UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
JOHN OLIVER SNOW, ï£¼
E. K. MCDANIEL, in his official
capacity as Warden at ELY STATE
PRISON (ESP); DEBRA BROOKS, in No. 10-16951
her official capacity as Associate D.C. No.
Warden for Operations at ESP; ï£½ 3:08-cv-00046-RCJ-
ADAM ENDEL, in his official VPC
capacity as Associate Warden for
Programs at ESP; ROBERT
BANNISTER, M.D. Medical Director
for Nevada Department of
Corrections; STEVEN MACARTHUR;
Appeal from the United States District Court for the District of Nevada
Robert Clive Jones, Chief District Judge, Presiding
Argued and Submitted October 13, 2011
Submission Withdrawn October 24, 2011
Resubmitted May 25, 2012
San Francisco, California
Filed May 25, 2012
Before: Betty B. Fletcher, Stephen Reinhardt, and
A. Wallace Tashima, Circuit Judges.
Opinion by Judge B. Fletcher
[End Page 5747]
SNOW v. MCDANIEL 5751
Marc Picker (argued), Angela Lightner, Marc Picker, Esq.,
Ltd., Reno, Nevada, for the appellant.
Clark G. Leslie, Senior Deputy Attorney General, Carson
City, Nevada, for the appellees. OPINION
B. FLETCHER, Circuit Judge:
John Snow, a 69-year-old death-row inmate, appeals the
grant of summary judgment denying his claims for violations
of his rights under the Eighth Amendment. Snow claims that
the doctors and wardens in the Nevada Department of Correc-
tions were deliberately indifferent to his medical needs; spe-
cifically, the diagnosis by more than one orthopedic surgeon
that Snow needed surgery to replace both of his hips, which
have degenerated so severely that Snow has excruciating pain
and can barely walk. Snow's medical records and statements
by physicians and specialists in the records, and all reasonable
interferences in favor of Snow drawn from the records, sug-
gest that the defendants' actions violated Snow's Eighth
5752 SNOW v. MCDANIEL
Amendment rights. We have jurisdiction under 28 U.S.C.
§ 1291. We reverse in part, affirm in part, and remand.
Because this case was resolved at summary judgment, we
present the facts in the light most favorable to Snow as the
non-moving party. RK Ventures, Inc. v. City of Seattle, 307
, 1051 n.1 (9th Cir. 2002).
Snow is a prisoner in the custody of the Nevada Depart-
ment of Corrections ("NDOC"). Before he began experienc-
ing chronic hip pain in 2004, Snow was able to walk and
exercise normally. Today, Snow cannot exercise and he needs
assistance just to get up off of his bunk. Even with help, Snow
can barely walk because of the pain caused by his degenera-
tive hip disease.
Snow first complained to NDOC medical staff about his
hip and leg pain in 2005. Steven MacArthur, M.D., a NDOC staff physician, examined Snow in late 2005. He told Snow
that he would schedule an appointment for Snow to see an
orthopedic surgeon about his hip and leg pain. Dr. MacArthur
never put anything into Snow's chart about a referral, how-
ever, and never scheduled an appointment. In January 2006,
in response to a medical kite (i.e., a written request) submitted
by Snow, NDOC medical staff prescribed ibuprofen and
ordered hip x-rays. Eric Goldberg, M.D., examined the x-rays
in March 2006. The x-rays showed that Snow had three pins
in his left hip. Investigation suggested this had been done as
a child to stabilize a slipped capital epiphysis. Dr. Goldberg
diagnosed Snow as having severe degenerative changes in
both of his hips. A staff nurse saw the x-rays and told Snow
that the amount of degeneration and arthritis shown by the x-
rays was "very impressive." To address the hip pain and
degeneration, NDOC medical staff prescribed Neurontin, a
neuropathic pain reliever, and Tums.
SNOW v. MCDANIEL 5753
An orthopedic surgeon finally examined Snow in Septem-
ber 2006. Mark Rhodes, M.D., an independent medical con- sultant, confirmed that Snow's hips exhibited severe
degeneration. Based on his observations, Dr. Rhodes guessed
that Snow was in distressing pain due to the condition of his
hips. Based on his clinical findings, Dr. Rhodes expected
Snow to suffer from excruciating and unbearable pain. He
was surprised Snow was able to walk at all. Dr. Rhodes pre- scribed pain relievers, and stated that in the long term Snow
needed a bilateral total hip arthroplasty ("THA") to replace
both hip joints. Mark Bishop, M.D., Snow's NDOC treating
physician, reviewed Dr. Rhodes's notes and ordered pain
relievers for Snow.
