“[A]s long as the claim seeks prospective relief for ongoing harm, the fact that a current violation can be traced to a past action does not bar relief under Young.” (cleaned up)
How later courts described this case
- “[A]s long as the claim seeks prospective relief for ongoing harm, the fact that a current violation can be traced to a past action does not bar relief under Young.” (cleaned up)
- “[N]either a State nor its officials acting in their official capacities are ‘persons’ under § 1983.”
Written by the judges who cited it.
The opinion
Case: 25-50014 Document: 47-1 Page: 1 Date Filed: 09/04/2025
United States Court of Appeals
for the Fifth Circuit United States Court of Appeals
Fifth Circuit
____________
FILED
September 4, 2025
No. 25-50014
____________ Lyle W. Cayce
Clerk
Doctor Sonia Hernandez Caruso, D.O.,
Plaintiff—Appellant,
versus
Texas Medical Board; Susan D. Rodriguez, Individually and
in her official capacity as an officer of the Texas Medical Board; Scott M.
Freshour, Individually and in his official capacity as an officer of the Texas
Medical Board; Amy Swanholm, J.D., Individually and in her official
capacity as an officer of the Texas Medical Board; Sherif Zaafran,
M.D., Individually and in his official capacity as an officer of the Texas Medical
Board,
Defendants—Appellees.
______________________________
Appeal from the United States District Court
for the Western District of Texas
USDC No. 1:24-CV-217
______________________________
Before Higginson, Willett, and Engelhardt, Circuit Judges.
Per Curiam: *
_____________________
*
This opinion is not designated for publication. See 5th Cir. R. 47.5.
Case: 25-50014 Document: 47-1 Page: 2 Date Filed: 09/04/2025
No. 25-50014
Sonia Hernandez Caruso, D.O., proceeding pro se, challenges the
denial of a full medical license by the Texas Medical Board. The district court
granted the Board’s motion to dismiss. We AFFIRM.
I
A
The Texas Medical Board “is an agency of the executive branch of
state government with the power to regulate the practice of medicine.” Tex.
Occ. Code § 152.001. The Board has “sole discretion” to issue a medical
license to applicants who meet statutory requirements. Id. § 155.002. It may
also issue a “limited” or “restrict[ed]” license and “prescribe additional
qualifications for an applicant, including education and examination
requirements, conditions of employment, and application procedures.” Id.
§ 155.006. After an initial review by the Executive Director, applications
proceed to the Board’s Licensure Committee. Id. § 155.007(a), (c). If the
Licensure Committee determines that an applicant is ineligible for a license,
it “submit[s] that determination” and its reasons to the full Board. Id.
§ 155.007(c). Before the Board finalizes that determination, an applicant may
request a hearing before an administrative law judge (ALJ) of the State Office
of Administrative Hearings (SOAH) within a certain window. Id.
§ 155.007(c), (e). The ALJ then submits proposed findings of fact and
conclusions of law, and the Board decides the applicant’s eligibility. Id.
§ 155.007(f). If the Board denies a license, it must provide the applicant “a
written statement containing the reasons for the [B]oard’s action.” Id.
Under Texas law, issuing a restricted medical license or denying a full
license is considered a “Method[] of Discipline.” Id. § 164.001(b)(3). Under
federal and state law, the Board must report any disciplinary action against a
physician to the National Practitioner Data Bank. See 42 U.S.C. § 11101(2)
(reporting obligations help “restrict the ability of incompetent physicians to
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move from State to State without disclosure or discovery of the physician’s
previous damaging or incompetent performance”); Tex. Occ. Code
§ 164.060(b)(4).
B
In 2006, Caruso received her Doctor of Osteopathic Medicine degree
from Ohio University College of Osteopathic Medicine. She completed a
one-year internship and one-year general surgery residency at St. John’s
Episcopal Hospital, followed by an ophthalmology residency at St. John’s
and Interfaith Medical Center. She later relocated to Texas.
