȱ sawȱ Cesalȱ atȱ aȱ followȬupȱ appointmentȱ onȱ
Marchȱ 31,ȱ whenȱ Cesalȱ reportedȱ havingȱ moderateȱ lowȬbackȱ
painȱ andȱ someȱ numbnessȱ inȱ hisȱ leg.ȱ Fourȱ daysȱ later,ȱ onȱ
4ȱ                                                     No.ȱ15Ȭ2562ȱ

Aprilȱ3,ȱ theȱ medicalȱ staěȱ tookȱ anȱ xȬrayȱ ofȱ Cesal’sȱ lumbarȱ
spine,ȱwhichȱisȱtheȱareaȱbetweenȱtheȱribȱcageȱandȱpelvis.ȱThatȱ
xȬrayȱ showedȱthatȱCesalȱhadȱ degenerativeȱ jointȱ diseaseȱ andȱ
discȱdisease,ȱaȱdiagnosisȱwhichȱpreviouslyȱhadȱshownȱupȱinȱaȱ
diěerentȱxȬray.ȱOtherwiseȱitȱrevealedȱnoȱproblems.ȱ
    TheȱveryȱnextȱdayȱCesalȱęledȱanȱinformalȱcomplaint—theȱ
ęrstȱstepȱinȱtheȱadministrativeȱgrievanceȱprocess—aboutȱtheȱ
treatmentȱ heȱ wasȱ receivingȱ forȱ hisȱ back.ȱ Inȱ thisȱ complaint,ȱ
Cesalȱreportedȱthatȱheȱhadȱ“acuteȱpainȱinȱmyȱhipȱandȱknee,ȱ
alsoȱnumbnessȱalongȱtheȱfrontȱofȱmyȱthigh”ȱandȱthatȱheȱcouldȱ
notȱ“standȱorȱwalkȱforȱaȱworthwhileȱduration.”ȱHeȱsaidȱthatȱ
heȱ“ha[d]ȱbeenȱtoȱMedicalȱDept.ȱrepeatedly,ȱbutȱexaminationȱ
orȱcareȱhaveȱbeenȱdenied.”ȱCesalȱaskedȱforȱaȱmedicalȱevaluaȬ
tionȱandȱappropriateȱtreatment.ȱ
    Hisȱ complaintȱ wasȱ rejected.ȱ Onȱ Mayȱ 6,ȱ 2008,ȱ Cesalȱ apȬ
pealedȱthisȱdenialȱtoȱtheȱWarden—theȱproperȱnextȱstepȱforȱanȱ
inmateȱwhoȱisȱunsatisęedȱbyȱtheȱresponseȱtoȱanȱinformalȱcomȬ
plaint.ȱCesalȱallegedȱthatȱheȱhadȱbeenȱevaluatedȱonlyȱsuperęȬ
ciallyȱandȱneverȱseenȱbyȱaȱdoctorȱforȱacuteȱpainȱinȱhisȱleftȱhipȱ
andȱ kneeȱ andȱ numbnessȱ inȱ hisȱ leftȱ thigh.ȱ Heȱ didȱ notȱ allegeȱ
backȱpain.ȱTheȱWardenȱrejectedȱCesal’sȱappealȱonȱJuneȱ9,ȱ2008,ȱ
notingȱthatȱCesal’sȱmedicalȱrecordsȱindicatedȱthatȱheȱwasȱreȬ
ceivingȱappropriateȱcare.ȱ
    TheȱWarden’sȱdenialȱalsoȱnotedȱthatȱmedicalȱoĜcialsȱwereȱ
awaitingȱtheȱresultsȱofȱaȱJuneȱ4,ȱ2008,ȱMRIȱofȱCesal’sȱlumbarȱ
spine.ȱThisȱscanȱhadȱbeenȱrequestedȱonȱAprilȱ15,ȱandȱwasȱapȬ
provedȱsometimeȱinȱtheȱinterim.ȱByȱJuneȱ16,ȱ2008,ȱtheȱresultsȱ
wereȱ in.ȱ Theȱ MRIȱ revealedȱ aȱ fewȱ problems—mildȱ stenosisȱ
(narrowingȱofȱtheȱspinalȱcanal)ȱinȱoneȱspot,ȱandȱdiscȱdegenerȬ
ationȱ withȱ mildȱ bulgingȱ elsewhereȱ withoutȱ majorȱ stenosis.ȱ
No.ȱ15Ȭ2562ȱ                                                        5

Butȱ thisȱ diagnosisȱdidȱnotȱassuageȱ Cesal’sȱ concerns.ȱ Heȱ apȬ
pealedȱtheȱdenialȱofȱhisȱgrievanceȱonȱJuneȱ25,ȱ2008,ȱmovingȱ
upȱanotherȱrungȱonȱBOP’sȱgrievanceȱladder.ȱ
     Twoȱ daysȱ afterȱ Cesalȱ ęledȱ thatȱ appeal,ȱ onȱ Juneȱ 27,ȱ Dr.ȱ
Moatsȱ sawȱ himȱ inȱ theȱ prison’sȱ chronicȱ careȱ clinicȱ forȱ whatȱ
Cesalȱdescribesȱasȱaȱ“nonȬroutineȱvisit.”ȱAsȱCesalȱtellsȱit,ȱDr.ȱ
MoatsȱhadȱlearnedȱofȱCesal’sȱgrievanceȱforȱtheȱ treatmentȱofȱ
hisȱ backȱ issueȱ andȱ wasȱ angry.ȱ Dr.ȱ Moatsȱ toldȱ Cesalȱ thatȱ heȱ
wouldȱ “showȱ him”ȱwhatȱ providingȱ noȱ medicalȱ careȱ lookedȱ
like,ȱandȱthenȱabruptlyȱterminatedȱCesal’sȱprescriptionȱforȱinȬ
sulinȱ forȱ noȱ medicalȱ reason.ȱ Cesalȱ isȱ anȱ insulinȬdependentȱ
Typeȱ IIȱ diabetic;ȱ heȱ hadȱ beenȱ takingȱ slidingȱ scaleȱ insulin.ȱ
Withoutȱ insulin,ȱ Cesalȱ wasȱ leftȱ toȱ manageȱ hisȱ bloodȱ sugarȱ
throughȱ diet,ȱ exercise,ȱ andȱ metformin,ȱ aȱ prescriptionȱ drugȱ
thatȱ Dr.ȱ Moatsȱ didȱ notȱ cancel,ȱ whichȱ isȱ commonlyȱ usedȱ forȱ
typeȱ IIȱ diabetesȱ toȱ controlȱ highȱ bloodȱ sugar.ȱ Metformin,ȱ
WEBMD,ȱ           hĴp://www.webmd.com/drugs/2/drugȬ11285Ȭ
7061/metforminȬoral/metforminȬȬȬoral/detailsȱ (lastȱ visitedȱ
Marchȱ20,ȱ2017).ȱ“Metforminȱworksȱbyȱhelpingȱtoȱrestoreȱyourȱ
body’sȱproperȱresponseȱtoȱtheȱinsulinȱyouȱnaturallyȱproduce.ȱ
Itȱ alsoȱdecreasesȱtheȱamountȱ ofȱ sugarȱ thatȱ yourȱ liverȱmakesȱ
andȱ thatȱ yourȱ stomach/intestinesȱ absorb.”ȱ Id.ȱ Cesalȱ skippedȱ
mealsȱ orȱ wentȱ forȱ runsȱ whenȱ hisȱ bloodȱ sugarȱ levelȱ gotȱ tooȱ
high.ȱButȱdespiteȱtheseȱeěorts,ȱCesal’sȱbloodȱsugarȱsoared.ȱAsȱ
aȱresult,ȱheȱfeltȱdizzyȱandȱsawȱstars,ȱandȱhisȱtoenailsȱfellȱoě.ȱ
    Cesal’sȱbackȱpainȱalsoȱcontinuedȱtoȱbotherȱhim.ȱDr.ȱMoatsȱ
requestedȱaȱconsultationȱforȱaȱ“backȱspecialist”ȱforȱCesalȱonȱ
Octoberȱ 6,ȱ 2008;ȱ hisȱ requestȱ wasȱ approvedȱ aboutȱ aȱ monthȱ
later.ȱ Inȱ theȱ meantime,ȱ Cesalȱ appealedȱ hisȱ backȬpainȱ grievȬ
anceȱinȱaccordanceȱwithȱBOPȱrules;ȱheȱexhaustedȱthisȱprocessȱ
onȱNovemberȱ25,ȱ2008,ȱwhenȱhisȱlastȱappealȱwasȱdenied.ȱHeȱ
6ȱ                                                     No.ȱ15Ȭ2562ȱ

