FI L ED U.S. COURT OF APPEAL S EL EVENTHCI RCUI T J ANUARY 19, 2012 J OHN L EY CL ERK [PUBLIS H] IN THE U

NITED STATE S COURT OF APPEALS FOR THE ELE VENTH CIRCUIT

__ __ __ __ __ __ __ __ __ __ __ __ Nos . 09 -1 05 96 , 09 -1 60 05 & 10 -1 10 74

__ __ __ __ __ __ __ __ __ __ __ __ D.C. Dock etNos . 08 -0 00 27 -CR- 3- LAC-MD,

3: 08 -cr- 00 02 7- LC-MD- 1 UNITED STAT ES OF AMERIC A, ll ll ll ll ll ll ll ll l App el le e, ve rs us ROBERT L. IGNASIAK, JR., ll ll ll ll ll ll ll ll ll App el la nt .

__ __ __ __ __ __ __ __ __ __ __ __ App eal s fr om

th e Uni te d S ta te s Di st ric t Co urt forth e North ernDis tri ctof F lo rid a

__ __ __ __ __ __ __ __ __ __ __ __ (J anua ry 19 , 20 12 ) Befo re EDMONDSON, MARTIN an d C OX, Circ ui t J ud ge s. MARTIN, Ci rcu itJu dg e:The App el la nt , Rob ertL. Ign as ia k, u nt il th is cas e a m ed ic al do ct orli cen se d

by the Sta te of F lo rid a, ap pe al s h is co nv ic ti on s fo r di sp en si ng co nt ro ll ed subs ta nc es in vi ol at io n o f th e Co nt ro ll edSubs ta nc es Act (“ CSA”) an d fo r he al th care frau d. Ig na si akwas c ha rg edin a fi fty-fou r co un t i nd ic tm en t wi th fou rte en co un ts of h eal th care frau d i n v io la ti on of 1 8 U.S.C. § 13 47 , andforty cou nt s o f di sp en si ng co nt ro ll edsubs ta nc es in vi ol at io n o f 21 U.S.C. §§ 84 1( a)(1 ) an d 84 1( b) (1 )(C) . The g ov ern m en t’s the ory of p ro se cu ti on forbo th set s o f ch arg es was subs ta nt ia ll y

th e sa m e—t ha t Ig na si akha d p res cri be d u nn eces sa ry or e xc es si ve qu an ti ti es of c on tro ll edsubs tanc es witho uta le gi ti m at e m ed ic al pu rp os e an d

“ ou ts id e th e u su al co ur se of p ro fes si on al pra ct ic e.” All fif ty-fou r co un ts of t he in di ctm en t re la te d t o t he tre atm en t o f twe nt y pa ti en ts . Two of

th e co un ts , twen ty ei gh t an d fo rty eig ht , furth er ch arg edth at“ de ath re su lt ed ” fro m th e u se of co nt ro ll edsubs ta nc es pre sc rib edby Ign as ia k t o t wo o f th e twe nty pa ti en ts , M.B. an d B .E. A jury fou ndIgn as ia k g ui lt y

of f orty-th ree o f th e fi fty-fou r co un ts ch arg ed . He was sen te nc edto a to ta l t erm of 2 92 -m on th s i m

pr is on m en t, the bo tt om

en d o f hi s ad vi so ry

gu id el in e ran ge . Ign as ia k’s co nv ic ti on s re su lt edin th ree s ep arat e b ut

2rel at edap pe al s t o t hi s C ou rt, a ll of wh ic h are d is po se d o f inth is op in io n. In h is 1
m eri ts ap pe al , Ign as ia k c la im s: (1) th atth e ev id en ce d idno t s up po rt h is co nv ic ti on s; (2) th atth e Dis tri ctCo urt co urt ab us edit s d is cret io n b y reject in g h is pr op os edjury in st ru ct io ns on Flo rid a la w go ve rn in g t he us e o f co nt ro ll ed subs ta nc es ; (3 ) th atth e Dis tri ctCo urt ab us edit s d is cret io n b y all owi ng ex pe rt witne ss es to tes ti fy

as t o t he ul ti m at e le ga l i ss ue s; (4) th atth e Dis tri ctCo urt erred orab us edit s d is cret io n b y all owi ng th e in tro du ct io n o f au to ps y rep orts or ha nd writ te n m ed ic al no te s wi th ou t re qu iri ng tes ti m on y by the ir aut ho rs , in vi ol at io n o f th e Co nf

ro nt at io n C laus e an d t he rul es of e vi de nc e; an d (5 ) th atth e Dis tri ctCo urt ab us edit s d is cret io n u nd er the rul es of e vi de nc e b y “ al lo win g un ch arg edco nduc t t o b eco m e th e fea tu re o f th e tr ia l.” Aft er ca refu ll y rev ie win g th e rec or d andha vi ng th e b en efi t o f or al arg um en t, we rev ers e Ig na si ak ’s co nv ic ti on s b ecau se th e ad m is si on of aut op sy repo rts an d t es ti m on y ab ou t tho se rep orts , witho utli ve in -co urt t es ti m on y fro m th e m ed ic al ex am in ers who actua ll y pe rfo rm edth e au to ps ie s (a ndwher e n o e vi de nc e was pre se nt edto sh ow t ha t the
Appea l No. 09-10596 is I gnasiak’s me rits appea l from his convictions. In Appea l No. 1 09-16005, I gnasiak a

ppeals the D istrict Court’s denial of his motion to unseal the g overnme nt’s post-trial in came ra notice to the District Court which containe d impeachme nt evidence conce rningthe g overnme nt’s key witness, Dr. Ar

thur J ordan. I

n Appea l No. 10-11074, I gnasiak appea ls the District Court’s denial of his motion for newtrial based upon B rady v. Maryland, 373 U.S. 83, 83 S. C t. 1194 (1963), re lated to the impeac hment evidenc e ag ainst Dr. Jordan that was the subject of the g overnme nt’s in camer a notice. 3co ro ne rs who pe rfo rm edth e au to ps ie s wer e u na va il ab le an d t he accu se d h ada

pr io r op po rtu ni ty to cr os s ex am in e th atwitne ss ), vi ol at edth e Co nf ro nt at io n Cl au se un de r th e fac ts of t hi s ca se . Becau se we co nc lu de th atth e fo urth is su e is di sp os it iv e, we de cl in e to ad dr es s t he ot he r is su es rai se d i n Ig na si ak ’s m eri ts ap pe al , ex cep t fo r th e su ffi ci en cy of t he ev id en ce cl ai m . Whi le we ul ti m at el y 2 3
co nc lu de th atth e ev id en ce was su ffi ci en t, the de gr ee t o wh ic h we v ie w th e go ve rn m en t’s ca se as l es s t ha n o ve rwh el m in g c om pe ls ou r co nc lu si on th atth e Co nf ro nt at io n C laus e v io la ti on was n otha rm le ss in th is cas e. To g iv e o urha rm fu l erro r de te rm in at io n s uf

fic ie ntco nt ex t, i t i s n eces sa ry to de sc rib e th e ev id en ce i n so m e d et ai l. I. STAT EMENT O F FACTS AND P ROCEDURAL HI STO RY Dur in g Ig na si ak ’s ni ne te enda y tri al , th e g ov ern m en t p res en te d fo rty-on e witne ss es , in cl ud in g p at ie nt s, p at ie nt s’ fam il y m em be rs , form er cl in ic em

pl oyees,
See, e.g ., United States v. McGough, 412 F.3d 1232, 1236 n.3 ( 11th Cir. 2005) 2 (re versingconvictions on one ground but dec lining to addr ess other issues r aised on dire ct appea l). Even though we r ever se I gnasiak’s c onvictions on other grounds, we r eview his

3 sufficie ncy

of the e vidence claim for pr udential re asons. See, e .g ., United States v. Bobo, 419 F.3d 1264, 1268 ( 11th Cir. 2005) (discussingprudential re asons for a ddressingsufficie ncy of evidenc e cla ims raised on direc t appea l); United States v. Adkinson , 135 F.3d 1363, 1379 n. 48 (11th Cir.1998) (“ Although not manda ted by the double jeopa

rdy clause , it is clearly

the better prac tice for

the appe llate cour

t on an initial appeal to dispose of a ny claim prope rly

prese nted to it that the evidence at trial wa s leg ally insufficient to wa

rra nt the thus challeng ed convic tion.”). 4an d v ari ou s ex pe rt wi tn es se s. Th e g ov ern m en t al so in tro du cedex hi bi ts in cl ud in g

th e m ed ic al ch art s fo r th e twe nty pa ti en ts at i ss ue in th e in di ctm en t, au to ps y rep orts , th ou sa nd s o f pr es cri pt io ns writ te n b y Ign as ia k a ndfin al ly the m ed ic al ch art s an d aut op sy repo rts of o th er p at ie nt s n otrefe ren cedin th e in di ctm en t. Unt il hi s re ti rem en t o n Dec em be r 15 , 20 05 , Ign as ia k o pe rat eda m ed ic al cl in ic in Free po rt, Fl or id a, a ru ral to wn i n t he Flo rid a Pan ha nd le wher e h e was th e on ly m ed ic al do ct or . He hada bu sy m ed ic al pra ct ic e an d ty pi cal ly saw be twee n th irt y to th irty -two pa ti en ts eachda y at f ift een–m in ut e in te rv al s. Mo stpa ti en ts cam e to ren ew th ei r pr es cri pt io ns , andth os e who work edat t he cli ni c te st ifi edth at Ig na si akalwa y s i nt erv ie wedan d e xa m in edhi s p at ie nt s b efo re the y go t a pr es cri pt io n. In ad di ti onto hi s re gu la rly sch edul edap po in tm en ts , Ign as ia k s aw

“ work- in ” p at ie nt s, p eo pl e who be cam e si ck an d n eed edto see a do ct orrig ht away, at t he rat e o f on e o r two pe r ho ur . As on e fo rm er em pl oyee who work edat th e cl in ic affi rm eddu rin g t he tri al , “ if s om eb od y was s ic k i n F reep ort an d n eed ed to see a do ct or

th atpa rti cu la r da y , th ey

wou ldco m e to see Dr. Ign as iak.” Inth e sp rin g o f 20 05 , th e fed eral Agen cy forHeal th Care Adm in is tra ti on (ACHA) u nd ert oo k arev ie w of Ig na si ak ’s fil es du e to co nc ernth at , as afam il y

5pr act ic e d oc to r, he was re gu la rly bil li ng forhi gh er-t ha n- no rm al lev el s o f se rv ic e. 4

The au di to r, Dr. Tim ot hy W al ke r, rev ie wedth irty of I gn as ia k’s p at ie nt s’ cha rts th atwere s el ect edby A CHA ou t o f m or e th an3,7 00 ch art s. He fo un d t ha t Ig na si ak ’s cha rts di d n otjus ti fy th e ch arg es he was s ub m it ti ng to Med ic ai d be cau se th ey

co ns is te nt ly fail edto do cu m en t a d et ai le d h is to ry or d et ai le d p hysic al ex am . As Dr. W al ke r ex pl ai ne d wi th reg ardto th e as su m pt io n h e m ad e in rev ie win g t he fil e: “ if i t’s n otdo cu m en te d, i t d id n’t h ap pe n.” Dr. W al ke r was m or e co nc ern ed , ho wev er, ab ou t wh athe pe rcei ve d a s Ig na si ak ’s pra ct ic e o f pr es cri bi ng cert ai n c om

bi na ti on s o f na rco ti c p ai n- ki ll ers in si gn ifi can t qua nt it ie s. Of th e th irt y

ch art s t ha t h e rev ie wed , Dr. W al ke r fo un d t ha t, as id e fro m si x ch il dr enwho were n otrece iv in g n arco ti cs , m os t o f th e rem ai ni ng twen ty-fou r adul ts were re cei vi ng so m e co m bi na ti on of n arco ti c dru gs . ButDr. W al ke r ackno wled ge d t ha t the ch art s al so co nt ai ne d p res cri pt io ns forno n- pa in m ed ic at io n fo r tr eat in g i ll ne ss es su ch as “ hypert en si on , cho le st ero l, d iabe te s, m ig rai ne s, [a nd ] pe pt ic ul cers .” Ig na si akreque st eda pe er m eet in g wi thDr. W al ke r to rev ie w hi s bi ll in g. Dr. Walk er ag reedbu t i nf orm edIgn as ia k t ha t h e al so want edan

In order to provide Medica id service s to patients, a doctor must keep written or dictated 4 documentation of e very

thing he does with respe ct to patient ca re, inc luding e x aminations, treatment plans, patients’ complaints, and pr ogress. Doc umentation is require d beca use Medica id reimburses doc tors based upon the amount and complexity of the wor

k they do. 6ex pl an at io n o f Ig na si ak ’s pre sc rip ti on of c on tro ll edsubs tanc es . Dr. W al ke r di d

no t h ear b ackfro m

Ign as ia k By Decem be r of 20 05 , Ign as ia k h adret ire d a ndso ldhi s Fr eep ort m ed ic al pr act ic e to Hos pi ta l Co rp or at io ns of Am eri ca (HCA) , whi ch sen t a r ep la cem en t do ct or . Dr. Mau ric e Marh ol in , a ch iro pr act or , arri ve d a t the cli ni c o n J anua ry 23 , 20 06 , fol lo win g asev eral weekper io d wh ere t he re was no do ct orpre se nt . Upo n rev ie win g t he pa ti en t fi le s i n p rep arat io n fo r hi s fi rs t v is it s, h e was ala rm edby the qu an ti ty of co ntro ll edsubs ta nc es be in g p res cri be d, an d b el ie ve d t he de fen da ntha d be enop erat in g apa in m an ag em en t cl in ic rathe r th ana fam il y pra ct ic e. Dr.

