Torrey v. Infectious Diseases Socty ( 2023 )

Case: 22-40728 Document: 00516971426 Page: 1 Date Filed: 11/16/2023
United States Court of Appeals
for the Fifth Circuit
United States Court of Appeals
Fifth Circuit
____________ FILED
November 16, 2023
No. 22-40728 Lyle W. Cayce
____________ Clerk
Lisa Torrey; Kathryn Kocurek, Individually and on behalf of the
Estate of J. David Kocurek, Ph.D.; Amy Hanneken; Jane
Powell; Carol Fisch; John Valerio, Individually and as Next
Friend of Christopher Valerio; Randy Sykes; Brienna
Reed; Rosetta Fuller; Adriana Monteiro Moreira;
Jessica McKinnie; Kristine Woodard; Gayle Clarke;
Allison Lynn Caruana; Chloe Lohmeyer; Tawnya Dawn
Smith, Individually and as Next Friend of Monet Pitre; Mike
Peacher, Individually and as Next Friend of Ashleigh Peacher;
Alarie Bowerman, Individually and as Next Friend of Elisa
Bowerman, Emory Bowerman and Anais Bowerman,
Plaintiffs—Appellants,
versus
Infectious Diseases Society of America,
Defendant—Appellee.
______________________________
Appeal from the United States District Court
for the Eastern District of Texas
USDC No. 5:17-CV-190
______________________________
Before Jones, Stewart, and Duncan, Circuit Judges.
Stuart Kyle Duncan, Circuit Judge:
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A professional society specializing in the study and treatment of
infectious diseases published guidelines in a peer-reviewed medical journal
for treating Lyme disease. Individuals who claim to suffer from persistent
Lyme disease symptoms sued the society, alleging the guidelines harmed
them by casting doubt on how chronic Lyme disease should be treated and
even whether the condition exists. The district court dismissed the claims
because it concluded that the statements at issue were non-actionable
medical opinions, not factual assertions that could support a claim for
fraudulent or negligent misrepresentation. We AFFIRM.
I.
A.
Plaintiffs are people who claim to suffer from chronic Lyme disease.
A person contracts Lyme disease from ticks carrying the bacterium Borrelia
burgdorferi. See generally Robert L. Bratton et al., Diagnosis and Treatment of
Lyme Disease, 83 Mayo Clinic Proc. 566 (2008). Typical symptoms are
fever, headache, swollen joints, fatigue, and rashes. Many patients respond
to short-term antibiotics, but some do not. This latter group is said by some
to experience “post-Lyme disease syndrome,” “posttreatment chronic
Lyme disease,” or “chronic Lyme disease.”
The nature of chronic Lyme disease, and how to properly treat the
condition, are matters of scientific dispute. Plaintiffs allege that some
doctors, accepting the phenomenon’s existence, recommend a holistic
approach that may include long-term antibiotics. Others take a different
view—like the Defendant here, the Infectious Diseases Society of America
(“IDSA”), a professional society of doctors, scientists, and other healthcare
professionals.
In 2006, IDSA published The Clinical Assessment, Treatment, and
Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis:
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Clinical Practice Guidelines by the Infectious Diseases Society of America
(“the Guidelines”). The Guidelines appeared in the peer-reviewed medical
journal Clinical Infectious Diseases, one of IDSA’s publications. The
Guidelines extensively discuss how to diagnose and treat Lyme disease. 1
Throughout, they express doubt about the causes, frequency, and even the
existence of chronic Lyme disease. Moreover, the Guidelines do not
recommend long-term antibiotic therapy for persons with persistent Lyme
symptoms who have already received recommended treatments.
B.
In November 2017, Plaintiffs sued IDSA, six health insurance
companies and a health insurance trade association (collectively, the
“Insurance Defendants”), and seven doctors (“the Doctors”) who were
among the fourteen authors of IDSA’s 2006 Guidelines. Plaintiffs alleged
that the Insurance Defendants paid the Doctors “large consulting fees” to
include baseless treatment recommendations in the Guidelines, which, in
turn, would allow the Insurance Defendants to deny coverage for chronic
Lyme disease. Plaintiffs asserted claims under the Racketeer Influenced and
Corrupt Organizations Act (RICO), 18 U.S.C. § 1962(a)–(d), as well the
Sherman Act.
From 2019 to 2021, Plaintiffs settled with all Insurance Defendants.
They also conducted full discovery on their RICO and antitrust claims. In
January 2021, on the last day of fact discovery, Plaintiffs filed a Second
Amended Complaint, adding for the first time fraudulent and negligent
misrepresentation claims against IDSA. IDSA and the Doctors moved to
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1
We discuss specific statements from the Guidelines below, as necessary to
address Plaintiffs’ arguments.