ęnallyȱsawȱtheȱspecialistȱonȱMarchȱ31,ȱ2009,ȱsomeȱęveȱmonthsȱ
afterȱ theȱ visitȱ hadȱbeenȱ approved.ȱ Cesalȱtoldȱ theȱ consultingȱ
neurologistȱthatȱhisȱpainȱwasȱmoderate,ȱbutȱheȱalsoȱreportedȱ
thatȱheȱusuallyȱjoggedȱtwoȱorȱthreeȱmilesȱaȱday.ȱTheȱneuroloȬ
gistȱrecommendedȱnoȱmajorȱchangesȱtoȱCesal’sȱcurrentȱ“conȬ
servative”ȱ treatmentȱ planȱ andȱ indicatedȱ thatȱ heȱ didȱ notȱ beȬ
lieveȱthatȱsurgeryȱorȱsteroidȱinjectionsȱwouldȱhelp.ȱ
    OnȱDecemberȱ23,ȱ2008,ȱafterȱnearlyȱsixȱmonthsȱwithoutȱhisȱ
slidingȱ scaleȱ insulin,ȱ Cesalȱ ęledȱ aȱ secondȱ administrativeȱ
grievanceȱconcerningȱ hisȱdiabetesȱ treatment.ȱHeȱspecięcallyȱ
requestedȱ theȱ restorationȱ ofȱ hisȱ insulinȱ prescription.ȱAgain,ȱ
hisȱgrievanceȱandȱrelatedȱappealsȱwereȱdeniedȱatȱeachȱlevelȱofȱ
theȱBOPȱadministrativeȱprocess.ȱTheȱdenialȱdatedȱJanuaryȱ21,ȱ
2009,ȱ notedȱ thatȱ Pekin’sȱ clinicalȱ directorȱ (presumablyȱ Dr.ȱ
Moats)ȱhadȱdiscussedȱwithȱCesalȱaȱdiěerentȱdiabetesȱmanageȬ
mentȱprogramȱthatȱwasȱ“tailoredȱtoȱpreventȱhyperglycemia,ȱ
notȱtoȱtreatȱitȱafterȱitȱoccurs.”ȱAȱsubsequentȱdenialȱfromȱMarchȱ
6,ȱ2009,ȱnotedȱthatȱCesalȱstillȱhadȱoralȱmedicationȱforȱhisȱdiaȬ
betesȱ andȱ concludedȱ thatȱ “soundȱ clinicalȱ judgmentȱ isȱ beingȱ
demonstrated”ȱ inȱ Cesal’sȱ treatment.ȱ Cesalȱ exhaustedȱ theȱ
prisonȱgrievanceȱprocessȱforȱthisȱclaimȱonȱMayȱ26,ȱ2009,ȱwhenȱ
hisȱęnalȱappealȱwasȱdenied.ȱ
    Medicalȱ recordsȱ showȱ thatȱ Cesalȱ hadȱ severalȱ visitsȱ withȱ
Dr.ȱMoatsȱinȱ2009ȱandȱ2010,ȱbutȱDr.ȱMoatsȱdidȱnotȱreȬprescribeȱ
himȱ insulinȱ untilȱ Octoberȱ 29,ȱ 2010.ȱ Onȱ thatȱ date,ȱ Dr.ȱ Moatsȱ
prescribedȱCesalȱęveȱunitsȱofȱinsulin—halfȱtheȱdosageȱheȱhadȱ
beenȱreceivingȱinȱJuneȱ2008,ȱwhenȱhisȱprescriptionȱhadȱbeenȱ
cancelled.ȱ Inȱ theȱ monthsȱ followingȱ theȱ insulinȱ renewal,ȱ Dr.ȱ
MoatsȱsteppedȱupȱCesal’sȱdosageȱincrementally.ȱByȱFebruaryȱ
22,ȱ2011,ȱCesalȱwasȱbackȱonȱtheȱsameȱtenȬunitȱdosageȱheȱhadȱ
receivedȱinȱJuneȱ2008.ȱ
No.ȱ15Ȭ2562ȱ                                                                      7

    Onȱ Marchȱ 28,ȱ 2011,ȱ Cesalȱ wasȱ transferredȱ fromȱ Pekinȱ toȱ
theȱFederalȱCorrectionalȱInstitutionȱinȱGreenville,ȱIllinois.ȱHisȱ
backȱpainȱworsened,ȱandȱsoȱheȱsoughtȱtreatmentȱthere.ȱAnȱOcȬ
toberȱ9,ȱ2012ȱxȬrayȱofȱCesal’sȱmiddleȱbackȱrevealedȱanȱold,ȱparȬ
tialȱ fractureȱ ofȱ aȱ vertebra.ȱ Cesalȱ aĴributesȱ thisȱ injuryȱ toȱ hisȱ
Marchȱ 2008ȱ liftingȱ accident,ȱ althoughȱ hisȱ medicalȱ recordsȱ
showȱ thisȱ wasȱ justȱ hisȱ guess—noȱ medicalȱ professionalȱ everȱ
concludedȱasȱmuch.ȱ
    Cesalȱ ęledȱ aȱ suitȱ againstȱ Drs.ȱ Moatsȱ andȱ Molinaȱ onȱ DeȬ
cemberȱ 20,ȱ 2012,1ȱ invokingȱ theȱ doctrineȱ ofȱ Bivensȱ v.ȱ Sixȱ UnȬ
knownȱ Namedȱ Agents,ȱ 403ȱ U.S.ȱ 388ȱ (1971);ȱ heȱ amendedȱ hisȱ
complaintȱthreeȱmonthsȱlater.ȱ(Hisȱsuitȱincludedȱotherȱclaimsȱ
againstȱdiěerentȱPekinȱoĜcials;ȱbecauseȱtheyȱareȱnotȱrelevantȱ
toȱthisȱappeal,ȱweȱdoȱnotȱdiscussȱthem.)ȱHisȱamendedȱcomȬ
plaintȱ alleged,ȱ inȱ relevantȱ part,ȱ thatȱ Drs.ȱ Moatsȱ andȱ Molinaȱ
refusedȱ toȱ provideȱ careȱ forȱ hisȱ fracturedȱ vertebraȱ andȱ thatȱ
theyȱterminatedȱhisȱinsulinȱprescriptionȱafterȱheȱcomplainedȱ
aboutȱtheirȱlackȱofȱcareȱforȱhisȱback.ȱAtȱscreening,ȱseeȱ28ȱU.S.C.ȱ
§ȱ1915A,ȱtheȱdistrictȱcourtȱparedȱdownȱhisȱproȱseȱcomplaintȱtoȱ
twoȱcounts:ȱanȱEighthȱAmendmentȱclaimȱofȱdeliberateȱindifȬ
ferenceȱtoȱtheȱbackȱinjury,ȱandȱaȱFirstȱAmendmentȱretaliationȱ
claimȱforȱwithholdingȱtheȱinsulinȱprescription.ȱ
    TheȱdistrictȱcourtȱgrantedȱsummaryȱjudgmentȱforȱbothȱdeȬ
fendantsȱonȱMarchȱ24,ȱ2015,ȱreasoningȱthatȱCesalȱęledȱhisȱlawȬ
suitȱ afterȱ theȱ twoȬyearȱ statuteȱ ofȱ limitationsȱ hadȱ run—aȱ deȬ
fenseȱ thatȱ theȱ defendantsȱ promptlyȱ raisedȱ inȱ thatȱ court.ȱ Itȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
1ȱSomeȱofȱtheȱdocumentsȱshowȱtheȱfilingȱdateȱasȱDecemberȱ17,ȱ2012,ȱandȱ

othersȱindicateȱthatȱitȱwasȱDecemberȱ20,ȱ2012.ȱTheȱdifference,ȱweȱassume,ȱ
isȱattributableȱtoȱtheȱmailboxȱrule.ȱWeȱuseȱDecemberȱ20,ȱ2012,ȱbecauseȱitȱ
isȱ theȱ dateȱ thatȱappearsȱinȱ theȱ districtȱ court’sȱ docket,ȱ andȱ theȱ threeȬdayȱ
differenceȱisȱimmaterialȱforȱpresentȱpurposes.ȱȱ
8ȱ                                                        No.ȱ15Ȭ2562ȱ