5 Marho li n was no t equi pp edto run a pa in m an ag em en t cl in ic an d c omm un ic at ed hi s co nc ern s t o HCA, wh ic h p os te d am em o o n t he cli ni c’s fro ntdo orin fo rm in g pa ti en ts th atna rco ti cs wou ldno t b e p res cri be d fo r two week s. Pat ie nt s wh o ex pe ct edth atDr. Marh ol in wou ldwrit e p ai n m ed ic at io ns were v is ib ly ang ry when he di d n ot . Dr. Marh ol in fear edforhi s s afety an d b eg anto wear a b ul le t-p ro of 6
ve st .

Dr. Mar

holin could not remember if he ha d treated any

of the twe nty

patients at issue in 5 the indictment. Mary Be ll Cosner, an HCA employee who helped with the tra nsition, t estified that 6 when unna

med patients we re una

ble to g et their pre scriptions for na rcotics f illed by Dr. Marholin, they

beca me angry . 7Dr. Marh ol in als o n ot edth atpa ti en ts were co m in g fr om co ns id erab le di st an ces , andhe “ th ou gh t tha t [i t was ] un us ua l tha t p eo pl e wou lddri ve pa stso m an y qu al ifi eddo ct or s ju stto co m e to th is cli ni c fo r pa in m an ag em en t.” In de ed , al th ou gh th e g ov ern m en t n ev er ca lc ul at edth e to ta l n um be r of th e d efen da nt ’s pr es cri pt io ns , itdi d d et erm in e th at44 ,08 3 o f th em du rin g afiv e-year pe rio d wer e fo r co nt ro ll edsubs ta nc es , su ch as h y dr oc od on e, al pr azo la m , di azep am , ox y co do ne , andcari so pr od ol . Of th es e 4 4,0 83 pre sc rip ti on s, a re la ti ve ly sm al l nu m be r were n otforFlo rid a p at ie nt s. Accor di ng to Dr. Marh ol in , th e m ed ic al 7 pr act ic e rap id ly decl in edas ares ul t o f hi s re fu sa l t o p res cri be pa in m ed ic at io ns . In Feb ru ary 20 06 , th e g ov ern m en t s ei zedall th e p at ie ntfil es . Thre e o th er i nd iv idua ls who were i nv ol ve d i n t he tra ns it io n a ls o t es ti fie d fo r th e g ov ern m en t. A nu rs e, St ep ha ni e Hug he s, wh o wo rk edfor Ign as iak fo r on ly si x wee ks , tes ti fie d o ve r ob jecti on th atnu m ero us un id en ti fie d p at ie nt s ca m e fo r ap po in tm en ts , ask in g fo r pr es cri pt io n re fil ls . It was “ co m m on ” fo r Ig na si ak

to

One pr escription each wa s filled by patients who g ave thefilling pha rmac y a zip code 7 in Indiana, Ne w York, a

nd Wis consin, three wer e filled by patients with a zip code in West Virg inia, four we re f

illed by patients with a zip code in Texas, six wer e filled by a patient with a zip code in L ouisiana, seve nteen we re f illed by patients with a zip code in Mississi ppi, forty
eight were filled by

a patient with a zip code in Ala bama, a nd forty-nine we re f

illed by a patient with a zip code in Geor g ia. 8pr es cri be Dura ge si c pa tc he s, wh ic h s he tes ti fie d was “ st ran ge ” an d “ tro ub le d” 8 he r. Ther e was als o ago ve rn m en t ex pe rt wh o l at er t es ti fie d t ha t l arg e d os es of fen ta nyl are u se d “ no t i nf reque nt ly, fo r ch ro ni c, no nm al ig na ntpa in by som e do ct or s,” a ndth athe hi m se lf “ ha [s ] pa ti en ts on fen ta nyl pa tc he s . . . who are cl ear he ad edan d wo rkev ery day .” AndHug he s ac kn owl ed ge d t ha t n o p at ie nt s g ot pr es cri pt io ns witho utfir stbe in g e xa m in edby Ign as ia k. In Hug he s’s ex pe rie nc e, fen ta nyl pa tc he s wer e o nl y writ te n fo r te rm in al ly ill pa ti en ts . Reb eccaCla rk

work edbri efl y

in Ign as ia k’s cl in ic fro m so m et im e in 20 04 un ti l h e ret ire d, an d re cal le d t he tra ns it io n p eri od . Clark t es ti fie d t ha t Ig na si ak sa w m an y pa ti en ts , so m et im es as m an y as s ix in anho ur , andth atth e m ajor it y were n otth ere b ecau se th ey were, i n C la rk ’s term s, “ si ck ,” bu t ra th er t o g et m on th ly m ed ic at io n re fil ls . A thi rdwitne ss , Dr. Grego ry Sta vi sk i, a p ai n m an ag em en t s pe ci al is t, s aw ap pr ox im at el y twen ty-four of

Ign as iak’s p at ie nt s refe rredto hi m

by D r. Marho li n, an d re cal le d t ha t the m ajor it y want edth ei r m ed ic at io ns , app eare d t o h av e li tt le in te res t i n b ei ng “ tre at ed ,” an d d idno t s ho w up forap po in tm en ts .

Dura g esic is a tra

nsdermal patch that deliver s fentany l, a sche dule I Iopioid pain 8 medication, into the body slowly through the skin, where it works to relieve pain.

9The go ve rn m en t al so off eredth e te st im on y

of s ev eral pa ti en ts or t he ir rel at iv es an d v ari ou s ex pe rts . Pati en t K.M. (c ou nt s o f co nv ic ti on eig ht , ni ne , twen ty one , th irt y

eig ht , andforty sev en ) was th e o nl y pa ti en t o f th e twe nt y refe ren cedin th e in di ctm en t wh o t es ti fie d a t tria l. K.M. b ecame add ic te d to Lort ab aft er an ot he r do ct orpre sc rib editforhe r pa in fol lo win g fo otsu rg ery in 19 99 . Once a dd ic te d, K.M. g otLort ab by buyin g i t o n t he st reetor b y tel li ng do ct or s “ [w]hat ev er I n eed edto say” to co nv in ce the m to gi ve he r pr es cri pt io ns . In20 01 , K.M. m ov edto Free po rt a ndst art edsee in g Ig na si ak . InK.M.’ s fi rs t v is itwith Ig na si ak , sh e to ldhi m sh e h adba ckpro bl em s an d aft er a p hysic al ex am in at io n h e p res cri be d h er Lo rtab, Ce le br ex , andSk el ax in . Fro m 20 01 un ti l M ay

20 03 , Ign as ia k p res cri be d K.M. Lo rtab andva rio us no nn arco ti c m ed ic at io ns forba ckan d jo in t p ai n, h ead ach es , andot he r no n- pa in rel at edm ed ic al pro bl em s, s uc h a s co ng es ti on an d a ll erg ic rhi ni ti s. Alt ho ug h K.M. adm it te d s he jus t wan te d p ai n m ed ic at io n, s he di d i n fa ctsu fferfro m lo wer b ack pa in whi ch th e p ai n m ed ic at io n re li ev edan d a ll owe d h er t o fu nc ti on in ev ery da y li fe. K.M. ne ve r to ldIgn as ia k t ha t s he was d ep en de ntup on th e p ai n m ed ic at io n an d t ha t i t was on ly part ia ll y for pa in be cau se sh e was afra idto tel l h im th e trut h. Acco rd in g t o K.M., Ig na si akex am in edhe r eac h t im e sh e wen t t o s ee h im

10fo r a p res cri pt io n, p al pi ta ti ng so re ar eas , hav in g h er ra is e an d l owe r he r arm s an d

le gs to ass es s t he ran ge of m ot io n i n h er joi nt s, an d u si ng a vi su al pa in an al og y sc al e to de te rm in e th e le ve l o f he r pa in . K.M. st at edIgn as iak was tre at in g h er “ as a d oc to r” an d “ ne ve r” g av e p res cri pt io ns witho utanex am , bu t the re was ev id en ce th atIgn as ia k re fil le d o ne to th ree p res cri pt io ns in be twee n o ffi ce v is it s o ve r th e co ur se of f

ou r y ears . At o ne po in t, a p ha rm aci stcal le d Ig na si akto say tha t K.M. was att em pt in g pr em atur el y

to fil l a p res cri pt io n fo r Lortab wri tt enby ano th er d oc to r, bu t the de fen da ntau th or iz edth e ad di ti on al refi ll on ce i t was ex pl ai ne d t ha t K.M. was go in g t o t he Bah am as fortwo week s. K.M. t es ti fie d t ha t s he di d, i n fa ct , go to th e Bah am as . Afte r th is in ci de nt , Ign as ia k s wit ch edK.M.’ s p rimary m ed ic at io n t o Dur ag es ic pa in pa tc he s an d re qu ire d h er t o re turnth e u se d o ne s t o h im so he co ul d
m on it orho w sh e was us in g t he dru gs . Two week s l at er, K.M. returne d t he us ed pa tc he s an d Ig na si akco un te d a ndin sp ect edth em , as h e d idev ery ti m e K.M. cam e in foranoff

ic e v is it . Bet ween20 03 –2 00 5, Ig na si akst ead il y in crea se d t he do sa ge in th e p at ch es , an d c on ti nu edto pre sc rib e Lortab fo r br eakth ro ug h p ai n, an d l at er Xan ax , un ti l h is ret ire m en t. Ig na si akpe rio di cal ly ord eredlab tes ts , whi ch he rev ie wedwith K.M.

