The opinion
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
SOUTH BEND DIVISION
UNDRAY KNIGHTEN,
Plaintiff,
v. CAUSE NO. 3:21-CV-64-JD
DR. NANCY MARTHAKIS and
WARDEN,
Defendants.
OPINION AND ORDER
Undray Knighten, a prisoner without a lawyer, is proceeding in this case on two
claims. ECF 5. First, he is proceeding “against the Indiana State Prison Warden in an
official capacity to obtain permanent injunctive relief for constitutionally adequate
medical care for his chronic diarrhea and foot warts as required by the Eighth
Amendment[.]” Id. at 5. Second, he is proceeding “against Dr. Nancy Marthakis in her
individual capacity for compensatory and punitive damages for decreasing or
discontinuing the medications treating his chronic diarrhea in violation of the Eighth
Amendment[.]” Id. Warden Neal and Dr. Marthakis filed motions for summary
judgment. ECF 63, 85. Knighten filed responses to both summary judgment motions,
and both defendants filed replies. ECF 72, 74, 97, 98. The summary judgment motions
are now fully briefed and ripe for ruling.
Under the Eighth Amendment, inmates are entitled to adequate medical care.
Estelle v. Gamble, 429 U.S. 97, 104 (1976). To establish liability, a prisoner must satisfy
both an objective and subjective component by showing: (1) his medical need was
objectively serious; and (2) the defendant acted with deliberate indifference to that
medical need. Farmer v. Brennan, 511 U.S. 825, 834 (1994). To be held liable for deliberate
indifference to an inmate’s medical needs, a medical professional must make a decision
that represents “such a substantial departure from accepted professional judgment,
practice, or standards, as to demonstrate that the person responsible actually did not
base the decision on such a judgment.” Jackson v. Kotter, 541 F.3d 688, 697 (7th Cir. 2008).
Furthermore, a prisoner is not entitled to demand specific care, nor is he entitled
to the “best care possible.” Forbes v. Edgar, 112 F.3d 262, 267 (7th Cir. 1997). “Whether
and how pain associated with medical treatment should be mitigated is for doctors to
decide free from judicial interference, except in the most extreme situations.” Snipes v.
DeTella, 95 F.3d 586, 592 (7th Cir. 1996). Where the defendants have provided some level
of care for a prisoner’s medical condition, in order to establish deliberate indifference
the prisoner must show that “the defendants’ responses to [his condition] were so
plainly inappropriate as to permit the inference that the defendants intentionally or
recklessly disregarded his needs.” Hayes v. Snyder, 546 F.3d 516, 524 (7th Cir. 2008). A
mere disagreement with medical professionals about the appropriate treatment does
not amount to an Eighth Amendment violation. Ciarpaglini v. Saini, 352 F.3d 328, 331
(7th Cir. 2003).
a. Dr. Marthakis
Knighten is proceeding against Dr. Marthakis for violating his Eighth
Amendment rights by “decreasing or discontinuing the medications treating his chronic
diarrhea[.]” ECF 5 at 5. The parties provide evidence showing the following.
In 2007, Mr. Knighten underwent treatment for anorectal carcinoma while at a
different Indiana Department of Correction facility. ECF 94-1 at 1-2. His rectum and
part of his colon was removed. Id. at 52. Knighten was transferred to Indiana State
Prison (“ISP”) on August 14, 2019. ECF 86-2 at 1; ECF 86-4 at 41-46. Upon his arrival, he
had a number of current medications, including Loperamide. ECF 86-2 at 1; ECF 86-4 at
38-46. Loperamide, also known and referred to in the record as Imodium, is a
medication to treat symptoms of persistent diarrhea by slowing down the movement of
bowel through the intestine. ECF 86-2 at 2. At ISP, Knighten was scheduled to receive
Loperamide two times per day. ECF 86-2 at 1; ECF 86-4 at 42. According to Knighten, he
received Loperamide three times per day at his previous prison facility, but Dr.
Marthakis lowered his dosage once he arrived at ISP. ECF 97 at 4-5.
Dr. Marthakis first saw Knighten on August 27, 2019. ECF 86-2 at 2; ECF 86-4 at
34-37. During this visit, Knighten requested that he receive Loperamide three times per
day. Id. Dr. Marthakis assessed Knighten and noted he had been diagnosed with
irritable bowel syndrome due to a long history of abdominal complaints and surgeries,
but informed him Loperamide would have to be dispensed during med-line which was
run only two times per day at ISP. Id. Because Knighten indicated he would like some
medication around lunch time, Dr. Marthakis ordered he receive Pepto Bismol he could
take before lunch. Id. Dr. Marthakis also continued an order for adult diapers and
various other medications, including a probiotic. Id. Knighten continued to have an
active prescription for Loperamide. Id.
On December 17, 2019, Dr. Marthakis saw Knighten for a chronic care visit. ECF
86-2 at 2-3; ECF 86-4 at 30-33. They discussed Knighten’s abdominal and intestinal
complaints, but no significant concerns were noted at that time. Id. Dr. Marthakis
continued Knighten’s Loperamide prescription. Id.