addedȱthatȱevenȱifȱCesal’sȱlawsuitȱwasȱtimely,ȱsummaryȱjudgȬ
mentȱwasȱalsoȱappropriateȱbecauseȱCesal’sȱevidenceȱshowedȱ
thatȱatȱmostȱtheȱdefendantsȱwereȱnegligentȱinȱmisdiagnosingȱ
hisȱbackȱinjury,ȱandȱthereȱwasȱnoȱevidenceȱsupportingȱhisȱreȬ
taliationȱargument.ȱ
                                   IIȱ
    CesalȱappealsȱtheȱjudgmentȱinȱfavorȱofȱDr.ȱMoatsȱ(only)ȱonȱ
theȱtwoȱtheoriesȱtheȱdistrictȱcourtȱidentięed.ȱHeȱalsoȱassertsȱ
thatȱ theȱ court,ȱ onȱ screening,ȱ improperlyȱ failedȱ toȱ recognizeȱ
thatȱheȱhadȱallegedȱaȱdeliberateȬindiěerenceȱclaimȱregardingȱ
hisȱinsulinȱprescription.ȱ
                                   Aȱ
    Weȱ beginȱ withȱ Cesal’sȱ challengeȱ toȱ theȱ districtȱ court’sȱ
screeningȱofȱhisȱproȱseȱcomplaintȱbecauseȱthatȱaěectsȱtheȱscopeȱ
ofȱtheȱcaseȱthatȱisȱbeforeȱus.ȱCesalȱarguesȱthatȱtheȱdistrictȱcourtȱ
erredȱ inȱ theȱ initialȱ screeningȱ ofȱ hisȱ complaint,ȱ seeȱ 28ȱ U.S.C.ȱ
§ȱ1915A,ȱwhenȱitȱfailedȱtoȱrecognizeȱthatȱheȱpleadedȱanȱEighthȱ
AmendmentȱdeliberateȬindiěerenceȱclaimȱregardingȱhisȱinsuȬ
linȱcancellation,ȱinȱadditionȱtoȱtheȱretaliationȱclaim.ȱWeȱreviewȱ
aȱdismissalȱunderȱ§ȱ1915Aȱdeȱnovo,ȱusingȱtheȱstandardȱthatȱapȬ
pliesȱtoȱordinaryȱRuleȱ12(b)(6)ȱdismissals.ȱBookerȬElȱv.ȱSuperȬ
intendent,ȱInd.ȱStateȱPrison,ȱ668ȱF.3dȱ896,ȱ899ȱ(7thȱCir.ȱ2012).ȱWeȱ
construeȱ proȱ seȱ complaintsȱ liberally,ȱ holdingȱ themȱ toȱ aȱ lessȱ
stringentȱstandardȱthanȱpleadingsȱdraftedȱbyȱlawyers.ȱPerezȱv.ȱ
Fenoglio,ȱ792ȱF.3dȱ768,ȱ776ȱ(7thȱCir.ȱ2015).ȱ
     Cesal’sȱamendedȱcomplaintȱalleged,ȱinȱrelevantȱpart:ȱ
            Whenȱ Cesalȱ complained,ȱ throughȱ theȱ AdȬ
        ministrativeȱRemedyȱProcedure,ȱaboutȱtheȱlackȱ
        ofȱcare,ȱtheȱrequisiteȱpolicyȱmakersȱwouldȱneiȬ
No.ȱ15Ȭ2562ȱ                                                      9

       therȱ grantȱ norȱ denyȱ Cesal’sȱ requestȱ forȱ treatȬ
       ment.ȱ Angryȱ regardingȱ theȱ complaintȱ againstȱ
       them,ȱMoatsȱandȱMolinaȱterminatedȱCesal’sȱinȬ
       sulinȱprescriptionȱevenȱthoughȱCesalȱisȱanȱinsuȬ
       linȬdependentȱdiabetic.ȱ…ȱ
          Cesalȱcontinuesȱtoȱendureȱmiddleȱbackȱpain,ȱ
       painȱinȱhisȱhipȱarea,ȱandȱnumbnessȱinȱhisȱleftȱlegȱ
       fromȱtheȱspinalȱinjury.ȱHisȱfeetȱareȱswollenȱandȱ
       numb,ȱ hisȱ visionȱ blurred,ȱ andȱ heȱ experiencesȱ
       kidneyȱpainȱfromȱtheȱlackȱofȱadequateȱdiabetesȱ
       therapy.ȱ Moatsȱ andȱ Molinaȱ violatedȱ Cesal’sȱ
       EighthȱAmendmentȱrightȱtoȱbeȱfreeȱfromȱcruelȱ
       andȱ unusualȱ punishmentȱ whenȱ Defendantsȱ
       knewȱtheirȱactionsȱwouldȱbothȱinĚictȱpainȱandȱ
       causeȱ permanentȱ physicalȱ harm.ȱ Cesal’sȱ Firstȱ
       AmendmentȱrightsȱwereȱimpingedȱbyȱtheȱdelibȬ
       erateȱretaliationȱandȱlackȱofȱdueȱprocessȱregardȬ
       ingȱhisȱloss.ȱ
    PrisonȱoĜcialsȱviolateȱtheȱEighthȱAmendment’sȱprohibiȬ
tionȱ againstȱ cruelȱ andȱ unusualȱ punishmentȱ whenȱ theyȱ actȱ
withȱ deliberateȱ indiěerenceȱ toȱ theȱ seriousȱ medicalȱ needsȱ ofȱ
prisoners.ȱEstelleȱv.ȱGamble,ȱ429ȱU.S.ȱ97,ȱ104–05ȱ(1976).ȱToȱstateȱ
aȱclaimȱforȱdeliberateȱindiěerenceȱforȱdeęcientȱmedicalȱcare,ȱ
theȱplaintiěȱ“mustȱallegeȱanȱobjectivelyȱseriousȱmedicalȱconȬ
ditionȱandȱanȱ oĜcial’sȱdeliberateȱindiěerenceȱtoȱthatȱcondiȬ
tion.”ȱPerez,ȱ792ȱF.3dȱatȱ776.ȱ
    ObjectivelyȱseriousȱmedicalȱneedsȱareȱthoseȱthatȱhaveȱeiȬ
therȱbeenȱdiagnosedȱbyȱaȱphysicianȱandȱdemandȱtreatment,ȱ
orȱareȱ“soȱobviousȱthatȱevenȱaȱlayȱpersonȱwouldȱeasilyȱrecogȬ
nizeȱtheȱnecessityȱforȱaȱdoctor’sȱaĴention.”ȱKingȱv.ȱKramer,ȱ680ȱ
F.3dȱ 1013,ȱ 1018ȱ (7thȱ Cir.ȱ 2012).ȱ Forȱ presentȱ purposes,ȱ Dr.ȱ
10ȱ                                                        No.ȱ15Ȭ2562ȱ

MoatsȱconcedesȱthatȱCesal’sȱallegationsȱofȱkidneyȱpain,ȱvisionȱ
blurriness,ȱandȱnumbnessȱmeetȱthisȱstandard.ȱ
    Theȱ complaintȱ alsoȱ allegesȱ thatȱ Dr.ȱ Moatsȱ hadȱ aȱ suĜȬ
cientlyȱculpableȱstateȱofȱmind.ȱSeeȱFarmerȱv.ȱBrennan,ȱ511ȱU.S.ȱ
825,ȱ834,ȱ839–40ȱ(1994).ȱTheȱsubjectiveȱcomponentȱrequiresȱtheȱ
plaintiěȱtoȱallegeȱthatȱtheȱoĜcialȱactuallyȱknewȱof,ȱbutȱdisreȬ
garded,ȱaȱsubstantialȱriskȱtoȱtheȱinmate’sȱhealth.ȱId.ȱatȱ836–38;ȱ
Greenoȱv.ȱDaley,ȱ414ȱF.3dȱ645,ȱ653ȱ(7thȱCir.ȱ2005).ȱAȱfailureȱtoȱ
actȱinȱtheȱfaceȱofȱanȱobviousȱriskȱofȱwhichȱtheȱoĜcialȱshouldȱ
haveȱknownȱisȱinsuĜcientȱ toȱ makeȱoutȱaȱ claim.ȱFarmer,ȱ511ȱ
U.S.ȱatȱ836–38.ȱCesal’sȱallegationȱclearsȱthatȱbarȱbecauseȱheȱalȬ
legesȱ thatȱ Dr.ȱ Moatsȱ knewȱ thatȱ terminatingȱ Cesal’sȱ insulinȱ
wouldȱcauseȱhimȱpain,ȱbutȱthatȱheȱtookȱthatȱstepȱanyway.ȱ
    Dr.ȱMoatsȱarguesȱthatȱCesalȱhasȱfailedȱtoȱstateȱaȱclaimȱunȬ
derȱtheȱEighthȱAmendment,ȱbutȱthisȱargumentȱmisconstruesȱ
Cesal’sȱallegationȱasȱoneȱofȱsubjectiveȱinadequacy.ȱDr.ȱMoatsȱisȱ
correctȱthatȱtheȱEighthȱAmendmentȱdoesȱnotȱreachȱdisputesȱ
concerningȱtheȱexerciseȱofȱaȱprofessional’sȱmedicalȱjudgment,ȱ
suchȱasȱdisagreementȱoverȱwhetherȱoneȱcourseȱofȱtreatmentȱisȱ
preferableȱtoȱanother.ȱSnipesȱv.ȱDeTella,ȱ95ȱF.3dȱ586,ȱ591ȱ(7thȱ
Cir.ȱ 1996);ȱ seeȱ Estelle,ȱ 429ȱ U.S.ȱ atȱ 107.ȱ Butȱ Cesalȱ hasȱ allegedȱ
moreȱthanȱthis.ȱHisȱcomplaintȱaccusedȱDr.ȱMoatsȱofȱabusingȱ
hisȱ positionȱ asȱ Cesal’sȱ careȬproviderȱ byȱ adjustingȱ hisȱ treatȬ
mentȱplanȱwithȱtheȱknowledgeȱthatȱdoingȱsoȱwouldȱresultȱinȱ
unnecessaryȱpain.ȱThisȱallegation,ȱifȱtrue,ȱconstitutesȱdeliberȬ
ateȱindiěerenceȱforȱpurposesȱofȱtheȱEighthȱAmendment.ȱ
    HavingȱconcludedȱthatȱCesalȱproperlyȱallegedȱaȱdeliberȬ
ateȬindiěerenceȱ claimȱforȱtheȱinsulinȱwithholding,ȱweȱmoveȱ
toȱtheȱquestionȱwhetherȱDr.ȱMoatsȱwasȱentitledȱtoȱsummaryȱ
judgmentȱonȱallȱthreeȱtheories.ȱ
No.ȱ15Ȭ2562ȱ                                                      11