11an d s ug ge st edsh e se e a p sychi atris t. He al so cau ti on edK.M. on ly to t ak e h er

m ed ic at io n a s p res cri be d a ndno t t o t ak e Xan ax an d Am bi ento ge th er. Bev erl y Fei n, the daug ht er o f pa ti en t J .S. (co un ts of c on vi ct io n t hi rty two an d t hi rty sev en ), te st ifi edab ou t h er m ot he r’s tre atm en ts with Ig na si ak fro m 19 89 –2 00 4. J .S. di d n ottes ti fy . Accor di ng to Fei n, al th ou gh J.S. h ad“ a lo t o f pa in ev erywhe re,” Ig na si ak ’s pre sc rip ti on s t o t reatth e p ai n c au se d h er t o de te rio rat e to th e p oi ntwher e sh e st ay edin he r ro om all da y watc hi ng tel ev is io n, freque nt ly stu m

bl ed , sl urredhe r wor ds , andin jure d h ers el f. The dru gs m ad e h er

“ba si cal ly non -fu nc ti on al .” J.S.’s m ed ic al reco rd s re fle ct edth atIgn as ia k h ad sc he du le d re pe at edul tra so un d t es ts of h er g al lb la dd er an d o th er t es ts for os te op or os is , ren al fai lu re, p ep ti c u lc er d is eas e an d h y pe rte ns io n, as well as refe rral s fo r he r to see di ffer en t s pe ci al is ts . In 2 00 0, Ig na si ak refe rredJ.S. t o a pa in cli ni c b utsh e co ul d n otaffo rdto go . Whe n J .S. ha d ado ub le bypas s s ur ge ry du e to co ng es ti ve he artfai lu re, Ig na si akwas the fir stto no ti ce tha t J .S. ha d de ve lo pe d g an gr en e in on e o f he r to es , andto di sc ov er tha t h er k idne y s wer e fai li ng as aco ns eque nc e o f th e su rg ery. Fei n a ls o t es ti fie d t ha t s he to ldIgn as ia k a t o ne po in t tha t J .S. was a dd ic te d to he r pi ll s an d h adalm os t o ve rd os edonsev eral oc cas io ns . As a res ul t, Ig na si ak

12st op pe d p res cri bi ng co nt ro ll edsubs ta nc es to J.S. fo r awh il e an d s to pp edtre at in g

he r al to ge th er i n 2 00 4. Dan a Eas te rly, the wid owe r of pa ti en t B.E. (co un ts of c on vi ct io n s ev en , ten , fif te en , si xt een , th irt y

si x, an d fo rty eig ht ), te st ifi edth atIgn as ia k b eg antre at in g hi s wi fe wi th in a few m on th s af te r th ey m ov edto Free po rt f

ro m Lou is ia nain 19 99 . B.E. hadbe enina tr ag ic car ac ci de ntin 19 94 in whi ch he r ni ne -y ear o lddaug ht er was ki ll edan d B .E. was eject edth ro ug h t he win ds hi el d h eadfir st , cau si ng ser io us in juri es to he r fac e. Befo re s eei ng Ign as ia k, B.E. h adsev eral reco ns tru ct iv e su rg eri es an d h ada hi st ory of m ajorde pr es si on , anx ie ty, se iz ur es , pep ti c u lc ers , an d fa in ti ng sp el ls . Ind eed , fol lo win g t he car ac ci de nt , B.E. hadbe entre at edby a ps y ch ia tri stin Lou is ia naan d h adbe entak in g Tra zo ne , Rem ero n, an d Val iu m , whi chm ad e h er co nf

us edan d fo rg et fu l. Pri orto B.E.’ s d eath o n Ap ril 15 , 20 05 , reco rd s fr om

Sacr edHeartHos pi ta l co nt em po ran eo us with Ig na si ak ’s tre atm en ts of B.E. sh owe d t ha t s he was b ei ng tre at edforsev eral m ed ic al co nd it io ns , m an y of whi chst em

m edfro m th e carcras h, i nc lu di ng de pr es si on an d a nx ie ty, st ro ke , di ve rti cu li ti s, re curren t p ai n s ynd ro m e, ch ro ni c b ackpa in , hep at it is , di ab et es , pa nc reat it is , hypot hyrod is m , andhypert en si on . On h er d ecea se d d au gh te r’s bi rth day in 20 03 , herhu sb an d t oo k h er t o t he em erg en cy roo m be cau se sh e was in

13em ot io na l p ai n a ndco ul d n otfeel th e le ft s id e o f he r bo dy. Hos pi ta l p hysic ia ns

pr es cri be d h er Xan ax , Lort ab , andVali um . B.E.’ s h us ba ndan d s on bo th tes ti fie d t ha t the pre sc rip ti on s Ig na si akwrot e B.E. forLort ab , Vali um , Dura ge si c p at ch es , andXana x m ad e h er l etha rg ic an d no nf un ct io na l. Onth e d ay

B.E. di ed , B.E. “ se em edfin e,” b utwhen he r hu sb an d returne d h om e fro m

worksh e was sl um

pe d o ve r on th e so fa b edan d p aram ed ic s were n otab le to rev iv e h er. Med ic al ex am in er Dr. An dr ea M in y ardco nduc te d a n au to ps y th ree d ay s af

te r B.E.’ s d eat h a ndtes ti fie d t ha t s he di edof “ m ul ti pl e dru g in to xi cat io n.” Altho ug h Dr. M in y ardco ul d n ottel l wh atth e le ve ls of c on tro ll ed subs ta nc es were atth e ti m e o f de ath fr om th e b lo odtes te d dur in g the au to ps y , ho sp it al reco rd s s ho wedth atth e Xan ax in B.E.’ s s y st em was i n the th erap eu ti c ran ge bu t the fen ta nyl was s li gh tl y hi gh er tha n t ha t. Dr. Mi nyard was un ab le to ru le ou t the po ss ib il it y

th atB.E. di edfro m

a st ro ke sh e su ffer edth ree wee ks pri or to he r de ath. The Co urt ad m it te d Dr. M in y ard ’s aut op sy repo rt o f B.E. in to ev id en ce. Dur in g Dr. M in y ard ’s tes ti m on y , th e Dis tri ctCo urt al so adm it te d i nt o ev id en ce, o ve r Ig na si ak ’s Con fro nt at io n C laus e o bjec ti on , th e au to ps y rep orts of 9

I gnasiak interpose d two objections about the a utopsy repor ts during D r. Minyard’ s 9 testimony . I gnasiak objec ted at the time the a utopsy repor ts wereoffe red into evide nce a nd asked to a pproac h side bar to plac e his objections on the re cord, but wa s instructed to do so 14se ve n o th er p at ie nt s o f Ig na si akwho were n otrefe ren cedin th e in di ctm en t. Fo r

al l s ev enpa ti en ts , th e au to ps y rep orts co nc lu de d t he cau se of d eath was ph arm aceu ti cal dru g o ve rd os es . Whi le Dr. Min y ardha d p erfo rm edtwo of tho se se ve n aut op si es , two ot he r m ed ic al ex am in ers , Dr. Mic ha el Berk la ndan d Dr. Karen L. Kelly, hadpe rfo rm edth e au to ps ie s fo r th e rem ai ni ng fiv e p at ie nt s.
duringa bre ak in the proc eeding s. Duringthe bre ak, I gnasiak objec ted, inter a lia, “bec ause [the repor ts] violate the conf

rontation clausein the Crawf ord ca se, in that the witness is testifying from the r eports; howeve r, the individual who wrote the re port is not here to testify , which inhibits eff

ective c ross-examination.” I gnasiak’s obje ctions were overr uled. In addition to his contemporaneous obje ction to the autopsy repor ts, I gnasiak ha d filed a motion in l imine to ex clude e vidence of uncha rg ed patients de aths, arguing that such evidenc e was ne ither re levant under Fe d. R. Evid. Rul e 401 nor pr oper unde r Rule 404(b). T he District Court was initially

inclined to grant I gnasiak’s motion, but later r ever sed itself and grante d the g overnme nt’s motion for rec onsideration. The g overnme nt’s motion argued that the e vidence of other de aths was r eleva

nt to all of the cha

rg es and a dmissibl e under Rule 404(b) to counte r I gnasiak’s de fense that “he w as simply a small town doctor who w as doingthe best he c ould to help his patients and ac ted in g ood faith in his prescription practice s.” “Implicit in t hat repr esentation,” the g overnme nt argued, wa s I gnasiak’s “ sug g etion that [he] had no knowledg e nor re ason to suspect that he was improperly presc ribingcontrolled substanc es or that suc h prac tices we re c ausingdeath to his patients.” Ac cordingto the g overnme nt, proof of the other deaths wa s releva

nt and important for two r easons. F irst, “[e]vi dence that duringthe same time periods the De fenda

nt knew that his patients wer e over dosing on the medications to the point that they wer e dying is re levant and pr obative of thefac t that the Def endant wa s not actingin good faith.” Sec ond, the g overnme nt argued: a prosec ution unde r § 841 require s proof beyond a rea sonable doubt that the doctor was acting outside the bounds of profe ssional medical prac tice, as his au thority to presc ribe controlled substances was being used not for treatment of a patient, but for the purpose of assisting another in the maintenanc e of a drug habit or of dispensing controlled subst ance s fo r o ther than a legitimate medical purpose, i.e. the personal profit of the phy sician. Proof t h at the Def endant continued to presc ribe massive doses of controlled substanc es eve n afte r he le arne d that his patients were dying of overdose s g oes a long way t o es t ab lishing that the defe ndant was knowing ly and willfully dispensing controlled substances for other than a leg itim at e m edica l purpose, in the or dinary

course of his medical pr actice .

15Neit he r Dr. Berk landno r Dr. Kell y tes ti fie d a t tria l. In st ead , Dr. Min y ardtes ti fie d ab ou t the fiv e au to ps ie s p erfo rm edby the no n- te st ifyin g m ed ic al ex am in ers , in cl ud in g t es ti m on y

th ateach no n- te st ifyin g m ed ic al ex am in er h adco nc lu de d t he cau se of d eat h was dru g o ve rd os e fo r eac h p at ie nt , andth atth e m anne r of de ath was acci de nt al forfou r of fiv e p at ie nt s, an d s ui ci de for th e fi fth pa ti en t (S .P.). In ad di ti on , Dr. Min y ardtes ti fie d t ha t s he ag reedwith t he co nc lu si on s o f th e n on te st ifyin g m ed ic al ex am in ers reg ard in g c au se of d eat h fo r fo urof t he fiv e pa ti en ts . ButDr. Min y ardin di cat edsh e la ck eden ou gh in fo rm at io n t o a gr ee o r

1 0 di sa gr ee wi th Dr. Kell y ’s con cl us io n t ha t p at ie ntS.P.’s de ath was a su ic id e. The go ve rn m en t al so pre se nt edth e te st im on y of a no th er m ed ic al ex am in er, Dr. Gary Cum be rla nd , who ha d c on du ct edanau to ps y of p at ie ntM.B. (co un ts of co nv ic ti on eig ht een an d t wen ty-eig ht ). Dr. Cum be rla ndtes ti fie d t ha t M .B. was a

“ wom anwho lo ok edli ke sh e h adbe enhavi ng a do wnh il l p ath [f ro m ] a m ed ic al vi ewp oi nt , [an d] . . . was he ad in g t owa rd s d eat h.” Ult im at el y , Dr. Cum be rla nd co nc lu de d t ha t M .B. di edof c om pl ic at io ns fro m

m ul ti pl e dru gs in he r syste m . M.B.’s t ox ic ol og y

rep ort fr om

bl oo d d rawndurin g t he au to ps y sh owe d t ox ic le ve ls of d ia zep am

an d m or ph in e.

The re cord doe s not indicate Dr. Minyard’ s opinion on whether she agree d with the 1 0 cause of death for one of

the dec edents. 16Dr. Bru ce Go ldbe rg er, wh os e labo rat ory co m pl et edth e to xi co lo gy repo rts fo r M.B., B.E., an d s ev enothe r de ced en ts no t re fere nc edinth e in di ctm en t b ut who se au to ps y

rep orts were ad m it te d i nt o e vi de nc e, te st ifi edab ou t the to xi co lo gy as itrel at edto each of t he ni ne de ced en ts . His c on cl us io ns were co ns is te ntwith th e cau se of d eat h l is te d i n t he au to ps y rep orts . Inad di ti on , th e g ov ern m en t o ffer edex pe rt t es ti m on y co nc ern in g t he
m ed ic al pro pr ie ty of Ig na si ak ’s tre atm en ts . Pha rm aco lo gi stPau l Do eri ng rev ie wedth e fi le s o f twe nt y of I gn as ia k’s p at ie nt s, wi th a fo cu s o n t he pr es cri pt io ns is su edto th os e p at ie nt s. Dr. Doe rin g t es ti fie d t ha t ce rta in co m bi na ti on s o f drug s—Vali um , Dura ge si c, an d S om a—m ay have a po te nt ia ll y da ng ero us synerg is ti c eff ectwhen us edto ge th er, tha t the de fen da ntpre sc rib ed su ch co m bi na ti on s t o anu m

be r of pa ti en ts , andth atth is cau se d Dr. Do eri ng

“ se rio us [] con cern .” Altho ug h Dr. Do eri ng was n ota ph y si ci anan d t he refo re wou ldno t h av e d ia gn os edpa ti en ts , hi s re vi ew of th e twe nt y

pa ti en t fi le s co rres po nd in g t o t he in di ctm en t “ cau se d h im co nc ern ” b ecau se th e d efen da ntha d a p at te rnof p res cri bi ng cert ai n d ru g c om bi na ti on s t ha t wer e u nh eal th y an d
m or eo ve r be cau se “ itdi dn ’t lo okli ke a who le lo t o f go odwas g oi ng to co m e to th os e co m

