USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 1 of 18

UNPUBLISHED

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT

No. 24-1994

JANE DOE,

Plaintiff - Appellant,

v.

UNIVERSITY OF MARYLAND MEDICAL SYSTEM CORPORATION; BALTIMORE WASHINGTON MEDICAL CENTER, INC.; KATHLEEN MCCOLLUM; THOMAS J. CUMMINGS, JR., M.D.,

Defendants - Appellees.

Appeal from the United States District Court for the District of Maryland, at Baltimore. Julie R. Rubin, District Judge. (1:23-cv-03318-JRR)

Argued: October 22, 2025 Decided: December 11, 2025

Before WILKINSON, WYNN and RUSHING, Circuit Judges.

Affirmed by unpublished opinion. Judge Wynn wrote the opinion, in which Judge Wilkinson and Judge Rushing joined.

ARGUED: Ray M. Shepard, THE SHEPARD LAW FIRM, LLC, Pasadena, Maryland, for Appellant. Mark S. Saudek, GALLAGHER LLP, Baltimore, Maryland, for Appellees. ON BRIEF: Ella R. Aiken, GALLAGHER LLP, Baltimore, Maryland, for Appellees.

Unpublished opinions are not binding precedent in this circuit. USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 2 of 18

WYNN, Circuit Judge:

Under the Maryland statute governing health care advance directives, an individual

who is appointed as a health care agent in an advance directive cannot also sign that

document as a witness. Md. Code, Health-Gen. § 5-602(c)(2)(ii).

In this case, Jane Doe executed a document that appointed her father as a primary

health care agent and her mother as an alternate health care agent. Doe’s mother also signed

the document as a witness. After Defendants refused to honor the document and

involuntarily committed Doe during an episode of psychosis, Doe sued the hospital,

alleging disability discrimination under the Affordable Care Act, the Americans with

Disabilities Act, and the Rehabilitation Act.

Because Doe’s mother could not serve as a witness, Doe did not create an advance

directive, and we affirm the district court’s dismissal of Doe’s disability-discrimination

claims.

I.

On this appeal from an order granting a motion to dismiss, “we recount the facts as

alleged in the complaint, accepting all well-pleaded factual allegations as true.”

Washington v. Hous. Auth. of Columbia,

(4th Cir. 2023).

Doe suffers from episodes of psychosis. At some point between 2016 and 2022, her

private physician diagnosed her with a form of non-celiac gluten sensitivity in which

ingesting gluten can trigger psychotic episodes.

In July 2022, Doe signed an advance directive form that was downloaded from the

Maryland Attorney General’s Office website. The document designates Doe’s father as her

2 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 3 of 18

primary health care agent and Doe’s mother as her alternate health care agent. Doe circled

the option that permitted her agent to approve her admission to a psychiatric hospital. She

selected the option to grant her agent authority upon the execution of the directive, rather

than when two physicians determined that she was no longer competent. Two witnesses

signed the document, one of whom was Doe’s mother.

In November 2022, Doe experienced an episode of psychosis and was voluntarily

admitted for one month to the Baltimore Washington Medical Center. 1 Dr. Thomas

Cummings treated Doe during her admission.

In March 2023, police escorted Doe to the same hospital’s emergency room during

a similar episode. Dr. Cummings evaluated Doe and noted that her private physician had

weaned her off her anti-psychotic medication over the last few months. Dr. Cummings

rejected a gluten-related diagnosis and instead diagnosed Doe with schizophrenia. When

Doe’s father presented Dr. Cummings with the advance directive document, Dr. Cummings

told him that the document was invalid under Maryland law, though he did not explain

why.

The hospital did not allow Doe’s father to voluntarily admit Doe and instead

involuntarily committed her. After a hearing, an administrative law judge (“ALJ”) certified

Doe’s involuntary commitment.

1 Baltimore Washington Medical Center is a wholly owned subsidiary of the University of Maryland Medical System, a corporation created by Maryland statute and treated as a state actor. See Hammons v. Univ. of Md. Med. Sys. Corp.,

, 584 (D. Md. 2021). 3 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 4 of 18

Doe’s family retained outside physicians to evaluate Doe in April and May, while

she remained involuntarily committed. Dr. Richard Ratner observed Doe and concluded

that she no longer appeared actively psychotic and thus that there was no longer a basis to

involuntarily confine her. Dr. Erik Messamore concluded that Doe showed no evidence of

psychosis and did not require inpatient treatment.

