OPINION OF THE COURT
This is an appeal from a district court order denying a motion for summary judgment based on qualified immunity in an action under 42 U.S.C. § 1983. The action was filed by James Smith, now deceased, against two Philadelphia Fire Department paramedics and the city. Smith alleged that the paramedics rendered him a quadriplegic by lifting him after he had fallen from a wall and sustained spinal injury.
I.
In the early morning hours of May 16, 1998, after a night of drinking, James Smith, then 24 years old, went to his aunt’s residence in Philadelphia, where he often stayed. App. at 5a. He was not able to enter the house because he did not have a key and no one responded to his knocks on the door. Id. He therefore sat down on the wall in front of the house and eventually fell asleep. Id. He apparently fell from the wall and dropped about eight feet to the sidewalk below. Id. After Smith fell, several neighbors heard him groaning and yelling, but by all accounts he was moving his legs and arms. Id.
Joseph DiFrancesca and Roger Mоrfitt (“the appellants”), Philadelphia Fire Department paramedics, responded to a 911 call placed by a neighbor. According to Maceo Gatewood, a neighbor, the following then occurred. When the paramedics approached Smith, they asked him what his name was and what was wrong. Supp. App. at 5b. He said: “I’m hurt. I hurt my head.” Id. Smith repeated several times that he had hurt his neck.
Another neighbor, Roberta Brown, gave the following account. She said that when the paramedics arrived at the scene, she told them that Smith was called “Man,” and they said: “[G]et up, Man. Get up before we call the police. You’re only drunk, get up.” App. at 186a. Smith responded: “I’m hurt.” Id. at 187a. The paramedics then each took one of his arms and “yanked him up.” Id. In Brown’s words, Smith then “started hollering, ‘Miss Burt, Miss Burt, tell them to put me down. I can’t move.’ And they yanked him up and his head went back.” Id. at 186a 87a. The paramedics then got the stretcher; one lifted his feet and the other lifted the upper part of his body, and they put him on the stretcher and took him away. Id. at 187a.
When Smith reached the hospital, the doctors recognized the seriousness of his condition and stabilized his neck by putting him in a hard collar and placing him on a board. App. at 208a. He was diagnosed with permanent quadriplegia. Id. at 7a. A physician who treated Smith at the hospital stated:
It is a medical certainty that [the paramedics] should have immobilized his cervical spine prior to moving him. To hаve, instead, lifted him by his arms and then by his shoulders and legs is unconscionable. It is my opinion within a reasonable degree of medical certainty, that Mr. Smith’s quadriplegia is directly attributable to the actions of the paramedics.
Id. at 213a.
Dr. Stephan Lynn, an expert in emergency medical services, reviewed the records and opined that the paramedics “demonstrated incredible and shockingly deliberate indifference to Mr. James Smith and to his needs as an injured person seeking ambulance assistance.” App. at 225a.
In October 1999, Smith filed a complaint in the Court of Common Pleas of Philadelphia County, asserting due process claims against the two paramedics and the city. The complaint alleged that the paramedics’ actions in lifting him improperly had deprived him of his liberty interest in bodily integrity. The complaint also alleged that the paramedics’ conduct was in accordance with an established city custom of treatment toward intoxicated individuals and that the paramedics’ conduct resulted from the city’s failure to prоvide proper training despite prior instances of mistreatment.
The defendants removed the case to the United States District Court for the Eastern District of Pennsylvania and, after discovery, moved for summary judgment. The individual defendants asserted the defense of qualified immunity, but the district court refused to grant summary judgment on that ground. The court held that “a reasonable jury could find that the defendant paramedics acted with deliberate indifference and in a manner that shocks the conscience in injuring the plaintiff.” Dist. Ct. Op. at 2. The district court also concluded that “clearly established law at the time of the incident provided sufficient guidance to the defendants about the unconstitutionality of their conduct.” Id. In addition, the court denied the city’s request for summary judgment because that request was based solely on the contention that no underlying due process violation could be established. Id. The individual defendants then took this appeal.
II.