Snow saw Dr. Rhodes again in January 2007. Dr. Rhodes
wrote in his notes that Snow "can barely walk" due to his
degenerated hips and that "[t]here is no option here other than surgery for relief (THA Bilateral)." Dr. Rhodes indicated that
Snow's condition was an "emergency," and that although it significantly affected Snow's quality of life, it was not life-
threatening. As a short-term measure to offer Snow relief until
he was able to get hip surgery, Dr. Rhodes prescribed a non- steroidal anti-inflammatory drug ("NSAID") called Indocin.
Dr. Bishop ordered the Indocin and referred the recommen-
dation for surgery to the NDOC Utilization Review Panel
("URP"). The URP is composed of six NDOC physicians who
are board-certified in family medicine or other similar disci-
plines, and includes the NDOC Medical Director. The URP
reviews requests for significant medical procedures by outside
providers, such as surgery for an inmate. The URP denied the
"emergency" recommendation for Snow to undergo hip sur-
gery because "it was not a life[-]threatening situation." The
URP stated only that it was "[o]kay to treat pain" but that
there would be "[n]o joint replacements."
Snow continued to have significant hip pain, and sporadi-
cally received the pain medication and Indocin that had been
5754 SNOW v. MCDANIEL
prescribed for him. In March 2007, Warden E.K. McDaniel
approved a request from the medical staff to prohibit correc-
tions officers from using ankle restraints on Snow or from
ordering Snow to kneel. The request states that Snow "has
frozen hips [and] joints" and that he "needs hip replacement."
In July, Dr. Bishop referred Snow to NDOC's Regional
Medical Facility, a facility that provides full-time medical
care for inmates, because Snow's creatinine levels were very
high. Dr. Bishop concluded that Snow's creatinine levels were
going up because of the NSAIDs he was taking to manage his severely degenerated hips. Dr. Bishop submitted an "urgent"
request to the URP for Snow to receive hip surgery, writing
that Snow "[n]eeds hip surgery[;] creatinine rapidly rising on
needed pain meds." In contrast to the request for surgery in
January, Dr. Bishop changed his mind and stated that Snow's
medical problem was "potentially life threatening."
David Mar, M.D., another NDOC physician, examined
Snow two weeks later and prescribed Tylenol and an analge- sic balm for his pain. Dr. Mar decided that nothing else was
needed. The URP reviewed and rejected the recommendation
for hip surgery.
Robert Bannister, M.D., the NDOC Medical Director,
noted in Snow's medical chart that NSAIDs can be nephro-
toxic when combined with other medications taken regularly
by Snow. Dr. Bannister ordered an increase in the dosage of
Tylenol Snow received each morning and additionally pre- scribed Tylenol with codeine to take every night. Although
Snow could not kneel or exercise outside and had to use a
wheelchair to go to the visiting area, Dr. Bannister concluded
that Snow was "functioning satisfactorily in his current living situation and in performance of any required activities." Later,
because the NDOC could not provide Snow with enough of
the analgesic balm prescribed by Dr. Mar, NDOC medical staff supplemented Snow's medication regimen with oxyco-
done, a powerful narcotic. NDOC medical staff subsequently
SNOW v. MCDANIEL 5755
prescribed a regular dose of oxycodone to allow Snow to be
able to get through the day.
In 2008, Snow filed a complaint alleging several 42 U.S.C.
§ 1983 claims. In his first amended complaint, Snow alleges
that prison officials, acting in their individual and official
capacities, violated his rights under the Fourth, Eighth, and
Fourteenth Amendments. Count I of the first amended com-
plaint requests declaratory and injunctive relief to remedy a
custom or policy of inappropriate treatment of serious medical
conditions, such as his hip condition. Count II requests dam-
ages for the defendants' deliberate indifference to Snow's
medical needs and their deliberate interference with recom-
mended medical treatment. Count III requests damages under
the same cause of action as Count I. The rest of Snow's
claims were dismissed by the district court after the defen-
dants filed a motion to dismiss.
