Argued and Submitted April 7, 2014, San Francisco, California
As Corrected October 24, 2014.
[Copyrighted Material Omitted]
Appeal from the United States District Court for the District of Nevada. D.C. No. 3:10-cv-00669-LRH-WGC. Larry R. Hicks, District Judge, Presiding.
Prisoner Civil Rights
The panel reversed the district court's summary judgment and remanded for trial in an action brought pursuant to 42 U.S.C. § 1983 by a Nevada state prisoner who was denied cataract surgery because of a Nevada Department of Corrections policy under which cataract surgery is refused if an inmate can manage to function in prison with one eye.
The panel held that blindness in one eye caused by a cataract is a serious medical condition. The panel further held that the blanket, categorical denial of medically indicated surgery solely on the basis of an administrative policy that " one eye is good enough for prison inmates" is the paradigm of deliberate indifference.
Dissenting, Judge Bybee stated that he would hold that the respondents were not deliberately indifferent to plaintiff's alleged serious medical needs because plaintiff did not meet the difficult legal burden of showing a purposeful act or failure to respond to a prisoner's pain or possible medical need and harm caused by the indifference.
Mason Boling (argued) and Lauren Murphy (argued), Certified Law Student Representatives, and Dustin E. Buehler, Supervising Attorney, University of Arkansas Federal Appellate Litigation Project, Fayetteville, Arkansas; Michelle King and Joy Nissen, Certified Law Student Representatives, and Gregory C. Sisk, Supervising Attorney, University of St. Thomas School of Law Appellate Clinic, Minneapolis, Minnesota, for Plaintiff-Appellant.
Catherine Cortez Masto, Attorney General, and Clark G. Leslie (argued), Senior Deputy Attorney General, Office of the Nevada Attorney General, Carson City, Nevada, for Defendants-Appellees.
Before: Barry G. Silverman, William A. Fletcher, and Jay S. Bybee, Circuit Judges.
SILVERMAN, Circuit Judge.
Plaintiff John Colwell, an inmate in the Nevada Department of Corrections, is blind in one eye due to a cataract. It is undisputed that his treating doctors recommended cataract surgery and that the surgery would restore his vision. However, the surgery was denied by NDOC supervisory medical personnel because of the NDOC's " one eye policy" -- cataract surgery is refused if an inmate can manage to function in prison with one eye.
We hold today, as numerous other courts considering the question have, that blindness in one eye caused by a cataract is a serious medical condition. We also hold that the blanket, categorical denial of medically indicated surgery solely on the basis of an administrative policy that " one eye is good enough for prison inmates" is the paradigm of deliberate indifference. We reverse the grant of summary judgment in favor of the prison officials and remand for trial.
Because this case was resolved at summary judgment, we present the facts in the light most favorable to Colwell, the non-moving party. See Snow v. McDaniel, 681 F.3d 978, 982 (9th Cir. 2012), overruled in part on other grounds by Peralta v. Dillard, 744 F.3d 1076 (9th Cir. 2014) (en banc).
Colwell is a 67-year-old man serving multiple criminal sentences, including life without the possibility of parole. He did not have eye problems when he was incarcerated in 1991, but he subsequently developed cataracts in both eyes and underwent cataract-removal surgery on his left eye in 2001. By October 2001, a cataract had developed in Colwell's right eye that rendered him totally blind in that eye by 2002. That cataract has never been treated and is the medical condition at issue in this case.
According to R. Bruce Bannister, D.O., the NDOC Medical Director, a cataract is " cloudiness (opacity) of the lens of the eye" which " does no damage to the eye and can be removed at any time." Dr. Bannister, who is not an optometrist or ophthalmologist, declared that a cataract does not cause pain, require urgent attention, or lead to permanent vision loss. He declared further that a delay in removing a cataract causes no harm. The NDOC has a formal written policy for cataract treatment, Medical Directive 106, which states in part:
It is the policy of the Department that inmates with cataracts will be evaluated
on a case by case basis, taking into consideration their ability to function within their current living environment.
106.01 Surgical Removal of Cataracts
1. Patients with visual impairment incompatible with the ability to perform the required tasks of daily living in their current living environment may be considered for removal of a cataract.
2. All cataracts extraction requests must be approved by the Utilization Review Panel and the Medical Director.
At least three medical providers -- Drs. Snider, Fischer (ophthalmologist), and Fisher (optometrist) -- recommended that Colwell's right-eye cataract be treated. Colwell first informed the NDOC of blindness in his right eye during an October 2001 physical with prison physician Dr. Snider. In July 2002, Dr. Snider noted the presence of the cataract and that Colwell " need[ed] two functioning eyes" because he worked sewing mattresses. Dr. Snider referred Colwell to Michael J. Fischer, M.D., an outside ophthalmologist. Dr. Fischer examined Colwell in September 2002, observed that Colwell's " visual acuity was correctable to 20/20 in the left eye," found " a mature cataract in the right eye," and concluded that right-eye cataract surgery was indicated. Based on Dr. Fischer's recommendation, Dr. Snider submitted three requests for surgery to the Utilization Review Panel. The Panel denied Dr. Snider's requests, first indicating that Colwell was on a waiting list but then denying the two subsequent requests without explanation. Colwell filed several written grievances between October and December 2003, complaining that although Dr. Fischer had recommended surgery, Dr. Snider told him that the " department policy is 'one eye only' is needed" and the surgery would not be approved. All of Colwell's grievances were denied.
