                               In the

    United States Court of Appeals
                 For the Seventh Circuit
                     ____________________ȱ
No.ȱ14Ȭ2674ȱ
TYRONEȱPETTIES,ȱ
                                                  PlaintiffȬAppellant,ȱ

                                  v.ȱ

IMHOTEPȱCARTERȱandȱSALEHȱOBAISI,ȱȱ
                                               DefendantsȬAppellees.ȱ
                     ____________________ȱ

         AppealȱfromȱtheȱUnitedȱStatesȱDistrictȱCourtȱforȱtheȱ
           NorthernȱDistrictȱofȱIllinois,ȱEasternȱDivision.ȱ
           No.ȱ12ȱCȱ9353ȱ—ȱGeorgeȱM.ȱMarovich,ȱJudge.ȱ
                     ____________________ȱ

                     ARGUEDȱAPRILȱ28,ȱ2015ȱ

            REARGUEDȱENȱBANCȱDECEMBERȱ1,ȱ2015ȱ

                   DECIDEDȱAUGUSTȱ23,ȱ2016ȱ
                     ____________________ȱ

   Beforeȱ WOOD,ȱ Chiefȱ Judge,ȱ andȱ POSNER,ȱ FLAUM,ȱ
EASTERBROOK,ȱ KANNE,ȱ ROVNER,ȱ WILLIAMS,ȱ SYKES,ȱ andȱ
HAMILTON,ȱCircuitȱJudges.ȱ
   WILLIAMS,ȱCircuitȱJudge.ȱTyroneȱPettiesȱsufferedȱaȱdebilitatȬ
ingȱruptureȱinȱhisȱAchillesȱtendon,ȱwhichȱcausedȱhimȱextremeȱ
2ȱ                                                     ȱNo.ȱ14Ȭ2674ȱ

painȱandȱimpededȱhisȱmobilityȱoverȱtheȱcourseȱofȱthreeȱyears.ȱ
Heȱbroughtȱaȱlawsuitȱunderȱ42ȱU.S.C.ȱ§ȱ1983ȱagainstȱhisȱdocȬ
torsȱatȱStatevilleȱCorrectionalȱFacility,ȱallegingȱtheyȱfailedȱtoȱ
alleviateȱhisȱsufferingȱandȱtoȱenableȱhisȱrecoveryȱfromȱtheȱinȬ
jury.ȱWeȱheardȱthisȱcaseȱenȱbancȱtoȱclarifyȱwhenȱaȱdoctor’sȱraȬ
tionaleȱforȱhisȱtreatmentȱdecisionsȱsupportsȱaȱtriableȱissueȱasȱ
toȱwhetherȱthatȱdoctorȱactedȱwithȱdeliberateȱindifferenceȱunȬ
derȱtheȱEighthȱAmendment.ȱWeȱconcludeȱthatȱevenȱifȱaȱdoctorȱ
deniesȱknowingȱthatȱheȱwasȱexposingȱaȱplaintiffȱtoȱaȱsubstanȬ
tialȱ riskȱ ofȱ seriousȱ harm,ȱ evidenceȱ fromȱ whichȱ aȱ reasonableȱ
juryȱ couldȱ inferȱ aȱ doctorȱ knewȱ heȱ wasȱ providingȱ deficientȱ
treatmentȱisȱsufficientȱtoȱsurviveȱsummaryȱjudgment.ȱBecauseȱ
weȱ findȱ thatȱ Pettiesȱ hasȱ producedȱ sufficientȱ evidenceȱ forȱ aȱ
juryȱ toȱ concludeȱ thatȱ theȱ doctorsȱ knewȱ theȱ careȱ theyȱ wereȱ
providingȱ wasȱ insufficient,ȱ weȱ reverseȱ theȱ districtȱ court’sȱ
grantȱofȱsummaryȱjudgmentȱtoȱtheȱdefendants.ȱ
                       I.ȱBACKGROUNDȱ
    PettiesȱwasȱwalkingȱupȱtheȱstairsȱofȱhisȱcellȱhouseȱatȱStatȬ
evilleȱinȱJanuaryȱ2012ȱwhenȱheȱheardȱaȱloudȱpopȱandȱfeltȱexȬ
cruciatingȱ painȱ andȱ weaknessȱ inȱ hisȱ leftȱ Achillesȱ tendon.ȱ Itȱ
wasȱnotȱtheȱfirstȱtimeȱheȱhadȱsufferedȱsuchȱanȱinjury.ȱInȱ2010ȱ
heȱsufferedȱaȱpartialȱruptureȱinȱhisȱrightȱAchillesȱtendonȱatȱtheȱ
prisonȱwhichȱhadȱnotȱfullyȱhealed.ȱ
    AnȱAchillesȱtendonȱruptureȱisȱaȱtearȱinȱtheȱtendonȱwhichȱ
impedesȱ theȱ abilityȱ ofȱ theȱ footȱ toȱ pointȱ downward,ȱ causingȱ
painȱ andȱ limitingȱ mobility.ȱ Walkingȱ aroundȱ onȱ aȱ rupturedȱ
tendonȱexacerbatesȱtheȱinjury,ȱincreasingȱtheȱgapȱbetweenȱtheȱ
tornȱedgesȱofȱaȱtendonȱbecauseȱofȱtheȱwayȱthatȱmusclesȱconȬ
tractȱinȱtheȱfootȱandȱcalf.ȱImmobilizingȱtheȱinjuredȱfootȱpreȬ
ventsȱstretchingȱofȱtheȱtearȱandȱallowsȱtheȱtornȱedgesȱofȱtheȱ
tendonȱtoȱsitȱtogether,ȱandȱscarȱtissueȱtoȱform,ȱrejoiningȱtheȱ
No.ȱ14Ȭ2674ȱ                                                        ȱ3ȱ

edges.ȱ Whenȱ anȱ Achillesȱ ruptureȱ isȱ notȱ immobilized,ȱ theȱ
stretchingȱ apartȱ ofȱ theȱ tornȱ tendonȱ edgesȱ whenȱ theȱ injuredȱ
footȱhitsȱtheȱgroundȱcausesȱsevereȱpainȱandȱweakness.ȱ
    PettiesȱwentȱtoȱStateville’sȱhealthȱclinicȱandȱeventuallyȱsawȱ
Dr.ȱImhotepȱCarter,ȱtheȱmedicalȱdirectorȱofȱStatevilleȱ(thoughȱ
hisȱ actualȱ employerȱ wasȱ Wexfordȱ Healthȱ Sources,ȱ aȱ privateȱ
contractorȱofȱmedicalȱservicesȱtoȱcorrectionalȱfacilities).ȱBeforeȱ
Petties,ȱ Dr.ȱ Carterȱ hadȱ seenȱ approximatelyȱ tenȱ Achillesȱ tenȬ
donȱrupturesȱinȱhisȱtwentyȬyearȱcareer.ȱAsȱtheȱprison’sȱmediȬ
calȱdirector,ȱDr.ȱCarterȱwasȱinȱchargeȱofȱimplementingȱWexȬ
ford’sȱmedicalȱpoliciesȱandȱprocedures,ȱamongȱwhichȱwasȱaȱ
specificȱtreatmentȱprotocolȱforȱpatientsȱwithȱrupturedȱAchilȬ
lesȱ tendons.ȱ Theȱ protocolȱ advisedȱ thatȱ patientsȱ receiveȱ aȱ
splint,ȱcrutches,ȱandȱantibioticsȱifȱthereȱwereȱlacerationsȱtoȱtheȱ
siteȱofȱinjury,ȱandȱthenȱbeȱsentȱtoȱaȱspecialistȱforȱfurtherȱtreatȬ
ment.ȱ
    Dr.ȱ Carter’sȱ notesȱ reflectȱ thatȱ heȱ thoughtȱ Pettiesȱ hadȱ anȱ
Achillesȱtendonȱrupture,ȱandȱthatȱheȱfollowedȱsomeȱofȱWexȬ
ford’sȱprotocol,ȱbutȱnotȱallȱofȱit.ȱHeȱgaveȱPettiesȱcrutches,ȱice,ȱ
andȱVicodin.ȱHeȱalsoȱauthorizedȱoneȱweekȱofȱ“layȬin”ȱmeals,ȱ
whichȱmeantȱthatȱPettiesȱdidȱnotȱhaveȱtoȱwalkȱtoȱtheȱcafeteria,ȱ
butȱcouldȱeatȱinȱhisȱcell.ȱFinally,ȱheȱreferredȱPettiesȱtoȱaȱspeȬ
cialist,ȱ butȱ thatȱ appointmentȱ didȱ notȱ happenȱ forȱ almostȱ sixȱ
weeks.ȱ Inȱ theȱ meantime,ȱ Dr.ȱ Carterȱ didȱ notȱ provideȱ Pettiesȱ
withȱaȱsplint,ȱboot,ȱcast,ȱorȱotherȱdeviceȱthatȱwouldȱimmobiȬ
lizeȱhisȱfoot.ȱAboutȱaȱmonthȱlater,ȱafterȱPettiesȱreportedȱtoȱtheȱ
infirmaryȱthatȱhisȱtendonȱwasȱ“killingȱhim”ȱandȱkeepingȱhimȱ
fromȱ climbingȱ stairs,ȱ Pettiesȱ sawȱ Dr.ȱ Carterȱ againȱ andȱ reȬ
ceivedȱaȱrenewedȱprescriptionȱforȱcrutches,ȱpainȱmedication,ȱ
layȬinȱmeals,ȱandȱassignmentȱtoȱaȱlowerȱbunkȱtoȱkeepȱpressureȱ
offȱhisȱfoot.ȱButȱheȱstillȱdidȱnotȱreceiveȱaȱsplint.ȱ
4ȱ                                                      ȱNo.ȱ14Ȭ2674ȱ