After Snow filed his lawsuit, the defendants sent Snow to see another orthopedic surgeon. Richard Long, M.D.,
described Snow's condition from 2004 to 2008:
He has progressively worsened to where at this time
he is able to walk only a few feet unsupported. He
has not left his building to go outside in the yard to
exercise for two years. He can get down a flight of
stairs, hanging on to the banister. He can walk prob-
ably 50 feet, to a shower and back unsupported, but
with difficulty. He is able to sleep only on his side.
He has extreme difficulty getting any socks on and
his pants on.
Dr. Long recommended a bilateral THA for Snow. The URP
again rejected surgery.
More than a year later, in September 2009, the URP finally
approved Snow for bilateral THA surgery.
5756 SNOW v. MCDANIEL
In 2010, the defendants filed a motion for summary judg-
ment. The magistrate judge submitted a report and recommen-
dation to the district court, in which he concluded that there
was a material issue of fact as to whether the defendants'
treatment of Snow was medically acceptable. The magistrate
judge also recommended that five of the six defendants
named in the lawsuit were not entitled to summary judgment
because there were material issues of fact as to whether they
had been deliberately indifferent to Snow's serious hip condi-
tion. Next, the magistrate judge concluded that Snow's claim
for injunctive relief was moot based on the 2009 URP
approval of bilateral THA surgery for Snow and a scheduled
date for the surgery that had already passed.
Snow filed objections to the magistrate judge's report and
recommendation. Snow objected that he did not have hip sur-
gery in 2009 and that hip surgery had never been scheduled
by the NDOC.
The district court rejected the report and recommendation,
and granted the defendants' motion for summary judgment.
The district court concluded that there was merely a disagree-
ment of opinion about the treatment of Snow with pain medi-
cations until surgery was approved in 2009. The district court stated that "[p]laintiff has provided no evidence to support
that the use of pain medications, as prescribed by the treating
medical officials, was medically unacceptable under the cir-
cumstances as required by the Ninth Circuit." The district
court did not discuss the magistrate judge's recommendations
on Snow's policy and practice claims and did not reach the
issue of personal liability for each defendant.
Snow contends that the district court erred by granting summary judgment on Count II""his claim that the defen-
SNOW v. MCDANIEL 5757
dants were deliberately indifferent to his serious medical
needs and that they deliberately interfered with the recom-
mendation that he undergo a bilateral THA. We review a
grant of summary judgment de novo and must determine,
viewing the facts 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. Lopez v. Smith, 203 F.3d 1122
, 1131 (9th Cir.
2000) (en banc).
 The Eighth Amendment prohibits the imposition of
cruel and unusual punishment and "embodies broad and ideal-
istic concepts of dignity, civilized standards, humanity, and
decency." Estelle v. Gamble, 429 U.S. 97
, 102 (1976) (quota-
tion marks removed). A prison official violates the Eighth
Amendment when he acts with "deliberate indifference" to
the serious medical needs of an inmate. Farmer v. Brennan,
511 U.S. 825, 828 (1994). To establish an Eighth Amendment
violation, a plaintiff must satisfy both an objective standard""
that the deprivation was serious enough to constitute cruel and
unusual punishment""and a subjective standard""deliberate
 To meet the objective standard, the denial of a plain-
tiff 's serious medical need must result in the "unnecessary
and wanton infliction of pain." Estelle, 429 U.S. at 104. The
State concedes that Snow's hip condition presents a serious
medical need and meets the objective standard.
The subjective standard of deliberate indifference requires
"more than ordinary lack of due care for the prisoner's inter-
ests or safety." Farmer, 511 U.S. at 835 (quoting Whitley v.
Albers, 475 U.S. 312
, 319 (1986)). The state of mind for
deliberate indifference is subjective recklessness. See id. at
835-41. But the standard is "less stringent in cases involving
a prisoner's medical needs . . . because "˜the State's responsi-
bility to provide inmates with medical care ordinarily does not
conflict with competing administrative concerns.' "
5758 SNOW v. MCDANIEL
McGuckin v. Smith, 974 F.2d 1050
, 1060 (9th Cir. 1992) (par-
tially overruled on other grounds) (quoting Hudson v. McMil-
lian, 503 U.S. 1
, 6 (1992)) (alterations omitted). Similarly,
"[i]n 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).
 The record shows that the defendants provided medical
care, medications, and specialist referrals to Snow during the
period in question. Even so, "[a] prisoner need not prove that
he was completely denied medical care" in order to prevail.