Colwell refused his annual physical every year from 2004 to 2008 and did not receive further vision care until September 2009, when he requested a cataract consultation. A prison optometrist, a different Dr. Fisher, examined Colwell and noted that he was " having trouble working" and that his right eye was " eligible for cataract surgery." Following up on Dr. Fisher's findings, Dr. John Scott, an NDOC senior physician, requested an ophthalmology consultation. The consultation report indicates that Colwell's condition was not life-threatening but did " significantly affect" his quality of life.
The next week, however, Dr. Scott discontinued the request. His handwritten notes state:
I had originally submitted request for consult on 10-6-09 based purely on optometrists [sic] opinion. But pt has 20/20 vision OS [left eye]. So can actually qualify to drive a car in many states of . . . U.S. As well this issue has no implications of damage to [right] eye if cataract goes unrepaired. Therefor[e] on further reflection I am [discontinuing] the original request for ophthalogic consultation.
There is no indication Colwell was informed of the discontinuation, and he filed at least one written request inquiring about the status of the referral. He also spoke with Dr. Gedney, another prison physician, about the issue during an appointment on February 18, 2010. Dr. Gedney's notes reflect that Colwell did not meet the criteria for surgery because he has sight out of his left eye, and she told Colwell that he did not qualify for cataract removal due to a " one eye only" policy.
Colwell again filed a series of grievances. He complained that the optometrist who had examined him recommended a cataract consult for possible surgery, but that Dr. Scott had discontinued the consult because he has one " good" eye. His informal grievance was denied with the following response:
Administrative Regulation 618 defines your request for cataract surgery as cosmetic/elective surgery. One is corrected to 20/20 vision now. This places this, the 2nd cataract surgery[,] in a non-essential category, despite recommendation from Dr[.] Fisher [the prison optometrist]. I cannot predict when this may be considered for repair, but at this time, it is not considered for repair by Utilization Review.
(Emphasis added.) Colwell's first-level grievance was denied for the same reason. Dr. Bannister personally denied his second-level grievance on March 9, 2010, stating:
I have reviewed your written grievance and the answers provided at the informal and first level. I agree with these responses. In almost cases [sic] cataract surgery is not an emergency. You should be evaluated periodically to determine the degree of impairment caused by your cataract with regard to your ability to perform the activities required in your current living situation. Based on the practitioner[']s evaluation the request can be re-considered.
Colwell filed this lawsuit under 42 U.S.C. § 1983 alleging a violation of his Eighth Amendment rights. Specifically, he claims that the prison officials were deliberately indifferent to his serious medical needs in refusing him surgery to restore his vision. On the defendants' motion for summary judgment, the district court ruled, first, that Colwell's cataract-induced blindness was a serious medical need. However, it also held that Colwell failed to establish that the defendants were deliberately indifferent to that need. It reasoned that Colwell had not shown that the Utilization Review Panel's denial or delay in approving surgery led to further injury to his eye, and explained that " medical providers have determined that surgery is not medically warranted in light of Plaintiff's overall visual acuity and ability to adequately function." The court also held that the Panel's decision to refuse surgery amounted to a difference of opinion over the best course of treatment, and that Colwell had not shown that the NDOC's course of action was " medically unacceptable" or " made in conscious disregard of an excessive risk to his health."
1. Legal Standards
We have jurisdiction pursuant to 28 U.S.C. § 1291, and review de novo the district court's grant of summary judgment. Toguchi v. Chung, 391 F.3d 1051, 1056 (9th Cir. 2004). " We must determine, viewing the evidence in the light most favorable to the nonmoving party, whether there are any genuine issues of material fact and whether the district court correctly applied the relevant substantive law." Prison Legal News v. Lehman, 397 F.3d 692, 698 (9th Cir. 2005).
The government has an " obligation to provide medical care for those whom it is punishing by incarceration," and failure to meet that obligation can constitute an Eighth Amendment violation cognizable under § 1983. Estelle v. Gamble, 429 U.S. 97, 103-05, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976). In order to prevail on an Eighth Amendment claim for inadequate medical care, a plaintiff must show " deliberate indifference" to his " serious medical needs." Id. at 104. This includes " both an objective standard--that the deprivation was serious enough to constitute cruel and unusual punishment--and a subjective standard--deliberate indifference." Snow, 681 F.3d at 985.