                                 Bȱ
   Weȱ beginȱ withȱ Cesal’sȱ backȱ pain.ȱ Theȱ districtȱ courtȱ
grantedȱsummaryȱjudgmentȱforȱDr.ȱMoatsȱonȱthisȱpartȱofȱtheȱ
caseȱforȱtwoȱreasons:ȱęrst,ȱbecauseȱtheȱstatuteȱofȱlimitationsȱ
hadȱrun;ȱandȱsecond,ȱbecauseȱCesalȱfailedȱtoȱpresentȱfactsȱthatȱ
wouldȱhaveȱpermiĴedȱaȱjuryȱtoȱęndȱinȱhisȱfavor.ȱWeȱmayȱafȬ
ęrmȱbasedȱonȱanyȱproperlyȱpreservedȱground.ȱHesterȱv.ȱInd.ȱ
StateȱDep’tȱofȱHealth,ȱ726ȱF.3dȱ942,ȱ946ȱ(7thȱCir.ȱ2013).ȱ
                                  1ȱ
    Weȱbeginȱwithȱtheȱstatuteȱofȱlimitations.ȱCesalȱarguesȱthatȱ
theȱdistrictȱcourtȱmiscalculatedȱtheȱdateȱbyȱwhichȱheȱneededȱ
toȱęleȱhisȱBivensȱactionȱagainstȱDr.ȱMoatsȱbecauseȱitȱfailedȱtoȱ
appreciateȱtheȱongoingȱnatureȱofȱhisȱinjury.ȱHeȱisȱcorrect.ȱ
    TheȱstatuteȱofȱlimitationsȱforȱBivensȱclaimsȱagainstȱfederalȱ
oĜcersȱisȱtheȱsameȱasȱforȱ§ȱ1983ȱactionsȱagainstȱstateȱoĜcers:ȱ
bothȱperiodsȱareȱborrowedȱfromȱtheȱstateȱinȱwhichȱtheȱallegedȱ
injuryȱ occurred.ȱ Kingȱ v.ȱ Oneȱ Unknownȱ Fed.ȱ Corr.ȱ OĜcer,ȱ 201ȱ
F.3dȱ910,ȱ913ȱ(7thȱCir.ȱ2000).ȱInȱthisȱcase,ȱCesal’sȱinjuryȱtookȱ
placeȱinȱIllinois,ȱwhichȱhasȱaȱtwoȬyearȱstatuteȱofȱlimitations.ȱ
735ȱILCSȱ5/13Ȭ202.ȱAlthoughȱCesalȱinjuredȱhisȱbackȱonȱMarchȱ
21,ȱ2008,ȱheȱcouldȱnotȱbringȱsuitȱuntilȱheȱexhaustedȱtheȱprisonȱ
grievanceȱ process.ȱ 42ȱ U.S.C.ȱ §ȱ1997e(a);ȱ seeȱ alsoȱ Porterȱ v.ȱ
Nussle,ȱ534ȱU.S.ȱ516,ȱ524ȱ(2002)ȱ(notingȱthatȱfederalȱprisonersȱ
suingȱ underȱ Bivens,ȱ likeȱ stateȱ prisonersȱ suingȱ underȱ §ȱ 1983,ȱ
mustȱ exhaustȱ inmateȱ grievanceȱ proceduresȱ beforeȱ theyȱ canȱ
ęleȱtheirȱsuit).ȱTheȱdistrictȱcourtȱconcludedȱthatȱtheȱlimitationsȱ
periodȱ wasȱ tolledȱ whileȱ Cesalȱ pursuedȱ theȱ grievance.ȱ Seeȱ
Walkerȱv.ȱSheahan,ȱ526ȱF.3dȱ973,ȱ978ȱ(7thȱCir.ȱ2008)ȱ(limitationsȱ
periodȱ forȱ aȱ §ȱ1983ȱ actionȱ isȱ tolledȱ whileȱ theȱ prisonerȱ comȬ
pletesȱtheȱadministrativeȱgrievanceȱprocess).ȱAndȱso,ȱbyȱtheȱ
12ȱ                                                       No.ȱ15Ȭ2562ȱ

districtȱcourt’sȱcalculation,ȱCesalȱneededȱtoȱęleȱhisȱclaimȱbyȱ
Novemberȱ25,ȱ2010,ȱtwoȱyearsȱafterȱhisȱbackȱgrievanceȱwasȱęȬ
nallyȱdenied.ȱ
    Butȱthisȱcalculationȱdoesȱnotȱtakeȱintoȱaccountȱtheȱongoingȱ
natureȱofȱCesal’sȱinjury.ȱWhenȱaȱplaintiěȱallegesȱthatȱinactionȱ
isȱleadingȱtoȱanȱongoingȱharm,ȱheȱcanȱ“reachȱbackȱtoȱitsȱbeȬ
ginningȱevenȱifȱthatȱbeginningȱliesȱoutsideȱtheȱstatutoryȱlimiȬ
tationsȱperiod,ȱwhenȱitȱwouldȱbeȱunreasonableȱtoȱrequireȱorȱ
evenȱpermitȱhimȱtoȱsueȱseparatelyȱoverȱeveryȱincidentȱofȱtheȱ
defendant’sȱ unlawfulȱ conduct.”ȱ Heardȱ v.ȱ Sheahan,ȱ 253ȱ F.3dȱ
316,ȱ319ȱ(7thȱCir.ȱ2001).ȱInȱtheseȱcases,ȱ“itȱwouldȱbeȱunreasonȬ
ableȱtoȱrequireȱorȱevenȱpermitȱ[theȱprisoner]ȱtoȱsueȱseparatelyȱ
overȱeveryȱincidentȱofȱtheȱdefendant’sȱunlawfulȱconduct.”ȱId.ȱ
Theȱstatuteȱofȱlimitationsȱthusȱ“startsȱtoȱrunȱ(thatȱis,ȱtheȱcauseȱ
ofȱactionȱaccrues)ȱfromȱtheȱdateȱofȱtheȱlastȱincidenceȱofȱthatȱ
violation,ȱ notȱ theȱ ęrst.”ȱ Turleyȱ v.ȱ Rednour,ȱ 729ȱ F.3dȱ 645,ȱ 651ȱ
(7thȱCir.ȱ2013);ȱseeȱalsoȱid.ȱatȱ654ȱ(Easterbrook,ȱJ.,ȱconcurring).ȱ
    CesalȱwasȱnotȱrequiredȱtoȱsueȱuntilȱafterȱtheȱunlawfulȱconȬ
ductȱended.ȱButȱCesalȱsaysȱitȱneverȱendedȱwhileȱheȱwasȱatȱPeȬ
kin;ȱheȱallegesȱthatȱDr.ȱMoats’sȱdeliberateȱindiěerenceȱendedȱ
onlyȱonȱMarchȱ28,ȱ2011,ȱwhenȱCesalȱwasȱtransferredȱtoȱGreenȬ
villeȱandȱthusȱoutȱofȱDr.ȱMoats’sȱcare.ȱWeȱconcludeȱthatȱsumȬ
maryȱjudgmentȱonȱstatuteȱofȱlimitationsȱgroundsȱforȱCesal’sȱ
backȱclaimȱwasȱnotȱappropriate.ȱ
                                   2ȱ
    NextȱisȱtheȱquestionȱwhetherȱCesalȱpresentedȱenoughȱtoȱ
raiseȱaȱgenuineȱissueȱofȱmaterialȱfact,ȱagainȱwithȱrespectȱtoȱhisȱ
backȱinjury.ȱCesalȱcontendsȱthatȱaȱreasonableȱjuryȱcouldȱęndȱ
thatȱDr.ȱMoatsȱwasȱdeliberatelyȱindiěerentȱtoȱhisȱbackȱinjuryȱ
fromȱtheȱfactsȱheȱwasȱableȱtoȱcollect.ȱAȱprisonȱoĜcialȱactsȱwithȱ
No.ȱ15Ȭ2562ȱ                                                     13