At least five state-court actions followed Doe’s commitment, seeking Doe’s release

and judicial review of administrative decisions, among other things. A federal action also

alleged substantive and procedural due process violations. On June 12, the parties executed

a consent order in one of the state-court cases, a petition for habeas relief, after which Doe

was released. The Consent Order conditioned Doe’s release on the dismissal of all pending

claims and on her agreement to certain post-release treatment requirements, including

continuing her medication and switching psychiatrists. Doe challenged the consent order

in federal district court. This Court affirmed the dismissal of that challenge under the

Rooker-Feldman doctrine. T.M. v. Univ. of Md. Med. Sys. Corp.,

(4th

Cir. 2025).

After Doe’s release, a Maryland trial court considered the administrative appeal of

the ALJ’s decision to certify her involuntary commitment. The court determined that the

ALJ had erred in issuing the certification. It concluded that Defendants could not disregard

Doe’s directive without formally challenging its validity. It further determined that the

ALJ’s decision to disregard the directive was not supported by evidence because the ALJ

heard minimal argument on the directive and did not make factual findings on its validity.

4 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 5 of 18

Defendants moved for reconsideration and asked the court to find that the Directive

was invalid for failing to comply with the witness requirement under the Maryland statute.

Md. Code, Health-Gen. § 5-602(c)(2)(ii). The court denied the motion, concluding that the

issue was not before the court because it was not adequately addressed in the record.

Defendants appealed, but the Maryland appellate court dismissed for mootness because

Doe had been released.

Doe then brought this action in the District of Maryland. As relevant to this appeal,

Doe alleged disability-discrimination claims under Section 1557 of the Affordable Care

Act, Title II of the Americans with Disabilities Act, and Section 504 of the Rehabilitation

Act, each of which arose from the same set of factual allegations. The district court

dismissed all of Doe’s claims.

II.

We review the order granting Defendants’ motion to dismiss under Rule 12(b)(6)

de novo. Washington,

. We consider documents that are integral to the

complaint and take judicial notice of proceedings in other courts. See Philips v. Pitt Cnty.

Mem’l Hosp.,

(4th Cir. 2009); Colonial Penn Ins. Co. v. Coil,

(4th Cir. 1989).

III.

The Affordable Care Act (“ACA”), the Rehabilitation Act, and the Americans with

Disabilities Act (“ADA”) each protect individuals from being “excluded from”

participation in, “denied the benefits of,” or “subjected to discrimination” under the

programs covered by each statute. See

(a) (ACA);

5 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 6 of 18

(ADA);

(a) (Rehabilitation Act). The ACA and the Rehabilitation Act

cover programs that receive federal funding. Basta v. Novant Health Inc.,

(4th Cir. 2022); Cummings v. Premier Rehab Keller, P.L.L.C.,

(2022). The ADA covers programs provided by a public entity. Fauconier v. Clarke,

(4th Cir. 2020). The parties do not dispute that the program at issue is

covered under all three statutes.

Section 1557 of the ACA “does not have its own anti-discrimination language;

instead, it incorporates the grounds of discrimination covered in . . . the Rehabilitation

Act.” Lucas v. VHC Health,

, 222–23 (4th Cir. 2025). Thus, Doe must allege

facts adequate to state a claim under either the ADA or the Rehabilitation Act. See, e.g.,

Basta,

(analyzing an ACA claim under the framework of the Rehabilitation

Act).

Moreover, we construe the ADA and the Rehabilitation Act “to impose similar

requirements,” such that “they require a plaintiff to demonstrate the same elements to

establish liability.” Timpson ex rel. Timpson v. Anderson Cnty. Disabilities & Special

Needs Bd.,

(4th Cir. 2022). The statutes differ, however, with respect to

the causation element. “To succeed on a claim under the Rehabilitation Act, the plaintiff

must establish he was excluded ‘solely by reason of’ his disability; [Title II of] the ADA

requires only that the disability was ‘a motivating cause’ of the exclusion.” Halpern v.

Wake Forest Univ. Health Scis.,

, 461–62 (4th Cir. 2012).

Given the overlapping pleading standards, the district court properly considered

Doe’s federal claims together. Thus, Doe was required to allege that (1) she is a disabled

6 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 7 of 18

individual, (2) she was “otherwise qualified” to participate in the program, and (3) she was

excluded from or denied the benefits of the program on the basis of her disability.