     InȱMarchȱ2012,ȱPettiesȱhadȱanȱMRIȱtakenȱwhichȱshowedȱanȱ
Achillesȱ tendonȱ rupture.ȱ Thereȱ wasȱ aȱ gapȱ betweenȱ theȱ tornȱ
endsȱofȱtheȱtendonȱthatȱmeasuredȱapproximatelyȱ4.7ȱcentimeȬ
ters.ȱAboutȱaȱweekȱlater,ȱPettiesȱmetȱwithȱDr.ȱAnujȱPuppala,ȱ
anȱorthopedicȱspecialist,ȱwhoȱnotedȱthatȱtheȱlackȱofȱ“anyȱsortȱ
ofȱ cast”ȱ wasȱ potentiallyȱ creatingȱ theȱ gappingȱ atȱ theȱ tendonȱ
ruptureȱsite.ȱHeȱrecommendedȱanȱorthopedicȱbootȱtoȱpreventȱ
furtherȱgappingȱandȱtoȱalleviateȱpain,ȱandȱgaveȱoneȱtoȱPetties.ȱ
Finally,ȱheȱthoughtȱthatȱsurgeryȱmightȱbeȱnecessaryȱdueȱtoȱtheȱ
gapping,ȱandȱreferredȱPettiesȱtoȱanȱankleȱspecialist.ȱWhenȱPetȬ
tiesȱ returnedȱ toȱ Stateville,ȱ Dr.ȱ Carterȱ authorizedȱ useȱ ofȱ theȱ
boot,ȱ alongȱ withȱ crutches,ȱ ice,ȱ andȱ assignmentȱ toȱ aȱ lowerȱ
bunk.ȱPettiesȱassertsȱthatȱDr.ȱCarterȱsaidȱheȱwouldȱnotȱorderȱ
surgeryȱbecauseȱitȱwasȱtooȱcostly.ȱ
    Inȱ Julyȱ 2012,ȱ Pettiesȱ finallyȱ sawȱ anȱ ankleȱ specialist,ȱ Dr.ȱ
Samuelȱ Chmell,ȱ whoȱ orderedȱ aȱ secondȱ MRIȱ afterȱ notingȱ
weaknessȱinȱPetties’sȱankle.ȱDr.ȱChmellȱalsoȱorderedȱphysicalȱ
therapy,ȱgentleȱstretchingȱexercises,ȱandȱfollowȬupȱtreatment.ȱ
InȱAugustȱ2012,ȱDr.ȱCarterȱwasȱreplacedȱasȱtheȱmedicalȱdirecȬ
torȱofȱStatevilleȱbyȱDr.ȱSalehȱObaisi.ȱDr.ȱObaisiȱapprovedȱtheȱ
orderȱforȱaȱsecondȱMRI,ȱbutȱdidȱnotȱauthorizeȱphysicalȱtherȬ
apy.ȱ Accordingȱ toȱ Petties,ȱ heȱ alsoȱ saidȱ thatȱ surgeryȱ wasȱ tooȱ
expensive.ȱ
    Thatȱ September,ȱ Pettiesȱ hadȱ hisȱ secondȱ MRI,ȱ whichȱ
showedȱaȱpartialȱtearȱinȱhisȱtendon,ȱindicatingȱsomeȱhealing.ȱ
Butȱheȱcontinuedȱtoȱcomplainȱofȱpain,ȱandȱDr.ȱObaisiȱgaveȱhimȱ
Tylenol,ȱapprovedȱaȱlowȱbunkȱpermit,ȱandȱcontinuedȱhisȱuseȱ
ofȱtheȱboot.ȱDr.ȱObaisiȱrenewedȱtheȱlowȱbunkȱpermitȱandȱuseȱ
ofȱtheȱbootȱinȱNovember,ȱandȱagainȱtheȱfollowingȱJune.ȱPettiesȱ
experiencedȱpain,ȱsorenessȱandȱstiffnessȱasȱlateȱasȱMarchȱ2014,ȱ
overȱtwoȱyearsȱafterȱtheȱinjury.ȱ
No.ȱ14Ȭ2674ȱ                                                             ȱ5ȱ

    InȱNovemberȱ2012,ȱPettiesȱfiledȱaȱlawsuitȱunderȱ42ȱU.S.C.ȱ
§ȱ1983ȱagainstȱDr.ȱCarterȱandȱDr.ȱObaisiȱforȱdeliberateȱindifȬ
ferenceȱ inȱ violationȱ ofȱ theȱ Eighthȱ Amendment.ȱ Theȱ districtȱ
courtȱ grantedȱ summaryȱ judgmentȱ toȱ Dr.ȱ Carterȱ andȱ Dr.ȱ
Obaisi.ȱPettiesȱappeals.ȱ
                                         II.ȱANALYSISȱ
    Weȱreviewȱtheȱdistrictȱcourt’sȱgrantȱofȱsummaryȱjudgmentȱ
deȱnovo,ȱviewingȱtheȱrecordȱinȱtheȱlightȱmostȱfavorableȱtoȱPetȬ
ties,ȱandȱdrawingȱallȱinferencesȱinȱhisȱfavor.ȱPagalȱv.ȱTINȱInc.,ȱ
695ȱF.3dȱ622,ȱ624ȱ(7thȱCir.ȱ2012).ȱȱ
    “TheȱConstitutionȱdoesȱnotȱmandateȱcomfortableȱprisons,ȱ
butȱneitherȱdoesȱitȱpermitȱinhumaneȱones.”ȱFarmerȱv.ȱBrennan,ȱ
511ȱ U.S.ȱ 825,ȱ 832ȱ (1994)ȱ (internalȱ citationsȱ andȱ quotationȱ
marksȱomitted).ȱEveryȱclaimȱbyȱaȱprisonerȱthatȱheȱhasȱnotȱreȬ
ceivedȱ adequateȱ medicalȱ treatmentȱ isȱ notȱ aȱ violationȱ ofȱ theȱ
EighthȱAmendment.ȱEstelleȱv.ȱGamble,ȱ429ȱU.S.ȱ97,ȱ105ȱ(1976).ȱ
ButȱtheȱEighthȱAmendmentȱsafeguardsȱtheȱprisonerȱagainstȱaȱ
lackȱ ofȱ medicalȱ careȱ thatȱ “mayȱ resultȱ inȱ painȱ andȱ sufferingȱ
whichȱ noȱ oneȱ suggestsȱ wouldȱ serveȱ anyȱ penologicalȱ purȬ
pose.”ȱId.ȱatȱ103.1ȱToȱdetermineȱifȱtheȱEighthȱAmendmentȱhasȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
1ȱOur dissenting colleagues suggest that Estelle shields doctors from lia-
bility if they provide palliative care to prisoners. Unless a doctor refuses
to provide care or leaves the inmate worse off than before, the dissent
would have us draw the legal conclusion that the prison doctor did not
intentionally disregard a prisoner’s serious medical needs. But Estelle ex-
plicitly held that a violation of the Eighth Amendment can be established
whether “the indifference is manifested by prison doctors in their response
to the prisoner's needs or by prison guards in intentionally denying or de-
laying access to medical care or intentionally interfering with the treat-
ment once prescribed. Regardless of how evidenced, deliberate indifference
to a prisoner's serious illness or injury states a cause of action under
§ 1983.” 429 U.S. 97, 104–05 (emphasis added). The dissent collapses these
distinct avenues to proving deliberate indifference into one—any response
6ȱ                                                         ȱNo.ȱ14Ȭ2674ȱ

beenȱ violatedȱ inȱ theȱ prisonȱ medicalȱ context,ȱ weȱ performȱ aȱ
twoȬstepȱanalysis,ȱfirstȱexaminingȱwhetherȱaȱplaintiffȱsufferedȱ
fromȱanȱobjectivelyȱseriousȱmedicalȱcondition,ȱandȱthenȱdeterȬ
miningȱwhetherȱtheȱindividualȱdefendantȱwasȱdeliberatelyȱinȬ
differentȱ toȱ thatȱ condition.ȱ Farmer,ȱ 511ȱ U.S.ȱ atȱ 834;ȱ seeȱ alsoȱ
Berryȱv.ȱPeterman,ȱ604ȱF.3dȱ435,ȱ440ȱ(7thȱCir.ȱ2010).ȱ
    InȱevaluatingȱanȱEighthȱAmendmentȱclaim,ȱweȱstartȱbyȱdeȬ
terminingȱifȱtheȱmedicalȱconditionȱtheȱplaintiffȱsufferedȱwasȱ
objectivelyȱserious.ȱ Farmer,ȱ511ȱU.S.ȱatȱ834;ȱseeȱalsoȱWalkerȱv.ȱ
Peters,ȱ233ȱF.3dȱ494,ȱ498ȱ(7thȱCir.ȱ2000).ȱHere,ȱtheȱpartiesȱagreeȱ
thatȱanȱAchillesȱtendonȱruptureȱisȱanȱobjectivelyȱseriousȱconȬ
dition,ȱbutȱtheyȱdisputeȱwhetherȱinȱrespondingȱtoȱtheȱrupture,ȱ
theȱdefendantsȱactedȱwithȱdeliberateȱindifference.ȱȱ
      ToȱdetermineȱifȱaȱprisonȱofficialȱactedȱwithȱdeliberateȱinȬ
difference,ȱ weȱ lookȱ intoȱ hisȱ orȱ herȱ subjectiveȱ stateȱ ofȱ mind.ȱ
Vanceȱv.ȱPeters,ȱ97ȱF.3dȱ987,ȱ992ȱ(7thȱCir.ȱ1996)ȱ(citingȱFarmer,ȱ
511ȱU.S.ȱatȱ842).ȱForȱaȱprisonȱofficial’sȱactsȱorȱomissionsȱtoȱconȬ
stituteȱ deliberateȱ indifference,ȱ aȱ plaintiffȱ doesȱ notȱ needȱ toȱ
showȱ thatȱ theȱ officialȱ intendedȱ harmȱ orȱ believedȱ thatȱ harmȱ
wouldȱoccur.ȱId.ȱatȱ992.ȱButȱshowingȱmereȱnegligenceȱisȱnotȱ
enough.ȱEstelle,ȱ429ȱU.S.ȱatȱ106ȱ(“Medicalȱmalpracticeȱdoesȱnotȱ
becomeȱaȱconstitutionalȱviolationȱmerelyȱbecauseȱtheȱvictimȱ
isȱ aȱ prisoner.”);ȱ McGeeȱ v.ȱ Adams,ȱ 721ȱ F.3dȱ 474,ȱ 481ȱ (7thȱ Cir.ȱ
2013)ȱ(“Deliberateȱindifferenceȱisȱnotȱmedicalȱmalpractice.”).ȱ
Evenȱobjectiveȱrecklessness—failingȱtoȱactȱinȱtheȱfaceȱofȱanȱunȬ
justifiablyȱ highȱ riskȱ thatȱ isȱ soȱ obviousȱ thatȱ itȱ shouldȱ beȱ
known—isȱinsufficientȱtoȱmakeȱoutȱaȱclaim.ȱFarmer,ȱ511ȱU.S.ȱ
atȱ836–38.ȱInstead,ȱtheȱSupremeȱCourtȱhasȱinstructedȱusȱthatȱaȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
by a physician, so long as it is not harmful, satisfies the Eighth Amend-
ment. But that is not the holding of Estelle, and we decline to make such a
leap here.
No.ȱ14Ȭ2674ȱ                                                          ȱ7ȱ