deliberateȱindiěerenceȱwhenȱheȱknowsȱofȱandȱdisregardsȱanȱ
excessiveȱriskȱtoȱinmateȱhealthȱorȱsafety.ȱFarmer,ȱ511ȱU.S.ȱatȱ
837.ȱTheȱplaintiěȱmustȱshowȱthatȱtheȱdefendantȱactedȱorȱfailedȱ
toȱactȱinȱaȱwayȱthatȱdisregardedȱanȱexcessiveȱriskȱofȱharmȱtoȱ
theȱinmate;ȱheȱdoesȱnotȱneedȱtoȱshowȱthatȱtheȱdefendantȱinȬ
tendedȱorȱdesiredȱtoȱcauseȱharm.ȱWalkerȱv.ȱBenjamin,ȱ293ȱF.3dȱ
1030,ȱ1037ȱ(7thȱCir.ȱ2002).ȱIntentionalȱdelaysȱinȱmedicalȱcareȱ
mayȱ constituteȱ deliberateȱ indiěerence,ȱ evenȱ ifȱ theȱ inmate’sȱ
medicalȱ conditionȱ isȱ nonȬlifeȱ threatening.ȱ ArneĴȱ v.ȱ Webster,ȱ
658ȱF.3dȱ742,ȱ753ȱ(7thȱCir.ȱ2011).ȱAȱdoctor’sȱchoiceȱofȱ“easierȱ
andȱlessȱeĜcaciousȱtreatment”ȱforȱanȱobjectivelyȱseriousȱmedȬ
icalȱconditionȱalsoȱmayȱbeȱsuĜcient.ȱEstelle,ȱ429ȱU.S.ȱatȱ104ȱ&ȱ
n.ȱ10.ȱButȱ“mereȱdisagreementȱwithȱaȱdoctor’sȱmedicalȱjudgȬ
ment”ȱisȱnotȱenoughȱtoȱsupportȱanȱEighthȱAmendmentȱviolaȬ
tion.ȱBerryȱv.ȱPeterman,ȱ604ȱF.3dȱ435,ȱ441ȱ(7thȱCir.ȱ2010).ȱ
    Ourȱreviewȱofȱtheȱundisputedȱfactsȱinȱtheȱrecordȱconvincesȱ
usȱthatȱnoȱreasonableȱtrierȱofȱfactȱcouldȱęndȱthatȱDr.ȱ Moatsȱ
wasȱdeliberatelyȱindiěerentȱtoȱCesal’sȱbackȱpain.ȱAlthoughȱnoȱ
doctorȱ examinedȱ Cesalȱ onȱ theȱ afternoonȱ ofȱ theȱ accident,ȱ heȱ
wasȱexcusedȱfromȱhisȱjobȱandȱwasȱgivenȱaȱwheelchairȱafterȱheȱ
reportedȱthatȱhisȱpainȱwasȱgeĴingȱworse.ȱCesalȱsawȱaȱnurseȱ
onȱMonday,ȱMarchȱ24,ȱandȱheȱthenȱsawȱaȱphysicianȱassistantȱ
onȱ Marchȱ 27.ȱ Heȱ alsoȱ receivedȱ medicationȱ forȱ hisȱ pain.ȱ Inȱ
otherȱwords,ȱheȱwasȱunderȱactiveȱtreatment;ȱnoȱoneȱwasȱigȬ
noringȱhim.ȱSeeȱPerez,ȱ792ȱF.3dȱatȱ777ȱ(“PrisonȱoĜcialsȱmustȱ
provideȱinmatesȱwithȱmedicalȱcareȱthatȱisȱadequateȱinȱlightȱofȱ
theȱseverityȱofȱtheȱconditionȱandȱprofessionalȱnorms.”).ȱ
   Importantly,ȱthereȱisȱnoȱindicationȱthatȱDr.ȱMoatsȱwasȱperȬ
sonallyȱ involvedȱ inȱ Cesal’sȱ earlyȱ care.ȱ Dr.ȱ Moatsȱ couldȱ notȱ
haveȱactedȱwithȱtheȱsubjectiveȱintentȱthatȱaȱdeliberateȱindiěerȬ
enceȱclaimȱrequiresȱifȱheȱwasȱnotȱawareȱofȱaȱriskȱofȱaȱharmȱtoȱ
14ȱ                                                    No.ȱ15Ȭ2562ȱ

Cesal.ȱSeeȱFarmer,ȱ511ȱU.S.ȱatȱ838–39.ȱWhileȱCesalȱallegesȱthatȱ
Dr.ȱMoatsȱrefusedȱtoȱseeȱhimȱinȱtheȱdaysȱimmediatelyȱfollowȬ
ingȱ hisȱ Marchȱ 21,ȱ 2008ȱ accident,ȱ noȱ evidenceȱ substantiatesȱ
thatȱallegation,ȱnorȱisȱthereȱanyȱreasonȱinȱthisȱrecordȱtoȱthinkȱ
thatȱstartingȱwithȱtheȱphysicianȱassistantȱandȱnurseȱwasȱnotȱaȱ
reasonableȱ step.ȱ Cesalȱ acknowledgesȱ thatȱ Dr.ȱ Moatsȱ neverȱ
treatedȱ himȱ beforeȱ Juneȱ 27,ȱ 2008,ȱ theȱ dayȱ theȱ doctorȱ termiȬ
natedȱCesal’sȱinsulinȱprescription.ȱInȱanyȱevent,ȱaȱprisonȱoĜȬ
cial’sȱrefusalȱtoȱindulgeȱanȱinmate’sȱrequestȱtoȱseeȱaȱspecięcȱ
staěȱmember,ȱwhenȱtheȱprisonerȱisȱreceivingȱcareȱfromȱotherȱ
membersȱofȱtheȱmedicalȱstaě,ȱisȱnotȱdeliberateȱindiěerence.ȱ
    Cesalȱcontinuedȱtoȱreceiveȱappropriateȱcareȱinȱtheȱmonthsȱ
thatȱfollowedȱhisȱaccident.ȱThisȱcareȱincludedȱanȱxȬrayȱofȱhisȱ
back,ȱtakenȱ justȱ twoȱweeksȱafterȱhisȱ liftingȱaccident,ȱ andȱ anȱ
MRIȱofȱhisȱlumbarȱspineȱonȱJuneȱ16,ȱ2008.ȱDr.ȱMoatsȱalsoȱsucȬ
cessfullyȱ arrangedȱ forȱ anȱ outsideȱ consult.ȱ Cesalȱ writesȱ oěȱ
theseȱmeasuresȱbecauseȱtheyȱdidȱnotȱtargetȱhisȱmiddleȱback,ȱ
whereȱhisȱfracturedȱvertebraȱwasȱlocated,ȱbutȱheȱignoresȱtheȱ
factȱthatȱheȱfailedȱforȱmanyȱmonthsȱtoȱidentifyȱhisȱmiddleȱbackȱ
asȱtheȱsourceȱofȱhisȱpain.ȱInitiallyȱCesalȱcomplainedȱonlyȱofȱ
painȱinȱhisȱleftȱhip,ȱknee,ȱandȱthigh.ȱHisȱinitialȱprisonȱgrievȬ
anceȱsaidȱnothingȱaboutȱbackȱpain.ȱCesalȱalsoȱdeniedȱhavingȱ
anyȱbackȱpainȱinȱaȱSeptemberȱ17,ȱ2008ȱappealȱofȱhisȱgrievanceȱ
inȱ whichȱ heȱ questionedȱ theȱ reasonȱ forȱ theȱ MRI.ȱAsȱ heȱ conȬ
cedesȱinȱhisȱbriefȱtoȱthisȱcourt,ȱDr.ȱMoatsȱmayȱnotȱhaveȱbeenȱ
awareȱofȱanyȱmiddleȱbackȱpainȱuntilȱNovemberȱ29,ȱ2009,ȱtheȱ
dateȱonȱwhichȱDr.ȱMoats’sȱexamȱnotesȱreĚectȱthatȱCesalȱhadȱ
reportedȱmiddleȱbackȱpain.ȱAlthoughȱCesal’sȱlegȱandȱhipȱpainȱ
mayȱhaveȱstemmedȱfromȱaȱspinalȱinjury,ȱCesal’sȱinabilityȱtoȱ
provideȱanyȱrelevantȱdetailsȱprecludesȱaȱfactęnderȱfromȱconȬ
cludingȱthatȱDr.ȱMoatsȱwasȱdeliberatelyȱindiěerent.ȱDr.ȱMoatsȱ
No.ȱ15Ȭ2562ȱ                                                      15