. Defendants do not dispute that Doe has satisfied the first element.

Doe contends that she has plausibly alleged two bases for her disability

discrimination claims. First, she alleges that Defendants’ refusal to follow her advance

directive denied her the benefits of a covered program. Second, she alleges that Defendants

continued her confinement after it was no longer justified. We address each in turn.

A.

Doe alleges that Defendants’ refusal to follow her advance directive denied her the

benefits of the Maryland Advance Directive Program and thus violated her rights under the

federal statutes. The district court found that Doe failed to meet the second element to

establish her disability claim because she was not “otherwise qualified” for the Advance

Directive Program, as her advance directive did not comply with Maryland’s statutory

requirements.

Maryland’s Health Care Decisions Act permits a competent individual to create an

advance directive regarding mental health services provided during a period of

incompetency. Md. Code, Health-Gen. § 5-602.1(b). The advance directive allows the

individual to appoint “an agent to make health care decisions for the individual.” Id. § 5-

602(b)(2); see id. § 5-602.1(d)(1) (health care decisions may include “mental health

services decisions”). As relevant here, a written advance directive must be “subscribed by

two witnesses.” Id. § 5-602(c)(1). But “[t]he health care agent of the declarant may not

serve as a witness.” Id. § 5-602(c)(2)(ii).

7 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 8 of 18

1.

As a preliminary matter, Doe argues that a prior Maryland court determination

precludes this Court from determining the validity of her advance directive. As discussed

above, a Maryland court concluded that the ALJ who certified Doe’s involuntary

commitment erred by disregarding Doe’s advance directive without a formal challenge

from the Defendants or any factual findings concerning validity. According to Doe, that

means that the directive remains “binding” on the Defendants here. Opening Br. at 37.

We give preclusive effect to state-court judgments according to that state’s

preclusion law. Washington v. Pellegrini,

, 127 (4th Cir. 2025). The

Maryland test for issue preclusion is familiar: “(i) the issue decided in the prior adjudication

is identical with the one presented in the action in question; (ii) there was a final judgment

on the merits; (iii) the party against whom the plea is asserted is a party or in privity with

a party to the prior adjudication; and (iv) the party against whom the plea is asserted was

given a fair opportunity to be heard on the issue.”

(citing Nat’l Union Fire Ins. Co. of

Pittsburgh v. Fund for Animals, Inc.,

(Md. 2017)).

Doe’s argument fails at the first step of the issue-preclusion analysis. The Maryland

court explicitly declined to determine whether Doe’s advance directive was invalid for

failure to comply with the witness requirement, explaining that the issue was not before it.

Because the Maryland court did not resolve that issue, there is no identical issue to which

we can give preclusive effect. We therefore consider the issue in the first instance.

8 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 9 of 18

2.

We proceed to statutory interpretation. Doe argues that section 5-602(c)(2)(ii)’s

declaration that “[t]he health care agent of the declarant may not serve as a witness” bars

only a primary health care agent from serving as a witness. We disagree. Applying

Maryland law, we hold that the agent-as-witness prohibition applies to any health care

agent—primary or alternate—who is designated in an advance directive.

“When faced with a question of state law, we must look to decisions of the state’s

highest court and, if those decisions do not resolve the matter, predict how that court would

rule on the state law issue in question.” Real Time Med. Sys., Inc. v. PointClickCare Techs.,

Inc.,

, 224 (4th Cir. 2025) (cleaned up). Because we find no state court

opinion that answers the statutory question at issue, “we use the Supreme Court of

[Maryland’s] methodology to interpret it in the first instance.” See United States v.

Edwards,

, 565 (4th Cir. 2025) (citing Whitmire v. S. Farm Bureau Life Ins.

Co.,

(4th Cir. 2022)).

Under Maryland law, the “cardinal rule of statutory construction is to ascertain and

effectuate the intent of the Legislature.” Watts v. State,

(Md. 2018)

(citation omitted). “In conducting this inquiry, ‘we begin with the plain language of the

statute, and ordinary, popular understanding of the English language dictates interpretation

of its terminology.’” Canton Harbor Healthcare Ctr., Inc. v. Robinson,

, 745

(Md. 2025) (citation omitted). We read a provision “within the context of the statutory

scheme to which it belongs, considering the purpose, aim, or policy of the Legislature in

enacting the statute.” Id. at 746.