plaintiffȱmustȱprovideȱevidenceȱthatȱanȱofficialȱactuallyȱknewȱ
ofȱandȱdisregardedȱaȱsubstantialȱriskȱofȱharm.ȱId.ȱatȱ837.ȱOffiȬ
cialsȱcanȱavoidȱliabilityȱbyȱprovingȱtheyȱwereȱunawareȱevenȱ
ofȱanȱobviousȱriskȱtoȱinmateȱhealthȱorȱsafety.ȱId.ȱatȱ844.ȱ
    Theȱdifficultyȱ isȱ thatȱ exceptȱinȱtheȱmostȱ egregiousȱcases,ȱ
plaintiffsȱgenerallyȱlackȱdirectȱevidenceȱofȱactualȱknowledge.ȱ
Rarelyȱifȱeverȱwillȱanȱofficialȱdeclare,ȱ“IȱknewȱthisȱwouldȱprobȬ
ablyȱharmȱyou,ȱandȱIȱdidȱitȱanyway!”ȱMostȱcasesȱturnȱonȱcirȬ
cumstantialȱevidence,ȱoftenȱoriginatingȱinȱaȱdoctor’sȱfailureȱtoȱ
conformȱtoȱbasicȱstandardsȱofȱcare.ȱWhileȱevidenceȱofȱmedicalȱ
malpracticeȱoftenȱformsȱtheȱbasisȱofȱaȱdeliberateȱindifferenceȱ
claim,ȱtheȱSupremeȱCourtȱhasȱdeterminedȱthatȱplaintiffsȱmustȱ
showȱmoreȱthanȱmereȱevidenceȱofȱmalpracticeȱtoȱproveȱdelibȬ
erateȱ indifference.ȱ Estelle,ȱ 429ȱ U.S.ȱ atȱ 106.ȱ Butȱ blatantȱ disreȬ
gardȱforȱmedicalȱstandardsȱcouldȱsupportȱaȱfindingȱofȱmereȱ
medicalȱmalpractice,ȱorȱitȱcouldȱriseȱtoȱtheȱlevelȱofȱdeliberateȱ
indifference,ȱdependingȱonȱtheȱcircumstances.ȱAndȱthatȱisȱtheȱ
questionȱweȱareȱfacedȱwithȱtoday—howȱbadȱdoesȱanȱinmate’sȱ
careȱhaveȱtoȱbeȱtoȱcreateȱaȱreasonableȱinferenceȱthatȱaȱdoctorȱ
didȱnotȱjustȱslipȱup,ȱbutȱwasȱawareȱof,ȱandȱdisregarded,ȱaȱsubȬ
stantialȱriskȱofȱharm?ȱWeȱmustȱdetermineȱwhatȱkindȱofȱeviȬ
denceȱ isȱ adequateȱ forȱ aȱ juryȱ toȱ drawȱ aȱ reasonableȱ inferenceȱ
thatȱaȱprisonȱofficialȱactedȱwithȱdeliberateȱindifference.ȱȱ
    Weȱstartȱthisȱinquiryȱbyȱexaminingȱourȱexistingȱprecedent.ȱ
Asȱanȱinitialȱmatter,ȱweȱlookȱatȱtheȱtotalityȱofȱanȱinmate’sȱmedȬ
icalȱcareȱwhenȱconsideringȱwhetherȱthatȱcareȱevidencesȱdelibȬ
erateȱ indifferenceȱ toȱ seriousȱ medicalȱ needs.ȱ Cavalieriȱ v.ȱ
Shephard,ȱ321ȱF.3dȱ616,ȱ625–26ȱ(7thȱCir.ȱ2003).ȱWeȱhaveȱidentiȬ
fiedȱseveralȱcircumstancesȱthatȱcanȱbeȱenoughȱtoȱshowȱdelibȬ
erateȱindifference.ȱFirst,ȱandȱmostȱobvious,ȱisȱaȱprisonȱofficial’sȱ
decisionȱtoȱignoreȱaȱrequestȱforȱmedicalȱassistance.ȱEstelle,ȱ429ȱ
8ȱ                                                     ȱNo.ȱ14Ȭ2674ȱ

U.S.ȱatȱ104Ȭ05.ȱButȱanȱinmateȱisȱnotȱrequiredȱtoȱshowȱthatȱheȱ
wasȱliterallyȱignoredȱbyȱprisonȱstaffȱtoȱdemonstrateȱdeliberateȱ
indifference.ȱSherrodȱv.ȱLingle,ȱ223ȱF.3dȱ605,ȱ611ȱ(7thȱCir.ȱ2000).ȱ
Ifȱaȱriskȱfromȱaȱparticularȱcourseȱofȱmedicalȱtreatmentȱ(orȱlackȱ
thereof)ȱisȱobviousȱenough,ȱaȱfactfinderȱcanȱinferȱthatȱaȱprisonȱ
officialȱknewȱaboutȱitȱandȱdisregardedȱit.ȱNorfleetȱv.ȱWebster,ȱ
439ȱF.3dȱ392,ȱ396ȱ(7thȱCir.ȱ2006);ȱColeȱv.ȱFromm,ȱ94ȱF.3dȱ254,ȱ260ȱ
(7thȱCir.ȱ1996).ȱȱ
    Inȱtheȱmedicalȱcontext,ȱofȱcourse,ȱobviousnessȱofȱaȱriskȱcanȱ
beȱ obscuredȱ byȱ theȱ needȱ forȱ specializedȱ expertiseȱ toȱ underȬ
standȱtheȱvariousȱimplicationsȱofȱaȱparticularȱcourseȱofȱtreatȬ
ment.ȱSoȱweȱhaveȱfoundȱinȱthoseȱcasesȱwhereȱunnecessaryȱriskȱ
mayȱbeȱimperceptibleȱtoȱaȱlayȱpersonȱthatȱaȱmedicalȱprofesȬ
sional’sȱtreatmentȱdecisionȱmustȱbeȱ“suchȱaȱsubstantialȱdeparȬ
tureȱfromȱacceptedȱprofessionalȱjudgment,ȱpractice,ȱorȱstandȬ
ardsȱ asȱ toȱ demonstrateȱ thatȱ theȱ personȱ responsibleȱ didȱ notȱ
baseȱtheȱdecisionȱonȱsuchȱaȱjudgment.”ȱCole,ȱ94ȱF.3dȱatȱ261–62;ȱ
seeȱalsoȱCollignonȱv.ȱMilwaukeeȱCnty.,ȱ163ȱF.3dȱ982,ȱ989ȱ(7thȱCir.ȱ
1998)ȱ(“Aȱplaintiffȱcanȱshowȱthatȱtheȱprofessionalȱdisregardedȱ
theȱneedȱonlyȱifȱtheȱprofessional’sȱsubjectiveȱresponseȱwasȱsoȱ
inadequateȱ thatȱ itȱ demonstratedȱ anȱ absenceȱ ofȱ professionalȱ
judgment,ȱ thatȱ is,ȱ noȱ minimallyȱ competentȱ professionalȱ
wouldȱ haveȱ soȱ respondedȱ underȱ thoseȱ circumstances.”).ȱ Byȱ
contrast,ȱ evidenceȱ thatȱ someȱ medicalȱ professionalsȱ wouldȱ
haveȱchosenȱaȱdifferentȱcourseȱofȱtreatmentȱisȱinsufficientȱtoȱ
makeȱoutȱaȱconstitutionalȱclaim.ȱSteeleȱv.ȱChoi,ȱ82ȱF.3dȱ175,ȱ179ȱ
(7thȱCir.ȱ1996).ȱ
   Evenȱ amongȱ theȱ medicalȱ community,ȱ theȱ permissibleȱ
boundsȱofȱcompetentȱmedicalȱjudgmentȱareȱnotȱalwaysȱclear,ȱ
particularlyȱ becauseȱ “itȱ isȱ implicitȱ inȱ theȱ professionalȱ judgȬ
mentȱ standardȱ itself…thatȱ inmateȱ medicalȱ careȱ decisionsȱ
No.ȱ14Ȭ2674ȱ                                                              ȱ9ȱ

mustȱbeȱfactȬbasedȱwithȱrespectȱtoȱtheȱparticularȱinmate,ȱtheȱ
severityȱandȱstageȱofȱhisȱcondition,ȱtheȱlikelihoodȱandȱimmiȬ
nenceȱ ofȱ furtherȱ harmȱ andȱ theȱ efficacyȱ ofȱ availableȱ treatȬ
ments.”ȱRoe,ȱ631ȱF.3dȱatȱ859.ȱSoȱitȱcanȱbeȱchallengingȱtoȱdrawȱ
aȱlineȱbetweenȱanȱacceptableȱdifferenceȱofȱopinionȱ(especiallyȱ
becauseȱ evenȱ admittedȱ medicalȱ malpracticeȱ doesȱ notȱ autoȬ
maticallyȱgiveȱriseȱtoȱaȱconstitutionalȱviolation),ȱandȱanȱactionȱ
thatȱreflectsȱsubȬminimalȱcompetence2ȱandȱcrossesȱtheȱthreshȬ
oldȱintoȱdeliberateȱindifference.ȱOneȱhintȱofȱsuchȱaȱdepartureȱ
isȱwhenȱaȱdoctorȱrefusesȱtoȱtakeȱinstructionsȱfromȱaȱspecialist.ȱ
Arnettȱ v.ȱ Webster,ȱ 658ȱ F.3dȱ 742,ȱ 753ȱ (7thȱ Cir.ȱ 2011);ȱ Jonesȱ v.ȱ
Simek,ȱ193ȱF.3dȱ485,ȱ490ȱ(7thȱCir.ȱ1999).ȱAnotherȱisȱwhenȱheȱorȱ
sheȱfailsȱtoȱfollowȱanȱexistingȱprotocol.ȱ“WhileȱpublishedȱreȬ
quirementsȱforȱhealthȱcareȱdoȱnotȱcreateȱconstitutionalȱrights,ȱ
suchȱprotocolsȱcertainlyȱprovideȱcircumstantialȱevidenceȱthatȱ
aȱprisonȱhealthȱcareȱgatekeeperȱknewȱofȱaȱsubstantialȱriskȱofȱ
seriousȱharm.”ȱMataȱv.ȱSaiz,ȱ427ȱF.3dȱ745,ȱ757ȱ(10thȱCir.ȱ2005).ȱ
    Anotherȱ situationȱ thatȱ mightȱ establishȱ aȱ departureȱ fromȱ
minimallyȱcompetentȱmedicalȱjudgmentȱisȱwhereȱaȱprisonȱofȬ
ficialȱpersistsȱinȱaȱcourseȱofȱtreatmentȱknownȱtoȱbeȱineffective.ȱ
Walker,ȱ 233ȱ F.3dȱ atȱ 499ȱ (citationsȱ omitted).ȱ Forȱ example,ȱ ifȱ
knowingȱ aȱ patientȱ facesȱ aȱ seriousȱ riskȱ ofȱ appendicitis,ȱ theȱ

ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
2 Our colleagues take issue with our repeated references to the competence
of medical professionals, suggesting we are injecting state malpractice
standards into the constitutional test for deliberate indifference. But we do
not suggest that incompetent doctors violate the Constitution. We simply
note that a medical decision that has no support in the medical commu-
nity, along with a suspect rationale provided for making it, can support a
jury finding that a doctor knew his decision created a serious risk to an
inmate’s health. To hold otherwise would mean that any treatment deci-
sion a doctor made, regardless of whether it had any scientific basis,
would be immune from scrutiny.
10ȱ                                                   ȱNo.ȱ14Ȭ2674ȱ

prisonȱofficialȱgivesȱtheȱpatientȱanȱaspirinȱandȱsendsȱhimȱbackȱ
toȱ hisȱ cell,ȱ aȱ juryȱ couldȱ findȱ deliberateȱ indifferenceȱ evenȱ
thoughȱ theȱ prisonerȱ receivedȱ someȱ treatment.ȱ Sherrod,ȱ 223ȱ
F.3dȱatȱ612;ȱseeȱalsoȱGreenoȱv.ȱDaley,ȱ414ȱF.3dȱ645,ȱ655ȱ(7thȱCir.ȱ
2005)ȱ(continuingȱtoȱtreatȱsevereȱvomitingȱwithȱantacidsȱoverȱ
threeȱyearsȱcreatedȱmaterialȱfactȱissueȱofȱdeliberateȱindifferȬ
ence);ȱSnipesȱv.ȱDetella,ȱ95ȱF.3dȱ586,ȱ592ȱ(7thȱCir.ȱ1996)ȱ(holdingȱ
EighthȱAmendmentȱclaimȱmayȱexistȱifȱmedicalȱtreatmentȱisȱsoȱ
blatantlyȱ inappropriateȱ asȱ toȱ evidenceȱ intentionalȱ mistreatȬ
mentȱ likelyȱ toȱ seriouslyȱ aggravateȱ theȱ prisoner’sȱ condition);ȱ
Kelleyȱv.ȱMcGinnis,ȱ899ȱF.2dȱ612,ȱ616–17ȱ(7thȱCir.ȱ1990)ȱ(perȱcuȬ
riam).ȱȱ
    Ifȱaȱprisonȱdoctorȱchoosesȱanȱ“easierȱandȱlessȱefficaciousȱ
treatment”ȱwithoutȱexercisingȱprofessionalȱjudgment,ȱsuchȱaȱ
decisionȱcanȱalsoȱconstituteȱdeliberateȱindifference.ȱEstelle,ȱ429ȱ
U.S.ȱatȱ104ȱn.10;ȱConleyȱv.ȱBirch,ȱ796ȱF.3dȱ742,ȱ747ȱ(7thȱCir.ȱ2015)ȱ
(materialȱfactȱissueȱwhetherȱprovisionȱofȱonlyȱpainkillersȱandȱ
iceȱtoȱanȱinmateȱsufferingȱfromȱsuspectedȱfractureȱconstitutedȱ
deliberateȱindifference).ȱWhileȱtheȱcostȱofȱtreatmentȱisȱaȱfactorȱ
inȱ determiningȱ whatȱ constitutesȱ adequate,ȱ minimumȬlevelȱ
care,ȱ medicalȱ personnelȱ cannotȱ simplyȱ resortȱ toȱ anȱ easierȱ
courseȱofȱtreatmentȱthatȱtheyȱknowȱisȱineffective.ȱJohnson,ȱ433ȱ
F.3dȱatȱ1013;ȱRoe,ȱ631ȱF.3dȱatȱ863ȱ(althoughȱadministrativeȱconȬ
venienceȱandȱcostȱmayȱbeȱpermissibleȱfactorsȱforȱcorrectionalȱ
systemsȱ toȱ consider,ȱ theȱ Constitutionȱ isȱ violatedȱ whenȱ theyȱ
areȱ consideredȱ toȱ theȱ exclusionȱ ofȱ reasonableȱ medicalȱ judgȬ
mentȱaboutȱinmateȱhealth).ȱ
    Yetȱanotherȱtypeȱofȱevidenceȱthatȱcanȱsupportȱanȱinferenceȱ
ofȱdeliberateȱindifferenceȱisȱanȱinexplicableȱdelayȱinȱtreatmentȱ
whichȱ servesȱ noȱ penologicalȱ interest.ȱ Grievesonȱ v.ȱ Anderson,ȱ
No.ȱ14Ȭ2674ȱ                                                       ȱ11ȱ

538ȱF.3dȱ763,ȱ779ȱ(7thȱCir.ȱ2008)ȱ(guardsȱcouldȱbeȱliableȱforȱdeȬ
layingȱtreatmentȱofȱbrokenȱnoseȱforȱaȱdayȱandȱhalf);ȱEdwardsȱ
v.ȱSnyder,ȱ478ȱF.3dȱ827,ȱ830–31ȱ(7thȱCir.ȱ2007)ȱ(aȱplaintiffȱwhoȱ
painfullyȱ dislocatedȱ hisȱ fingerȱ andȱ wasȱ needlesslyȱ deniedȱ
treatmentȱforȱtwoȱdaysȱstatedȱaȱclaimȱforȱdeliberateȱindifferȬ
ence).ȱOfȱcourse,ȱdelaysȱareȱcommonȱinȱtheȱprisonȱsettingȱwithȱ
limitedȱresources,ȱandȱwhetherȱtheȱlengthȱofȱaȱdelayȱisȱtoleraȬ
bleȱdependsȱonȱtheȱseriousnessȱofȱtheȱconditionȱandȱtheȱeaseȱ
ofȱprovidingȱtreatment.ȱCompareȱMillerȱv.ȱCampanella,ȱ794ȱF.3dȱ
878,ȱ880ȱ(7thȱCir.ȱ2015)ȱ(givenȱextremeȱeaseȱofȱsupplyingȱsufȬ
fererȱofȱgastroȬesophagealȱrefluxȱdiseaseȱwithȱoverȬtheȬcounȬ
terȱpills,ȱfailingȱtoȱdoȱsoȱforȱtwoȱmonthsȱcreatedȱfactȱquestionȱ
overȱ deliberateȱ indifference),ȱ Berry,ȱ 604ȱ F.3dȱ atȱ 441ȱ (findingȱ
refusalȱtoȱreferȱpatientȱtoȱaȱdentistȱactionableȱbecauseȱ“aȱbasicȱ
dentalȱ examinationȱ isȱ notȱ anȱ expensiveȱ orȱ unconventionalȱ
treatment,ȱnorȱisȱitȱesotericȱorȱexperimental”)ȱ(internalȱquotaȬ
tionȱmarksȱomitted),ȱArnett,ȱ658ȱF.3dȱatȱ752ȱ(medicalȱpersonȬ
nelȱcouldȱnotȱstandȱidlyȱbyȱforȱmoreȱthanȱtenȱmonthsȱwhileȱ
patient’sȱrheumatoidȱarthritisȱprogressivelyȱworsened),ȱSimek,ȱ
193ȱF.3dȱatȱ490ȱ(viableȱclaimȱwhereȱdoctorȱdelayedȱschedulingȱ
appointmentȱwithȱspecialistȱandȱthenȱfailedȱtoȱfollowȱspecialȬ
ist’sȱadvice,ȱwhileȱinmate’sȱconditionȱworsened);ȱRodriguezȱv.ȱ
Plymouthȱ Ambulanceȱ Serv.,ȱ 577ȱ F.3dȱ 816,ȱ 832ȱ (7thȱ Cir.ȱ 2009)ȱ
(stateȱ employeesȱ couldȱ beȱ liableȱ forȱ fourȬdayȱ delayȱ whereȱ
prisonerȱ complainedȱ hisȱ intravenousȱ therapyȱ wasȱ causingȱ
himȱpain),ȱwithȱGutierrezȱv.ȱPeters,ȱ111ȱF.3dȱ1364,ȱ1374ȱ(7thȱCir.ȱ
1997)ȱ(noȱvalidȱclaimȱforȱsixȬdayȱdelayȱinȱtreatingȱaȱmildȱcystȱ
infection).ȱToȱshowȱthatȱaȱdelayȱinȱprovidingȱtreatmentȱisȱacȬ
tionableȱunderȱtheȱEighthȱAmendment,ȱaȱplaintiffȱmustȱalsoȱ
provideȱindependentȱevidenceȱthatȱtheȱdelayȱexacerbatedȱtheȱ
injuryȱorȱunnecessarilyȱprolongedȱpain.ȱWilliamsȱv.ȱLiefer,ȱ491ȱ
F.3dȱ710,ȱ716ȱ(7thȱCir.ȱ2007)ȱ(delayȱactionableȱwhereȱmedicalȱ
12ȱ                                                       ȱNo.ȱ14Ȭ2674ȱ

recordsȱ showedȱ itȱ unnecessarilyȱ prolongedȱ plaintiff’sȱ painȱ
andȱ highȱ bloodȱpressure);ȱ Gilȱv.ȱReed,ȱ 381ȱF.3dȱ649,ȱ 662ȱ (7thȱ
Cir.ȱ2004)ȱ(hoursȱofȱneedlessȱsufferingȱcanȱconstituteȱharm).ȱȱ
     Theseȱ casesȱ bearȱ aȱ fewȱ notableȱ commonalities.ȱ Mostȱ ofȱ
themȱinvolveȱtreatment,ȱsometimesȱoverȱanȱextendedȱperiodȱ
ofȱtime.ȱButȱrepeatedly,ȱweȱhaveȱrejectedȱtheȱnotionȱthatȱtheȱ
provisionȱ ofȱ someȱ careȱ meansȱ theȱ doctorȱ providedȱ medicalȱ
treatmentȱwhichȱmeetsȱtheȱbasicȱrequirementsȱofȱtheȱEighthȱ
Amendment.ȱRather,ȱtheȱcontextȱsurroundingȱaȱdoctor’sȱtreatȬ
mentȱdecisionȱcanȱsometimesȱoverrideȱhisȱclaimedȱignoranceȱ
ofȱtheȱrisksȱstemmingȱfromȱthatȱdecision.ȱWhenȱaȱdoctorȱsaysȱ
heȱ didȱ notȱ realizeȱ hisȱ treatmentȱ decisionsȱ (orȱ lackȱ thereof)ȱ
couldȱ causeȱ seriousȱ harmȱ toȱ aȱ plaintiff,ȱ aȱ juryȱ isȱ entitledȱ toȱ
weighȱ thatȱ explanationȱ againstȱ certainȱ cluesȱ thatȱ theȱ doctorȱ
didȱknow.ȱThoseȱcontextȱcluesȱmightȱincludeȱtheȱexistenceȱofȱ
documentsȱ theȱ doctorȱ regularlyȱ consultedȱ whichȱ advisedȱ
againstȱhisȱcourseȱofȱtreatment,ȱevidenceȱthatȱtheȱpatientȱreȬ
peatedlyȱcomplainedȱofȱenduringȱpainȱwithȱnoȱmodificationsȱ
inȱcare,ȱinexplicableȱdelaysȱorȱdeparturesȱfromȱcommonȱmedȬ
icalȱstandards,ȱorȱofȱcourse,ȱtheȱdoctor’sȱownȱtestimonyȱthatȱ
indicatesȱknowledgeȱofȱnecessaryȱtreatmentȱheȱfailedȱtoȱproȬ
vide.ȱWhileȱevidenceȱofȱmalpracticeȱisȱnotȱenoughȱforȱaȱplainȬ
tiffȱtoȱsurviveȱsummaryȱjudgmentȱonȱanȱEighthȱAmendmentȱ
claim,ȱnorȱisȱaȱdoctor’sȱclaimȱheȱdidȱnotȱknowȱanyȱbetterȱsufȬ
ficientȱtoȱimmunizeȱhimȱfromȱliabilityȱinȱeveryȱcircumstance.ȱ
Otherwise,ȱprisonȱdoctorsȱwouldȱgetȱaȱfreeȱpassȱtoȱignoreȱprisȬ
oners’ȱ medicalȱ needsȱ byȱ hidingȱ behindȱ theȱ precedentȱ thatȱ
medicalȱ malpracticeȱ isȱ notȱ actionableȱ underȱ theȱ Eighthȱ
Amendment.ȱ Prisonersȱ areȱ notȱ entitledȱ toȱ stateȬofȬtheȱ artȱ
medicalȱtreatment.ȱButȱwhereȱevidenceȱexistsȱthatȱtheȱdefendȬ
antsȱknewȱbetterȱthanȱtoȱmakeȱtheȱmedicalȱdecisionsȱthatȱtheyȱ
No.ȱ14Ȭ2674ȱ                                                              ȱ13ȱ

