What a week in SCOTUS news! While the media has chosen to focus almost exclusively on you- know-what, there is another medical holding that merits coverage. In the consolidated cases of Ruan v. United States and Kahn v. United States, the Court delivered a 9-0 opinion, written by Justice Breyer, taking the feet of the law off of the necks of doctors who prescribe drugs to treat pain in their patients.
Drs. Ruan and Kahn were convicted under a provision of the Controlled Substances Act (codified at 21 U. S. C. §841) which makes it a federal crime to prescribe a controlled substance, “except as authorized.” A prescription is only authorized when it is a prescribed “for a legitimate medical purpose… acting in the usual course of his professional practice.”
The Department of Justice portrayed the doctors as pseudo drug dealers operating “pill mills.” At trial, Dr. Ruan asked for a jury instruction that would have required the State to prove that he subjectively knew that his prescriptions fell outside the scope of his prescribing authority, but that request was rejected.
Instead, the District Court instructed the jury that a doctor acts lawfully when he prescribes “in good faith as part of his medical treatment of a patient in accordance with the standard of medical practice generally recognized and accepted in the United States.” The court further instructed the jury that a doctor violates §841 when “the doctor’s actions were either not for a legitimate medical purpose or were outside the usual course of professional medical practice.” Following his conviction, Dr. Ruan was sentenced to over 20 years in prison and was ordered to pay millions in restitution and forfeiture. Dr. Kahn was sentenced to over 25 years in prison.
The question before the Supreme Court was what state of mind the government has to prove in order to convict a doctor for dispensing controlled substances not as authorized. The Court held as follows:
“We now hold that §841’s “knowingly or intentionally” mens rea applies to the “except as authorized” clause. This means that once a defendant meets the burden of producing evidence that his or her conduct was “authorized,” the Government must prove beyond a reasonable doubt that the defendant knowingly or intentionally acted in an unauthorized manner.”
Mens rea or guilty mind is defined by Black’s Law Dictionary as the state of mind that the prosecution, to secure a conviction, must prove that a defendant had when committing a crime.
If a prosecutor decides to go after a doctor who prescribed pain meds to a patient, said prosecutor needs to prove beyond a reasonable doubt that the doctor knew he or she was acting in an unauthorized manner or intended to do so. So without the mens rea to dispense prescriptions for an illegitimate purpose outside of the course of usual professional practice, a doctor cannot be convicted.
The Court began its analysis with the general principle that a defendant must have scienter, or a “culpable mental state” in order to be guilty of a crime. It acknowledged that “we expect, and indeed usually want, doctors to prescribe the medications that their patients need. In §841 prosecutions, then, it is the fact that the doctor issued an unauthorized prescription that renders his or her conduct wrongful, not the fact of the dispensation itself. In other words, authorization plays a “crucial” role in separating innocent conduct—and, in the case of doctors, socially beneficial conduct—from wrongful conduct…Applying §841’s “knowingly or intentionally” mens rea to the authorization clause thus “helps advance the purpose of scienter, for it helps to separate wrongful from innocent acts.”
This was critical per the Court because “[a] strong scienter requirement helps to diminish the risk of “overdeterrence,” i.e., punishing acceptable and beneficial conduct that lies close to, but on the permissible side of, the criminal line.” The severe penalties that §841 carries, namely the potential for life imprisonment and fines up to $1 million, was additional evidence that the Court pointed to in furtherance of a strong scienter requirement.
The concurrence was authored by Justice Alito, and joined by Justice Thomas as well as partially by Justice Barrett, and advocates for a simpler standard, namely whether the doctor wrote the prescription(s) in “good faith.” The Justices accuse the holding of suffering from “an obvious conceptual mistake,” confusing the mens rea requirement for an element of the offense instead of as an affirmative defense.
There is undoubtedly a staggering drug problem in this country. Tragically, too many Americans and their families have suffered.
Provisional data from CDC’s National Center for Health Statistics indicate that there were an estimated 100,306 drug overdose deaths in the United States during 12-month period ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before.
Here are the visuals.
But as recognized by all 9 justices on the Court, instilling fear of jail time and financial ruin in the hearts of doctors is not going to solve the drug abuse problem. The proper course of medical treatment should be decided by doctors and their patients, without the overbearing control of the Feds’s power-hungry prosecutors.
Throughout the opioid crisis, doctors have increasingly faced “the idea of criminalization of physician conduct,” Nelson said, creating “a climate of fear” around prescribing. Now, attorneys say the Supreme Court has eased constraints on doctors, allowing them to use their best judgment in filling prescriptions for patients. This decision gives physicians “a day to celebrate,” Nelson said. As they’re “prescribing in good faith,” doctors “don’t have to be worried about criminal prosecution.”
A huge range of patients need these meds. It’s a “‘major win for patients with chronic pain, and also a major win for patients with opioid use disorder as well as a whole range of conditions for which the medically appropriate care includes controlled substances,” such as ADHD and anxiety, said Kelly Dineen, director of the health law program at Creighton University, who authored a brief in the case. This is also going to help ensure that the dying are treated compassionately not denied the medications they need to lessen suffering at the end of their life.
Perhaps the most significant takeaway from this case is that the ruling makes sense! It was practical! And it was unanimous! It is considered a “win” for both doctors and patients! Does this mean there is hope, after all?
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