In April 2011, Caruso applied for a Texas medical license. In
November 2012, she and her attorney appeared before the Licensure
Committee, which recommended denial “based on a failure to practice
medicine in a competent manner consistent with public health and welfare,
as well as disciplinary action taken against Dr. [Caruso] by a health care entity
due to unprofessional conduct and professional incompetence likely to harm
the public.” The Committee also recommended that, if requested within a
year, she be granted a physician-in-training permit for additional
ophthalmology training. The Board unanimously adopted the
recommendation and denied Caruso’s 2011 application. Caruso appealed and
requested a hearing. In August 2015, an ALJ issued a Proposal for Decision
concluding she was ineligible for an unrestricted medical license because,
“among other things, she had not performed surgery since 2011 and needed
additional training before she could safely operate again.”
Meanwhile, Caruso was a research fellow at the Valley Retina
Institute in McAllen, Texas. In December 2015, she informed the Board she
had been accepted to a surgical fellowship and would require a full license.
But on December 3, 2015, the Board issued a Final Order adopting the ALJ’s
findings and holding her ineligible.
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No. 25-50014
From March 2016 to April 2018, Caruso worked for Kwiat Eye &
Laser Surgery in Amsterdam, New York. In 2018, Caruso reapplied for a
Texas medical license. The Licensure Committee found “no substantive
changes” in her surgical training since her prior denial in 2015 and again
recommended denial. The Board adopted that recommendation in 2019.
Caruso again appealed. Before her hearing, the Board sent Caruso a
notice that “provided a statement of the time, place, and nature of the
hearing; a statement of the legal authority and jurisdiction under which the
hearing was to be held; a reference to the particular sections of the statutes
and rules involved; and [a] short, plain statement of the factual matters
asserted.” The ALJ held a hearing in December 2020 at which Caruso
represented herself. The record remained open for post-hearing submissions
until April 2, 2021. The ALJ ultimately concluded the Board had carried its
burden. On March 4, 2022, the Board adopted the ALJ’s findings and
granted Caruso a license—but only with restrictions:
Applicant is RESTRICTED from performing any
ophthalmological surgical procedures, including any form of
eye surgery, laser procedures, intra-viscous procedures, or
injections.
This restriction remains in effect until such time as Applicant
requests permission in writing to resume such surgical
practice, personally appears before the Board to orally petition
for the restriction [to] be lifted and provides clear and
convincing evidence and information which in the discretion of
the Board adequately indicates that Applicant is competent to
independently perform such surgical procedures. Such
evidence and information shall include at a minimum, but shall
not be limited to, evidence that Applicant has completed an
ACGME approved ophthalmology surgical training program.
Upon presentation of clear and convincing evidenc[e] to the
Board that Applicant is competent to independently perform
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No. 25-50014
ophthalmological procedures, the restriction may be lifted
under such terms and conditions and for such time that the
Board in its discretion determines are necessary to adequately
protect the public.
The Board then updated her physician profile to reflect “Disciplinary
Restrictions” and notified the Data Bank as required. At the time, Caruso
also held active licenses in New Mexico and New York, traveling from Texas
to practice in those states.
She unsuccessfully sought rehearing before SOAH. She did not
appeal in state court but instead filed this pro se lawsuit on March 1, 2024,
against the Board and four officers.
She raised claims under §§ 1983 and 1981, alleging that the Board
violated her procedural due process rights under the Fifth and Fourteenth
Amendments by denying rehearing, failing to give notice of the basis for
discipline, and posting “wrong, false, [and] misleading” information on its
website and to the Data Bank. Caruso also alleged Defendants discriminated
against her when the Board granted unrestricted licenses to three male
applicants with no retina or surgery training, while denying her the same.
Caruso also raised a Title VII retaliation claim, alleging that the Board
retaliated against her by both denying her a full license and posting the Final
Order describing her restricted license as “Disciplinary Restrictions” after
she raised concerns about discriminatory practices. Finally, Caruso alleged
Defendants tortiously interfered with her employment contracts, disparaged
her business reputation, defamed her, and exceeded their authority, in
violation of state law. She later added claims under the Equal Protection
Clause and the Eighth Amendment. She seeks money damages and injunctive
relief ordering the Board to remove the restrictions from her license, its
website, and the Data Bank.