did,ȱaȱjuryȱshouldȱdecideȱwhetherȱorȱnotȱtheȱdefendantsȱwereȱ
actuallyȱignorantȱtoȱriskȱofȱtheȱharmȱthatȱtheyȱcaused.ȱ
   WeȱnowȱturnȱourȱattentionȱtoȱPetties’sȱclaimsȱagainstȱhisȱ
doctors.ȱ
     A. Materialȱ Factualȱ Disputeȱ Existsȱ asȱ toȱ Whetherȱ Dr.ȱ
        CarterȱWasȱDeliberatelyȱIndifferentȱ
     Petties’sȱ principalȱ claimsȱ againstȱ Dr.ȱ Carterȱ areȱ thatȱ heȱ
actedȱwithȱdeliberateȱindifferenceȱtoȱhisȱinjuryȱwhenȱheȱfailedȱ
toȱ immobilizeȱ Petties’sȱ rupturedȱ tendonȱ forȱ sixȱ weeks,ȱ deȬ
layedȱPetties’sȱappointmentȱwithȱaȱspecialist,ȱandȱrefusedȱtoȱ
orderȱsurgeryȱtoȱrepairȱtheȱtendon.3ȱ
    Dr.ȱCarter’sȱdeposition,ȱasȱwellȱasȱStateville’sȱmedicalȱrecȬ
ords,ȱconfirmȱthatȱDr.ȱCarter’sȱinitialȱdiagnosisȱofȱPetties’sȱinȬ
juryȱwasȱanȱAchillesȱtear.ȱDr.ȱCarterȱalsoȱtestifiedȱthatȱtheȱapȬ
propriateȱtreatmentȱforȱaȱcompleteȱAchillesȱruptureȱisȱtoȱimȬ
mobilizeȱtheȱankle,ȱputȱitȱinȱaȱnonȬweightȱbearingȱstatus,ȱandȱ
prescribeȱantiȬinflammatoryȱdrugsȱandȱpassiveȱstretchingȱexȬ
ercises.ȱHeȱexplainedȱtheȱpurposeȱofȱimmobilization,ȱstating,ȱ
“inȱtheȱacuteȱphaseȱofȱhealing,ȱyouȱareȱgeneratingȱanȱimmuneȱ
systemȱresponseȱinȱtheȱbody,”ȱandȱwhenȱaskedȱifȱkeepingȱtheȱ
tendonȱinȱoneȱplaceȱenablesȱthisȱhealingȱprocessȱtoȱgoȱforwardȱ
favorably,ȱheȱreplied,ȱ“Correct.ȱAndȱifȱyou’reȱcontinuouslyȱinȬ
juringȱ it,ȱ itȱ hindersȱ thatȱ process.”ȱ Heȱ alsoȱ testifiedȱ thatȱ forȱ



ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
3 We reject the dissent’s characterization of Petties’s claims against both of
his doctors as a challenge to the quality of his medical care. Rather, Petties
argued that his doctors’ treatment decisions—and their harmful conse-
quences—supported his claim that the defendants deliberately refused to
pursue care they knew he needed. Petties has never argued that his doc-
tors’ poor care by itself violated the Eighth Amendment.
14ȱ                                                         ȱNo.ȱ14Ȭ2674ȱ

bothȱpartialȱandȱcompleteȱAchillesȱruptures,ȱheȱwouldȱalwaysȱ
immobilizeȱtheȱtendon.ȱȱ
    Dr.ȱ Carter’sȱ opinionȱ wasȱ consistentȱ withȱ theȱ depositionȱ
testimonyȱofȱPetties’sȱorthopedicȱspecialist,ȱDr.ȱPuppala,ȱwhoȱ
testifiedȱthatȱheȱwouldȱalwaysȱimmobilizeȱaȱrupturedȱAchillesȱ
tendon,ȱunlessȱtheȱinjuryȱhadȱanȱopenȱsoreȱthatȱneededȱtoȱbeȱ
addressedȱ first.ȱ Itȱwasȱ alsoȱconsistentȱwithȱ theȱtestimonyȱofȱ
Dr.ȱChmell,ȱtheȱankleȱspecialistȱwhoȱtreatedȱPettiesȱafterȱDr.ȱ
CarterȱhadȱleftȱStateville.ȱHeȱtestifiedȱthatȱimmobilizationȱisȱ
essentialȱtoȱtheȱhealingȱofȱanȱAchillesȱtendon,ȱandȱthatȱhealingȱ
withoutȱimmobilizationȱisȱ“possibleȱbutȱnotȱveryȱlikely.”4ȱAndȱ
finally,ȱWexford’sȱownȱprotocol,ȱwhichȱDr.ȱCarterȱtestifiedȱheȱ
wasȱ responsibleȱ forȱ implementing,ȱ statedȱ thatȱ theȱ primaryȱ
courseȱofȱtreatmentȱforȱanȱAchillesȱruptureȱincludedȱaȱsplint.ȱ
Dr.ȱCarterȱalsoȱtestifiedȱheȱwasȱnotȱawareȱofȱanyȱshortageȱofȱ
splintsȱatȱStatevilleȱduringȱtheȱtimeȱthatȱheȱwasȱtreatingȱPetȬ
ties.ȱ
    Together,ȱtheseȱpiecesȱofȱcircumstantialȱevidenceȱsupportȱ
aȱreasonableȱinferenceȱthatȱDr.ȱCarterȱknewȱthatȱfailureȱtoȱimȬ
mobilizeȱanȱAchillesȱruptureȱwouldȱimpedeȱPetties’sȱrecoveryȱ
andȱprolongȱhisȱpain.ȱItȱisȱcertainlyȱtrueȱthatȱDr.ȱCarter’sȱdeciȬ
sionȱ notȱ toȱ immobilizeȱ Petties’sȱ ankleȱ couldȱ haveȱ beenȱ anȱ
oversight,ȱorȱaȱfundamentalȱmisunderstandingȱofȱtheȱproperȱ
courseȱofȱtreatment.ȱSomeȱofȱhisȱtestimonyȱsuggestsȱthatȱheȱ
believedȱcrutchesȱservedȱtheȱsameȱpurposeȱasȱaȱboot.ȱButȱthatȱ
testimonyȱconflictsȱwithȱotherȱpartsȱofȱhisȱdepositionȱthatȱexȬ
plainedȱtheȱdistinctȱpurposeȱofȱimmobilization,ȱwhichȱisȱnotȱ
ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ
4 We are puzzled by the dissent’s proposition that the care Petties received
did not worsen his condition because his health eventually improved. We
do not ascribe to the view that the eventual resolution of a long-ignored
medical issue establishes compliance with the Eighth Amendment.
No.ȱ14Ȭ2674ȱ                                                        ȱ15ȱ

toȱpreventȱbearingȱweightȱonȱtheȱinjuredȱfoot,ȱbutȱtoȱkeepȱtheȱ
rupturedȱtendonȱinȱoneȱplace.ȱItȱalsoȱconflictsȱwithȱtheȱtestiȬ
monyȱofȱtheȱotherȱdoctorsȱwhoȱtreatedȱPetties.ȱAȱjuryȱcouldȱ
alsoȱfindȱsuspiciousȱthatȱDr.ȱCarterȱdidȱnotȱprovideȱtheȱbootȱ
untilȱanȱoutsideȱdoctorȱdocumentedȱtheȱimportanceȱofȱimmoȬ
bilizationȱinȱwriting.ȱAȱreasonableȱinferenceȱtoȱdrawȱfromȱthisȱ
evidenceȱisȱthatȱDr.ȱCarterȱwasȱawareȱofȱtheȱneedȱforȱimmobiȬ
lizingȱaȱrupturedȱtendon,ȱbutȱsimplyȱdecidedȱnotȱtoȱuntilȱheȱ
cameȱunderȱscrutiny.ȱAlso,ȱaȱjuryȱcouldȱreasonablyȱconcludeȱ
thatȱDr.ȱCarter’sȱdecisionȱcausedȱsubstantialȱharm—Petties’sȱ
affidavitȱstatedȱthatȱwithoutȱaȱsplint,ȱheȱhadȱnothingȱtoȱkeepȱ
hisȱ ankleȱ fromȱ movingȱ around,ȱ whichȱ madeȱ himȱ feelȱ “conȬ
stant,ȱ severeȱ pain”ȱ wheneverȱ heȱ gotȱ upȱ toȱ walk,ȱ andȱ madeȱ
sleepingȱdifficult.ȱ
    BesidesȱDr.ȱCarter’sȱfailureȱtoȱimmobilizeȱhisȱfoot,ȱPettiesȱ
alsoȱclaimsȱthatȱDr.ȱCarterȱwasȱresponsibleȱ forȱ theȱ sixȬweekȱ
delayȱ inȱ seeingȱ Dr.ȱ Puppalaȱ toȱ confirmȱ Petties’sȱ diagnosis,ȱ
whichȱisȱwhenȱheȱfinallyȱreceivedȱaȱboot.ȱAsȱanȱinitialȱmatter,ȱ
Pettiesȱhasȱprovidedȱcorroboratingȱmedicalȱevidenceȱthatȱtheȱ
delayȱ hadȱ aȱ detrimentalȱ effectȱ onȱ hisȱ conditionȱ throughȱ Dr.ȱ
Puppala’sȱtreatmentȱnotes,ȱwhichȱindicateȱPettiesȱwasȱsufferȬ
ingȱ painȱ andȱ gappingȱ atȱ theȱ ruptureȱ siteȱ dueȱ toȱ theȱ lackȱ ofȱ
immobilization.ȱThisȱfindingȱisȱconsistentȱwithȱPetties’sȱownȱ
testimonyȱthatȱheȱwasȱinȱconstantȱandȱsevereȱpainȱwhileȱheȱ
waitedȱtoȱseeȱaȱspecialist.ȱ
    Dr.ȱCarterȱarguesȱthatȱtheȱdelayȱwasȱattributableȱtoȱprisonȱ
lockȬdowns,ȱwhichȱbarredȱvisitsȱtoȱoutsideȱspecialistsȱunlessȱ
heȱ issuedȱ anȱ emergencyȱ overrideȱ orderȱ whichȱ allowedȱ paȬ
tientsȱ toȱ receiveȱ emergencyȱ care.ȱ Butȱ immobilizationȱ couldȱ
haveȱalleviatedȱPetties’sȱpainȱwhileȱheȱwaited,ȱsoȱthisȱexplanaȬ
16ȱ                                                     ȱNo.ȱ14Ȭ2674ȱ