To meet the objective element of the standard, a plaintiff must demonstrate the existence of a serious medical need. Estelle, 429 U.S. at 104. Such a need exists if failure to treat the injury or condition " could result in further significant injury" or cause " the unnecessary and wanton infliction of pain." Jett v. Penner, 439 F.3d 1091, 1096 (9th Cir. 2006) (quoting McGuckin v. Smith, 974 F.2d 1050, 1059 (9th Cir. 1992), overruled in part on other grounds by WMX Techs., Inc. v. Miller, 104 F.3d 1133 (9th Cir. 1997) (en banc)) (internal quotation marks omitted). Indications that a plaintiff has a serious medical need include " [t]he existence of an injury that a reasonable doctor or patient would find important and worthy of comment or treatment; the presence of a medical condition that significantly affects an individual's daily activities; or the existence of chronic and substantial pain." McGuckin, 974 F.2d at 1059-60.
A prison official is deliberately indifferent under the subjective element of the test only if the official " knows of and disregards an excessive risk to inmate health and safety." Toguchi, 391 F.3d at 1057 (quoting Gibson v. Cnty. of Washoe, 290 F.3d 1175, 1187 (9th Cir. 2002)) (internal quotation mark omitted). This " requires more than ordinary lack of due care." Farmer v. Brennan, 511 U.S. 825, 835, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994) (quoting Whitley v. Albers, 475 U.S. 312, 319, 106 S.Ct. 1078, 89 L.Ed.2d 251 (1986)) (internal quotation mark omitted). " [T]he official must both be aware of facts from which the inference could be drawn that a substantial risk of serious harm exists, and he must also draw the inference." Id. at 837. Deliberate indifference " may appear when prison officials deny, delay or intentionally interfere with medical treatment, or it may be shown by the way in which prison physicians provide medical care." Hutchinson v. United States, 838 F.2d 390, 394 (9th Cir. 1988). " In deciding whether there has been deliberate indifference to an inmate's serious medical needs, we need not defer to the judgment of prison doctors or administrators." Hunt v. Dental Dep't, 865 F.2d 198, 200 (9th Cir. 1989).
2. Serious Medical Need
We agree with the district court that monocular blindness is a serious medical need. Although blindness in one eye is not life-threatening, it is no trifling matter either. It is not a bump or scrape or tummy ache. Monocular blindness is the loss of the function of an organ. Other courts have held that similar and even less severe losses of vision are serious medical needs. For example, in Koehl v. Dalsheim, the Second Circuit held that an inmate who needed eyeglasses for double vision and loss of depth perception had a serious medical need. 85 F.3d 86, 88 (2d Cir. 1996). Although the inmate's condition did not " inevitably entail pain," he alleged he suffered injuries caused by falling or walking into objects. Id. The court ruled
these consequences " adequately meet the test of 'suffering'" the Supreme Court " recognized is inconsistent with 'contemporary standards of decency.'" Id. (quoting Estelle, 429 U.S. at 103).
Nevada district courts addressing claims similar to Colwell's have found cataracts to be serious medical needs. The district court in White v. Snider concluded that a cataract causing complete blindness in one eye was a serious medical need where doctors recommended cataract removal and the plaintiff experienced headaches and had difficulty seeing in the prison yard. No. 3:08-CV-252-RCJ(VPC), 2010 WL 331742, at *5 (D. Nev. Jan. 26, 2010). The court in Michaud v. Bannister likewise held that a plaintiff's " advanced cataract" was " squarely within the ambit of 'serious medical needs'" where the plaintiff testified that " he had lost almost all of his ability to see in his right eye," and " blindness and irreparable injury could result from his untreated cataract." No. 2:08-cv-01371-MMD-PAL, 2012 WL 6720602, at *5 (D. Nev. Dec. 26, 2012). Most recently, the court in Layton v. Bannister held that a right-eye cataract was a serious medical need despite the plaintiff's high visual acuity in his left eye, because his affected eye was blind and the condition was significant enough that an examining optometry consultant referred him to the Utilization Review Panel for surgery. No. 3:10-CV-00443-LRH-WGC, 2012 WL 6969758, at *6 (D. Nev. Sept. 28, 2012), report and recommendation adopted, No. 3:10-CV-00443-LRH-WGC, 2013 WL 420427 (D. Nev. Jan. 31, 2013).
Like the medical conditions in White, Michaud, and Layton, Colwell's cataract is severe. " [I]t is clear that this is not a situation of a minor cataract with little impact on an inmate's vision." Michaud, 2012 WL 6720602, at *5. Colwell's right eye has been blind for more than a decade, and his condition affects his perception and renders him unable to see if he turns to the left. Several doctors, including an ophthalmologist and an optometrist, have found the cataract and resulting vision loss " important and worthy of comment or treatment." McGuckin, 974 F.2d at 1059.
Furthermore, the evidence showed that Colwell was not " merely blind" in one eye, but that his monocular blindness caused him physical injury: He ran his hand through a sewing machine on two occasions while working in the prison mattress factory; he ran into a concrete block, splitting open his forehead; he regularly hits his head on the upper bunk of his cell; and he bumps into other ...