5
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The Board and its officers moved to dismiss for lack of subject-matter
jurisdiction under Rule 12(b)(1) based on sovereign immunity and for failure
to state a claim under Rule 12(b)(6). The magistrate judge recommended
dismissing all of Caruso’s claims as follows: (1) Caruso’s constitutional
claims against the Board and the individual defendants in their official
capacities for money damages were barred by sovereign immunity; (2)
Caruso’s constitutional claims against the individual defendants for
prospective injunctive relief failed to meet the pleading standard under Rule
12(b)(6); (3) Caruso’s remaining federal claims likewise failed under Rule
12(b)(6); and (4) since all federal claims were dismissed, the court declined
supplemental jurisdiction over Caruso’s state-law claims. Caruso filed timely
objections, but the district court overruled them, adopted the
recommendation in full, and granted Defendants’ motion to dismiss.
II
“We review dismissals under Rule 12(b)(1) and Rule 12(b)(6) de
novo.” Boudreaux v. La. State Bar Ass’n, 3 F.4th 748, 753 (5th Cir. 2021). For
a 12(b)(1) motion, “the party asserting federal subject-matter jurisdiction[]
has the burden.” Ala.-Coushatta Tribe of Tex. v. United States, 757 F.3d 484,
487 (5th Cir. 2014). And “[t]o survive a [12(b)(6)] motion to dismiss, a
complaint must contain sufficient factual matter, accepted as true, to ‘state a
claim to relief that is plausible on its face.’” Ashcroft v. Iqbal, 556 U.S. 662,
678 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)).
Pro se complaints are held “to less stringent standards than formal pleadings
drafted by lawyers.” Erickson v. Pardus, 551 U.S. 89, 94 (2007) (quoting
Estelle v. Gamble, 429 U.S. 97, 106 (1976)). But, “[e]ven so, mere conclusory
allegations on a critical issue are insufficient.” Brown v. Tarrant Cnty., 985
F.3d 489, 494 (5th Cir. 2021) (internal quotations omitted).
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No. 25-50014
III
A
We start with sovereign immunity. 1
“[S]overeign immunity bars private suits against nonconsenting
states in federal court.” City of Austin v. Paxton, 943 F.3d 993, 997 (5th Cir.
2019). That bar extends equally to state agencies as well as to state officials
acting in their official capacities. Id.; see also Will v. Mich. Dep’t of State Police,
491 U.S. 58, 71 (1989) (“[N]either a State nor its officials acting in their
official capacities are ‘persons’ under § 1983.”). Accordingly, the district
court properly dismissed Caruso’s claims against the Board and her damages
claims against its officers. 2
As for Caruso’s claims for prospective injunctive relief, she argues the
Ex parte Young exception applies. See 209 U.S. 123 (1908). Ex parte Young
_____________________
1
At the lower court and on appeal, Defendants have urged a qualified-immunity
defense. The district court made no determination on qualified immunity, and neither do
we. “[W]e employ the general rule ‘that a federal appellate court does not consider an issue
not passed upon below.’” See Wise v. Wilkie, 955 F.3d 430, 439 n.39 (5th Cir. 2020)
(quoting Firefighters’ Ret. Sys. v. EisnerAmper, L.L.P., 898 F.3d 553, 561 (5th Cir. 2018)).
2
Caruso argues the Board acted ultra vires, presenting an exception to sovereign
immunity under Texas law. The district court concluded that the ultra vires exception did
not apply. We agree. To invoke the ultra vires exception, a plaintiff must “do more than
simply allege that the actions of the officer are illegal or unauthorized.” Danos v. Jones, 652
F.3d 577, 583 (5th Cir. 2011) (internal quotations omitted). Here, Caruso’s allegation of
ultra vires action was limited to a single sentence: “The Texas Medical Board and the other
four Defendants acted in Ultra Vires—(beyond their authority).” That falls well short.
Further, Caruso raised additional arguments that the district court did not address,
concerning (1) congressional abrogation through federal law requiring the Data Bank’s
reporting scheme, (2) structural waiver by the Board’s participation in the Data Bank, and
(3) the Supremacy Clause. Even if any abrogation or waiver of sovereign immunity applies,
Caruso’s claims must nonetheless be dismissed under Rule 12(b)(6). See infra Section
III.B–C. Therefore, we need not address these arguments here. See Wise, 955 F.3d at 439
n.39.