tionȱdoesȱnotȱresolveȱDr.ȱCarter’sȱtestimonyȱthatȱheȱwasȱunaȬ
wareȱ ofȱ anyȱ shortageȱ ofȱ splintsȱ atȱ Statevilleȱ duringȱ theȱ sixȱ
weeksȱthatȱPettiesȱsufferedȱsevereȱpainȱwhileȱwaitingȱtoȱseeȱ
Dr.ȱPuppala.ȱItȱalsoȱdoesȱnotȱexplainȱwhyȱDr.ȱCarterȱdidȱnotȱ
viewȱPetties’sȱsituationȱasȱanȱ“emergency”ȱasȱcomparedȱwithȱ
otherȱseriousȱinjuries.ȱTheȱharmȱstemmingȱfromȱtheȱdelayȱinȱ
receivingȱtheȱbootȱwouldȱhaveȱbeenȱavoidedȱbyȱsendingȱPetȬ
tiesȱtoȱtheȱemergencyȱroomȱsoȱheȱcouldȱgetȱanȱMRI.ȱAndȱtheȱ
harmȱfromȱtheȱdelayȱinȱseeingȱaȱspecialistȱwouldȱhaveȱbeenȱ
mitigatedȱbyȱsplintingȱPetties’sȱfootȱwhileȱsecurityȱissuesȱwereȱ
resolved.ȱTheȱdelayȱofȱboth,ȱwithoutȱ aȱ clearȱ justificationȱ forȱ
either,ȱ doomsȱ Dr.ȱ Carter’sȱ argumentȱ thatȱ Petties’sȱ sufferingȱ
wasȱunavoidable.ȱOnȱthisȱrecord,ȱwhetherȱtheȱdelayȱwasȱtheȱ
resultȱofȱnegligenceȱorȱdeliberateȱindifferenceȱisȱaȱquestionȱforȱ
theȱjuryȱtoȱdecide.ȱ
    Finally,ȱ Pettiesȱ arguesȱ thatȱ Dr.ȱ Carterȱ shouldȱ haveȱ folȬ
lowedȱ Dr.ȱ Puppala’sȱ recommendationȱ toȱ exploreȱ surgeryȱ asȱ
anȱoption.ȱButȱPettiesȱdidȱnotȱproduceȱmedicalȱevidenceȱconȬ
firmingȱthatȱheȱwouldȱhaveȱbenefitedȱfromȱsurgery,ȱandȱwhenȱ
heȱvisitedȱDr.ȱChmellȱinȱJulyȱ2012,ȱhisȱtendonȱshowedȱsignsȱofȱ
improvement.ȱ However,ȱ Petties’sȱ contentionȱ thatȱ Dr.ȱ Carterȱ
saidȱsurgeryȱwouldȱbeȱ“tooȱexpensive”ȱisȱaȱpieceȱofȱcircumȬ
stantialȱ evidenceȱ thatȱ aȱ juryȱ couldȱ viewȱ asȱ supportingȱ hisȱ
otherȱclaims.ȱIfȱaȱjuryȱbelievesȱthatȱDr.ȱCarterȱcitedȱcostȱasȱaȱ
reasonȱforȱrefusingȱoneȱformȱofȱtreatment,ȱthenȱ itȱwouldȱbeȱ
reasonableȱtoȱinferȱthatȱDr.ȱCarterȱmadeȱotherȱmedicalȱdeciȬ
sionsȱinȱPetties’sȱcaseȱ—ȱfailingȱtoȱsplintȱhisȱfoot,ȱnotȱissuingȱ
anȱemergencyȱoverrideȱorderȱsoȱheȱcouldȱseeȱaȱspecialistȱ—ȱ
thatȱ wereȱ dictatedȱ byȱ cost,ȱ administrativeȱ convenience,ȱ orȱ
both,ȱratherȱthanȱmedicalȱjudgment.ȱȱ
No.ȱ14Ȭ2674ȱ                                                       ȱ17ȱ

  Pettiesȱ hasȱ providedȱ sufficientȱ evidenceȱ toȱ surviveȱ sumȬ
maryȱjudgmentȱonȱhisȱ§ȱ1983ȱclaimsȱagainstȱDr.ȱCarter.ȱ
   B. Materialȱ Factualȱ Disputeȱ Existsȱ asȱ toȱ Whetherȱ Dr.ȱ
      ObaisiȱWasȱDeliberatelyȱIndifferentȱ
     PettiesȱalsoȱarguesȱthatȱDr.ȱObaisiȱwasȱdeliberatelyȱindifȬ
ferentȱ whenȱ heȱ refusedȱ toȱ orderȱ physicalȱ therapyȱ afterȱ Dr.ȱ
Chmellȱ orderedȱ it.ȱ Dr.ȱ Obaisiȱ respondsȱ thatȱ Pettiesȱ didȱ notȱ
needȱaȱphysicalȱtherapistȱbecauseȱheȱalreadyȱknewȱwhichȱexȬ
ercisesȱtoȱuseȱfromȱaȱpriorȱAchillesȱinjury.ȱHeȱalsoȱarguesȱthatȱ
Pettiesȱcouldȱhaveȱwalkedȱonȱhisȱinjuredȱankleȱtoȱstrengthenȱ
it.ȱ
    TheȱproblemȱwithȱDr.ȱObaisi’sȱargumentsȱisȱthatȱtheyȱareȱ
totallyȱatȱoddsȱwithȱtheȱevidenceȱinȱthisȱcase.ȱHeȱtestifiedȱthatȱ
heȱalwaysȱfollowsȱtheȱadviceȱofȱspecialists,ȱthatȱPetties’sȱspeȬ
cialistȱrecommendedȱphysicalȱtherapy,ȱandȱthatȱheȱdidȱnotȱorȬ
derȱ physicalȱ therapyȱ forȱ Petties.ȱ Toȱ justifyȱ thisȱ questionableȱ
decision,ȱheȱstatesȱthatȱPettiesȱknewȱwhatȱtoȱdoȱbasedȱonȱpriorȱ
physicalȱtherapy.ȱThisȱisȱclearlyȱaȱpostȬhocȱrationalization,ȱbeȬ
causeȱheȱalsoȱtestifiedȱheȱdidȱnotȱknowȱwhetherȱPettiesȱhadȱ
previouslyȱundergoneȱphysicalȱtherapyȱatȱtheȱtimeȱthatȱheȱdeȬ
cidedȱtoȱrefuseȱhimȱphysicalȱtherapy.ȱAndȱfinally,ȱhisȱcontenȬ
tionȱ thatȱ walkingȱ onȱ anȱ injuryȱ isȱ theȱ equivalentȱ ofȱ physicalȱ
therapyȱisȱunsupportedȱbyȱanyȱmedicalȱevidence,ȱandȱstrainsȱ
evenȱaȱlayȱperson’sȱunderstandingȱofȱhowȱtoȱtreatȱanȱinjury.ȱ
Professionalȱjudgmentȱisȱneededȱtoȱdetermineȱwhether,ȱwhenȱ
andȱ howȱ muchȱ exertionȱ willȱ healȱ ratherȱ thanȱ aggravateȱ theȱ
injury.ȱAndȱaȱreasonableȱjuryȱcouldȱfindȱleavingȱaȱpatientȱtoȱ
makeȱthisȱdeterminationȱbyȱhimselfȱcarriedȱanȱimpermissibleȱ
andȱunjustifiableȱriskȱofȱpainȱandȱprolongedȱrecovery.ȱAtȱtheȱ
veryȱleast,ȱPettiesȱhasȱtheȱrightȱforȱaȱjuryȱtoȱhearȱDr.ȱObaisi’sȱ
justificationsȱforȱhisȱtreatmentȱdecisionsȱ(orȱlackȱthereof)ȱandȱ
18ȱ                                                 ȱNo.ȱ14Ȭ2674ȱ

toȱdetermineȱifȱDr.ȱObaisiȱwasȱdeliberatelyȱindifferent,ȱratherȱ
thanȱsimplyȱincompetent,ȱinȱtreatingȱhisȱinjury.ȱ
      C. Qualifiedȱ Immunityȱ Inappropriateȱ atȱ Summaryȱ
         JudgmentȱStageȱ
    Whileȱtheȱdistrictȱcourtȱdidȱnotȱreachȱtheȱissue,ȱinȱtheȱproȬ
ceedingsȱbelow,ȱtheȱdefendantsȱpursuedȱtheȱadditionalȱarguȬ
mentȱthatȱtheyȱwereȱentitledȱtoȱqualifiedȱimmunity.ȱButȱevenȱ
assumingȱ theȱ defendantsȱ preservedȱ thisȱ argument,ȱ ifȱ aȱ juryȱ
findsȱthatȱDr.ȱCarterȱandȱDr.ȱObaisiȱknewȱthatȱtheȱcourseȱofȱ
treatmentȱ theyȱ wereȱ pursuingȱ wasȱ inadequateȱ toȱ meetȱ PetȬ
ties’sȱseriousȱmedicalȱneeds,ȱsuchȱconductȱviolatesȱclearlyȱesȬ
tablishedȱlawȱunderȱtheȱEighthȱAmendment.ȱSeeȱFarmer,ȱ511ȱ
U.S.ȱatȱ837.ȱGivenȱthatȱtheȱthresholdȱfactualȱquestionsȱofȱtheȱ
defendants’ȱstatesȱofȱmindȱremainȱdisputed,ȱsummaryȱjudgȬ
mentȱonȱtheȱbasisȱofȱqualifiedȱimmunityȱisȱinappropriate.ȱSeeȱ
DuFourȬDowellȱv.ȱCogger,ȱ152ȱF.3dȱ678,ȱ680ȱ(7thȱCir.ȱ1998).ȱ
                      III.ȱCONCLUSIONȱ
   Forȱtheȱforegoingȱreasons,ȱweȱREVERSEȱtheȱdistrictȱcourt’sȱ
grantȱ ofȱ summaryȱ judgmentȱ andȱ REMANDȱ forȱ furtherȱ proȬ
ceedings.ȱ
No.ȱ14Ȭ2674ȱ                                                         19ȱ