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dismiss Plaintiffs’ Second Amended Complaint and also moved for summary
judgment on the RICO and antitrust claims.
In March 2021, Plaintiffs filed a Third Amended Complaint, adding
allegations supporting their misrepresentation claims. IDSA and the
Doctors again moved to dismiss. Plaintiffs later voluntarily dismissed with
prejudice their RICO claims against IDSA and the Doctors and likewise
dismissed their antitrust claim against the Doctors (but not against IDSA).
In September 2021, the district court granted IDSA’s motion for summary
judgment on the antitrust claims.
All that remained were Plaintiffs’ misrepresentation claims against
IDSA, which the district court dismissed shortly thereafter. The court
reasoned that “the statements in the IDSA Guidelines are not the type of
statements that Plaintiffs can recover for based on misrepresentation, as they
are medical opinions, not factual representations.” At best, the court
observed, “Plaintiffs cite other studies or statements that have reached
different conclusions or formed different opinions than those expressed in
the IDSA Guidelines.”
Subsequently, IDSA moved to recover $43,940.06 in costs for
defending against Plaintiffs’ RICO and antitrust claims. Plaintiffs filed a
notice stating they agreed with IDSA’s proposed bill of costs. Accordingly,
the district court granted IDSA $43,940.06 in costs and entered final
judgment against Plaintiffs.
Plaintiffs timely appealed.
II.
We review de novo a Rule 12(b)(6) dismissal for failure to state a claim.
See Norsworthy v. Hous. Indep. Sch. Dist., 70 F.4th 332, 336 (5th Cir. 2023). A
complaint that fails to state a facially plausible claim must be dismissed. Bell
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Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007). “[F]acial plausibility”
means “factual content that allows the court to draw the reasonable inference
that the defendant is liable for the misconduct alleged.” Ashcroft v. Iqbal, 556
U.S. 662, 678 (2009). We accept well-pled facts as true and view them in the
light most favorable to the plaintiff. PHI Grp., Inc. v. Zurich Am. Ins. Co., 58
F.4th 838, 841 (5th Cir. 2023). But we disregard “conclusory allegations,
unwarranted factual inferences, or legal conclusions.” Heinze v. Tesco Corp.,
971 F.3d 475, 479 (5th Cir. 2020) (citation omitted).
III.
Plaintiffs argue the district court erred in dismissing their
misrepresentation claims against IDSA. They contend that the Guidelines,
properly read, do not merely report medical opinions but instead make
factual representations about the proper treatment for, and indeed the very
existence of, chronic Lyme disease. We disagree. Instead, as explained below,
we agree with the district court that the Guidelines “are medical opinions,
not factual representations,” and cannot form the basis for a claim of
fraudulent or negligent misrepresentation.
Before beginning our analysis, we say a brief word about the applicable
law. Plaintiffs’ misrepresentation claims might be governed by the laws of
three different States—Texas, New York, or Virginia. See generally
Restatement (Second) of Conflict of Laws §§ 6, 145 (Am. L.
Inst. 1971). The parties spar over this choice-of-law question, but their
disagreement does not touch the key issue on which we resolve this appeal—
i.e., whether the Guidelines constitute non-actionable medical opinions or
actionable factual representations. 2 As to that issue, the parties appear to
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2
The parties’ disagreement about applicable state law instead centers on the issue
of “derivative” reliance—specifically, whether Plaintiffs may maintain a claim based on
the allegation that their doctors relied on IDSA’s alleged misrepresentations. Because we
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agree that those States’ laws do not meaningfully differ. 3 Accordingly, we
need not resolve the choice-of-law question. See LHC Nashua P’ship, Ltd. v.
PDNED Sagamore Nashua, L.L.C., 659 F.3d 450, 456–57 (5th Cir. 2011)
(explaining we need not decide governing State law “if our conclusions
would be the same”). We therefore turn to Plaintiffs’ arguments.
Plaintiffs appear to agree that merely publishing a medical opinion—
even a hotly debated one—in a peer-reviewed journal cannot give rise to a
misrepresentation claim. Some of our sister circuits have adopted that
proposition in analogous contexts, relying on both the First Amendment and
commonsense observations about the nature of scientific debate. See Pacira
Biosci., Inc. v. Am. Soc’y of Anesthesiologists, Inc., 63 F.4th 240, 249 (3d Cir.