bi na ti on s.” Whi le cri ti ci zi ng Ign as ia k’s l on g t erm us e o f op io ds to tre at pa in , Dr. Doeri ng als o a ckno wled ge d t ha t s uc h u se ha d b eenap pr ov edby the 17Fed eral Drug Adm in is tra ti on an d t ha t i t was di ffi cu ltto de te rm in e whe n p at ie nt s

were fa ki ng th ei r pa in . Dr. Arth urJo rd an , a So ut h C aro li nam ed ic al do ct orwho sp eci al iz es in pa in
m an ag em en t, was th e cen te rp ie ce o f th e g ov ern m en t’s p res en ta ti on reg ard in g pr es cri bi ng pra ct ic es . He tes ti fie d fo r al m os t thr ee d ay s co nc ern in g h is op in io n o n th e g en eral ly accep te d treat m en t p hi lo so ph y in th e fi el d o f pa in m an ag em en t; th e da ng ers an d ri sk s o f us in g n arco ti cs in di vi du al ly or inco m bi na ti on with o th er drug s; th e cri ti cal im

po rta nc e o f do cu m en ti ng a pa ti en t’s fi le reg ard in g co m pl ai nt s, ca re, an d t reatm en t; th e warn in g s ig ns of p res cri pt io n d ru g abu se ; an d th e res po ns ib il it y

of m ed ic al do ct or s t o e ns ur e co ntro ll edsubs ta nc es are p ro pe rly us edan d p res cri be d. Bu t Dr. J or da n was no t fa m il ia r wit h F lo rid a la w and pr act ic es co nc ern in g p ai n m an ag em en t an d t he pra ct ic e o f m ed ic in e. Dr. Jo rd anrev ie wedth e m ed ic al an d p ha rm acy recor ds of t he twen ty pa ti en ts nam edin th e in di ctm en t. Dr. Jo rd anoff eredth e o pi ni onth atth e do cu m en ta ti on in Ign as ia k’s ch art s d idno t s up po rt t he qu an ti ti es an d s ub st an ces pr es cri be d. Fo r eac h o f th e p at ie nt s re fere nc edinth e in di ctm en t, Dr. J or da n affi rm edor s ta te d, o ve r de fen se co un se l’s o bjec ti on , th atIgn as ia k h adno t pr es cri be d t he co nt ro ll edsubs tanc es “ fo r a l eg it im at e m ed ic al pu rp os e” o r “ in th e us ua l co ur se of m ed ic al pra ct ic e.” Dr. Jo rd anals o t es ti fie d t ha t M .B. an d B .E. 18m ig htno t h av e d ie d i f th ey ha d n otbe enpre sc rib edco ntro ll edsubs ta nc es by Ig na si ak . The n o n c ro ss -ex am in at io n, Dr. J or da n a ckno wled ge d tha t, due to th e se rio us m ed ic al co nd it io ns refl ect edin th e rec or ds , a nu m be r of Ign as ia k’s tre atm en t p ract ic es were “ reas on ab le ,” “ le gi ti m at e,” “ ap pr op ria te ,” th e co nduc t o f

“ a d oc to r” an d/ orinth e u su al pra ct ic e o f m ed ic in e. At l eas t fo r so m e o f Ig na si ak ’s pat ie nt s, Dr. J or da n a ckno wled ge d t ha t i t m ay have be enreas on ab le to tre atth em

with c on tro ll edsubs ta nc es , in cl ud in g p ai n m ed ic at io n, o n s om e oc cas io ns . Also , inat l eas t s om e in st an ces , th e rec or ds rev ie wedby D r. Jo rd an al so refl ect edth atot he r he al thcare pro vi de rs ha d p res cri be d the same, or si m il ar, co nt ro ll edsubs ta nc es to th e sa m e p at ie nt s. Fu rth erm or e, whi le Dr. Jo rd an ge ne ral ly faul te d Ig na si ak forin ad equa te ly doc um en ti ng hi s p at ie nt s’ cha rts , he reco gn iz edth atso m e o f th e ch art s s ho wedIgn as iak h adco un se le d h is pa ti en ts on he al th is su es , ord ereddi ag no st ic tes ti ng , andrefe rredpa ti en ts to va rio us sp eci al is ts forfurth er treat m en t, i nc lu di ng pa in sp eci al is ts . The go ve rn m en t al so in tro du cedth e m ed ic al reco rd s o f ei gh t p at ie nt s n ot m en ti on edin th e in di ctm en t. The se reco rd s co nt ai ne d h an dwr it te n n ot at io ns ab ou t rep orts m ai nl y

fro m un id en ti fie d o r an on y

m ou s p eo pl e cl ai m in g t ha t the pa ti en ts were s el li ng or o th erwi se ab us in g t he ir m ed ic at io ns . Furt he r, th e g ov ern m en t 19in tro du cedsi xt y -o ne Drug Uti li zat io n R ev ie w let te rs th atIgn as ia k re cei ve d fr om

th e St at e o f Fl or id a b etween19 96 an d 2 00 6. Ign as ia k re sp on de d t o o nl y on e o f 1 1 th es e le tt ers . Altho ug h Ig na si akdi d n ottes ti fy , th e d efen se di d c al l i ts own ex pe rt witne ss es to di sp ut e th e g ov ern m en t’s al le ga ti on s. Th e d efen se cal le d ph arm aco lo gy exp ertLeon ardRap pa , who tes ti fie d t ha t the co m bi na ti on s o f drug s pr es cri be d b y

Ign as ia k wer e n otex ces si ve , eithe r in di vi du al ly or in co m bi na ti on , an d wer e ap pr op ria te forth e co nd it io ns do cu m en te d i n t he m ed ic al reco rd s fr om a ph arm aceu ti cal st an dp oi nt . He al so tes ti fie d t ha t Ig na si ak ’s pre sc rip ti on s n ev er ex ceed edth e d ia gn os is -s pe ci fic do sa ge s an d qua nt it ie s l is te d i n t he Ph y si ci an ’s Des k R efer en ce (“ PDR”) , a co m pi la ti on of a ll m ed ic at io ns , m on og rap hs , andFDA ap pr ov al li m it at io ns . The g ov ern m en t d idno t d is pu te th is las t p oi nt . Dr. Davi d F owl er, the Ch ie f Med ic al Exam in er fo r th e St at e o f Mary la nd , rev ie wedth e au to ps y

rep orts th atwere ad m it te d dur in g t he tri al . He crit ic iz edth e de la y s i n t he au to ps ie s an d t es ti fie d t ha t t ox ic ol og y rep orts canbe m is le ad in g due to th e “ red is tri bu ti on ” o f drug s i n t he bo dy after de ath. Ba se d o n arev ie w of t he

Medica id has a provide r re view sy stem in which a re viewingpharma cist 1 1 or phy sician may , upon identifying a conce rn such a s a an ove rutiliz ation of a pr oduct or a duplication in therapy , reque st that the provider be sent a Dr ugUtiliz ation Review (D UR) letter advisingthe provider

of the c oncer

n. 20au to ps y

rep orts , Dr. Fowl er o pi ne d t ha t the de aths were ei th er “ na tu ral ,” th e res ul t of su ic id es , or u nc ert ai n. At the clo se of t he ev id en ce, the Dis tri ctCo urt d en ie d Ig na si ak ’s m ot io n fo r jud gm en t o f acqui tt al . The jury returne d ave rd ic t o f gu il ty as to forty thre e o f th e co un ts an d ave rd ic t o f no t g ui lt y as t o e le ve n c ou nt s p ert ai ni ng to fiv e p at ie nt s. Ig na si akti m el y

ap pe al ed . II . STANDARDS OF REVIEW W e rev ie w th e su ffi ci en cy of t he ev id en ce d e n ov o, v ie win g t he ev id en ce an d a ll reas on ab le in fere nc es an d c red ib il it y ch oi ces in fav orof the go ve rn m en t an d t he jury’ s v erd ic t. Un it edSta te s v . Fris ke , 64 0 F .3d12 88 , 12 90 –9 1 (1 1t h C ir. 20 11 ). A con vi ct io n m

us t b e aff irmed un le ss th ere i s n o re as on ab le co ns tru ct io n of th e ev id en ce fr om

whi ch th e jury cou ldha ve fou ndth e d efen da ntgu il ty bey on d a rea so nabl e d oubt . Uni te d S ta te s v . Garci a, 40 5 F .3d12 60 , 12 69 (11 thCir . 20 05 ). A defe nd an t’s cl ai m th athi s Si xt h Am en dm en t ri gh ts were v io la te d i s rev ie wedde no vo . Uni te d S ta te s v . Gari, 5 72 F.3d13 52 , 13 61 –6 2 (1 1t h C ir. 20 09 ). II I. DI SCUSSI ON A. Suff ic ie nc y of t he Evi de nc e

21As n ot edab ov e, Ig na si akwas c ha rg edin fou rte enco un ts of h eal th care

frau d andforty cou nt s o f di sp en si ng co nt ro ll edsubs ta nc es . The g ov ern m en t’s th eo ry of p ro se cu ti on forbo th set s o f ch arg es was s ub st an ti al ly the same—th at Ig na si akha d p res cri be d unn eces sa ry or e xc es si ve qu an ti ti es of c on tro ll ed subs ta nc es witho uta le gi ti m at e m ed ic al pu rp os e an d “ ou ts id e th e u su al co ur se of pr of es si on al pra ct ic e.” Thu s, al th ou gh Ign as iak was co nv ic te d o f bo th subs ta nt iv e frau d c ou nt s an d d is pe ns in g c on tro ll edsubs tanc es co un ts , th e co nv ic ti on s ar e in ex tri cab ly int ertwin ed . The i nd ic tm en t co m pe ls th is co nc lu si on be cau se th e m an ne r an d m ean s i n wh ic h t he frau du le ntsch em e was carr ie d o utdi rect ly relat ed to whet he r Ig na si ak ’s pre sc rip ti on s fo r co ntro ll edsubs ta nc es were l eg it im at e an d withi n t he us ua l co ur se of p ro fes si on al pra ct ic e. In de ed , th e g ov ern m en t ch arac te riz edth e fo urte enfrau d c ou nt s as a “ sc he m e to de frau d h eal th care pr ov id ers . . . by bil li ng foroff ic e v is it s wh enth ey

were, i n re al it y

no t m or e th an drug di st rib ut io n.” Thu s, we ev al ua te th e su ffi ci en cy of t he ev id en ce fo r th e fraud an d d is pe ns in g c ou nt s t og ethe r in th is cas e, fo cu si ng up on th e requi rem en ts un de r th e CSA. The CSA co m

pr eh en si ve ly regu la te s t he flo w of c ert ai n c la ss es of d ru gs in th e Uni te d S ta te s, ra ng in g fr om co m m on sl eep aid s t o c rackco cai ne . The s ta tu te , whi chis adm in is te redby the Drug Enfo rcem en t Ag en cy (“ DEA”), pro vi de s fo r th e 22sc he du li ng , res ch edul in g, an d d es ch edul in g o f co ntro ll edsubs ta nc es in to on e o f

fiv e cat eg or ie s b as edon vario us fact or s, s uc h a s t he ir a dd ic ti ve pro pe rti es an d ri sk of si de effe ct s. 2 1 U.S.C. § § 8 11 , 81 2. Itcri m in al iz es th e m anuf actur e, di st rib ut io n, d is pe ns at io n, o r po ss es si on of t he se subs ta nc es , exc ep t i n am an ne r au th or iz edby the CSA. 21 U.S.C. §§ 84 1( a)(1 ), 84 4( a). One us e au th or iz edun de r th e st atut e is form ed ic al tre atm en t b y a ph y si ci an reg is te redwith t he DEA purs ua ntto hi s s ta te m ed ic al li cen se . See i d. § 82 3( f). A DEA-reg is te redph y si ci anm ay di sp en se co nt ro ll edsubs ta nc es so lo ng as h e d oe s so “ fo r a l eg it im at e m ed ic al pu rp os e” an d wh il e “ act in g i n t he us ua l co ur se of h is pr of es si on al pra ct ic e.” 2 1 U.S.C. § § 8 30 (b )(3 )(A)(i i); acco rdid . at 8 02 (2 1) ; 2 1 CFR § 13 06 .04 (a) (2 00 5) . Con ve rs el y , “ [t]o c on vi ct[a DEA-li cen se d p hysic ia n un de r § 8 41 ], it[is ] in cu m be ntup onth e g ov ern m en t t o p ro ve th athe di sp en se d co nt ro ll edsubs ta nc es forothe r th anleg it im at e m ed ic al pu rp os es in th e u su al co ur se of p ro fes si on al pra ct ic e, an d t ha t h e d idso kn owi ng ly andin te nt io na ll y .” Uni te d S ta te s v . Guerrero , 65 0 F .2d72 8, 7 30 (5th C ir. J ul y 16 , 19 81 ) (ci ta ti on om it te d) . 1 2