couldȱnotȱhaveȱdisregardedȱCesal’sȱmiddleȱbackȱinjuryȱifȱheȱ
wasȱnotȱawareȱofȱit.ȱ
    Toȱ beȱ sure,ȱ theȱ renderingȱ ofȱ someȱ medicalȱ careȱ doesȱ notȱ
necessarilyȱ disproveȱ deliberateȱ indiěerence;ȱ theȱ treatmentȱ
renderedȱmayȱbeȱsoȱblatantlyȱ inappropriateȱ thatȱ itȱcanȱsupȬ
portȱ anȱ inferenceȱ ofȱ intentionalȱ mistreatment.ȱ Seeȱ PeĴiesȱ v.ȱ
Carter,ȱ836ȱF.3dȱ722,ȱ731ȱ(7thȱCir.ȱ2016)ȱ(enȱbanc);ȱEdwardsȱv.ȱ
Snyder,ȱ478ȱF.3dȱ827,ȱ831ȱ(7thȱCir.ȱ2007).ȱContinuingȱanȱinefȬ
fectiveȱtreatmentȱplanȱalsoȱmayȱevidenceȱdeliberateȱindiěerȬ
ence.ȱSeeȱBerry,ȱ604ȱF.3dȱatȱ441–42.ȱButȱnoȱtrierȱofȱfactȱcouldȱ
ęndȱthatȱDr.ȱMoats’sȱtreatmentȱofȱCesalȱwasȱblatantlyȱinapȬ
propriate.ȱTheȱconsultingȱneurologistȱrecommendedȱthatȱtheȱ
PekinȱstaěȱcontinueȱCesal’sȱ“conservative”ȱtreatment;ȱheȱbeȬ
lievedȱthatȱmoreȱextremeȱmeasures,ȱsuchȱasȱsteroidsȱorȱsurȬ
gery,ȱwouldȱbeȱineěective.ȱCesalȱalsoȱtoldȱtheȱconsultingȱphyȬ
sicianȱthatȱheȱwasȱjoggingȱtwoȱorȱthreeȱmilesȱaȱday,ȱdespiteȱ
hisȱreportȱofȱmoderateȱpain.ȱThatȱisȱaȱmarkedȱimprovementȱ
fromȱtheȱdaysȱafterȱCesal’sȱaccident,ȱwhenȱheȱneededȱaȱwheelȬ
chair.ȱ
    TheȱfactȱthatȱDr.ȱMoatsȱ“neverȱdiagnosedȱMr.ȱCesal’sȱbroȬ
kenȱspine,”ȱasȱCesalȱargues,ȱdoesȱnotȱpushȱthisȱoverȱtheȱline.ȱ
DeliberateȱindiěerenceȱrequiresȱmoreȱthanȱevidenceȱofȱnegliȬ
genceȱ orȱ medicalȱ malpractice.ȱ Seeȱ Estelle,ȱ 429ȱ U.S.ȱ atȱ 106;ȱ
McGeeȱv.ȱAdams,ȱ721ȱF.3dȱ474,ȱ481ȱ(7thȱCir.ȱ2013).ȱCesal’sȱdisȬ
satisfactionȱwithȱDr.ȱMoats’sȱmedicalȱjudgmentȱandȱcareȱisȱinȬ
suĜcientȱtoȱsurviveȱsummaryȱjudgment.ȱSeeȱWhitingȱv.ȱWexȬ
fordȱHealthȱSources,ȱInc.,ȱ839ȱF.3dȱ658,ȱ662–63ȱ(7thȱCir.ȱ2016).ȱ
                                 Cȱ
  Thatȱ bringsȱ usȱ toȱ Dr.ȱ Moats’sȱ withholdingȱ ofȱ insulin,ȱ
whichȱformsȱtheȱbasisȱforȱbothȱCesal’sȱretaliationȱtheoryȱandȱ
16ȱ                                                        No.ȱ15Ȭ2562ȱ

hisȱdeliberateȱindiěerenceȱtheory.ȱWithȱrespectȱtoȱtheȱformer,ȱ
theȱdistrictȱcourtȱassumedȱthatȱtheȱwithholdingȱofȱinsulinȱdeȬ
scribedȱaȱviolationȱthatȱexistedȱasȱlongȱasȱtheȱmedicationȱwasȱ
withheld.ȱ (Thisȱ wasȱ notȱ aȱ singleȱ injuryȱ thatȱ accruedȱ whenȱ
Cesalȱęrstȱlostȱhisȱinsulin;ȱeachȱnewȱdayȱbroughtȱwithȱitȱnewȱ
injury,ȱ andȱ aȱ newȱ violation.)ȱ Accordingly,ȱ theȱ courtȱ conȬ
cludedȱthatȱtheȱlimitationsȱperiodȱbeganȱtoȱrunȱonȱOctoberȱ29,ȱ
2010,ȱ theȱ dayȱ whenȱ Dr.ȱ Moatsȱ restoredȱ theȱ prescription,ȱ
thoughȱatȱtheȱreduced,ȱęveȬunit,ȱlevel.ȱCesalȱęledȱhisȱsuitȱonȱ
Decemberȱ20,ȱ2012,ȱwellȱmoreȱthanȱtwoȱyearsȱafterȱthatȱdate,ȱ
andȱthisȱwasȱtooȱlateȱinȱtheȱcourt’sȱview.ȱIfȱOctoberȱ29,ȱ2010,ȱ
isȱtheȱcorrectȱstartingȱpoint,ȱCesalȱcannotȱprevail.ȱDr.ȱMoatsȱ
didȱ notȱ waiveȱ hisȱ rightȱ toȱ relyȱ onȱ theȱ statuteȱ ofȱ limitations,ȱ
andȱweȱareȱawareȱofȱnoȱruleȱofȱlawȱthatȱwouldȱentitleȱusȱtoȱ
stripȱhimȱofȱthatȱdefenseȱonȱourȱown.ȱCesalȱhasȱnotȱarguedȱ
otherwise,ȱeitherȱinȱtheȱdistrictȱcourtȱorȱinȱthisȱcourt.ȱInstead,ȱ
heȱcontendsȱthatȱhisȱinsulinȱproblemȱwasȱnotȱsolvedȱuntilȱFebȬ
ruaryȱ22,ȱ2011,ȱwhenȱDr.ȱMoatsȱęnallyȱrestoredȱCesal’sȱinsulinȱ
prescriptionȱtoȱtenȱunits—theȱsameȱamountȱheȱhadȱbeenȱpreȬ
scribedȱbackȱinȱ2008.ȱ
     BecauseȱweȱmustȱtakeȱCesal’sȱallegationȱasȱtrueȱatȱtheȱsumȬ
maryȱjudgmentȱstage,ȱweȱdisregardȱDr.ȱMoats’sȱexplanationȱ
ofȱ theȱ cancellationȱ asȱ hisȱ aĴemptȱ toȱ manageȱ Cesal’sȱ bloodȱ
sugarȱ usingȱ aȱ diěerent,ȱ proactiveȱ method.ȱ Indeed,ȱ weȱ areȱ
troubledȱbyȱDr.ȱMoats’sȱcancellationȱofȱCesal’sȱinsulinȱandȱhisȱ
failureȱtoȱprescribeȱanyȱinsulin—whetherȱslidingȱscale,ȱorȱothȬ
erwise—forȱnearlyȱ2ȱ½ȱyears.ȱWeȱconclude,ȱhowever,ȱthatȱforȱ
purposesȱ ofȱ bothȱ retaliationȱ andȱ deliberateȱ indiěerence,ȱ theȱ
criticalȱ dateȱ isȱ Octoberȱ 29,ȱ 2010,ȱ whenȱ Dr.ȱ Moatsȱ putȱ Cesalȱ
backȱonȱtheȱreducedȱinsulinȱdose.ȱ
No.ȱ15Ȭ2562ȱ                                                      17

