Proof of Intent Required to Convict Doctors Under CSA, Supreme Court Rules

A pile of empty, orange prescription bottles most without labels and a few with unreadable labels.
The high court overturned two opinions by appeals courts, including one by the 10th Circuit, and ruled that prosecutors must prove a doctor knowingly wrote prescriptions illegally. / Photo by Haley Lawrence on Unsplash.

The U.S. Supreme Court ruled on a pair of appeals over the state of mind prosecutors must prove to convict doctors of writing illegal prescriptions under the Controlled Substances Act. 

On June 27, the high court overturned two opinions by appeals courts, including one by the 10th Circuit, and unanimously ruled that prosecutors must prove a doctor knowingly wrote prescriptions that fell outside the course of professional practice standards. 

Six of the court’s justices joined the majority opinion written by Justice Stephen Breyer, with Justice Samuel Alito writing a separate concurrence joined by Justice Clarence Thomas and in part by Justice Amy Coney Barrett. 

The CSA permits medical providers to prescribe controlled substances as long as they are “issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice.”  While nearly all federal appeals courts previously held prosecutors must prove that a prescription was written outside professional norms or without a medical purpose, the circuits had a more split approach to the mens rea, or a doctor’s knowledge of committing a crime, behind these prescriptions. 

“We hold that the statute’s ‘knowingly or intentionally’ mens rea applies to authorization,” wrote Breyer for the majority. “After a defendant produces evidence that he or she was authorized to dispense controlled substances, the government must prove beyond a reasonable doubt that the defendant knew that he or she was acting in an unauthorized manner, or intended to do so.”

Ruan v. United States consolidated the appeals from a Dr. Xiulu Ruan, based out of Alabama, and Dr. Shakeel Kahn, based out of Wyoming and Arizona. Both physicians were convicted under the CSA for crimes around prescriptions they wrote, but argued that the juries in their trials were given incorrect instructions on the good faith defense. Federal appeals courts in both cases affirmed the convictions, leading to the appeals to the U.S. Supreme Court. 

Federal courts generally allow doctors to put forward a good faith defense, but federal circuits were split on whether prosecutors must prove that a doctor “reasonably believed” or “subjectively intended” a prescription be used outside of professional practice standards. 

The 11th, 10th and Fifth Circuits ruled doctors charged with writing prescriptions outside professional norms are liable for writing the prescriptions regardless of if they understood the practice wasn’t an industry standard, but the First, Second, Third, Fourth, Sixth, Seventh, Eighth and Ninth Circuits had required prosecutors to prove that defendants knowingly or intentionally acted outside industry standards.

Siding with the doctors in the appeal, the U.S. Supreme Court found that the general intent of wrongdoing language in the CSA, “knowingly or intentionally,” modified both the language immediately following it as well as other statutory terms that mean to separate wrong acts from innocent ones. Given the potentially harsh sentences that can come from prosecutions under the CSA, the court added, a strict scienter standard, or proof that a defendant knew they were doing something wrong, is supported. 

The court wasn’t convinced by arguments from the federal government that it should adopt an objective mens rea standard based on the medical industry’s standards around prescriptions. “The government’s standard would turn a defendant’s criminal liability on the mental state of a hypothetical ‘reasonable’ doctor, not on the mental state of the defendant himself or herself,” wrote Breyer. 

The Supreme Court vacated the judgments of both cases and remanded them for further consideration by their respective circuits in light of the court’s ruling. 

Writing separately, Alito agreed that both doctors should have their cases reversed and remanded but justified his conclusion with different reasoning and expressed concern that the majority’s stance would create future confusion for criminal defense. 

The Supreme Court already ruled on the necessary mental state of doctors under the CSA’s predecessor, the Harrison Narcotics Act of 1914, Alito wrote, which held that when a physician prescribes “in good faith,” they’re within the course of their professional practice. “I would hold that this rule applies under the CSA and would therefore vacate the judgments below and remand for further proceedings,” he added. 

The court’s decision blended characteristics of an element of a crime and an affirmative defense, Alito found, adding that “the consequences of this innovation are hard to foresee, but the result may well be confusion and disruption.” 

The court’s decision was a win for members of the medical community who filed amicus briefs in support of the doctors. 

In practice, some doctors have been hesitant to prescribe necessary controlled substances in response to “scope of practice” charges that have been brought against colleagues, according to some of the amicus curiae who joined the appeal. Compassion & Choices, a non-profit that advocates for end-of-life medical care and choices, added that current prosecution standards have led to hesitance by providers to prescribe controlled substances to people at the end of their lives, ultimately hurting patients. Writing in support of neither party, a group of health and legal scholars explained that in reaction to the opioid crisis, the CSA has been “weaponized” against providers and added that while doctors can make bad medical decisions, “the statute was not intended to remedy poor or even harmful medical decision-making.” 

Kahn was convicted in a Wyoming federal court on 23 counts including conspiracy to distribute controlled substances resulting in death, possession of firearms to further drug trafficking and money laundering. Prosecutors alleged that from 2008 through 2016, Kahn’s office wrote prescriptions for opioids and other controlled substances in exchange for cash and sometimes guns without always seeing patients in person. Eventually, regional pharmacies in Arizona became suspicious of the clinic and stopped filling prescriptions written by Kahn and a federal investigation was launched into the practice. Kahn’s wife and brother were also convicted for their roles in the clinic. 

Kahn received a 25-year sentence and appealed to the 10th Circuit Court of Appeals which, in February last year, upheld the convictions.

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