On appeal, the appellants first contend that the district court applied the
The appellants maintаin that we have jurisdiction to consider both of their arguments under the collateral order doctrine first recognized in Cohen v. Beneficial Industrial Loan Corp.,
Johnson involved an action under 42 U.S.C. § 1983 against five police officers for use of excessive force in effecting an arrest. Id. Three of the officers moved for summary judgment, arguing that there was insufficient evidence in the summary judgment record to permit a reasonable finder of fact to find that they were present when the plaintiff was beaten. Id. The district court denied this motion, concluding that there was enough evidence tо defeat summary judgment. Id. at 308,
The appellants urge us to read Johnson to apply only to evidentiary questions regarding conduct as opposed to intent. Relying chiefly on Jeffers v. Gomez, 267 F.3d 895, 907-10 (9th Cir.2001), they argue that Johnson permits us to entertain a collаteral order appeal that challenges a district court’s decision denying summary judgment on the ground that there is a genuine issue of fact as to whether the defendant acted with the intent required by the particular constitutional claim asserted. We cannot agree. In our view, Johnson clearly applies to factual disputes about intent, as well as conduct.
First, we see nothing in the Johnson Court’s reasoning that supports a distinction between issues of conduct and issues of intent. Referring to the requirement of the collateral order doctrine that an appeal must present an issue completely separate from the merits of the case, Johnson observed that “[w]here ... a defendant simply wants to appeal a district court’s determination that the evidence is sufficient to permit a particular finding of fact after trial, it will often prove difficult to find any such ‘separate’ question — one that is significantly different from the fact-related legal issues that likely underlie the plaintiffs claim on the merits.” Johnson,
The Johnson Court also noted that “the existence, or nonexistence, of a triable issue of fact [ ] is the kind of issue that trial judges, not appellate judges, confront almost daily,” and the Court added that “[institutionally speaking, appellate judges enjoy no comparative expertise in such matters.” Id. at 316,
Finally, Johnson reasoned that “the close connection between [the kind of issue raised in the case before it] and the factual matter that will likely surface at trial means that the appellate court, in the many instances in which it upholds a district court’s decision denying summary judgment, may well be faced with approximately the same factual issue again, after trial, with just enough change brought about by the trial testimony to require it, once again, to canvass the record.” Id. at 316-17. This, the Court observed, would result in an “unwise use of appellate courts’ time.” Id. at 317,
Second, at least one passage in Johnson refers directly to questions of intent and suggests that the Court specifically contemplated that its decision would not allow interlocutory appeals regarding the sufficiency of the evidence of intent. The Court wrote:
[Questions about whether or not a record demonstrates a ‘genuine’ issue of fact for trial, if appealable, can consume inordinate amounts of appellate time. Many constitutional tort cases, unlike the simple ‘we didn’t do it’ case before us, involve factual controversies about, for example, intent-controversies that, before trial, may seem nebulous. To resolve these controversies — to determine whether there is or is not a triable issue of fact about such a matter — may require reading a vast pretrial record, with numerous conflicting affidavits, depositions, and other discovery materials.
III.
With this understanding of the scope of our appellate jurisdiction in mind, we address the specific arguments raised by thе appellants. As noted, the appellants’ first argument is that, at an absolute minimum, the plaintiff is required to show that they acted with subjective deliberate indifference and that the district court did not apply this standard. This is a question of law, and it is therefore properly before us, but we reject the argument on the merits for the simple reason that the district court did apply the subjective indifference standard. The district court wrote:
Most courts have held that the deliberate indifference standard requires a showing of “subjectivе deliberate indifference” .... A subjective standard would require that the defendants actually knew of Smith’s injuries. The record reveals sufficient facts from which a reasonable jury could find that the defendants inferred that Smith was seriously injured.
Dist. Ct. Op. at 18-19. After recounting some of what the neighbors had said, the court concluded:
Whether DiFraneesca and Morfitt actually did draw the inference that Smith was seriously injured from these facts is an issue for a jury to decide. The Court finds that a reasonable fact-finder would be able to find that the paramedics had actual knowledge of the fact that Smith was seriously injured.
Id. at 20. The appellants’ argument that the district court did not apply the “subjective deliberate indifference” test is thus entirely without merit.