9 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 10 of 18

If the statute is ambiguous, we look to “other relevant sources intrinsic and extrinsic

to the legislative process.” Id. (quoting Lockshin v. Semsker,

(Md. 2010)).

Finally, we “check our interpretation against the consequences of alternative readings of

the text.”

“Throughout this process, we avoid constructions that are illogical or

nonsensical, or that render a statute meaningless.” Bell v. Chance,

(Md.

2018).

Here, the issue is whether an alternate agent is an “agent” within the meaning of

section 5-602(c)(2)(ii) such that they may not serve as a witness to the directive. Doe

designated her mother as her alternate health care agent, and then her mother witnessed the

document. If an alternate agent is an “agent” within the meaning of section 5-602(c)(2)(ii),

Doe’s advance directive fails the statutory requirements for execution.

As discussed above, Maryland’s Health Care Decisions Act allows an individual to

appoint “an agent” to make health care decisions. Md. Code, Health-Gen. § 5-602(b)(2);

see id. § 5-602.1(d)(1). It defines “[a]gent” as “an adult appointed by the declarant under

an advance directive . . . to make health care decisions for the declarant.” Id. § 5-601(c).

Then it issues the prohibition: “The health care agent” cannot also witness the advance

directive. Id. § 5-602(c)(2)(ii).

To start, we note that section 5-602(c)(2)(ii)’s prohibition is phrased in the singular:

“The health care agent” cannot be a witness. But Maryland’s rules of interpretation dictate

that “[t]he singular includes the plural and the plural includes the singular.” Md. Code,

Gen. Provisions § 1-202. Thus, “a singular word in a statute is not necessarily limited to

only one subject.” Motor Vehicle Admin. v. Gonce,

(Md. 2016). Indeed,

10 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 11 of 18

sections 602 and 602.1 speak only of appointing “an agent,” and yet the parties do not

dispute that a declarant may appoint more than one agent. See Md. Code, Health-Gen. §§ 5-

602(b)(2) (authorizing “appointing an agent”), 5-602.1(d)(1) (authorizing “designation of

an agent”). Interpreting the statute harmoniously, we read the singular uses of “agent”

throughout to refer to any agent or agents appointed within the advance directive.

Additionally, Doe argues from general principles of agency law that an agent must

be someone with authority. An alternate agent’s authority is contingent on certain

conditions precedent—here, the unavailability of the primary agent. Thus, Doe argues that

an alternate agent is not yet an agent when serving as a witness, and therefore that the

Maryland statute does not bar an alternate agent from serving as a witness.

But the statute does not define “agent” by authority. Instead, it defines an agent as

one “appointed” to make health care decisions. Id. § 5-601(c). To “appoint” means to

“choose or designate (someone) for a position or job.” Appoint, Black’s Law Dictionary

(12th ed. 2024); see also Appointed, Merriam-Webster Online Dictionary,

https://www.merriam-webster.com/dictionary/appointed [https://perma.cc/9VTR-MLDU]

(“chosen for a particular job”). Declarants choose or designate their agents—whether

primary or alternate—when they create the document.

Further, Doe’s reading would render much of the witness-as-agent prohibition

meaningless. See Bell,

. The statute allows a declarant to grant authority to

their primary health care agent at the time of execution. See Md. Code, Health-Gen. § 5-

602(e)(1). That is the option Doe chose. But “unless otherwise provided in the document,”

the advance directive is not effective until two physicians certify that the declarant is

11 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 12 of 18

incapable of making informed decisions. Id. Thus, the statutory default is that neither

primary nor alternate agents have authority at execution. Under Doe’s reading, that would

mean that even a primary agent could serve as a witness. We reject that illogical result. See

Bell,

.

Still, Doe urges that even if the statute defines agency by appointment rather than

by authority, an alternate agent is not appointed until after execution. She points to

language in the statutory form.

In section 5-603, the legislature provides an optional form advance directive. Md.

Code, Heath-Gen. § 5-603. There, a declarant may select a “back-up” agent with the

following language: “If my primary agent cannot be contacted in time or for any reason is

unavailable or unable or unwilling to act as my agent, then I select the following person to

act in this capacity[.]” Id. (emphasis added). Thus, Doe argues that an alternate agent is not

“selected” until the primary agent is unavailable. Opening Br. at 8.