2023) (holding that “content, verifiability, and context” all support
conclusion that statements in peer-reviewed medical journal are
“nonactionable opinions” for trade libel claims); ONY, Inc. v. Cornerstone
Therapeutics, Inc., 720 F.3d 490, 498 (2d Cir. 2013) (holding that contents of
article published in peer-reviewed medical journal are “non-actionable
scientific conclusions” for false advertising claim under Lanham Act). Our
circuit has discussed one of those precedents favorably, albeit in dicta. See
Eastman Chem. Co. v. Plastipure, Inc., 775 F.3d 230, 235 (5th Cir. 2014)
(“After a thorough analysis, the Second Circuit concluded that the First
Amendment places scientific debates unfolding within the scientific
community beyond the reach of the Lanham Act.” (citing ONY, 720 F.3d at
496–97)). We discuss those cases in greater detail below. For their part,
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do not address this issue, we need not address the antecedent choice-of-law question posed
by the parties.
3
Indeed, Plaintiffs’ brief concedes there is no substantive difference on this issue
among the laws of Texas, New York, or Virginia and that, consequently, “the Court need
not resolve the choice-of-law question with regards to this issue.”
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Plaintiffs do not contest the principle and, in any event, cite no decision
casting any doubt on it. 4
What Plaintiffs do argue, however, is that the district court failed to
read the Guidelines’ statements about chronic Lyme disease “in context.”
Had it done so, they contend, the court would have seen that the Guidelines
do not merely report opinions but, rather, make factual assertions intended
to influence doctors and insurance companies. These arguments miss the
mark.
Plaintiffs contend the district court “literally” read the Guidelines
without considering “the perception of them as applied by medical
practitioners, other researchers, and influential players within the medical
community.” We disagree. Plaintiffs cite no authority instructing courts to
read the Guidelines in that way. Instead, Plaintiffs cite cases merely saying
courts must consider “a reasonable person’s perception of the entirety of a
publication,” In re Lipsky, 460 S.W.3d 579, 594 (Tex. 2015), and must avoid
“literalism.” Immuno AG. v. Moor-Jankowski, 567 N.E.2d 1270, 1273 (N.Y.
1991). These are everyday interpretive rules, but Plaintiffs fail to show how
the district court violated them. To the contrary, the district court explicitly
recognized the Guidelines’ context: it noted that the Guidelines “set forth
explanations of medical research, experiments and knowledge based on
citations to other published studies and clinical trials, not naked assertions of
fact.” Indeed, if anyone has taken the Guidelines out of context, it is
Plaintiffs. As the district court observed, the statements targeted by Plaintiffs
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4
Accordingly, we need not determine when, if ever, the mere publication of a
medical or other scientific opinion might form the basis for a cause of action for
misrepresentation or any other tort.
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“are isolated portions of complex documents and reading the IDSA
Guidelines in their entirety undermines Plaintiffs’ pleadings.”
Plaintiffs also contend the Guidelines show that IDSA tried to
“bury” or “explain away” treatment failures, which Plaintiffs interpret as
the organization’s “skepticism and overall disapproval of the studies relating
to instances of chronic Lyme disease.” This argument is unavailing. Contrary
to Plaintiffs’ view, the Guidelines do not become actionable factual
representations merely because they disapprove of studies Plaintiffs prefer.
As the district court concluded, “[a]t best, Plaintiffs cite other studies or
statements that have reached different conclusions or formed different
opinions than those expressed in the IDSA Guidelines.” See Am. Sch. Of
Magnetic Healing v. McAnnulty, 187 U.S. 94, 106 (1902)) (“[D]ifferent
schools of medicine have their followers, and many who believe in the one
will pronounce the other wholly devoid of merit. But there is no precise
standard by which to measure the claims of either . . . .”).
Plaintiffs next argue that the district court erred by relying on a
Guidelines disclaimer which “contradicts” the Guidelines’ opening
sentence. We again disagree. The disclaimer states that the “[G]uidelines
cannot always account for individual variation among patients,” and that
“the ultimate determination” to apply them should “be made by the
physician in the light of each patient’s individual circumstances.” The
Guidelines’ introductory sentence states that they “are intended for use by
health care providers who care for patients who either have these infections
or may be at risk for them.” We see no contradiction between the two
statements. It is perfectly consistent (1) to offer general guidance to
physicians about treating Lyme disease, while (2) recognizing the final
decision should be left up to the treating physician given inevitable variation
in individual cases. In any event, even if Plaintiffs were correct that some
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tension existed between the two statements (although we see none), they cite
no authority that this amounts to an actionable misrepresentation.
As to specific statements in the Guidelines, Plaintiffs emphasize two.