The real thrust of the appellants’ argument appears to be that the summary judgment record is insufficient to prove that they acted with subjective deliberate indifference. Since the district court held to the contrary, they reason that the court must not in fact have applied the night legal standard. The appellants state that, while the district court’s opinion contains language “purporting to apply ... the ... subjective test of actual knowledge, the district court in reality applied a reasonable-person objective, negligence-like standard.” Appellants’ Br. at 10. The appellants’ argument is an attempt to circumvent Johnson by disguising what is in truth an evidentiary argument as a legal argument. The disguise is transparent, and we dismiss the appellants’ appeal to the extent that it presses this eviden-tiary issue.
IV.
A.
The appellants’ remаining argument is that even “subjective deliberate indifference” is not enough. In the district court, the appellants argued that the plaintiff was required to prove that they acted with an actual intent to harm him. See Dist. Ct. Op. at 9. The appellants’ briefs on appeal did not advance this argument, and at oral argument, however, counsel for the appellants specifically stated, in response to a question, that he was not arguing that an actual intent to harm is needed. Instead, the appellants have fallen back on the position that something more than subjective deliberate indifference but less than actual intent to harm is required. Relying on a phrase in Miller, they contend that the requisite intent is “gross negligence or arbitrariness that indeed ‘shocks the conscience.’ ” Miller,
B.
The intent needed to support a substantive due process claim is a question that has long troubled our court. See, e.g., Davidson v. O’Lone,
We have applied Lewis in several subsequent cases. In Miller, on which the appellants rely, a mother and her children claimed that a social worker violated their substantive due process rights by taking actions that led to an emergency ex parte order removing the children from the mother’s custody due to suspected child abuse. Miller,
In Nicini v. Morra,
C.
The appellants’ current argument — that Smith is requirеd to prove something more than subjective deliberate
We generally do not address arguments that were not made in the district court and we therefore decline to consider the appellants’ current argument as a ground for reversing the decision of the district court. See Bailey v. United Airlines,
We agree with the appellants that Miller, which is of course binding on us, mandates at least something more than subjective deliberate indifference as that term is defined in Farmer v. Brennan,
We must thus attempt to detеrmine exactly what Miller required. The appellants have seized upon the phrase “a level of gross negligence or arbitrariness that indeed ‘shocks the conscience.’ ” Id. at 375-76. The Miller court used this phrase as one part of its explanation of the ground for affirming a grant of summary judgment for the social worker, and we do not think that the phrase was intended as a precise articulation of the governing legal
So what did Miller require? We can approach an answer by noting what Miller did not demand. As noted, Miller expressly stated that the defendant social worker need not have acted with the purpose оf causing the relevant harm, namely, removal of the children without good cause. Id. at 375. Nor did Miller suggest that the defendant had to have known that this harm was practically certain to result.
This reading of Miller is supported by Miller’s discussion of Croft v. Westmoreland County Children & Youth Services,
[T]he social worker was acting solely on the basis of a sixth-level hearsay statement and had not personally formed an opinion as to whether abuse was likely. Breaking the parent-child bond under these circumstances, we held, was an arbitrary abuse of government power.
Miller,
In summary, then, we understand Miller to require in a case such as the one before us, proof thаt the defendants consciously disregarded, not just a substantial risk, but a great risk that serious harm would result if, knowing Smith was seriously injured, they moved Smith without support for his back and neck. On remand in the present case, we believe that the district court should apply this standard and in
V.
For the reasons explained above, this appeal is dismissed in part, and the order of the district court denying the appellants’ motion for summary judgment is affirmed.
Notes
. Gatewood said that these remarks were made “after the ambulance got there,” App. at 144a, but the defendants assert that the record does not show whether these alleged remarks were made when the paramedics were within earshot. Appellants' Br. at 5 n. 1. The defendants also note that neither Smith nor Roberta Brown, who was on the scene, recounted these remarks.
. While the appeal was pending, Smith died, and Joseph Ziccardi, Esq., the administrator of his estate, was substituted as the plaintiff.
. We reject the appellants’ suggestion that Saucier v. Katz,
. In Kneipp v. Tedder,
. The phrase is not well suited for that purpose. "[A]rbitrariness” is a general requirement for a substantive due process violation, see Lewis,
. Compare Model Penal Code § 2.02(2)(b) (a person acts "knowingly” with respect to a result if the person is aware that the result is "practically certain” to occur). In Farmer v. Brennan,