Lopez, 203 F.3d at 1132. Here, Snow may prove deliberate
indifference by showing that prison administrators or physi-
cians denied, delayed, or intentionally interfered with surgery
for his hip condition, or that the way prison staff delivered
medical care indicated deliberate indifference. See id. (citing
Estelle, 429 U.S. at 105).
We are specifically concerned with the URP's repeated
denials of bilateral THA surgery, which had been recom-
mended by specialists and by Snow's treating physician.
According to the URP policies, when deciding whether to
approve a significant medical procedure, such as surgery for
an inmate, the URP considers factors such as the length of the
inmate's remaining sentence, how well the inmate is able to
perform activities of daily living, the available resources, and
the risks and benefits of the proposal. The URP policy offi-
cially classifies joint replacement surgery as "not always nec-
essary." Stated differently, the URP policy supports
approving joint replacement surgery when the inmate's condi-
tion significantly interferes with his or her ability to function
But instead of approving the needed hip surgery when
Snow's treating physician and a specialist considered the
request an "emergency" and when the hip condition began to significantly interfere with Snow's ability to function""the
SNOW v. MCDANIEL 5759
medical staff and warden had to prohibit corrections officers
from using ankle restraints on Snow or ordering him to kneel,
among other limitations""the URP repeatedly refused to
authorize the procedure. The URP gave no medical reason for
the denials. Instead, the URP either gave no reason at all, or
flatly told Snow that they would not approve any requests for
joint replacement surgery.
The case of Hamilton v. Endell, 981 F.2d 1062
1992) (overruled in part on other grounds), is instructive. In
Hamilton, the prison officials referred the plaintiff to a sur-
geon to treat a chronic ear problem. At the same time, the
prison officials tried to arrange a flight to transport the plain-
tiff from the state prison in Alaska to a federal facility in
Oklahoma. The surgeon, who operated on the plaintiff 's ear several times, instructed that the plaintiff 's "ear had not yet
healed and the [the plaintiff] should . . . not fly anywhere for
about six months." Id. at 1064. Despite these instructions, the
defendants solicited a second medical opinion from another
physician. The second physician stated, based on his own per- sonal experience and based upon consultation with another specialist""but not based on examination of the plaintiff or
discussion with the surgeon""that the plaintiff could fly
immediately. The plaintiff alleged that he suffered severe
damage to his ear as a result of the flight. Analogizing to
cases that found deliberate indifference where prison officials
and doctors deliberately ignored a prior physician's instruc-
tions for reasons unrelated to the medical needs of the pris-
oner, the court held that "choosing to rely upon a medical
opinion which a reasonable person would likely determine to
be inferior" and forcing the plaintiff to fly "may have
amounted to the denial of medical treatment" and could have
constituted deliberate indifference. Id. at 1067.
 As in Hamilton, the circumstances here raise an infer-
ence that the defendants were unreasonably relying on their
own non-specialized conclusions with deliberate indifference
to Snow's medical needs. Both orthopedic surgeons hired by
5760 SNOW v. MCDANIEL
NDOC to consult on this case recommended a bilateral THA,
and did not recommend indefinite maintenance on NSAIDs, steroids, and narcotics as a solution. The NDOC physician
who treated Snow and who submitted the two 2007 requests
for surgery to the URP described the requests as an "emergen-
cy" and as "urgent." Conversely, the NDOC physicians on the
URP are not board-certified in orthopedic surgery or in
related disciplines, and with isolated exceptions none of them
ever directly examined or treated Snow. Only the July 2007
denial by the URP purported to rely on a contrary medical
opinion by a non-specialist physician who examined Snow.
 Further, evidence in the record suggests that the URP
ignored the recommendations of specialists and treating phy- sicians for reasons unrelated to Snow's medical needs. During
his deposition, Theodore D'Amico, M.D., who was the previ-
ous NDOC medical director, testified that he did not recall
any hip replacement surgeries at all during his tenure. And a
former NDOC nurse testified that around this time there was
an official policy against treating chronic pain, and Warden
McDaniel told the medical staff that "[i]f one of these [death
row] inmates gets deathly ill, don't knock yourself out to save
their life. There's plenty more to take their place." This depo- sition testimony supports the inference that the defendants had
improper motives when applying the URP policy to deny joint
replacement surgery and medical services to death row
inmates. A reasonable jury could conclude that the defendants
refused to authorize surgery in order to avoid eventually pay-
ing for it, relying on the possibility that Snow could die of
natural causes or be executed by the State in the near future.