In Bonne r v. City

of Prichard

, 661 F.2d 1206, 1209 ( 11th Cir. 1981) (en ba nc), this 1 2 Court adopted as bindingprec edent a ll decisions of the for mer F ifth Circuit handed down prior to October 1, 1981. 23Abo utth e su ffi ci en cy of t he ev id en ce, the re was in cu lp at in g e vi de nc e o f a ci rcu m st an ti al na tu re tha t Ig na si akwas p res cri bi ng co nt ro ll edsubs tanc es ou ts id e th e u su al co ur se of p ro fes si on al pra ct ic e. In de ed , th ere i s ev id en ce i n t he reco rd sh owi ng th atIgn as iak s om et im es fai le d t o a skforexpl an at io ns of t he erra ti c be ha vi orof c ert ai n p at ie nt s, an d d idno t al way s ex erci se pro pe r pr ecau ti on s wh en in fo rm edby pat ie nt s t ha t the y fear edad di ct io n t o t he na rco ti cs th ey were pr es cri be d. Dr. Ma rh ol in tes ti fie d t ha t Ig na si ak ’s pat ie nt s ex pr es se d a ng er wh en to ldth ey co ul d n o l on ge r rec ei ve na rco ti cs as am atte r of co ur se . Dr. Stav is ki te st ifi edth atat l eas t s om e o f Ig na si ak ’s pat ie nt s l ack edan y ap pa ren t d es ire to reco ve r fro m

th ei r pu rp orte d i ll ne ss es . Bu t am pl e rec or d e vi de nc e al so su gg es ts th atIgn as ia k’s p ract ic e ex po se d hi m to si ckpa ti en ts affl ic te d b y leg it im at el y

pa in fu l co nd it io ns . Ind eed , th e m ed ic al reco rd s o f al l twen ty pat ie nt s re fere nc edin th e in di ctm en t d oc um en t il ln es se s o r co nd it io ns th atcau se d t he m pa in , anx ie ty and/o r de pr es si on , ail m en ts th atco ul d wel l h av e jus ti fie d t he us e o f co nt ro ll edsubs ta nc es withi n t he ran ge of di sc ret io n a cco rd edph y si ci an s. Itwas a ls o n otdi sp ut edat tria l tha t al l o f Ig na si ak ’s pre sc rip ti on s wer e wri tt enwithi n t he di ag no si s- sp eci fic gu id el in es co nt ai ne d i n t he Ph y si ci an ’s DeskRefe ren ce.

24The go ve rn m en t re li edlar ge ly upo n m ed ic al reco rd s attri al . Spe ci fic al ly, of

th e twe nt y

pa ti en ts ch arg edin th e in di ctm en t, the go ve rn m en t co nduc te d in de pe nd en t ex am in at io ns of o nl y two —the au to ps ie s o f B.E. an d M .B. Furth er, th e g ov ern m en t ca ll edon ly one pa ti en t re fere nc edin th e in di ctm en t, K.M., to te st ify. Rat he r th ancal li ng or e xa m in in g the rem ai ni ng sev en te enpa ti en ts na m ed in th e in di ctm en t, the go ve rn m en t re li edalm os t ex cl us iv el y on th e te st im on y

of on e d oc to r—Dr. J or da n—who tes ti fie d e xt en si ve ly abo ut his r evi ew of Ign as ia k’s ch art s co nc ern in g t ho se ch arg edpa ti en ts . Dr. Jo rd andi d n otin te rv ie w or e xa m in e a si ng le pa ti en t t o d et erm in e whe th er the ir t reat m en ts were warr an te d. Bas edup onth is rev ie w, we con cl ud e th at , when vi ewedin th e li gh t m os t fav or ab le to th e g ov ern m en t, the ev id en ce was su ffi ci en t t o s up po rt I gn as ia k’s co nv ic ti on . In thi s ca se , li ke in Merr il l, the go ve rn m en t i nt ro du cedev id en ce tha t Ig na si akha d wri tt enm or e th an43 ,00 0 p res cri pt io ns for co nt ro ll edsubs ta nc es ov er a fi ve y ear p eri od , whi ch itth enall eg edwas c on du ct“ ou ts id e th e u su al co ur se of p ro fes si on al pra ct ic e.” 5 13 F.3dat 1 29 9– 13 01 . Base d upo n t hi s ev id en ce, i n c om

bi na ti on with t he ex pe rts ’ te st im on y , we can no t s ay th e “ jury co ul d n otha ve fou ndth e d efen da ntgu il ty und er an y reas on ab le co ns tru ct io n o f th e ev id en ce.” Id . at 1 29 9. Furth er, the factth e jury acqu it te d Ig na si akof s ev eral co un ts in vo lv in g p at ie nt s wh o d idno t t es ti fy whi le co nv ic ti ng hi m

on ot he rs , 25su ffi ci en tl y

m in im iz es th e ri skid en ti fie d i n C uo ng th atIgn as ia k’s jury m erel y co nv ic te d h im

ba se d o nl y

up on “ gu il t b y

ass oc ia ti on .” Cu on g, 1 8 F .3dat 1 14 2. B. Aut op sy Repo rts Ig na si akarg ue s t ha t the Dis tri ctCo urt v io la te d the Co nf ro nt at io n C laus e b y al lo win g t he go ve rn m en t t o i nt ro du ce, an d Dr. M in y ardto tes ti fy ab ou t, fi ve au to ps y rep orts whi ch ne ithe r sh e n or an y ot he r wit ne ss ha d aut ho red . Duri ng 1 3 Ig na si ak ’s tri al , th e g ov ern m en t i nt ro du cedth e au to ps y rep orts of f

iv e o f Ig na si ak ’s form er p at ie nt s i n wh ic h t he cau se of d eat h was de te rm in edto be , at le as t i n p art , in to xi cat io n fr om co nt ro ll edsubs ta nc es . In ea ch in st an ce, the go ve rn m en t o ffer edth es e au to ps y rep orts th ro ug h Dr. M in y ardin he r cap aci ty as ch ie f m ed ic al ex am in er an d re co rd s cu st od ia n fo r th e Offi ce o f th e Me di cal Exa m in er, Dis tri ctI. Becau se Dr. Min y ardha d n otpe rfo rm edth e au to ps ie s, de fen se co un se l o bjec te d b as edup on th e Co nf ro nt at io n C laus e. The Di st ric t Co urt ov erru le d Ig na si ak ’s ob

jecti on . As a res ul t, the fiv e au to ps y rep orts were ad m it te d in to ev id en ce an d Dr. M in y ardwas a ll owe d t o t es ti fy as t o t he ir c on te nt s wi th res pe ctto each pa ti en t’s d eat h h av in g b een cau se d b y co nt ro ll edsubs ta nc es . 1 4
I gnasiak a lso argues that his Confrontation rights were violated bec ause a nony mous 1 3 notations on his patients’ char ts were admitted into evidence over his objec tion. Bec ause w e find the autopsy

issue dispositi ve, we need not a ddress this aspec t of his claim. The a utopsy repor ts appea r to have been a dmitted into evidence unde r the he arsa y 1 4 exception for docume nts kept in the regular c ourse of business under F ed. R. Evid. 803(6). 26The go ve rn m en t ar gu es th atth e au to ps y rep orts adm it te d t hr ou gh th e cu st od ia n o f rec or ds as b us in es s re co rd s ar e n otsubjec t t o t he Co nf ro nt at io n Cl au se ’s rig or . The go ve rn m en t ar gu es alt ern at iv el y th at , eve n a ss um in g e rro r oc cu rred , itwas h arm le ss be cau se th e rep orts di d n otco nc ernpa ti en ts refe ren ced in th e in di ctm en t. To re so lv e th is di sp ut e, we m us t fi rs t d et erm in e whe th er the au to ps y rep orts at i ss ue are t es ti m on ia l ev id en ce s ub ject t o t he Co nf

ro nt at io n Cl au se . For the fol lo win g re as on s, we co nc lu de th atth e an swe r to th is qu es ti on is y es . InCrawfo rdv. Wash in gt on, 54 1 U.S. 3 6, 6 8– 69 , 12 4 S . Ct. 1 35 4, 1 37 4 (2 00 4) , th e Supr em e Co urt wro te , “ [w]here t es ti m on ia l s ta te m en ts are atis su e, th e on ly ind ic iu m

of r el iabi li ty suf

fic ie ntto sat is fy

co ns ti tu ti on al de m an ds is th e o ne th e Co ns ti tu ti on actua ll y

pre sc rib es : co nf

ro nt at io n.” Thi s m ean s t ha t the pr os ecu ti on m ay

no t i nt ro du ce “ te st im on ia l” he ars ay ag ai ns t a c riminal de fen da nt , reg ard le ss of wh ethe r su ch st at em en ts are d eem edrel iabl e, un le ss th e d efen da nt
Under that rule, the a

vailability

of the de clar ant is immaterial. Of c ourse, a dmissibi lity under the rules of e vidence does not vitiate Confrontation Clause re quirements. See Cra wford v. Washington, 541 U.S. 36, 50–51, 124 S. Ct. 1354, 1364 (2004) (“[W] e . . . re ject the view

that the Confrontation Clause a pplies of its own forc e only to in-court testimony , and that its application to out-of- court stateme nts introduced at tria l depends upon ‘the law of Evide nce f or the time being .’ L eavingthe re gulation of out-of-c ourt statements to the law of evidenc e would rende r the Confrontation Cl ause pow erle ss to prevent e ven the most flagrant inquisitorial prac tices.” ( citations omitt ed)) . The re cord is uncle ar a s to whether D r. Ke lly or Dr. B erkla

nd wer e unava ilable at the time of tria l. Nor is there any indication that I gnasiak ha d a prior opportunity

to cross-e x amine them. 27ha s an op po rtu ni ty to cr os s- ex am in e th e d ecl aran t, o r un le ss th e d ecl aran t i s

un av ai labl e an d the de fen da ntha d p rio r op po rtu ni ty for cro ss -ex am in at io n. Id . at 53 –5 4, 6 8, 1 24 S. Ct. at13 65 –6 6, 1 37 4. Cr awfo rdde sc rib edth e cl as s o f te st im on ia l s ta te m en ts co ve redby the Co nf ro nt at io n C laus e as fol lo ws: Vari ou s fo rm

ul at io ns of th is co re clas s of t es ti m on ia l s ta te m en ts ex is t: ex pa rt e in -co urt te st im on y or it s fu nc ti on al equi va le nt -th at is , m at eri al su ch as affi da vi ts , cu st od ia l ex am in at io ns , pr io r te st imo n y th at th e de fen da nt wa s u nabl e to cro ss -ex am in e, or si m il ar pr etria l st at em en ts th at de cl aran ts wou ld reas on ab ly ex pe c t t o be us ed pr os ecu to ria ll y ; ex tra jud ic ia l state m ents . . . co nta ine d in fo rm al iz ed te st im on ia l m at eri al s, su ch as affi da vi ts , d e p os it io ns , pr io r te st im on y , or co nf es si on s; st at em en ts th at were m ad e u n d er ci rcu m st an ces whi ch wou ld le ad an ob jecti ve witne ss reas on ab ly to be li ev e th at th e s t a t e m en t wou ld be av ai labl e fo r us e ata la te r tr ia l. Crawf or d, at51 -5 2, 1 24 S. Ct. 1 36 4 (quo ta ti on m ark s an d c it at io ns om it te d) . Fo ren si c rep orts co ns ti tu te tes ti m on ia l ev id en ce. To wi t, i n M el en de z-Di az v. M as sa ch us et ts , ---U.S.--- , 12 9 S . Ct. 2 52 7 (2 00 9) , th e Supr em e Co urt h el d t ha t a fo ren si c labo rat ory

rep ort s ta ti ng th atanun kn own subs ta nc e was co cai ne qu al ifi es as tes ti m on ia l ev id en ce t o wh ic h t he Co nf ro nt at io n C laus e ap pl ie s. Id . at25 32 . The Co urt re as on edth atbe cau se th e certi fic at es are “ in co ntro ve rti bl y a so le m n de cl arat io n o r affi rm at io n m ad e fo r th e p ur po se of e st ab li sh in g o r pr ov in g s om e fact ,” th ey