7
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No. 25-50014
allows a plaintiff to seek prospective injunctive relief “against individual state
officials acting in violation of federal law.” Paxton, 943 F.3d at 997 (internal
quotations omitted). The district court concluded the exception applied. “In
determining whether the doctrine of Ex parte Young applies, a court need only
conduct a straightforward inquiry into whether the complaint alleges an
ongoing violation of federal law and seeks relief properly characterized as
prospective.” Planned Parenthood Gulf Coast, Inc. v. Phillips, 24 F.4th 442,
451 (5th Cir. 2022) (quoting Verizon Md., Inc. v. Pub. Serv. Comm’n of Md.,
535 U.S. 635, 645 (2002) (internal quotations and alterations omitted)).
Here, the Board officials “have some connection” with Texas’s
medical licensing and reporting scheme. Book People, Inc. v. Wong, 91 F.4th
318, 334 (5th Cir. 2024). And the injunctive relief Caruso seeks—the removal
of the restrictions from her license and removal of the Board’s postings
reflecting those restrictions—is plainly prospective.
Defendants argue that Caruso seeks retrospective, rather than
prospective, relief, characterizing the remedy as “a declaration that the past
actions of [the Board] or any Individual Defendant were unlawful.” We
disagree. The posting of her restricted license on the Board’s website and in
the Data Bank is ongoing. So too is the status of her license itself. Like in
Planned Parenthood, Caruso alleged she is “entitled to a license,” that the
denial of a full license occurred without procedural due process, and that
“throughout the licensing process” she has been treated differently from
those similarly situated. See Planned Parenthood, 24 F.4th at 452–53; see also
Green Valley Special Util. Dist. v. City of Schertz, 969 F.3d 460, 471–72 (5th
Cir. 2020) (“[A]s long as the claim seeks prospective relief for ongoing harm,
the fact that a current violation can be traced to a past action does not bar
relief under Young.” (cleaned up)). As such, the district court properly found
that Caruso’s claims for prospective injunctive relief fall within the Ex parte
Young exception.
8
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No. 25-50014
But that does not end the matter. As we’ve said before, “[w]e
emphasize that the Rule 12(b)(1) inquiry ‘does not include an analysis of the
merits of the claim.’” Planned Parenthood, 24 F.4th at 454 (quoting Verizon,
535 U.S. at 646). Thus, while sovereign immunity doesn’t pose a problem for
Caruso’s claims for prospective injunctive relief, Rule 12(b)(6) does.
B
First, Caruso alleged that Defendants violated her procedural due
process rights under the Fifth and Fourteenth Amendments.
For starters, Caruso’s Fifth Amendment due process claim fails
because the Fifth Amendment applies only to “violations of constitutional
rights by the United States or a federal actor.” Jones v. City of Jackson, 203
F.3d 875, 880 (5th Cir. 2000). Caruso has not alleged, nor could she plausibly
allege, that Defendants were federal actors.
Likewise, Caruso’s Fourteenth Amendment due process claim is
insufficiently pled. Caruso offered several theories: that Defendants “failed
to provide” her notice and reasons, “failed to inform” her of the legal bases,
denied her motion for rehearing, and misreported the disciplinary action on
the Board’s website and to the Data Bank. 3
“An essential principle of due process is that a deprivation of life,
liberty, or property ‘be preceded by notice and opportunity for hearing
appropriate to the nature of the case.’” Greene v. Greenwood Pub. Sch. Dist.,
890 F.3d 240, 242 (5th Cir. 2018) (quoting Cleveland Bd. of Educ. v.
Loudermill, 470 U.S. 532, 542 (1985)). And “[t]o have a property interest in
_____________________
3
On appeal, Caruso raised a novel theory of due process based on an alleged denial
of an unbiased decisionmaker. But we “will not consider arguments first raised on
appeal . . . .” Estate of Duncan v. Comm’r of Internal Revenue, 890 F.3d 192, 202 (5th Cir.
2018) (citation omitted).
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a benefit, a person clearly must have more than an abstract need or desire for
it. [S]he must have more than a unilateral expectation of it.” Bd. of Regents of
State Colls. v. Roth, 408 U.S. 564, 577 (1972). The Texas Medical Practice
Act is clear: “[T]he practice of medicine is a privilege and not a natural right
of individuals.” Tex. Occ. Code § 151.003(1). That said, “[i]t is well
established that a reasonable, continued expectation of entitlement to a
previously acquired benefit, such as a medical license, constitutes a
cognizable property interest for purposes of due process protection.”