Evidence of an improper motive can support a conclusion that
a defendant acted with deliberate indifference. George v.
Sonoma Cnty. Sheriff's Dep't, 732 F. Supp. 2d 922, 937 (N.D.
Cal. 2010) (citing Jackson v. McIntosh, 90 F.3d 330
, 332 (9th
Cir. 1996)); see also Jones v. Johnson, 781 F.2d 769
, 771 (9th
Cir. 1986) (holding that budgetary constraints do not justify
cruel and unusual punishment).
SNOW v. MCDANIEL 5761
 We conclude that a reasonable jury could find that the
defendants acted with deliberate indifference to Snow's medi-
cal needs when they refused to authorize the recommended
joint-replacement surgery. The record also shows that Snow
presented sufficient evidence to support a finding that he was substantially harmed by the defendants' refusal to treat his hip
condition as recommended. See McGuckin, 974 F.2d at 1060
(requiring plaintiffs to show that delay led to further injury in
cases of deliberate indifference based on the delay of medical
The defendants argue and the district court ruled at sum-
mary judgment that the decision by NDOC physicians to treat
Snow pharmacologically rather than surgically was medically
acceptable, and that Snow cannot base his claimed Eighth
Amendment violation on a mere difference of opinion over
the course of treatment. Even if it is possible to characterize
the treatment decisions of the URP this way, we disagree with
the conclusion that the defendants are entitled to summary
judgment on these grounds.
A difference of opinion between a physician and the
prisoner""or between medical professionals""concerning
what medical care is appropriate does not amount to deliber-
ate indifference. Sanchez v. Vild, 891 F.2d 240
, 242 (9th Cir
1989). Even proof that a physician has committed medical
malpractice does not necessarily violate the Eighth Amend-
ment. See Estelle, 429 U.S. at 106. To show deliberate indif-
ference, the plaintiff "must show that the course of treatment
the doctors chose was medically unacceptable under the cir-
cumstances" and that the defendants "chose this course in
conscious disregard of an excessive risk to plaintiff 's health."
Jackson, 90 F.3d at 332 (internal citations removed).
There is clearly a difference of medical opinion here. On
the one hand, physicians often attempt non-surgical interven-
5762 SNOW v. MCDANIEL
tions to address hip pain.1 The NDOC physicians on the URP,
who are all board-certified in family medicine or other similar
disciplines, decided to treat Snow's hip pain and immobility
with medication instead of surgery. This persisted for several
years. The NDOC physicians adjusted the medications to
increasingly rely on narcotics when Snow's creatinine levels
rose to dangerous levels. On the other hand, from 2007
through 2009 two orthopedic specialists and Snow's NDOC
treating physician recommended bilateral THA surgery.
 The defendants argue that this was merely a difference
of opinion that cannot amount to deliberate indifference. We
disagree. Based on the unchallenged medical records and
inferences drawn in favor of Snow, a reasonable jury could
conclude that the decision of the non-treating, non-specialist
physicians to repeatedly deny the recommendations for sur-
gery was medically unacceptable under all of the circum- stances.
 After Snow developed severe hip pain, the defendants
eventually sent him for evaluation by orthopedic surgeons.
Both specialists hired by the NDOC recommended bilateral
THA surgery. One of the specialists, Dr. Rhodes, testified at
his deposition that Snow's likelihood of success after a THA
was very high, and that surgery would help improve Snow's
health and mobility. And Dr. Rhodes testified that after sur-
gery Snow's hip pain would probably disappear, and that
Snow would no longer require any painkillers for his hips.
Conversely, neither specialist recommended indefinite main-
tenance on NSAIDs, steroids, or narcotics. The record also shows that medications may have harmed Snow's kidneys,
and that the narcotics did not alleviate Snow's significant
mobility issues. In fact, Dr. Rhodes stated in January 2007
See Questions and Answers about Hip Replacement, National Institute
of Arthritis and Musculoskeletal and Skin Diseases, available at
visited May 17, 2012).
SNOW v. MCDANIEL 5763
that there "is no option here other than surgery for relief."
Because, on this record, it is a controverted issue of fact, it should be for the jury to decide whether any option other than surgery was medically acceptable.