“ are f un ct io na ll y

id en ti cal to li ve , in -co urt t es ti m on y , do in g p reci se ly wha t a wi tn es s d oe s o n d ire ctex am in at io n” —i .e. of feri ng pro of

th atth e subs ta nc e

28was co cai ne . Id. (quo ta ti on m ark s an d c it at io ns om it te d) . As a res ul t, an d b ecau se

sc ie nt ifi c ev id en ce i s n o m or e n eu tra l o r rel iabl e th anot he r te st im on ia l ev id en ce, co nf ro nt at io n s erv es to en su re i ts accu racy by “ weed [in g] ou t n oton ly the frau du le ntan al y st , bu t the in co m pe te nton e as well .” Id . at 2 53 7. Mo reo ve r, th e sc ie nt ifi c n atur e o f fo ren si c rep orts do es no t ju st ify subjec ti ng th em

to les se r sc ru ti ny tha n o th er t es ti m on ia l ev id en ce. To the co nt rary, in Bu ll co m in g v . New Mex ic o, -- -U.S.---, 1 31 S. Ct. 2 70 5 (J un e 2 3, 20 11 ), th e Co urt m ad e cl ear t ha t the Six thAm en dm en t re qu ire s t ha t, wh en in tro du ci ng tes ti m on ia l fo ren si c ev id en ce, the pro se cu ti onm us t p res en t t es ti m on y by a sci en ti stwho was a ctua ll y in vo lv edin pre pa rin g tha t fo ren si c ev id en ce. Id . at 27 10 , 27 13 . In s o d oi ng , th e Co urt s pe ci fic al ly rejectedth e u se of s o- cal le d

“ su rro ga te tes ti m on y ,” whi chin Bu ll co m in g was th atof aco ll eag ue fro m th e sa m e lab t ha t p rep aredth e d is pu te d fo ren si c rep ort, b utwho ha d n otsp eci fic al ly w orke d on th e rep orts in qu es ti on . Id. at27 10 , 27 12 –1 3. Ev enth ou ghth e co ll eag ue was ab le to tes ti fy

as t o the effi cacy andrel iabi li ty of th e labo rat ory equi pm en t, an d al so whet he r no rm al pro to co l was fol lo wed , th e Co urt ex pl ai ne d tha t the

“ co m pa rat iv e rel iabi li ty of anan al y st ’s tes ti m on ia l re po rt d rawnfro m m ach in epr oduc edda tado es no t o ve rco m e th e Si xt h Am en dm en t b ar . . . [be cau se ] th e ob vi ou s re li ab il it y

of ates ti m on ia l s ta te m en t d oe s n otdi sp en se with t he 29Co nf

ro nt at io n C laus e.” Id . at 2 71 4. In st ead , on ly test im on y by the actua l s ci en ti st who pre pa redth e fo ren si c rep ort co ul d p ro vi de in si gh t i nt o “ th e p art ic ul ar t es t an d te st in g p ro ces s . . . em

pl oyed,” an d a ls o “ ex po se an y lap se s o r li es onth e cert ifyin g a na lyst’s p art .” Id . App lying th e rea so ni ng of C rawfo rd , Mel en de z-Di az, an d B ul lc om in g, we co nc lu de th atth e fi ve au to ps y rep orts adm it te d i nt o e vi de nc e in co nju nc ti on with Dr. Mi nyard’s t es ti m on y , wher e sh e d idno t p ers on al ly obs erv e o r pa rti ci pa te in th os e au to ps ie s (andwher e n o e vi de nc e was pre se nt edto sh ow t ha t the co ro ne rs who pe rfo rm edth e au to ps ie s wer e u na va il ab le an d the accu se d h ada pr io r op po rtu ni ty to cr os s ex am in e th em ), vi ol at edth e Co nf ro nt at io n C laus e. For 1 5

Even be foreBullcomingmany states which ha d considere d the issue conc luded that 1 5 autopsy repor ts are te stimoni al and subjec t to the Confrontation Clause. See Smith v. Alabama, 898 So. 2d 907, 917 (Ala. Crim. App. 2004) (holdingthat admission of autopsy evidenc e and repor ts, without t estimony

of medica l examiner who perf ormed a utopsy , violated def

endant’ s Six th Amendment right to confrontation but was ha rmless err or); Commonwealth v. Avila, 912 N.E. 2d 1014, 1029 (Ma ss. 2009) (holdingthat the autopsy repor t was testimonial hear say ); Cuesta-Rodriguez v. State, 241 P.3d 214, 228 (Okla. Crim. App. 2010) (holdingthat admission of autopsy

repor t was testimonial); State v. L ocklea r, 681 S.E. 2d 293, 305 (N.C. 2009) (holding that the trial cour

t erre d under Cra

wford by admitting “f

orensic a naly ses per formed by

a for ensic patholog ist and a for ensic de ntist who did nottestify”); Wood v. Texas, 299 S.W . 3d 200, 209–10 (Tex. Crim. App. 2009) (holding the autopsy repor t was testimonial where police suspected the death wa s a homicide); but see People v. Cortez, 931 N.E. 2d 751, 756 (I ll. App. Ct. 2010) (holding that autopsy repor ts are non- testimonial business records) . Fur thermore , although the Fir st Circuit held United States v. Feliz, 467 F.3d 227 (1st Cir. 2006) that an a

utopsy repor t is admissi ble as a

business rec ord, id. at 236–37, the F eliz case c ame befor e Mele ndez-Diaz, which as discusse d below re jected that same business re cord a rgument as applied to the for ensic e videnceat issue in that case . See 129 S. Ct. at 2538. As such, we conclude that Fe liz has little persuasive va lue on this issue. 30ba ck gr ou nd , see Mel en de z-Di az, 1 29 S. Ct. at25 38 (bu si ne ss reco rdex cep ti on

do es no t en co m

pa ss do cu m en ts ge ne rat edby an en ti ty tha t re gu la rly “pr oduc [es ] . . . evi de nc e fo r us e attri al ”). W e th in k t he au to ps y

reco rd s p res en te d i n t hi s ca se were p rep ared“ fo r us e attri al .” Und er Fl or id a law, th e Me di cal Exam in ers Co m m is si on was c reat edan d ex is ts withi n t he Depa rtment o f Law Enfo rcem en t. Fl a. St at . § 4 06 .02 . Furt he r, th e Me di cal Exam in ers Co m m is si on it se lf m

us t i nc lu de on e m em

be r who is a st at e at to rn ey , on e m em

be r who is a publ ic de fen de r, on e m em be r who is sh eri ff, an d on e m em be r who is th e atto rn ey

ge ne ral or h is de si gn ee, i n a dd it io n t o fi ve ot he r no n- cri m in al jus ti ce m em be rs . Id. The m ed ic al ex am in er fo r eac h d is tri ct“ sh al l de te rm in e th e cau se of d eat h” in a va rie ty of ci rcu m st an ces an d “ sh al l, fo r th at 1 6 pu rp os e, m ak e o r ha ve pe rfo rm edsu ch ex am in at io ns , in ve st ig at io ns , andau to ps ie s as he or s he sh al l d eem

ne ces sa ry

or a s s ha ll be reque st edby the st at e at to rn ey .”

Those cir cumstance s include whe n any person dies in the stateof F lorida: 1 6 (1 ) Of cr iminal violence; (2) By acc ident; (3) By suicide; (4) Suddenly , when i n appar ent g ood health; (5) Una ttended by a prac ticing phy sician or other rec ognized pract i t i o n er ; (6) In any prison or penal institution; (7) In police custody ; (8) In any suspicious or unusual circ umstance; (9) By criminal abor

tion; (10) By

poison; (11) By disease constituting a threat t o p ub l i c h ea lth; (12) By disease, injury , or tox ic ag ent resulting from employ ment; [or] (b) When a dead body is brought into the state wi thout proper medical cer tification; [or] (c) When a body is to be cr em at ed , dissected, or

buried at sea. F la. Stat. § 406.11)(1)( a)–( c).

31Fl a. St at . § 4 06 .11 (1 ). Furth er, an y pe rs on who be co m es aware o f a p ers on dying un de r ci rcu m st an ces de sc rib edin sec ti on § 4 06 .11 ha s a dut y to rep ort the de ath t o th e m ed ic al ex am in er. Id . at § 40 6.1 2. Fa il ur e to do so is a fi rs t d eg ree m is de m ean or . Id.

“ Upo n re cei ptof s uc h n ot ifi cat io n . . . th e d is tri ctm ed ic al ex am in er . . . sh al l ex am in e o r othe rwis e take ch arg e o f th e d eadbo dy andsh al l n ot ify the ap pr op ria te la w enf or cem en t ag en cy .” Fla . Sta t. § 40 6.1 3. Th en , aft er the cau se of d eat h i s de te rm in ed , th e m ed ic al ex am in er i s re qu ire d t o “ rep ort o r m ak e av ai labl e to th e st at e at to rn ey , inwrit in g, h er . . . det erm in at io n a s t o t he cau se of d eat h.” Id. Th e m ed ic al ex am in er m ay

ret ai n “ [a]ny ev id en ce o r sp eci m enco m in g i nt o t he po ss es si on of s ai d m ed ic al ex am in er i n c on ne ct io n wi th an y in ve st ig at io n o r au to ps y ,” orde li ve r itto law en fo rcem en t. Id . Like wis e, la w enf or cem en t h as a du ty to m ak e “ [a]ny ev id en ce m at eri al to th e . . . caus e o f de ath” in th e p os se ss io n of law en fo rcem en t av ai labl e to th e m ed ic al ex am in er. Fl a. St at . at 4 06 .14 . 1 7 Inli gh t o f th is st atut ory

fram ewo rk , andth e te st im on y of Dr. M in y ard , th e au to ps y rep orts in th is cas e were t es ti m on ia l: “ m ad e und er ci rcu m st an ces whi ch wou ldlea d a n o bjec ti ve witne ss reas on ab ly to b el ie ve th atth e st at em en t wo ul d b e
That medica l examiners worked c losely with law enf

orce ment in connec tion with thi s 1 7 case is further illustrated by the fa ct that Dr. Minyard he rself te stified that she re lied upon information collec ted by

“deputies on the scene ” in her investigation of B.E. 32av ai labl e fo r us e ata la te r tr ia l.” Uni te d S ta te s v . Bak er, 4 32 F.3d11 89 , 12 03 1 8 (1 1t h C ir. 2 00 5) (qu ot at io n m ark s o m it te d) . As su ch , eve n t ho ug h n otall Flo rid a au to ps y rep orts wil l b e u se d i n c riminal tri al s, the rep orts in th is cas e are te st im on ia l an d s ub

ject t o t he Co nf

ro nt at io n C laus e. See Un it edSta te s v . Caraba ll o, 5 95 F.3d12 14 , 12 28 –2 9 (1 1t h C ir. 2 01 0) (fi nd in g a dm is si onwitho ut pr es en ta ti on of o rig in al witne ss of g ov ern m en t fo rm th atha d n on -te st im on ia l

“pr im ary pu rp os e” d idno t v io la te Co nf ro nt at io n C laus e). W e ad d tha t the re ar e ad di ti on al reas on s t o v ie w th es e au to ps y rep orts as te st im on ia l an d t he refo re s ub ject t o t he requi rem en ts of t he Co nf ro nt at io n C laus e. Med ic al ex am in ers are n otm ere s cri ve ne rs rep orti ng m ach in e g en erat edraw-d at a. See B ul lc om in g,1 31 S. Ct. at27 14 (reject in g a rg um en t tha t l ab or at ory tes ti ng an al y stis m ere “ sc riv en er” s im pl y tra ns cri bi ng m ach in e– ge ne rat edres ul ts an d th eref or e n otth e “ tru e acc us er” f orCo nf ro nt at io n C laus e p ur

po se s (c it at io ns om it te d) ). It i s cl ear f

ro m our rev ie w of Dr. M in y ard ’s tes ti m on y co nc ern in g t he au to ps y sh e p erfo rm edon B.E., as wel l as ou r rev ie w of t he au to ps y rep orts at is su e, th atth e o bs erv at io na l d at a an d c on cl us io ns co nt ai ne d i n t he au to ps y rep orts are t he pro du ctof t he sk il l, m etho do lo gy, andjud gm en t o f th e h ig hl y tra in ed