Ramirez v. Ahn, 843 F.2d 864, 867 (5th Cir. 1988).
Relevant here, Caruso never had a full, unrestricted license. Her first
medical license in Texas was the restricted license she received in March
2022. As such, Caruso had no “previously acquired” full, unrestricted
license in which she could claim a property interest. See Ramirez, 843 F.2d at
867. Accordingly, the district court properly dismissed her Fourteenth
Amendment due process claim for lack of a cognizable property interest. 4
C
Caruso’s other claims fare no better. 5
First, Caruso alleged a violation of her equal protection rights because
the Board “issued full unrestricted licenses” to three male doctors who had
“never performed retina surgeries,” but refused to grant the same license to
_____________________
4
The district court additionally explained that, even if Caruso had a cognizable
property interest in a Texas medical license, she received sufficient notice and opportunity
to be heard—“which is all that the Due Process Clause requires.” For the reasons given by
the district court, we likewise agree: even assuming Caruso held a property interest, her
complaint fails to allege a denial of procedural due process.
5
As discussed above, in her response to the motion to dismiss, Caruso introduced
new claims under the Eighth Amendment and the Equal Protection Clause. The district
court considered those newly raised claims in light of her pro se status. We do the same.
10
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No. 25-50014
her, thus precluding her from participation in a surgical fellowship.
“Generally, to establish [a Fourteenth Amendment] equal protection claim
the plaintiff must prove that similarly situated individuals were treated
differently.” Tex. Ent. Ass’n, Inc. v. Hegar, 10 F.4th 495, 513 (5th Cir. 2021)
(quoting Wheeler v. Miller, 168 F.3d 241, 252 (5th Cir. 1999) (per curiam)).
Though Caruso claims to have been on “equal playing ground but [] treated
differently,” she failed to provide any factual allegations that she and those
three males were “in all relevant respects alike,” Hegar, 10 F.4th at 513
(quoting Nordlinger v. Hahn, 505 U.S. 1, 10 (1992))—for example, whether
they had previously been denied medical licenses by the Board or had
previously been found to exhibit “unprofessional conduct or professional
incompetence likely to harm the public.” Accordingly, the district court
properly dismissed Caruso’s equal protection claim.
Next, Caruso failed to state an Eighth Amendment claim. “The cruel
and unusual punishment clause of the Eighth Amendment applies only in
criminal actions, following a conviction.” Palermo v. Rorex, 806 F.2d 1266,
1271 (5th Cir. 1987) (citing Ingraham v. Wright, 430 U.S. 651 (1977)).
Caruso also mentioned numerous other federal and state claims in her
complaint. 6 The district court properly dismissed the remaining federal
claims because each is inapplicable. See 18 U.S.C. § 242 (criminal statute
with no private right of action); 42 U.S.C. § 2000e (employment law
inapplicable to medical licensing disputes); Jett v. Dallas Indep. Sch. Dist., 491
U.S. 701, 735 (1989) (explaining that “the express cause of action for
damages created by § 1983 constitutes the exclusive federal remedy for
_____________________
6
In addition to her constitutional and § 1983 claims, Caruso listed the following
statutes and regulations in her complaint: 18 U.S.C. § 242; 42 C.F.R. Part 1003; 42 U.S.C.
§ 1981; 42 U.S.C. § 2000e; 42 U.S.C. §§ 11111–12; Tex. Occ. Code § 164.060(b)(4);
and 22 Tex. Admin. Code § 187.5.
11
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violation of the rights guaranteed in § 1981 by state governmental units”); 42
C.F.R. § 1003.100 (regulation concerning the Office of Inspector General’s
Civil Monetary Penalties); 42 U.S.C. §§ 11111–12 (Health Care Quality
Improvement Act, which Caruso has failed to show creates a private right of
action).
As for Caruso’s state-law claims, the district court properly declined
to exercise supplemental jurisdiction under 28 U.S.C. § 1367(c)(3). “The
general rule is that a court should decline to exercise jurisdiction over
remaining state-law claims when all federal-law claims are eliminated before
trial.” Brookshire Bros. Holding, Inc. v. Dayco Prods., Inc., 554 F.3d 595, 602
(5th Cir. 2009).
IV
The district court did not err in dismissing Caruso’s complaint. We
AFFIRM.
12