The defendants ignored outside expert advice, relying solely on their own medical judgment for three years before
eventually approving surgery. They claim that the specialists
did not explicitly recommend "immediate" surgery. While a
medication-only course of treatment may have been medically
acceptable for a certain period of time, the question remains
whether it was medically unacceptable and subjectively reck-
less to ignore a "long term" recommendation for three years,
or to ignore "emergency" and "urgent" requests for more than
two years. These are jury questions.
The cases relied upon by the defendants are distinguish-
able. The plaintiff in Toguchi v. Chung, 391 F.3d 1051
Cir. 2004), argued that the defendant physician should not
have discontinued the use of a "superior" type of anti-
psychotic medication. Plaintiff 's expert did not address that specific claim, and the defendant submitted expert testimony
that her actions met the standard of care. Id. at 1055-56. Here,
conversely, specific statements by physicians in the record
raise triable issues of fact whether refusing to authorize sur-
gery was medically unacceptable. And unlike in Sanchez v.
Vild, where only one prison doctor told the inmate that sur-
gery would be necessary, here the consistent recommendation
by two outside specialists over the course of three years was
that Snow needed hip surgery to alleviate his severe pain and
mobility issues. See Sanchez, 891 F.2d at 242.
In his lawsuit, Snow named the following defendants, act-
ing in their individual and official capacities: (a) E.K.
McDaniel, ESP Warden; (b) Adam Endel, ESP Associate
Warden of Programs; (c) Robert Bannister, M.D., NDOC
5764 SNOW v. MCDANIEL
Medical Director; (d) Steven MacArthur, M.D., an ESP staff
physician; (e) Max Carter, a physician's assistant employed
by NDOC; and (f) Debra Brooks, ESP Associate Warden of
Operations. Snow argues that summary judgment should have
been denied as to all of the defendants except Brooks, whom
he concedes is entitled to summary judgment.
A. Warden McDaniel and Associate Warden Endel
Snow argues that the prison administrators are liable for the
medical staff's Eighth Amendment violations because the
administrators were aware of Snow's hip condition and of the
medical staff's inadequate treatment and yet failed to act or
order changes to customs and policies. The defendants argue
that there is no evidence in the record that Warden McDaniel
or other administrators were personally involved in any of the
medical treatment decisions.
 "Under Section 1983, supervisory officials are not lia-
ble for actions of subordinates on any theory of vicarious lia-
bility." Hansen v. Black, 885 F.2d 642
, 645-46 (9th Cir.
1989). A supervisor may be liable only if (1) he or she is per- sonally involved in the constitutional deprivation, or (2) there
is "a sufficient causal connection between the supervisor's
wrongful conduct and the constitutional violation." Id. at 646.
A supervisor may be liable if the supervisor knew of the vio-
lations and failed to act to prevent them. Taylor v. List, 880
, 1045 (9th Cir. 1989).
 During her deposition, a former NDOC nurse testified
that the warden and his assistants were aware of all grievances
regarding inappropriate medical treatment. The record shows
that Snow submitted several grievances about the denial of
the recommended hip surgery. Also, Warden McDaniel and
Associate Warden Endel personally reviewed the "no-kneel"
order""which explicitly states that Snow "needs hip
replacement"""and other accommodations made on behalf of
Snow for his hip condition. Through these orders and griev-
SNOW v. MCDANIEL 5765
ances, Snow has sufficiently demonstrated that Warden
McDaniel and Associate Warden Endel were aware of his serious hip condition. Because they were aware Snow needed surgery and failed to act to prevent further harm, Warden
McDaniel and Associate Warden Endel are not entitled to summary judgment.
Further, the former nurse also testified that Warden
McDaniel told medical staff: "If one of these [death row]
inmates gets deathly ill, don't knock yourself out to save their
life. There's plenty more to take their place." Thus, there is
also a material issue of fact as to whether Warden McDaniel
failed to act to prevent the medically unacceptable care in
Snow's case because of animus towards death row inmates.