Even viewing that language in isolation, Doe’s reading is dubious. The phrase “I

select” is in the present tense, and the declarant must decide who to select before execution.

But more importantly, the form also gives an explicit warning: “Anyone selected as a health

care agent in Part I may not be a witness.” Md. Code, Heath-Gen. § 5-603. Part I includes

the selection of primary and alternate agents. Id. Thus, to the extent that the statutory form

is persuasive, it indicates that the legislature intended to prohibit primary and alternate

agents from serving as witnesses.

Finally, we note that our interpretation fits within the “object and scope” of the

statute, as reflected in its other provisions. See Canton Harbor, 340 A.3d at 746 (quoting

12 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 13 of 18

Lockshin,

). Section 5-602’s restrictions on witness qualifications reflect a

concern about conflicts of interest that is apparent across several subsections. For instance,

health care workers that are caring for the declarant may be witnesses only if they are

“acting in good faith.” Md. Code, Heath-Gen. § 5-602(c)(2)(i). And at least one witness

must be someone without a knowing financial interest in the declarant’s death. Id. § 5-

602(c)(2)(iii). These restrictions reflect a legislative concern with ensuring that a witness

to a directive does not operate under a conflict of interest, and the fact that the conflict may

be of a future or contingent nature does not resolve that concern.

In sum, Maryland law does not allow an alternate health care agent to serve as a

witness to the advance directive that appoints them. Because Doe’s mother was designated

as an alternate agent, she could not also sign as witness. Thus, the advance directive failed

to comply with the statutory requirements for its creation.

3.

In a final effort to save the advance directive, Doe argues that we can simply enforce

her father’s agency appointment and declare her mother’s appointment unenforceable. This

argument misapplies the severability doctrine.

“Formation challenges render the whole contract unenforceable. There is nothing to

enforce if a contract never existed.” Johnson v. Cont’l Fin. Co., LLC,

(4th Cir. 2025). And “if a contract was never formed, there is no agreement from which

any provision . . . can be severed.”

. So severability cannot save a contract if the

contract’s defect goes to the document’s execution. See

(explaining that “formation

issues such as ‘whether the alleged obligor ever signed the contract’” are distinct from

13 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 14 of 18

challenges to the validity of individual provisions); see also Trimble v. Entrata, Inc.,

, 631 (D. Md. 2025) (applying Maryland law) (refusing to sever a

modification provision that rendered consideration illusory, concluding that the agreement

was “never formed”).

Maryland law imposes statutory requirements on the formation of a written advance

directive. See Md. Code, Health-Gen. §§ 5-602, 5-602.1(c)(1) (“An individual making an

advance directive for mental health services shall follow the procedures for making an

advance directive provided under § 5-602 of this subtitle.”) (emphasis added). One of those

requirements is that the document must be signed and witnessed according to section 5-

602(c). Doe’s failure to comply with that requirement is a failure at formation that we

cannot remedy through severance.

* * *

In sum, Doe was not “otherwise qualified” to participate in Maryland’s Advance

Directive Program because she did not comply with its statutory requirements. Thus, she

has failed to state a claim for disability discrimination based on Defendants’ refusal to

follow her advance directive.

B.

Putting aside the advance directive, Doe contends that she has plausibly alleged a

claim for disability discrimination because Defendants prolonged her involuntary

14 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 15 of 18

commitment without justification in violation of the ACA, the Rehabilitation Act, and the

ADA. She advances two theories. 2

Under her first theory, Doe argues that Defendants discriminated against her on the

basis of disability by continuing her confinement based on a biased belief that she would

stop taking her medication and so that they could use her confinement as leverage to resolve

the then-pending lawsuits.

In considering this claim, we find persuasive the thoughtful analyses of the First

Circuit in Lesley v. Hee Man Chie,

(1st Cir. 2001) and the Second Circuit in

McGugan v. Aldana-Bernier,

(2d Cir. 2014).

To treat a disability, health care providers necessarily must make medical decisions

based on that disability, which constitutes a “benign form of discrimination” that does not

give rise to a discrimination claim. McGugan,

. But when providers make

medical decisions that are “dictated by bias rather than medical knowledge,” those

decisions fall within “the pejorative form of discrimination” and are thus barred.

When an individual’s disability is unrelated to the decision in question, it is an

“improper consideration[]” for their doctor to rely on in making that decision.