    EASTERBROOK,ȱCircuitȱJudge,ȱjoinedȱbyȱFLAUMȱandȱKANNE,ȱ
CircuitȱJudges,ȱdissenting.ȱMyȱcolleaguesȱtakeȱitȱasȱestablishedȱ
thatȱtheȱConstitutionȱentitledȱPettiesȱtoȱanȱorthopedicȱboot,ȱorȱ
someȱotherȱmeansȱtoȱimmobilizeȱhisȱfoot,ȱimmediatelyȱafterȱ
hisȱinjury.ȱTheyȱremandȱforȱaȱtrialȱatȱwhichȱaȱjuryȱmustȱdeterȬ
mineȱwhetherȱtheȱdefendantsȱwereȱdeliberatelyȱindifferentȱtoȱ
theȱpainȱhisȱrupturedȱAchillesȱtendonȱcaused.ȱThisȱapproachȱ
effectivelyȱbypassesȱoneȱofȱtheȱtwoȱissuesȱthatȱmatterȱtoȱanyȱ
claimȱunderȱtheȱCruelȱandȱUnusualȱPunishmentsȱClause:ȱfirstȱ
thereȱmustȱbeȱaȱcruelȱandȱunusualȱpunishment,ȱandȱonlyȱthenȱ
doesȱitȱmatterȱwhetherȱtheȱdefendantȱactedȱwithȱtheȱmentalȱ
stateȱ necessaryȱ forȱ liabilityȱ inȱ damages.ȱ See,ȱ e.g.,ȱ Hellingȱ v.ȱ
McKinney,ȱ509ȱU.S.ȱ25ȱ(1993).ȱAȱcourtȱshouldȱbeginȱwithȱtheȱ
conductȱissueȱandȱturnȱtoȱmentalȱstatesȱonlyȱifȱtheȱbehaviorȱ
wasȱobjectivelyȱcruelȱandȱunusual.ȱAndȱEstelleȱv.ȱGamble,ȱ429ȱ
U.S.ȱ97ȱ(1976),ȱtheȱSupremeȱCourt’sȱsoleȱdecisionȱaddressingȱ
theȱquestionȱwhetherȱpalliativeȱmedicalȱtreatmentȱ(painȱreliefȱ
withoutȱ anȱ effortȱ atȱ cure)ȱ violatesȱ theȱ Eighthȱ Amendment,ȱ
holdsȱthatȱpalliationȱsufficesȱevenȱifȱtheȱcareȱisȱwoefullyȱdefiȬ
cient.ȱ
    ToȱunderstandȱtheȱSupremeȱCourt’sȱconclusionȱthatȱmediȬ
calȱmalpracticeȱisȱaȱproblemȱunderȱstateȱlawȱratherȱthanȱtheȱ
Constitution,ȱitȱhelpsȱtoȱstartȱwithȱtheȱfactsȱofȱEstelle,ȱwhichȱ
mayȱbeȱfoundȱinȱtheȱFifthȱCircuit’sȱopinion,ȱGambleȱv.ȱEstelle,ȱ
516ȱF.2dȱ937ȱ(5thȱCir.ȱ1975),ȱasȱwellȱasȱtheȱSupremeȱCourt’s.ȱ
Gambleȱallegedȱthatȱaȱ600Ȭpoundȱbaleȱhadȱfallenȱonȱhimȱandȱ
injuredȱ hisȱ back,ȱ leavingȱ himȱ inȱ painȱ soȱ severeȱ thatȱ heȱ freȬ
quentlyȱ faintedȱ (hisȱ complaintȱ calledȱ theȱ episodesȱ “blankȬ
outs”).ȱHeȱvisitedȱtheȱprisonȱinfirmaryȱandȱreceivedȱmedicineȱ
designedȱtoȱdullȱtheȱpain.ȱWhenȱheȱsaidȱthatȱthisȱdidȱnotȱwork,ȱ
andȱthatȱtheȱpainȱandȱblackoutsȱwereȱcontinuing,ȱtheȱprisonȱ
gaveȱhimȱmoreȱofȱtheȱsameȱmedicine.ȱWhenȱheȱsaidȱthatȱhisȱ




    ȱ
20ȱ                                                        No.ȱ14Ȭ2674ȱ

painȱpreventedȱhimȱfromȱworking,ȱheȱwasȱtreatedȱasȱaȱshirkerȱ
andȱthrownȱintoȱsolitaryȱconfinement.ȱAlthoughȱtheȱprison’sȱ
medicalȱstaffȱstuckȱtoȱineffectiveȱmedication,ȱitȱdidȱnothingȱtoȱ
findȱoutȱwhatȱkindȱofȱinjuryȱGambleȱhadȱsufferedȱandȱhowȱ
theȱproblemȱmightȱbeȱfixed.ȱ
    TheȱFifthȱCircuitȱruledȱthatȱGambleȱhadȱestablishedȱaȱconȬ
stitutionalȱclaim,ȱbecauseȱ“theȱStateȱhasȱtotallyȱfailedȱtoȱproȬ
videȱadequateȱtreatmentȱofȱ[his]ȱcondition.ȱAgainȱandȱagain,ȱasȱ
theȱ complaintȱ makesȱ clear,ȱ theȱ onlyȱ medicationȱ prescribedȱ
wasȱtoȱrelieveȱtheȱpain,ȱnotȱtoȱcureȱtheȱinjury;ȱindeed,ȱtheȱexactȱ
natureȱofȱtheȱbackȱinjuryȱremainsȱunknown.”ȱ516ȱF.2dȱatȱ941ȱ
(emphasisȱadded).ȱTheȱFifthȱCircuitȱthoughtȱthatȱtheȱConstiȬ
tutionȱrequiresȱnotȱonlyȱpalliationȱbutȱalsoȱaȱmedicallyȱcomȬ
petentȱeffortȱtoȱcure,ȱstartingȱwithȱanȱxȬray,ȱaȱdiagnosticȱproȬ
cedureȱthatȱtheȱprisonȱhadȱnotȱemployed.ȱ
    Theȱreaderȱofȱtoday’sȱmajorityȱopinionȱwouldȱsupposeȱthatȱ
theȱ Supremeȱ Courtȱ affirmedȱ theȱ Fifthȱ Circuit’sȱ demandȱ forȱ
competentȱcare.ȱButȱthat’sȱnotȱwhatȱhappened.ȱTheȱSupremeȱ
CourtȱreversedȱandȱheldȱthatȱpalliationȱsatisfiesȱtheȱConstituȬ
tion,ȱevenȱifȱtheȱprison’sȱmedicalȱstaffȱdoesȱnotȱtryȱtoȱdeterȬ
mineȱ howȱ painȱ isȱ beingȱ causedȱandȱ whatȱ mightȱ beȱ doneȱ toȱ
cureȱ it.ȱ Thatȱ someȱcareȱ wasȱ givenȱ wasȱ enough.ȱ Theȱ Justicesȱ
saidȱthatȱdeliberateȱindifferenceȱtoȱaȱprisoner’sȱpainȱviolatesȱ
theȱ Constitutionȱ ifȱ itȱ leadsȱ theȱ staffȱ toȱ doȱ nothing,ȱ butȱ thatȱ
medicalȱ careȱ meetsȱ theȱ constitutionalȱ standard.ȱ Gambleȱ reȬ
ceivedȱcare.ȱHeȱreceivedȱwretchedȱcare,ȱbutȱtheȱCourtȱheldȱthatȱ
aȱclaimȱbasedȱonȱdeficientȱcareȱdependsȱonȱstateȱmedicalȬmalȬ
practiceȱlaw.ȱ429ȱU.S.ȱatȱ107ȱ&ȱn.15.ȱTheȱJusticesȱdisapprovedȱ
theȱ Fifthȱ Circuit’sȱ conclusionȱ thatȱ theȱ Constitutionȱ entitlesȱ
prisonersȱtoȱ“adequate”ȱcare.ȱ




      ȱ
No.ȱ14Ȭ2674ȱ                                                      21ȱ

     Ourȱinitialȱquestionȱthereforeȱoughtȱtoȱbe:ȱDidȱtheȱdefendȬ
antsȱprovideȱPettiesȱwithȱmedicalȱcare?ȱThatȱquestionȱisȱeasilyȱ
answered.ȱ Pettiesȱ concedesȱ thatȱ heȱ receivedȱ medicalȱ care—
quiteȱaȱlotȱofȱit.ȱTheȱmajorityȱopinionȱoutlinesȱtheȱbasics.ȱInȱ
Januaryȱ2012ȱDr.ȱImhotepȱCarterȱcorrectlyȱdiagnosedȱaȱrupȬ
turedȱAchillesȱtendonȱandȱgaveȱPettiesȱcrutches,ȱice,ȱandȱViȬ
codinȱ(aȱpainȬreducingȱdrug).ȱHeȱreferredȱPettiesȱtoȱaȱspecialȬ
ist.ȱInȱMarchȱ2012ȱanȱMRIȱexamȱconfirmedȱCarter’sȱdiagnosis.ȱ
Dr.ȱAnujȱPuppala,ȱanȱorthopedist,ȱgaveȱPettiesȱanȱorthopedicȱ
bootȱtoȱreduceȱmotionȱofȱtheȱfootȱ(inȱrelationȱtoȱtheȱtendon)ȱ
whenȱheȱwalked.ȱCarterȱauthorizedȱtheȱuseȱofȱtheȱbootȱinȱtheȱ
prison,ȱassignedȱPettiesȱtoȱaȱlowerȱbunk,ȱandȱcontinuedȱtheȱ
iceȱandȱdrugȱtreatments.ȱInȱJulyȱ2012ȱCarterȱreferredȱPettiesȱtoȱ
Dr.ȱ Samuelȱ Chmell,ȱ anȱ ankleȱ specialistȱ whoȱ recommendedȱ
physicalȱtherapy,ȱstretching,ȱandȱanotherȱMRI.ȱAfterȱreplacingȱ
CarterȱasȱStateville’sȱmedicalȱdirector,ȱDr.ȱSalehȱObaisiȱcontinȬ
uedȱtheȱcourseȱofȱtreatmentȱthatȱPettiesȱwasȱreceiving,ȱincludȬ
ingȱuseȱofȱtheȱboot.ȱTheȱsecondȱMRI,ȱwhichȱObaisiȱapproved,ȱ
showedȱpartialȱhealing.ȱ
    PettiesȱmaintainsȱthatȱCarterȱandȱObaisiȱshouldȱhaveȱdoneȱ
more—thatȱCarterȱshouldȱhaveȱprovidedȱanȱorthopedicȱbootȱ
inȱJanuaryȱ2012ȱratherȱthanȱwaitingȱuntilȱPettiesȱsawȱPuppalaȱ
inȱ March,ȱ andȱ shouldȱ haveȱ authorizedȱ surgery;ȱ thatȱ Obaisiȱ
shouldȱhaveȱauthorizedȱphysicalȱtherapyȱinȱadditionȱtoȱorderȬ
ingȱ anotherȱ MRIȱ andȱcontinuingȱ theȱ treatmentȱ alreadyȱ proȬ
videdȱ (theȱ boot,ȱ theȱ lowerȱ bunk,ȱ andȱ soȱ on).ȱ Nonetheless,ȱ
thereȱcanȱbeȱnoȱquestionȱthatȱPettiesȱreceivedȱmore,ȱandȱbetȬ
ter,ȱ medicalȱ careȱ thanȱ Gambleȱ received.ȱ Yetȱ Gambleȱ lostȱ onȱ
theȱpleadings.ȱ
   Estelleȱ holdsȱ thatȱ aȱ claimȱ ofȱ deficientȱ medicalȱ careȱ mustȱ
proceedȱunderȱstateȱlawȱratherȱthanȱtheȱConstitution.ȱWhenȱ