B. NDOC Medical Director Robert Bannister, M.D.
 Dr. Bannister was the head of the URP during the rel-
evant period. Consequently, he was directly involved with the
decision to deny surgery recommended by specialists and
treating physicians in favor of a plan to treat Snow with medi-
cation alone. Because there is a material issue of fact as to
whether those decisions were deliberately indifferent to
Snow's medical needs, Dr. Bannister is not entitled to sum-
C. Staff Physician Steven MacArthur, M.D.
 Snow argues that Dr. MacArthur is not entitled to summary judgment because he refused to make an appoint-
ment in January 2006 for Snow to see an orthopedic surgeon
about his chronic severe hip pain. Snow also points to evi-
dence in the record that suggests that Dr. McArthur disliked
him and purposefully refused to treat him. In order to prove
deliberate indifference through delay of medical care, then,
Snow must show that Dr. McArthur's failure to schedule an
appointment for him led to further injury. See McGuckin, 974
F.2d at 1060. And "[a] finding that the defendant's neglect of
5766 SNOW v. MCDANIEL
a prisoner's condition was an "˜isolated occurrence' or an "˜iso-
lated exception' to the defendant's overall treatment of the
prisoner ordinarily militates against a finding of deliberate
indifference." Id. (internal citations removed). Although it is
unlikely that Dr. McArthur's failure to schedule a consulta-
tion for Snow had a substantial effect on the timing of Snow's
treatment, any delay in treatment that was potentially moti-
vated by animus creates a material issue of fact for the jury.
We reverse the grant of summary judgment to Dr. MacArthur.
D. Physician's Assistant Max Carter
Snow alleged that he received his pain medications incon- sistently and in doses that were not sufficient. In July 2007,
Snow sent a medical kite that asked: "If I can only have and
take Indocin for 10 days a month, are you prescribing some-
thing in its place to ease my pain the other 20 days?" In
response, Carter wrote: "[N]ope "" gonna let you suffer until
you tell me its [sic] working or not "" not much need in tak-
ing something that doesn't work." Dr. Bishop reviewed Car-
ter's response a week later and overruled it. Dr. Bishop wrote:
"Mr. Snow, I reviewed this kite response and totally disagree.
Pain meds are appropriate and I am ordering them today for
your needed well being." Carter testified at deposition that his
"gonna let you suffer" comment to Snow was a "tongue-and-
cheek" attempt at humor.
 Carter's "gonna let you suffer" statement is a textbook
example of the state of mind required to violate the Eighth
Amendment. Whether or not he made the statement in an
attempt at humor is an issue for the jury. We reverse the grant
of summary judgment to Carter.
In entering judgment dismissing Snow's lawsuit, the dis-
trict court granted summary judgment on Counts I and III,
Snow's two "custom and policy" claims against the State of
SNOW v. MCDANIEL 5767
Nevada and the NDOC. The magistrate judge recommended
granting summary judgment on Count III, Snow's claim for
damages. The magistrate judge concluded that Count I,
Snow's claim for injunctive relief, was moot because the date
defendants had scheduled for Snow's hip surgery had passed.
 The district court properly granted summary judgment
on Count III. That claim seeks damages from the State and the
NDOC for the custom or policy of refusing to provide certain
types of medical care to inmates. See Kentucky v. Graham,
473 U.S. 159
, 165-67 (1985) (discussing official capacity suits as a way to sue the governmental entity by alleging a
custom or policy claim). Because federal courts are barred by
the Eleventh Amendment from awarding damages against state officials acting in their official capacities, this claim is
dismissed. See Bank of Lake Tahoe v. Bank of Am., 318 F.3d
, 918 (9th Cir. 2003).
The district court improperly granted summary judgment
on Count I, Snow's claim for injunctive relief. After the mag-
istrate judge dismissed the claim as moot, Snow objected that
he had not yet received hip surgery and that it was no longer scheduled or approved. Snow's objection preserved this claim
for review by the district court, and created a factual dispute
as to whether the claim was moot.
Snow argues that he is entitled to injunctive relief based on
the defendants' policy or custom of deliberate indifference to
the medical needs of inmates. Specifically, Snow alleges that
NDOC medical staff and prison administrators have a policy
or custom of acting without adequate medical justification and
in deliberate indifference to the serious medical needs of
inmates when they refuse to treat non-life-threatening medical
conditions, such as the need for joint replacement surgery. In
order to survive summary judgment on this claim, Snow must
come forward with evidence from which it can be
inferred that the defendant-officials were at the time
5768 SNOW v. MCDANIEL
suit was filed, and are at the time of summary judg-
ment, knowingly and unreasonably disregarding an
objectively intolerable risk of harm, and that they
will continue to do so.
Farmer, 511 U.S. at 846.