.

For example, a patient’s physical paralysis is unrelated to his ability to consent to

hospitalization, so a physician may not properly disregard the patient’s objection to

hospitalization because of his paralysis.

Similarly, a decision based on “stereotypes of

2 In her reply brief, Doe argues for the first time that her discrimination claims include a retaliation claim. Doe forfeited that argument by not raising it in her opening brief, Short v. Hartman,

(4th Cir. 2023), so we do not address it here. 15 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 16 of 18

the disabled rather than an individualized inquiry into the patient’s condition” is

discriminatory. Lesley,

. For example, a physician’s refusal to treat a deaf

patient because “all deaf people are high risk” could be discriminatory.

(citing Sumes

v. Andres,

, 11–12 (D.D.C. 1996)).

A plaintiff may allege this type of discriminatory motive through allegations that

the defendant’s stated reasons for a medical decision were pretextual.

For example, a

physician’s explanation that he transferred a patient because of the patient’s rare blood

disorder could be pretextual when the transfer order mentioned only the patient’s HIV-

positive status.

(citing Howe v. Hull,

, 788–89 (N.D. Ohio 1994)).

Here, Doe has failed to allege that Defendants’ decision to continue her involuntary

confinement was based on stereotypes about her disability or based on an unrelated

disability.

By Doe’s own admission, Defendants continued her confinement out of fear that

she would not take her medications after she had previously discontinued her medications

upon release from the hospital. But those medications were related to the disability for

which Dr. Cummings was treating her, and Doe does not allege that the decision was based

on any stereotype.

And, even accepting as true Doe’s alternate allegation that Defendants continued

her confinement because they feared liability from her pending lawsuits, that motive is not

connected either to an unrelated disability or to stereotypes about the disabled.

Under her second theory, Doe argues that she has alleged an unjustified-isolation

claim under Olmstead v. L.C. by Zimring,

(1999). There, the Supreme Court

16 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 17 of 18

held that “unjustified institutional isolation of persons with disabilities is a form of

discrimination[.]”

. Thus, “under Title II of the ADA, States are required to

provide community-based treatment for persons with mental disabilities when the State’s

treatment professionals determine that such placement is appropriate, the affected persons

do not oppose such treatment, and the placement can be reasonably accommodated[.]”

. In determining whether an individual is qualified for a transfer, “the State generally

may rely on the reasonable assessments of its own professionals[.]”

.

The district court concluded that Doe had not stated a claim under Olmstead because

she did not allege that her treating professionals had “determined her involuntary

commitment was no longer legally or medically justified/necessary, or that Doe was

eligible for care in a less restrictive setting (at least until the Consent Order was signed).”

J.A. 70–71. 3

Doe argues that we may infer that Defendants had determined that Doe’s

involuntary commitment was unjustified but nevertheless continued to confine her. She

identifies two supporting allegations. First, she argues that the “mere existence” of the

Consent Order means that the Defendants “did not truly believe” that Doe required

inpatient care. Opening Br. at 43. Second, she argues that we may infer from the

evaluations of non-treating physicians, Drs. Ratner and Messamore, that Defendants would

have made the same observations.

3 Citations to the “J.A.” refer to the Joint Appendix filed by the parties in this appeal. 17 USCA4 Appeal: 24-1994 Doc: 78 Filed: 12/11/2025 Pg: 18 of 18

Neither argument is persuasive. The Consent Order, which conditioned Doe’s

release in part on her agreement to certain post-release treatment requirements, does not

support an inference that Defendants had determined that her confinement was no longer

justified at any time earlier than the day the Consent Order was executed. Nor do the

differing opinions of the non-treating physicians lead to a reasonable inference that her

treating physician, Dr. Cummings, would have made the same observations and similarly

concluded that Doe’s commitment was no longer justified several months before her

release.

IV.

Jane Doe has not stated a claim for disability discrimination under the ACA, the

Rehabilitation Act, or the ADA. By failing to comply with the statutory requirements to

create an advance directive, Doe was not qualified for the program from which she alleges

exclusion. Her alternative allegations based on the timing of Defendants’ decision to end

her involuntary commitment similarly fail to allege discrimination on the basis of a

disability or Defendants’ belief in her qualification for release.

For the foregoing reasons, the district court’s judgment is affirmed.

AFFIRMED

18