In this case, Dr . Miny ard’ s testimony aff irms that “an a

utopsy , as per formed by

a 1 8 medical e x aminer, is a f

orensic te st.” 33ex am in ers who actua ll y pe rfo rm edth e au to ps y . The au to ps y rep ort fo r T.S. 1 9 il lu st rat es th e p oi nt . T.S.’ s au to ps y was p erfo rm edby ass oc ia te m ed ic al ex am in er Dr. KarenKell y , a m ed ic al do ct or . W e m us t ac cep t Dr. Kel ly’ s au to ps y rep ort as accu rat e, si nc e sh e d idno t t es ti fy an d was no t cr os s- ex am in ed . W it h t ha t i n m in d, we ob se rv e th atDr. Kell y fol lo weda co m

pr eh en si ve au to ps y

pro to co l, wh ic h in cl ud eda de ta il edex te rn al an d i nt ern al ex am in at io n o f th e b od y . Her au to ps y rep ort s ta te s h er o bs erv at io ns an d i m pr es si on s o f T.S.’ s re sp ira to ry , card io va sc ul ar, g as tro in te st in al , gen it ou rin ary, ne rv ou s, m us cu lo sk el et al syste m s, as well m ic ro sc op ic de sc rip ti on s o f T.S.’ s l iv er, co ro na ry art eri es , ven tri cl e, lu ng , ki dn ey , andth yro id . Andm os t re le va ntto Ign as ia k’s ca se , Dr. Kell y ’s aut op sy rep ort s ta te s t ha t T.S.’s cau se of d eat h was “ co m bi ne d t ox ic effe ct s o f etha no l, al pr azo la m , hydro co do ne an d c ari sp ro do l,” a ndth atth e m an ne r of de ath was by acci de nt . Insh ort, the re i s l it tl e, if

any , raw da taor c on cl us io ns refl ect edin T.S.’ s au to ps y rep ort— as id e fro m

th e res ul ts of t ox ic ol og y tes ti ng —tha t i s n otde pe nd en t Dr. Minyard’ s testimony illustrate s that discretion, judg ment, and dire ct observation 1 9 are critica l to the medical examiners investig ation of the c ause of death. F or example, in decidingwhether

to preser ve tissue samples of the brain for later micr oscopic inspec tion for evidenc e of stroke , Dr. Minyard te stified that she re lies upon her judgment and dire ct observations during the a utopsy . Rather than r elying upon dia gnostic tools such as “CT sca n or an MRI ,” Dr . Miny ard state d: “I ’m g oing to use my eyes, and I ’m g oing to use my hands to figure out what ca

used the de ath.” 34up on th e sk il l, m etho do lo gy andjud gm en t ex erci se d b y th e actua l m ed ic al ex am in er wh o p erfo rm edth e au to ps y . As T.S.’s aut op sy repo rt i ll us tra te s, the 2 0 rep orts in th is cas e are rep le te with t he ex te ns iv e p res en ce an d i nt erv en ti onof hu m anha nd s an d e xe rci se of ju dg m en t tha t “pr es en ts a ri skof e rro r th atmig htbe ex pl or edon cro ss -ex am in at io n.” Mel en de z-Di az, 1 29 S. Ct. at25 37 . In thi s way, th es e au to ps y

rep orts are l ik e m an y

ot he r types of f

or en si c ev id en ce u se d i n cri m in al pro se cu ti on s. Th ey m ay be in va li d o r un rel iabl e b ecau se of t he ex am in er’s err or s, o m is si on s, m is ta ke s, o r bi as . To pa rap hr as e th e Supr em e Co urt’s re as on in g i n M el en de z-Di az, “ th ere i s l it tl e rea so n t o b el ie ve th at co nf ro nt at io n wi ll be us el es s i n t es ti ng [m ed ic al ex am in ers ’s] ho ne st y , pro fic ie nc y , an d m etho do lo gy—th e fea tu res th atare co m m on ly the foc us in th e cro ss ex am in at io n o f ex pe rts .” Id . at 2 53 8. Ourco nc lu si on th atth e au to ps y rep orts in th is cas e are tes ti m on ia l co m pe ls th e reject io n o f Dr. Mi nyard’s l iv e in -co urt t es ti m on y as aco ns ti tu ti on al ly We express no opinion about whether the toxicology results themselves pre sent 2 0 Confrontation Clause problems be cause that issue was not ra ised by I gnasiak a

nd, in any event, Dr. Goldbe rg er a ctually

testified at trial a s to the results of his laboratory ’s tox icology testing. Howeve r, that the toxi cology results wer e subjec t to cross-examination does not vitiate the confr ontation problem cre ated by the admission of the autopsy repor ts. As Dr. Goldberg er explained duringhis testimony , tox icology results alone a

re not de finitive of the ca use of de ath: “You wouldn’ t want to use the report alone to c ertify the ca use and ma

nner of death. It’s require d, but the medical e x aminer ha s to take under consideration the remainde r of the f indings, obviously , including f

rom the autopsy

and the investig ators involved. The repor t alone is not sufficie nt.” 35ad equa te su rro ga te forth e actua l m ed ic al ex am in er wh o p erfo rm edth e au to ps y .

Altho ug h Dr. M in y ardwas qua li fie d a s an ex pe rt, t he re i s n o e vi de nc e th atsh e ob se rv edth e au to ps ie s i n que st io n. Th eref or e, Dr. Mi nyard i s i n p reci se ly the sa m e p os it io n a s t he su rro ga te who se tes ti m on y was re jecte d i n B ul lc om in g. Adm is si on of t he au to ps y rep orts on so le ly thi s t es ti m on y —ab se ntev id en ce tha t th e actua l m ed ic al ex am in ers who pe rfo rm edth e au to ps y were u na va il ab le an d t he accu se d h ada pr io r op po rtu ni ty to cr os s ex am in e th em —thu s v io la te d Ig na si ak ’s Si xt h Am en dm en t ri gh ts un de r th e Co nf ro nt at io n C laus e. 2 1 Fu rth er, i n a dd it io n t o t he factth atth e au to ps y rep orts were ad m it te d i nt o ev id en ce, Ig na si aksu ffer edpre jud ic e b ecau se of t he si gn ifi can t ro le th atth e n on te st ifyin g e xp ert s p lay edin co nduc ti ng th e au to ps ie s an d g en erat in g t he da ta

We are awa

re that the Supreme Court re cently grante d cer

tiorari in People v. Willi ams, 2 1 939 N.E. 2d 268 (I ll. 2010), cer t. granted sub. nom. Will iams v. I llinois , --- U.S.---, 131 S. Ct. 3090 (June 28, 2011) (No. 10-8505) , to decide the followingquestion prese nted: “[w]hether a state rule of

evidenc e allowingan expert witness to testify about the re sults of DNA testing perf ormed by non-testifying a

naly sts, where the def

endant ha s no opportunity to confront the actua l analy sts, violates the Confrontation Clause.” See http://www.supre mecour

t.gov/Sea rch.a spx ? FileNa

me=/docke tfiles/10-8505.htm. But I gnasiak’s case is materially

differ ent than Willi ams. Wil liams involves admission of independent expert witness opinion about DNA testingperf ormed by a non-te stifying w itness, but neither the nontestifying a

naly sts report wa s admitted into evidence nor did the testifying e x pert re ad the contents of that r eport into evidenc e. See People v. Wil liams, 939 N.E. 2d 268, 345 (I ll. 2010). Her e, in contra st, the autopsy repor ts themselves wer e admitted into evidenc e and D r. Minyard essentially

rea d the contents of the se re ports into evidence . Moreove r, the manne r in which Dr . Miny ard te stified about the medica l examiners’s conclusions leave s us unable to view he r brief expression of agree ment with the non-testifying me dical examiners’ c onclusions as truly independe nt expert opinion. 36co nt ai ne d i n t he au to ps y rep orts up on whi ch Dr. Min y ardba se d h er o pi ni on . That Dr. Mi nyard m ay

ha ve bri efl y

ex pr es se d h er o wn i nd ep en de ntag reem en t wi th th e no n- te st ifyin g m ed ic al ex am in er’s co nc lu si on s re gard in g c au se of d eat h o nl y co m po un de d t he Co nf

ro nt at io n C laus e erro r th atoc cu rred . Becau se Dr. Min y ard ha d n ei th er p erfo rm edno r be enpre se ntdu rin g t he au to ps ie s i n que st io n, s he was no t i n apo si ti on to tes ti fy on cro ss -ex am in at io n a s t o t he fact s s urro un di ng ho w th e au to ps ie s wer e actua ll y co nduc te d o r whe th er an y erro rs , om is si on s, o r m is ta ke s wer e m ad e. See Bu ll co m in g, 1 31 S. Ct. at27 15 (“ Bu t s urro ga te 2 2 te st im on y of t he ki nd[th e te st ifyin g wi tn es s] was equi pp edto gi ve co ul d n ot co nv ey what[th e te st in g a na lyst] kn ew orob se rv edab ou t the ev en ts hi s cert ifi cat io n c on cern ed , i.e., th e p art ic ul ar t es t an d t es ti ng pro ces s h e em pl oyed. Norco ul d s uc h s urro ga te tes ti m on y ex po se any

lap se s o r li es on th e certi fy in g an al y st ’s part.” ( fo ot no te s o m it te d) ). Yet, Dr. Mi nyard g av e h er p ro fes si on al im pr im aturto th is effe ct . Tha t Dr. Mi nyard e xa cerb at edth e Co nf ro nt at io n C laus e v io la ti on is als o ev id en t fr om

th e li m it s o f he r te st im on y . For e xa m pl e, wit ho utha vi ng do ne or ob se rv edth e au to ps y , Dr. Min y ardco ul d n ottes ti fy fro m di rectkn owl ed ge ab ou t
Indeed, this point is demonstrated by Dr. Minyard’ s testimony when she aff

irmed that 2 2 she did not know if Dr. B erkla nd had made a mistake in re portinghis observations about A.B .’s lividit y in his autopsy

repor t. 37th e co nd it io n o f a p art ic ul ar p at ie nt ’s hea rt, l un gs or b rai n a nd , as ares ul t, wh ethe r

th atpa ti en t m ay

ha ve actua ll y

di edfro m

a he artatt ack , stro ke , or s om e cau se ot he r th andru g o ve rd os e. To an swe r th atqu es ti on on cro ss -ex am in at io n, Dr. Mi nyard wou ldha ve to refe r to Dr. Kell y ’s andDr. Berk la nd ’s aut op sy repo rts . Butas al read y no te d t he ul ti m at e co nc lu si on s an d s up po rti ng fin di ng s re fle ct edin th e au to ps y rep orts are the pro du ctof t he ex am in er’s s ki ll an d ju dg m en t, n otan in fal li bl e m ach in e th atrequi res no hu m anin te rv en ti on . Agai n, as Mel en de z-Di az in st ru ct s, b ecau se hu m anjud gm en t an d s ki ll were i nv ol ve d, we ca nn otass um e th e no n- te st ifyin g m ed ic al ex am in er’s fi nd in gs were re li ab le ev enif t he ex am in ers th em se lv es po ss es se d t he “ sc ie nt ifi c acu m enof M m e. Cu rie an d t he ve raci ty of Mo th er Tere sa .” Mel en de z-Di az, 1 29 S. Ct. at25 37 n.6 . Dr. Min y ard ’s os te ns ib ly in de pe nd en t o pi ni on , th eref or e, can no t tru ly be reg ard edas i nd ep en de ntin a way th atis m ean in gf

ul un de r Mel en de z-Di az an d B ul lc om in g, wh ic h e m ph as iz e th e ab so lu te rig htto co nf

ro ntth e an al y st , inth is cas e th e m ed ic al ex am in er, wh o actua ll y pe rfo rm edth e te st . Bec au se we de te rm in e th atIgn as iak’s Si xt h Am en dm en t ri gh ts were vi ol at ed , we m

us t co ns id er wh ethe r th e erro r was ha rm le ss . Uni te d S ta te s v . Gari, 57 2 F .3d13 52 , 13 62 (11 th Cir . 20 09 ). “ The tes t fo r de te rm in in g wh ethe r a co ns ti tu ti on al erro r is ha rm le ss is whet he r itap pe ars be y on d areas on ab le do ub t 38th atth e err or co m pl ai ne d o f di d n otco nt rib ut e to th e v erd ic t o bt ai ne d.” Id. (quo ta ti onm ark s o m it te d) . Alth ou gh th e rep orts refe rredto pa ti en ts no t refe ren cedin th e in di ctm en t, we ca nn otig no re the po werfu l i m pa ctth is co ll at eral ev id en ce m