They take issue with IDSA’s positions that (1) “[t]here is no convincing
biological evidence for the existence of symptomatic chronic B. burgdorferi
infection among patients after receipt of recommended treatment regimens
for Lyme disease,” and (2) “[a]ntibiotic therapy has not proven to be useful
and is not recommended for patients with chronic (>6 months) subjective
symptoms after recommended treatment regimens for Lyme disease.” 5 On
their face, however, these statements are medical opinions. In this context (a
scientific debate over treatment options for persistent Lyme symptoms), to
say that evidence is not “convincing” or that some treatment is “not
recommended” is plainly to express a medical opinion. Just because Plaintiffs
disagree with those opinions does not mean that IDSA is somehow liable
because their doctors or insurance providers found the opinions persuasive.
Not only do Plaintiffs misread the Guidelines, but accepting their
arguments would risk putting us at odds with other circuits. For instance, in
the Second Circuit’s ONY case, the plaintiff claimed an article in a peer-
reviewed medical journal made false statements about the effectiveness of
treatments to help lung function in premature infants. 720 F.3d at 492–95.
The Second Circuit recognized that scientific discourse “poses several
problems for the fact-opinion paradigm of First Amendment jurisprudence.”
Id. at 496. On the one hand, “[m]ost conclusions contained in a scientific
journal article are, in principle, capable of verification or refutation by means
of objective proof.” Ibid. (internal quotation marks and citation omitted). On
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5
Plaintiffs raise similar objections to IDSA’s not recommending long-term
antibiotic therapy “[b]ecause of a lack of biological plausibility, lack of efficacy, absence of
supporting data, or the potential for harm to the patient.”
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the other hand, “it is the essence of the scientific method that the conclusions
of empirical research are tentative and subject to revision, because they
represent inferences about the nature of reality based on the results of
experimentation and observation.” Ibid. Accordingly, the court concluded
that the statements at issue were “more closely akin to matters of opinion,
and [were] so understood by the relevant scientific communities.” Id. at 497.
It therefore held that “the contents of the article [were] non-actionable
scientific conclusions.” Id. at 498.
Similarly, the Third Circuit’s Pacira case involved a dispute over the
efficacy of an anesthetic to control post-surgical pain. 63 F.4th at 243. The
manufacturer plaintiff sued defendants for trade libel for publishing
statements in a medical journal criticizing the anesthetic. Ibid. Citing ONY,
the Third Circuit examined the content of the publication, the verifiability of
the assertions, and the context in which they were written. Id. at 245–49. The
court concluded that a “fair and natural reading of these statements shows
that these are nonactionable subjective expressions.” Id. at 246 (internal
quotation marks and citation omitted).
Plaintiffs rely on our opinion in Eastman Chemical Co. v. Plastipure,
Inc., but it does not help them. That case involved a plaintiff who
manufactured a plastic resin used in drinking containers. 775 F.3d at 233.
Defendants, who were plaintiff’s competitors, published an article in a peer-
reviewed journal “summarizing the results of its testing of more than 500
commercially available plastic products.” Ibid. They also distributed a three-
page brochure depicting plaintiff’s resin as containing harmful chemicals. Id.at 233–34. We allowed plaintiff’s Lanham Act suit to go forward, but only
after emphasizing that “[plaintiff] did not sue [defendants] for publishing an
article in a scientific journal.” Id. at 236. Rather, we stated, “[plaintiff]
sought to enjoin statements made in commercial advertisements and directed
at customers.” Ibid. Accordingly, we affirmed the injunction, which applied
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only to defendants’ statements “in connection with any advertising,
promotion, offering for sale, or sale of goods or services,” but not to the
journal article. Id. at 237. As this description of Eastman confirms, the case
helps IDSA, not Plaintiffs.
In sum, the district court did not err in holding that IDSA’s
Guidelines statements about chronic Lyme disease constitute nonactionable
medical opinions. 6
IV.
The district court’s judgment is AFFIRMED.
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6
Alternatively, Plaintiffs argue that—even if the Guidelines are nonactionable
medical opinions—they can still sue for misrepresentation because IDSA knew the
opinions were false. We need not address this argument because, as IDSA points out,
Plaintiffs did not raise it in the district court. Plaintiffs’ reply brief does not even attempt
to argue to the contrary. Accordingly, the argument is forfeited. See Moore v. LaSalle Mgmt.
Co., L.L.C., 41 F.4th 493, 509 (5th Cir. 2022) (“We do not consider arguments raised for
the first time on appeal.” (internal quotation marks and citation omitted)).
Finally, Plaintiffs argue the district court erred by granting IDSA’s bill of costs as
the prevailing party. But the only basis on which Plaintiffs argue for reversal is that the
district court erred in dismissing their misrepresentation claims. Because we affirm the
dismissal of those claims, we necessarily affirm the bill of costs.
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