    Cesal’sȱargumentȱassumes,ȱwithoutȱanyȱbasis,ȱthatȱthereȱisȱ
aȱęxed,ȱ“correct”ȱdosageȱofȱslidingȬscaleȱinsulinȱforȱhisȱdiabeȬ
tes.ȱThereȱisȱnoȱevidenceȱthatȱthisȱisȱtrue,ȱeitherȱgenerallyȱorȱ
forȱCesalȱhimself.ȱAllȱheȱhasȱmanagedȱtoȱdoȱisȱtoȱregisterȱdisȬ
agreementȱwithȱDr.ȱMoats’sȱmedicalȱjudgment.ȱThatȱisȱinsufȬ
ęcientȱtoȱproveȱdeliberateȱindiěerence,ȱBerry,ȱ604ȱF.3dȱatȱ441,ȱ
orȱanyȱretaliatoryȱmotive.ȱ
   IfȱCesalȱhadȱgivenȱusȱsomeȱreasonȱtoȱthinkȱthatȱDr.ȱMoatsȱ
knewȱ thatȱ theȱ ęveȬunitȱ dosageȱ wouldȱ beȱ ineěective,ȱ weȱ
wouldȱhaveȱaȱdiěerentȱcase.ȱTheȱEighthȱAmendmentȱprotectsȱ
againstȱ aȱ physician’sȱ persistenceȱ withȱ aȱ courseȱ ofȱ treatmentȱ
thatȱheȱknowsȱwillȱbeȱineěective,ȱid.ȱatȱ441,ȱasȱwellȱasȱaȱtreatȬ
mentȱ decisionȱ thatȱ isȱ “soȱ farȱ aęeldȱ ofȱ acceptedȱ professionalȱ
standards”ȱ thatȱ aȱ juryȱ couldȱ ęndȱ itȱ wasȱ notȱ theȱ productȱ ofȱ
medicalȱjudgment.ȱDuckworthȱv.ȱAhmed,ȱ532ȱF.3dȱ675,ȱ679ȱ(7thȱ
Cir.ȱ 2008).ȱ Butȱ Cesalȱ hasȱ notȱ pointedȱ toȱ anyȱ evidenceȱ thatȱ
wouldȱpermitȱaȱ factęnderȱtoȱ concludeȱ thatȱDr.ȱMoatsȱknewȱ
thatȱ ęveȱ unitsȱ wouldȱ beȱ inadequateȱ inȱ controllingȱ Cesal’sȱ
bloodȱ sugarȱ orȱ thatȱ theȱ prescriptionȱ wasȱ wildlyȱ outȱ ofȱ lineȱ
withȱprofessionalȱstandards.ȱIndeed,ȱCesal’sȱmedicalȱrecordsȱ
fromȱGreenvilleȱsupportȱtheȱoppositeȱinference:ȱoĜcialsȱthereȱ
repeatedlyȱ adjustedȱ Cesal’sȱ insulinȱ prescription,ȱ andȱ atȱ oneȱ
pointȱloweredȱitȱtoȱęveȱunits.ȱ
    Cesal’sȱ contentionȱ thatȱ theȱ ęveȬunitȱ prescriptionȱ wasȱ inȬ
suĜcientȱcannotȱextendȱtheȱlengthȱofȱtheȱviolation.ȱHeȱneededȱ
toȱęleȱsuitȱwithinȱtwoȱyearsȱofȱOctoberȱ29,ȱ2010—theȱdayȱDr.ȱ
Moatsȱagainȱprescribedȱhimȱinsulin.ȱEitherȱasȱofȱthatȱdateȱorȱ
veryȱshortlyȱafterwards,ȱheȱknewȱthatȱheȱwasȱdissatisęedȱwithȱ
theȱnewȱdose.ȱItȱisȱnotȱtooȱmuchȱtoȱaskȱthatȱheȱęleȱsuitȱwithinȱ
twoȱyearsȱofȱtheȱdateȱwhenȱhisȱinsulinȱwasȱpartiallyȱrestored,ȱ
andȱafterȱęling,ȱaskȱtheȱdistrictȱcourtȱtoȱappointȱtheȱkindȱofȱ
18ȱ                                                   No.ȱ15Ȭ2562ȱ

medicalȱ expertȱ ourȱ dissentingȱ colleagueȱ thinksȱ shouldȱ haveȱ
beenȱrecruited.ȱButȱCesalȱdidȱnotȱęleȱuntilȱDecemberȱ20,ȱ2012,ȱ
moreȱ thanȱ twoȱ yearsȱ afterȱ theȱ restoration.ȱ Thisȱ wasȱ almostȱ
twoȱ monthsȱ tooȱ late.ȱ Summaryȱ judgmentȱ inȱ favorȱ ofȱ Dr.ȱ
Moatsȱ wasȱ thusȱ properȱ forȱ bothȱ theȱ deliberateȱ indiěerenceȱ
andȱtheȱretaliationȱclaimsȱbasedȱonȱtheȱinsulinȱdeprivation.ȱ
                                IIIȱ
    ThisȱcaseȱillustratesȱyetȱagainȱtheȱimportantȱdiěerenceȱbeȬ
tweenȱordinary,ȱorȱevenȱaggravated,ȱmedicalȱmalpractice,ȱandȱ
anȱ EighthȱAmendmentȱ violation.ȱ Ourȱ taskȱ isȱ notȱ toȱ resolveȱ
whetherȱCesal’sȱcare—especiallyȱtheȱcancellationȱofȱhisȱinsuȬ
lin—wasȱ appropriate.ȱ Weȱ mustȱ insteadȱ applyȱ bothȱ theȱ statȬ
utesȱofȱlimitationsȱthatȱapplyȱtoȱBivensȱclaimsȱsuchȱasȱthisȱoneȱ
andȱtheȱunderlyingȱconstitutionalȱstandards.ȱDoingȱso,ȱweȱseeȱ
noȱerrorȱinȱtheȱdistrictȱcourt’sȱjudgment,ȱandȱsoȱweȱAFFIRM.ȱ
No.ȱ15Ȭ2562ȱ                                                        19ȱ


    POSNER,ȱ Circuitȱ Judge,ȱ dissenting.ȱ Thisȱ caseȱ isȱ indistinȬ
guishableȱ fromȱ Roweȱ v.ȱ Gibson,ȱ 798ȱ F.3dȱ 622ȱ (7thȱ Cir.ȱ 2015),ȱ
whichȱ reversedȱ aȱ grantȱ ofȱ summaryȱ judgmentȱ forȱ theȱ deȬ
fendantsȱinȱaȱstateȱprisoner’sȱsuitȱforȱdeliberateȱindifferenceȱ
toȱhisȱmedicalȱneedsȱandȱremandedȱforȱaȱcloserȱlook,ȱwithȱaȱ
strongȱexhortationȱtoȱtheȱdistrictȱjudgeȱtoȱrecruitȱaȱlawyerȱforȱ
Roweȱand,ȱifȱnecessaryȱbyȱinvokingȱRuleȱ706ȱofȱtheȱFederalȱ
Rulesȱ ofȱ Evidence,ȱ anȱ expertȱ witnessȱ forȱ himȱ asȱ well.ȱ LackȬ
ingȱtheseȱaids,ȱRoweȱhadȱbeenȱincapableȱofȱprovingȱthatȱtheȱ
prisonȱ medicalȱ staff,ȱ mainlyȱ hisȱ treatingȱ physician,ȱ hadȱ
gravelyȱ endangeredȱ hisȱ healthȱ byȱ failing,ȱ seeminglyȱ outȱ ofȱ
spite,ȱ toȱ provideȱ himȱ withȱ theȱ medicineȱ thatȱ heȱ neededȱ forȱ
treatmentȱ ofȱ hisȱ potentiallyȱ fatalȱ gastroesophagealȱ refluxȱ
disease.ȱThisȱcaseȱinvolvesȱaȱsimilarȱclaimȱofȱmisconductȱbyȱ
prisonȱ medicalȱ staff,ȱ specificallyȱ (asȱ inȱ Rowe)ȱ theȱ plaintiff’sȱ
treatingȱphysician,ȱDr.ȱScottȱMoats.ȱ
    Toȱ quoteȱ fromȱ theȱ majorityȱ opinionȱ (withȱ minorȱ alteraȬ
tionsȱforȱclarity):ȱ
    “AsȱCesalȱtellsȱit,ȱDr.ȱMoatsȱhadȱlearnedȱofȱCesal’sȱfilingȱ
ofȱaȱgrievanceȱconcerningȱMoats’sȱtreatmentȱofȱCesal’sȱbackȱ
injury,ȱandȱtheȱgrievanceȱhadȱmadeȱMoatsȱangryȱwithȱCesal.ȱ
Tellingȱ Cesalȱ he’dȱ ‘showȱ him’ȱ whatȱ providingȱ noȱ medicalȱ
careȱ lookedȱ like,ȱ Moatsȱ terminatedȱ Cesal’sȱ prescriptionȱ forȱ
insulin—seeminglyȱforȱnoȱmedicalȱreason.ȱ
    “CesalȱisȱanȱinsulinȬdependentȱTypeȱIIȱdiabeticȱwhoȱhadȱ
beenȱtakingȱslidingȬscaleȱinsulinȱ[wherebyȱtheȱsizeȱofȱtheȱinȬ
sulinȱdoseȱisȱbasedȱonȱtheȱpatient’sȱbloodȬsugarȱlevelȱjustȱbeȬ
foreȱ hisȱ meal;ȱ theȱ higherȱ theȱ level,ȱ theȱ moreȱ insulinȱ theȱ paȬ
tientȱtakes].ȱWithoutȱinsulinȱCesalȱwasȱleftȱtoȱtryȱtoȱmanageȱ
hisȱ bloodȬsugarȱ levelȱ throughȱ diet,ȱ exercise,ȱ andȱ theȱ diabeȬ
20ȱ                                                      No.ȱ15Ȭ2562ȱ