On June 2, 2020, Knighten had another chronic care visit, this time with Nurse
Diane Thews. ECF 86-2 at 3; ECF 86-4 at 26-29. There was no evidence of any significant
abnormality or problem. Id.
On August 25, 2020, Dr. Marthakis saw Knighten for another chronic care visit.
ECF 86-2 at 3; ECF 86-4 at 18-21. Dr. Marthakis noted Knighten had lost 30 pounds in
the last 6 months, and concluded further imaging of his abdomen was necessary. Id. As
such, Dr. Marthakis submitted an off-site patient request for Knighten to receive a CT
scan of his abdomen and pelvis. Id. She continued his Loperamide prescription. Id.
On September 16, 2020, Knighten received a CT scan of his abdomen which
returned normal for no acute abnormality or mass but noted “rather extensive fecal
stasis.”1 ECF 86-2 at 3-4; ECF 86-4 at 13. Dr. Marthakis assessed the CT scan results and
concluded Knighten had chronic constipation, as there was no evidence of any bowel
obstruction. Id.
1 A large area of fecal matter inside the intestinal tract that appears to have been present for quite
some time. ECF 86-2 at 3-4.
On September 24, 2020, Dr. Marthakis met with Knighten to discuss the CT scan
results. ECF 86-2 at 4; ECF 86-4 at 9-12. She informed him the CT scan did not reveal
any masses or tumors that may be consistent with malignant disease, but were
consistent with constipation. Id. Dr. Marthakis continued his order for Loperamide but
did not believe it was appropriate to increase the order due to the notation of chronic
stasis on the CT scan, as an increase in Loperamide would further slow his bowels. ECF
86-2 at 4, 7. Dr. Marthakis also ordered iron supplements and a probiotic to address any
ongoing gastrointestinal abnormality. Id. at 4.
On November 19, 2020, Knighten had a chronic care visit with Nurse Thews and
his medications were continued. ECF 86-2 at 4; ECF 86-4 at 5-8.
On January 5, 2021, Dr. Marthakis saw Knighten for a visit regarding his
medications. ECF 86-2 at 4; ECF 86-4 at 1-4. Knighten requested his Loperamide be
increased, but Dr. Marthakis did not believe that was appropriate due to the finding of
fecal stasis on the CT scan. Id. Instead, Dr. Marthakis ordered regular weight checks to
monitor Knighten’s weight loss, as his weight had dropped to 134 pounds. Id. At that
point, Knighten began refusing to appear in the healthcare unit for weight checks,
asserting he was going to refuse further care until he received Loperamide three times
per day. ECF 86-2 at 5; ECF 86-4 at 68-69.
On February 5, 2021, Knighten was brought to the medical unit for observation
and a weight check. ECF 86-2 at 5; ECF 86-4 at 64-67. At that time, he showed a slight
increase in his weight, from 132 pounds to 140 pounds. Id. A nurse monitored any
bowel movements, and noted no bowel movements over a six-to-seven-hour period. Id.
Dr. Marthakis was looking specifically for confirmation of repeated or uncontrollable
diarrhea, but none was observed. Id. A rectal examination was recommended, but
Knighten refused. Id. Knighten continued to receive Loperamide twice per day. Id.
On February 17, 2021, Dr. Marthakis saw Knighten for a chronic care visit. ECF 86-
2 at 5; ECF 86-4 at 60-63. Dr. Marthakis again recommended weight checks, but Knighten
had been refusing them. Id. He also refused another rectal examination. Id. There was no
noted change in his condition, and his medications were continued. Id.
On April 14, 2021, Dr. Marthakis submitted a request for Knighten to receive a
colonoscopy. ECF 86-2 at 5-6; ECF 86-4 at 57-59. Knighten thereafter received a
colonoscopy that returned normal, along with a biopsy that returned normal. ECF 86-2
at 6; ECF 86-4 at 51-56. The colonoscopy was performed by Dr. Zohair Ahmed, who
recommended that Knighten start Loperamide three times per day. Id.; ECF 86-4 at 56.
Upon Knight’s return to ISP, Dr. Marthakis did not order Loperamide to be provided
three times per day, as there was no indication from Dr. Ahmed’s medical records that
he was aware of the prior CT scan results indicating Knighten had fecal stasis. ECF 86-2
at 6. The presence of fecal stasis contraindicates an increase in Loperamide, as
Loperamide causes constipation and would increase the amount of fecal stasis. Id. at 7.
On August 19, 2021, Dr. Marthakis saw Knighten for another chronic care visit.
ECF 86-2 at 6; ECF 86-4 at 47-50. Dr. Marthakis noted Knighten was now gaining weight
and was stable on his treatment regimen. Id. His weight had increased to 190 pounds. Id.
She continued his numerous medications, including twice-per-day Loperamide. Id.