 On the record at summary judgment, the court could
infer that the defendants were acting with deliberate indiffer-
ence and were likely to continue to refuse to authorize hip surgery for Snow. See Gibson v. Cnty. of Washoe, 290 F.3d
, 1191 (9th Cir. 2002) (holding that summary judgment
is not appropriate if a jury could infer that policymakers knew
that their policies would pose a risk of substantial injury). We
conclude that summary judgment on this claim was prema-
ture. Snow's claim for an injunction to start the pre-operative
process for hip surgery may proceed. When considering this
claim on remand, however, the district court may consider supplemental medical records and filings by both parties. Far-
mer, 511 U.S. at 846 ("[T]he inmate may rely, in the district
court's discretion, on developments that postdate the plead-
ings and pretrial motions, as the defendants may rely on such
developments to establish that the inmate is not entitled to an
During this appeal, the defendants filed a motion to request
permission to supplement the record with medical records
generated, for the most part, after the defendants filed the
motion for summary judgment. At oral argument, plaintiff 's
counsel stated that Snow had not had hip surgery because of
a cardiac issue. Counsel stated that the cardiac issue prevented
Snow from undergoing surgery until at least November 2011,
and potentially beyond that date.
On appeal of summary judgment, courts generally consider
only the record that was before the district court. United
SNOW v. MCDANIEL 5769
States v. W.R. Grace, 504 F.3d 745, 766 (9th Cir. 2007); see
Lippi v. City Bank, 955 F.2d 599
, 604 (9th Cir. 1992) ("Our
review is limited to the record presented to the district court
at the time of summary judgment."). This rule has three
exceptions: "(1) to correct inadvertent omissions from the
record, (2) to take judicial notice, and (3) to exercise inherent
authority . . . in extraordinary cases. Considerations of institu-
tional expertise and notice support our limitation of these
exceptions to unusual circumstances." W.R. Grace, 504 F.3d
at 766 (citations and internal quotation marks removed).
The State concedes that the motion to supplement the
record does not fall within one of the three recognized excep-
tions. Instead, the State claims that the supplemental medical
records show good cause for delaying Snow's hip replace-
ment surgery. The State also claims that Snow's need for
injunctive relief is moot because pre-operative procedures had
previously been initiated for a hip replacement in 2009.
 We deny the State's motion to supplement the sum-
mary judgment record. The supplemental medical records do
not "establish beyond any doubt the proper resolution" of the
order granting summary judgment. Colbert v. Potter, 471 F.3d
, 165-66 (D.C. Cir. 2006) (quoting CSX Transp., Inc. v.
Garden City, 235 F.3d 1325, 1330 (11th Cir. 2000)).
Although Snow's cardiac issue could eventually affect his
claim for injunctive relief, the supplemental medical records
demonstrate only that Snow may not have been a candidate
for surgery until November 2011 because of a cardiac condi-
tion from some undetermined time. And the supplemental
medical records do not, on their own, demonstrate that Snow
could not have obtained surgery at an earlier date. In fact, if
the defendants are not able to prove that Snow was ineligible
for surgery in 2007 and 2008, Snow may be able to show that
the decision not to authorize surgery before the onset of the
cardiac problem has left him crippled for life. New evidence should be presented to the district court on remand.
5770 SNOW v. MCDANIEL
The district court improperly concluded that there is a mere
disagreement of medical opinion in this case. By treating the
record here as a mere disagreement of opinion, the district
court did not identify the triable issues of fact whether the
defendants denied, delayed, or intentionally interfered with
appropriate medical treatment, or whether the defendants'
course of treatment was medically unacceptable. And because
Snow has not yet had hip surgery, and may or may not be eli-
gible for surgery, his claim for injunctive relief is not moot
and should be addressed on remand.
For these reasons, we reverse: (1) the denial at summary
judgment of Snow's claim for injunctive relief against the
defendants in their official capacities; and (2) the denial at summary judgment of Snow's claim for damages against the
defendants in their individual capacities, other than Brooks.
We affirm the grant of summary judgment to Brooks and the
denial at summary judgment of Snow's claim for damages
against the defendants in their official capacities. We deny the
defendants' motion to supplement the record on appeal, and
remand for further proceedings.
REVERSED in part, AFFIRMED in part, and
REMANDED for further proceedings consistent with this
opinion. Snow is awarded costs on appeal.