   ȱ
22ȱ                                                     No.ȱ14Ȭ2674ȱ

theȱprisonȱ providesȱ noȱcareȱforȱaȱseriousȱmedicalȱcondition,ȱ
thatȱcountsȱasȱcruelȱandȱunusualȱpunishmentȱifȱtheȱphysiciansȱ
orȱotherȱresponsibleȱactorsȱareȱdeliberatelyȱindifferentȱtoȱtheȱ
condition.ȱ(Farmerȱv.ȱBrennan,ȱ511ȱU.S.ȱ825ȱ(1994),ȱsuppliesȱtheȱ
Court’sȱdefinitionȱofȱ“deliberateȱindifference”.)ȱEstelleȱrecogȬ
nizedȱoneȱmoreȱpotentialȱcategory:ȱharmfulȱinterventions.ȱ429ȱ
U.S.ȱatȱ104ȱ&ȱn.10.ȱButȱPettiesȱdoesȱnotȱcontendȱthatȱtheȱcareȱ
heȱreceivedȱfromȱCarterȱandȱObaisiȱmadeȱhisȱconditionȱworse,ȱ
comparedȱwithȱnoȱcareȱatȱall.ȱ
    Notesȱ10ȱandȱ12ȱofȱEstelleȱsuggestȱaȱpotentialȱwayȱtoȱdisȬ
tinguishȱ malpracticeȱ fromȱ aȱ violationȱ ofȱ theȱ Constitution:ȱ
whetherȱtheȱprison’sȱstaffȱexercisedȱmedicalȱjudgment.ȱPettiesȱ
doesȱnotȱpursueȱthisȱpossibility;ȱheȱdoesȱnotȱdenyȱthatȱtheȱdeȬ
fendantsȱexercisedȱmedicalȱjudgment.ȱInsteadȱheȱinsistsȱthatȱ
theyȱexercisedȱbadȱmedicalȱjudgment,ȱleadingȱtoȱinferiorȱcare.ȱ
AndȱEstelleȱholdsȱthatȱaȱclaimȱofȱpoorȱcareȱmustȱbeȱclassifiedȱ
underȱtheȱlawȱofȱmedicalȱmalpractice.ȱ(Pettiesȱcomplainsȱthatȱ
CarterȱandȱObaisiȱdeemedȱsurgeryȱandȱrehabilitativeȱtherapyȱ
tooȱ expensive,ȱ butȱ askingȱ whetherȱ aȱ potentialȱ treatmentȱ isȱ
costȬjustifiedȱisȱpartȱofȱprofessionalȱjudgment.ȱOutsideȱofȱprisȬ
ons,ȱsolventȱpatientsȱandȱtheirȱinsurers,ȱasȱwellȱasȱphysicians,ȱ
routinelyȱconsiderȱwhetherȱaȱparticularȱdrugȱorȱmedicalȱproȬ
cedureȱisȱworthȱtheȱprice.)ȱ
    Atȱ leastȱ threeȱ circuitsȱ askȱ whetherȱ theȱ prisonerȱ receivedȱ
someȱtreatment,ȱratherȱthanȱwhetherȱtheȱtreatmentȱwasȱinfeȬ
riorȱ (evenȱ grosslyȱ deficient).ȱ See,ȱ e.g.,ȱ Inmatesȱ ofȱ Alleghenyȱ
CountyȱJailȱv.ȱPierce,ȱ612ȱF.2dȱ754,ȱ762ȱ(3dȱCir.ȱ1979);ȱDurmerȱv.ȱ
O’Carroll,ȱ991ȱF.2dȱ64,ȱ68–69ȱ(3dȱCir.ȱ1993);ȱSelfȱv.ȱCrum,ȱ439ȱ
F.3dȱ1227,ȱ1230–33ȱ(10thȱCir.ȱ2006)ȱ(discussingȱotherȱcasesȱinȱ
theȱcircuit);ȱFarmerȱv.ȱMoritsugu,ȱ163ȱF.3dȱ610,ȱ614–16ȱ(D.C.ȱCir.ȱ
1998).ȱToday’sȱdecisionȱisȱincompatibleȱwithȱtheȱapproachȱofȱ




      ȱ
No.ȱ14Ȭ2674ȱ                                                           23ȱ

thoseȱcircuits,ȱthoughȱitȱhasȱsupportȱinȱdecisionsȱofȱtheȱNinthȱ
Circuit.ȱSee,ȱe.g.,ȱSnowȱv.ȱMcDaniel,ȱ681ȱF.3dȱ978ȱ(9thȱCir.ȱ2012);ȱ
Hamiltonȱv.ȱEndell,ȱ981ȱF.2dȱ1062,ȱ1066–67ȱ(9thȱCir.ȱ1992).ȱTheȱ
FirstȱCircuitȱmayȱhaveȱanȱintraȬcircuitȱconflict.ȱCompareȱPerryȱ
v.ȱRoy,ȱ 782ȱF.3dȱ73ȱ(1stȱ Cir.ȱ2015),ȱwithȱFeeneyȱ v.ȱ Correctionalȱ
MedicalȱServices,ȱInc.,ȱ464ȱF.3dȱ158ȱ(1stȱCir.ȱ2006).ȱStillȱotherȱcirȬ
cuitsȱareȱhardȱtoȱclassify.ȱ
    MyȱcolleaguesȱsayȱthatȱprisonersȱareȱentitledȱtoȱreliefȱunȬ
derȱ theȱ Eighthȱ Amendmentȱ whenȱ prisonȱ physiciansȱ doȱ notȱ
employȱ “competentȱ medicalȱ judgment”ȱ (opinionȱ atȱ 8)ȱ orȱ
“minimallyȱ competentȱ medicalȱ judgment”ȱ (id.ȱ atȱ 9).ȱ Thatȱ
tracksȱ stateȱ tortȱ lawȱ andȱ isȱ incompatibleȱ withȱ Estelle.ȱ Otherȱ
phrasesȱinȱtheȱopinion,ȱsuchȱasȱ“professionalȱjudgment”ȱ(id.ȱ
atȱ10ȱandȱ17)ȱandȱ“reasonableȱmedicalȱjudgment”ȱ(id.ȱatȱ10)ȱ
alsoȱseemȱtoȱbeȱproxiesȱforȱtheȱlawȱofȱmedicalȱmalpracticeȱandȱ
equallyȱatȱoddsȱwithȱEstelle.ȱ
     Andȱifȱweȱwereȱauthorizedȱtoȱfindȱaȱ“competentȱmedicalȱ
judgment”ȱstandardȱinȱtheȱConstitution,ȱwhyȱshouldȱweȱwantȱ
toȱfederalizeȱtheȱlawȱofȱmedicalȱmalpractice?ȱPrisonersȱsuchȱ
asȱ Pettiesȱ haveȱ aȱ tortȱ remedyȱ underȱ stateȱ law.ȱ Carterȱ andȱ
ObaisiȱwereȱemployedȱbyȱWexfordȱratherȱthanȱtheȱstate.ȱTheyȱ
oweȱprisonersȱtheȱsameȱdutiesȱasȱanyȱphysicianȱowesȱtoȱpriȬ
vateȱpatientsȱandȱareȱsubjectȱtoȱtheȱsameȱremediesȱunderȱIlliȬ
noisȱlaw.ȱSeeȱJinkinsȱv.ȱLee,ȱ209ȱIll.ȱ2dȱ320,ȱ336ȱ(2004).ȱEvenȱphyȬ
siciansȱemployedȱbyȱtheȱstateȱareȱsubjectȱtoȱtheȱnormalȱrulesȱ
ofȱ tortȱ law.ȱ Seeȱ 745ȱ ILCSȱ 10/6Ȭ106(d);ȱ Mossȱ v.ȱ Miller,ȱ 254ȱ Ill.ȱ
App.ȱ3dȱ174,ȱ181–82ȱ(1993).ȱWhenȱprisonȱphysiciansȱareȱemȬ
ployedȱ byȱ theȱ state,ȱ inmatesȱ haveȱ anȱ extraȱ remedyȱ byȱ suitȱ
againstȱtheȱstateȱitself,ȱseeȱ745ȱILCSȱ5/1;ȱ705ȱILCSȱ505/8(d),ȱjustȱ
asȱinmatesȱinjuredȱbyȱmedicalȱmalpracticeȱinȱfederalȱprisonsȱ
canȱuseȱtheȱFederalȱTortȱClaimsȱAct.ȱPerhapsȱprisonersȱhopeȱ




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24ȱ                                                    No.ȱ14Ȭ2674ȱ

thatȱ constitutionalȱ claimsȱ willȱ produceȱ awardsȱ ofȱ attorneys’ȱ
feesȱunderȱ42ȱU.S.C.ȱ§1988(b),ȱwhileȱIllinoisȱrequiresȱplaintiffsȱ
toȱbearȱtheirȱownȱfees,ȱbutȱ§1988ȱisȱnotȱaȱgoodȱreasonȱtoȱconȬ
stitutionalizeȱtortȱlaw.ȱAndȱfederalȱlawȱcomesȱwithȱcomplicaȬ
tions,ȱsuchȱasȱqualifiedȱimmunityȱandȱtheȱdeliberateȬindifferȬ
enceȱstandard,ȱmissingȱfromȱstateȱlaw.ȱEstelleȱtoldȱtheȱcourtsȱ
ofȱ appealsȱ toȱ relegateȱ badȬtreatmentȱ situationsȱ toȱ stateȱ law,ȱ
andȱweȱshouldȱcarryȱoutȱitsȱapproach.ȱ




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