Because neither party disputes these facts, the court accepts them as undisputed.
Dr. Marthakis argues she did not violate Knighten’s Eighth Amendment rights
because her decision not to increase his Loperamide dosage was based on her
professional judgment. ECF 86 at 14-19. Specifically, Dr. Marthakis attests that, because
Knighten’s CT scan showed signs of slower bowels with retained bowel, increasing his
Loperamide dose would have presented a risk to his health by further slowing his bowels
and increasing the amount of fecal stasis. ECF 86-2 at 7. Dr. Marthakis attests her
reasoning was further supported by observations of Knighten in the infirmary, which
showed no indication of recurrent and uncontrollable bowel movements, and by
Knighten’s unwillingness to participate in other modalities of their treatment, including
regular weight checks and examinations. Id.
In his response, Knighten first argues that Dr. Marthakis’ initial decision upon his
transfer to change his Loperamide from three time a day to two times a day was not based
on medical judgment. ECF 97 at 2. However, Dr. Marthakis explained that the medication
lines ran only twice a day. ECF 86-2 at 2. Administrative convenience is a permissible
factor to consider when making treatment decisions. Roe v. Elyea, 631 F.3d 843, 863 (7th
Cir. 2011). Dr. Marthakis examined Knighten within two weeks of his arrival and
determined that his now-discontinued lunchtime dose of Loperamide could be replaced
by Pepto Bismol. ECF 86-2 at 2. Knighten provides no evidence that this decision was not
based on her professional judgment.
Knighten further argues Dr. Marthakis’ refusal to increase his Loperamide dosage
after he began losing weight violated his Eighth Amendment rights because the decision
was not based on her professional judgment. ECF 97 at 4-5. However, Knighten does not
refute Dr. Marthakis’ explanation that increasing his Loperamide dosage was
contraindicated by the presence of fecal stasis in his CT scan. Instead, Knighten makes
various allegations about Dr. Marthakis’ demeanor at various appointments, including
that she seemed angry with him at times and placed medical holds that required him to
stay in isolated holding cells rather than return to his cellhouse. ECF 97 at 6-14; ECF 94-1
at 6-11. But these allegations do not show that Dr. Marthakis’ decision not to increase
Knighten’s Loperamide dosage was not based on her professional judgment. Moreover,
the record shows that Knighten’s condition eventually stabilized and his weight
increased without an increase to his Loperamide dosage. Thus, Dr. Marthakis has
provided undisputed evidence that her decisions about Knighten’s Loperamide dosage
were an exercise of her professional judgment, and Knighten provides no evidence by
which a reasonable jury could conclude this decision was “so plainly inappropriate as to
permit the inference that [she] intentionally or recklessly disregarded his needs.” See
Hayes, 546 F.3d at 524. Accordingly, summary judgment is warranted in favor of Dr.
Marthakis.
b. Warden Neal
Knighten is proceeding against Warden Neal “to obtain permanent injunctive
relief for constitutionally adequate medical care for his chronic diarrhea and foot warts
as required by the Eighth Amendment[.]” ECF 5 at 5. In his motion for summary
judgment, Warden Neal argues he is not subject “to any liability” because he reasonably
deferred to the treatment decisions of Dr. Marthakis and Knighten is not entitled to
dictate his own treatment. ECF 64 at 4-5; ECF 74.2 However, the question is not whether
Warden Neal is subject to any liability for deliberate indifference, but whether Knighten
is currently entitled to injunctive relief for constitutionally adequate medical care for his
chronic diarrhea and foot warts. The record contains evidence only that Knighten
received constitutionally adequate medical treatment between 2020 and 2021, and
contains no evidence regarding what treatment Knighten is currently receiving. Thus,
because the record contains no evidence regarding what treatment Knighten is
currently receiving for his chronic diarrhea and foot warts, the court cannot determine
whether Knighten is entitled to injunctive relief. In the interest of judicial economy, the
court DENIES Warden Neal’s summary judgment motion with leave to file a new
summary judgment motion.
For these reasons, the court:
(1) GRANTS Dr. Marthakis’ motion for summary judgment (ECF 85);
(2) DENIES Warden Neal’s motion for summary judgment (ECF 63) with leave
to refile a new summary judgment motion on or before March 15, 2023;
(3) DISMISSES Dr. Marthakis from this action; and
(4) REMINDS the parties this case is now proceeding only on Knighten’s
remaining claim against Warden Neal in an official capacity to obtain
permanent injunctive relief for constitutionally adequate medical care for his
chronic diarrhea and foot warts as required by the Eighth Amendment.
2 Warden Neal also argues he is entitled to qualified immunity on this claim, but “[q]ualified
immunity does not apply to a claim for injunctive relief[.]” Hamner v. Burls, 937 F.3d 1171, 1175 (8th Cir.
2019).
SO ORDERED on February 9, 2023
/s/JON E. DEGUILIO
CHIEF JUDGE
UNITED STATES DISTRICT COURT