tesȬmanagementȱdrugȱmetformin,ȱwhichȱMoatsȱhadȱnotȱcanȬ
celed.ȱCesalȱskippedȱmealsȱorȱwentȱforȱrunsȱwhenȱhisȱbloodȬ
sugarȱ levelȱ gotȱ tooȱ high.ȱ Butȱ despiteȱ theseȱ effortsȱ andȱ theȱ
metformin,ȱhisȱbloodȱsugarȱsoared.ȱAsȱaȱresultȱheȱfeltȱdizzyȱ
andȱsawȱstarsȱandȱhisȱtoenailsȱfellȱoff.ȱ…ȱ
    “OnȱDecemberȱ23,ȱ2008,ȱafterȱnearlyȱsixȱmonthsȱwithoutȱ
insulin,ȱ Cesalȱ filedȱ aȱ secondȱ administrativeȱ grievanceȱ conȬ
cerningȱ hisȱ diabetesȱ treatment,ȱ specificallyȱ requestingȱ theȱ
restorationȱofȱhisȱslidingȬscaleȱinsulinȱprescription.ȱAgainȱhisȱ
grievanceȱ andȱ relatedȱ appealsȱ wereȱ deniedȱ atȱ eachȱ levelȱ ofȱ
theȱBOPȱ[BureauȱofȱPrisons]ȱadministrativeȱprocess.ȱAȱdenialȱ
datedȱ Januaryȱ 21,ȱ 2009,ȱ notedȱ thatȱ theȱ clinicalȱ directorȱ (Dr.ȱ
Moats)ȱofȱtheȱprisonȱ[PekinȱCorrectionalȱInstitution]ȱhadȱdisȬ
cussedȱ withȱ Cesalȱ aȱ differentȱ diabetesȬmanagementȱ proȬ
gram,ȱ oneȱ ‘tailoredȱ toȱ preventȱ hyperglycemiaȱ [highȱ bloodȱ
sugar—aȱhallmarkȱsignȱofȱdiabetes],ȱnotȱtoȱtreatȱitȱafterȱitȱocȬ
curs.’”ȱThisȱmeantȱthatȱratherȱthanȱfollowingȱaȱslidingȬscaleȱ
insulinȱregime,ȱinȱwhichȱCesalȱwouldȱcheckȱhisȱbloodȱsugarȱ
beforeȱmealsȱandȱtakeȱinsulinȱifȱhisȱbloodȱsugarȱhadȱrisenȱtoȱ
aȱ highȱ level,ȱ heȱ wouldȱ onceȱ orȱ twiceȱ eachȱ dayȱ atȱ theȱ sameȱ
timeȱorȱtimesȱtakeȱaȱlongȬlastingȱformȱofȱinsulinȱthatȱwouldȱ
preventȱ hisȱ bloodȬsugarȱ levelȱ fromȱ risingȱ throughoutȱ theȱ
day.ȱ
    Butȱ wereȱ prisonȱ officials—Moatsȱ inȱ particular—reallyȱ
puttingȱ Cesalȱ onȱ thatȱ program,ȱ givenȱ theȱ suddenȱ cancellaȬ
tionȱ ofȱ hisȱ oldȱ prescription,ȱ theȱ delayȱ inȱ writingȱ himȱ aȱ newȱ
one,ȱ andȱ hisȱ allegationȱ thatȱ Moatsȱ wasȱ retaliatingȱ againstȱ
him?ȱ Althoughȱ aȱ subsequentȱ denialȱ ofȱ hisȱ grievance,ȱ onȱ
Marchȱ 6,ȱ 2009,ȱ notedȱ thatȱ heȱ wasȱ takingȱ oralȱ medicationsȱ
(butȱnotȱinsulin)ȱforȱhisȱdiabetes,ȱandȱconcludedȱthatȱ“soundȱ
clinicalȱ judgmentȱ isȱ beingȱ demonstrated”ȱ inȱ hisȱ treatment,ȱ
No.ȱ15Ȭ2562ȱ                                                        21ȱ


howȱ canȱ weȱ beȱ confidentȱ thatȱ Moatsȱ wasȱ demonstratingȱ
“soundȱ clinicalȱ judgment”?ȱ Theȱ doctor’sȱ anger,ȱ theȱ suddenȱ
withdrawalȱofȱallȱinsulin,ȱandȱtheȱlongȱdelayȱbeforeȱitsȱrestoȬ
ration,ȱmakeȱthisȱcaseȱsoundȱaȱlotȱlikeȱRoweȱv.ȱGibson.ȱ
    Evenȱtheȱjudgesȱinȱtheȱmajorityȱinȱthisȱcaseȱacknowledgeȱ
beingȱ“troubledȱbyȱDr.ȱMoats’sȱcancellationȱofȱCesal’sȱinsuȬ
linȱandȱhisȱfailureȱtoȱprescribeȱanyȱinsulin—whetherȱslidingȱ
scale,ȱ orȱ otherwise—forȱ nearlyȱ 2½ȱ years.”ȱ Yetȱ theȱ majorityȱ
retractȱ theirȱ concern,ȱ dismissively,ȱ withȱ theȱ remarkȱ thatȱ
“Cesal’sȱargumentȱassumes,ȱwithoutȱanyȱbasis,ȱthatȱthereȱisȱaȱ
fixed,ȱ ‘correct’ȱ dosageȱ ofȱ slidingȬscaleȱ insulinȱ forȱ hisȱ diabeȬ
tes.ȱ Thereȱ isȱ noȱ evidence,ȱ however,ȱ thatȱ thisȱ isȱ true,ȱ eitherȱ
generallyȱorȱforȱCesalȱhimself.ȱAllȱheȱhasȱmanagedȱtoȱdoȱisȱtoȱ
registerȱ disagreementȱ withȱ Dr.ȱ Moats’sȱ medicalȱ judgment.ȱ
Thatȱisȱinsufficientȱtoȱproveȱdeliberateȱindifference.”ȱȱ
   Butȱ whatȱ doesȱ theȱ majorityȱ expectȱ ofȱ Cesal,ȱ aȱ prisonerȱ
whoȱ hadȱ noȱ lawyerȱ andȱ noȱ witnesses,ȱ letȱ aloneȱ anȱ expertȱ
witness?ȱ Whatȱ moreȱ couldȱ heȱ doȱ thanȱ “registerȱ disagreeȬ
ment”?ȱ
    Theȱmajorityȱopinionȱattachesȱdecisiveȱsignificanceȱtoȱtheȱ
twoȬyearȱstatuteȱofȱlimitationsȱapplicableȱtoȱtheȱcase,ȱwhichȱ
accordingȱ toȱ theȱ opinionȱ expiredȱ beforeȱ Cesalȱ filedȱ hisȱ suit.ȱ
Theȱ purposeȱ ofȱ statutesȱ ofȱ limitationsȱ isȱ toȱ protectȱ defendȬ
antsȱ fromȱ beingȱ suedȱ afterȱ theȱ evidenceȱ onȱ whichȱ theirȱ deȬ
fenseȱwouldȱdependȱhasȱdisappeared,ȱandȱthereȱisȱnoȱindicaȬ
tionȱthatȱtheȱgovernmentȱwouldȱbeȱprejudicedȱinȱthisȱcaseȱbyȱ
ourȱwaivingȱtheȱstatuteȱofȱlimitations.ȱCesalȱarguesȱplausiblyȱ
thatȱDr.ȱMoats’ȱdeliberatelyȱindifferentȱtreatmentȱofȱhisȱdiaȬ
betesȱ continuedȱ untilȱ Februaryȱ 22,ȱ 2011,ȱ theȱ dateȱ onȱ whichȱ
Moatsȱrestoredȱtheȱfullȱinsulinȱprescription—andȱthatȱwasȱaȱ
dateȱ withinȱ theȱ statuteȱ ofȱ limitations.ȱ Althoughȱ Moatsȱ hadȱ
22ȱ                                                      No.ȱ15Ȭ2562ȱ


prescribedȱinsulinȱforȱCesal—albeitȱaȱreducedȱdose—onȱOcȬ
toberȱ 29,ȱ 2010ȱ (almostȱ twoȱ yearsȱ afterȱ Cesalȱ hadȱ filedȱ hisȱ
grievanceȱcomplainingȱaboutȱtheȱcancellationȱofȱhisȱinsulin),ȱ
CesalȱarguesȱthatȱMoatsȱmustȱhaveȱknownȱthatȱtheȱreducedȱ
doseȱwasȱinadequate,ȱbecauseȱCesal’sȱbloodȬsugarȱlevelsȱhadȱ
becomeȱ severelyȱ elevated,ȱ probablyȱ asȱ aȱ resultȱ ofȱ Moats’ȱ
havingȱwithheldȱinsulinȱfromȱCesalȱforȱthatȱlongȱperiod.ȱ
    Theȱ argumentȱ forȱ waivingȱ theȱ statuteȱ ofȱ limitationsȱ isȱ
strengthenedȱbyȱtheȱfactȱthatȱCesalȱwasȱunrepresentedȱinȱtheȱ
districtȱ court.ȱ Forȱ allȱ weȱ know,ȱ he’sȱ neverȱ heardȱ ofȱ statutesȱ
ofȱlimitations.ȱHeȱhasȱmadeȱaȱplausibleȱcaseȱofȱdeliberateȱinȬ
differenceȱ byȱ Dr.ȱ Moatsȱ toȱ anȱ acuteȱ medicalȱ need.ȱ Iȱ wouldȱ
reverseȱtheȱjudgmentȱinȱfavorȱofȱtheȱdefendantȱandȱremandȱ
theȱcaseȱforȱanȱevidentiaryȱhearing,ȱwithȱaȱstrongȱsuggestionȱ
thatȱtheȱdistrictȱjudgeȱrecruitȱaȱlawyerȱforȱCesalȱand,ȱpursuȬ
antȱ toȱ Ruleȱ 706ȱ ofȱ theȱ Federalȱ Rulesȱ ofȱ Evidence,ȱ appointȱ aȱ
neutralȱ expertȱ witness—aȱ specialistȱ inȱ diabetesȱ andȱ itsȱ
treatment—asȱwell.ȱ