us t h av e h adon Ign as ia k’s jury . Here, th e jury hear d l iv e in -co urt te st im on y fro m two di ffer en t m ed ic al ex am in ers , in cl ud in g Dr. M in y ard , th attwo pa ti en ts refe ren cedin th e in di ctm en t— M.B. an d B .E.—di edas ares ul t o f in to xi cat io n fr om

co ntro ll edsubs ta nc es gi ve n t o t he m by Ign as ia k. Bu t the jury was als o p erm it te d t o c on si de r te st im on ia l ev id en ce fr om two no n- te st ifyin g m ed ic al ex am in ers , Dr. Berk la ndan d Dr. Kel ly, by the adm is si on of t he ir aut op sy rep orts , th atfiv e o th er p at ie nt s o f Dr. Ig na si akdi edfro m pre sc rip ti ondru g ov erd os es . Bas edup onou r rev ie w of t he en ti re re co rdin th is cas e, we can no t s ay be y on d areas on ab le do ub t tha t ad m is si on of t he fiv e au to ps y rep orts di d n ot co nt rib ut e to all of the ve rd ic ts ob ta in ed . To be su re, eac h o f th e co un ts ch arg edin th e in di ctm en t re pr es en te d i nd iv idua l ev en ts of e it he r frau d o r di sp en si ng co nt ro ll edsubs ta nc es . Butall of t he frau d c ou nt s s ha reda co m m on de no m in at or with t he co nt ro ll edsubs tanc es co un ts : the go ve rn m en t’s o ve rarc hi ng th eo ry of pr os ecu ti on th atIgn as ia k h adpre sc rib edun ne ces sa ry or e xc es si ve qu an ti ti es of co nt ro ll edsubs ta nc es witho uta le gi ti m at e m ed ic al purp os e an d “ ou ts id e th e u su al 39co ur se of p ro fes si on al pra ct ic e.” Inth is way , bo th th e subs ta nt iv e fraudan d 2 3 di sp en si ng co nt ro ll edsubs ta nc es co nv ic ti on s wer e in ex tri cab ly int ertwin edan d di rect ly relat edto Dr. Ign as ia k’s g oo d fa it h d efen se . It b ears rep eat in g t ha t, o ve r Ig na si ak ’s ob jecti on s, the go ve rn m en t in tro du cedev id en ce o f othe r pa ti en ts ’ de aths by suc ces sf ul ly argu in g t ha t thi s ev id en ce was rel ev an t t o a ll of t he ch arg es an d a dm is si bl e u nd er Ru le 40 4( b) to co un te r Ig na si ak ’s def

en se th at“ he was s im

pl y a sm al l t owndo ct orwho was do in g t he be sthe co ul d t o h el p h is pa ti en ts an d a ct edin go odfai th in hi s pr es cri pt io n p ract ic es .” “ Im pl ic itin th atrep res en ta ti on ,” th e g ov ern m en t ar gu ed , was Ign as ia k’s “ su gg et io n t ha t [h e] hadno kn owl ed ge no r rea so n t o s us pe ctth at
Duringclosingarg

ument, the g overnme nt review ed the f raud c ounts of the indictment 2 3 with the jury

and then e x pressly

tied them to the leg itimacy of I gnasiak’s pr escription practice s for c ontrolled substance s as follows:

More spe cifica lly , as to Counts 1 through 14, the sc heme to def raud. A scheme to defra

ud basica lly

states, and the indictment state s, that he eng ag ed in a scheme to defra

ud a hea lth care benef

it program a

nd to obtain, by

materia lly

false and fr audulent pre tenses, represe ntations and promises, hea lth care benef it program money

-- in other

words, the Me dicaid information that you hear d during the trial, the B lue Cross information that you hear d duringthe trial, the other insurance money

that you hear d duringthe trial, is all money that he g ained beca use of this scheme to defra ud. And that’s fanc y leg al terms, basica lly , for that this doctor did what he did for something other than leg i t i m ate purpose, and to defr aud the health car e benef it progra m s o u t of money , out of the money for the presc riptions that wer e not leg itimately presc ribed and out of the office visits that wer e not medically nece ssary office visits. 40he was i m

pr op erl y pre sc rib in g c on tro ll edsubs ta nc es or t ha t s uc h p ract ic es were cau si ng de ath t o h is pa ti en ts .” Acco rd in g t o t he go ve rn m en t, p ro of of t he ot he r de aths was re le va ntan d i m po rta ntfor

two reas on s: (1) “ [e]vi de nc e th atdu rin g t he sa m e ti m e p eri od s [I gn as ia k] kn ew th athi s p at ie nt s wer e o ve rd os in g o n the
m ed ic at io ns to th e p oi ntth atth ey were dy in g i s re le va ntan d p ro ba ti ve of t he fact th at[Ig na si ak ] was no t ac ti ng ingo odfai th ”; (2) “ [p ]roo f th at[Ig na si ak ] co nt in ue d to pre sc rib e m as si ve do se s o f co nt ro ll edsubs ta nc es ev enaft er h e le arn edth athi s pa ti en ts were dy in g o f ov erd os es go es a lo ng way to est ab li sh in g tha t the de fen da ntwas kno win gl y an d wi ll fu ll y

di sp en si ng co nt ro ll edsubs tanc es forot he r th ana le gi ti m at e m ed ic al pu rp os e, in th e o rd in ary co ur se of h is m ed ic al pr act ic e.” The g ov ern m en t re tu rn edto th is th em e dur in g i ts clo si ng arg um en t,

2 4
That the unc harg ed patients’ de aths wer e conside red material to the jury ’s 2 4 deliberations is also demonstrated by the g overnme nt’s mid-trial reque st to ex cuse one of the seate d jurors in light of that juror’s attitude towar d suicide. Initially , we would note that the issue of suicide c ame up, a

ppare ntly , in response to testimony about whethe r one of

the uncha

rg ed patient’s death was ca

used by suicide and w as there forenot acc idental, e.g ., Dr. B erkla nd’s autopsy repor t for B .D. cha

rac terized her de ath as a

suicide, but Dr. Minyard r efuse d on crossexamination to agr ee or

disagree with this conclusion. Shortly afte r the suicide issue c ame up ag ain duringthe testimony of Dr. G oldberg er, the District Court announce d duringa bre ak that it had lea rned through a cour

t security office r that one of

the jurors ha d a conc ern a bout continuing to serve on the jury . Whil e questioned individually by the Court in the prese nce of the par ties, the juror disclosed that she wa s bothered to he ar a bout suicides or attempts to commit suicide beca use her son had attempted suicide on a number of occ asions. The juror

further explained that when an individual commits suicide it is that person’s choic e and that she could not blame a nother for his or her suicide. Ther eaf

ter, the g overnme nt reque sted that the juror be excused “ba sed on her inability to fairly and impartially

view the e vidence with reg ard to the pote ntial suicides,” although the g overnme nt acknowle dg ed “[t]here is not a suicide involved in the a ctual cha rg es.” 41arg ui ng th atth e d eat hs of u nc ha rg edpa ti en ts “pu t [I gn as iak] on no ti ce tha t h is

pr es cri bi ng habi ts co ul d b e k il li ng pe op le ,” an d “ th atat t he ve ry lea stsh ou ldha ve se rv edas n ot ic e to Dr. Ign as ia k t ha t p erh ap s t he re was so m ethi ng wron g wi th th e way th athe was p res cri bi ng [co nt ro ll edsubs ta nc es ]. ” Inli gh t o f th e g ov ern m en t’s st at edpu rp os es foradm it ti ng th e u nc ha rg edpa ti en ts ’ de aths at t ria l, we ca nn ot co nc lu de be y on d areas on ab le do ub t tha t the ev id en ce d idno t ac hi ev e it s i nt en de d pu rp os e an d c on tri bu te to th e v erd ic ts ob ta in ed . Inth is cas e, th e g ov ern m en t’s ev id en ce was no t o ve rwh el m in g. Whil e th e go ve rn m en t’s ev id en ce was leg al ly suf fic ie ntto supp ort the co nv ic ti on on ap pe al , a rea so nabl e jury cou ldha ve acqui tt edba se d o n a ll of t he ev id en ce. Our co nc lu si on th atth e ev id en ce s up po rts th e co nv ic ti on s i n t hi s ca se fol lo ws fr om th e requi rem en t tha t we re vi ew th e ev id en ce i n t he li gh t m os t favo rab le to th e pr ev ai li ng pa rty. See Merr il l, 5 13 F.3dat 1 29 9. Hav in g a rri ve d a t thi s co nc lu si on In response to the District Court’s question, “[w] hat does that leg ally have to do with your case ? ”, the g overnme nt expl ained, inter alia: Well, . . . if the defe nse is g oing to argue that these [uncharg ed p at i en t d ea t h s], instead of having acc idently overdose d on drugs , ac tu ally committed suicide, then this juror has indicated that this is an em o tional response that she is incapa ble of putting any kind of responsibility on any body but the patient, which is contra ry to the evidenc e, and shows an inability to be able to fairly and imparti all y deter mine whether or not these individuals ac tually did commit sui cide. I gnasiak opposed disc harg ing the juror, arguing, inter alia, that “a ll this deals with the 404(b) evidenc e, which is only

g oing to be used by

the jurors to dete rmine lac k of mistake or know ledg e or intent.” The juror wa s ultim ately remove d from fur

ther ser vice f rom the jury . 42reg ard in g t he su ffi ci en cy of t he ev id en ce b y

th is rou te , ho wev er, we m us t b e le ss to le ran t o f th e id ea tha t erro rs co m m it te d dur in g t he tri al of t hi s ca se are acce pt ab le be cau se th ey

are h arm le ss . See Stric kl an d v . W as hi ng to n, 4 66 U.S. 66 8, 6 96 , 10 4 S . Ct. 2 05 2, 2 06 9 (1 98 4) (“ a v erd ic t o r co nc lu si on on ly w eak ly supp orte d b y

th e rec or d i s m or e li ke ly to h av e b een affe ct edby error s t ha n o ne with o ve rwh el m in g re co rdsupp ort” ). W e can no t co nc lu de th atth e g ov ern m en t, as be ne fic ia ry

of t he co ns ti tu ti on al erro r, pr ov edbe y on d areas on ab le do ub t tha t adm it ti ng ev id en ce o f fi ve m or e p at ie nt s wh o a ll eg ed ly die d a s a r es ul t o f Ig na si ak ’s con du ct“ di d n otco nt rib ut e to th e v erd ic t o bt ai ne d.” Chapm anv. Cal ifo rn ia , 38 6 U.S. 1 8, 2 4, 8 7 S . Ct. 8 24 , 82 8 (1 96 7) .

IV. NEW TRIAL AND RECORD SEALI NG APPEALS In l ig htof o urrul in g, Ig na si ak ’s sep arat e ap pe al in cas e num be r 10 -1 10 74 fro m th e d en ia l o f hi s m ot io n fo r ne w tri al is m oo t. Thi s i s n otth e cas e, ho wev er, fo r Ig na si ak ’s app eal in cas e num be r 09 -1 60 05 . In tha t s ep arat e p ro ceed in g, Ig na si akap pe al s t he Dis tri ctCo urt’s d en ia l o f hi s m ot io n t o u ns eal th e go ve rn m en t’s p os t-t ria l i n c am era n ot ic e to th e Dis tri ctCo urt, wh ic h c on ta in ed im pe ach m en t i nf

orm at io n abo utth e g ov ern m en t’s k ey witne ss , Dr. Arth urJo rd an . Inli gh t o f ou r se rio us co nc ern s ab ou t the go ve rn m en t’s re as on s fo r ke ep in g t ha t no ti ce s eal ed , we rev ers e th e Dis tri ctCo urt’s d en ia l o f Ig na si ak ’s m ot io n. 43To b rie fly pro vi de ba ck gr ou nd , sev eral m on th s af te r Ig na si ak ’s con vi ct io n, th e g ov ern m en t fi le d apl ead in g u nd er s eal inth e Dis tri ctCo urt en ti tl ed

“ Gov ern m en t’s In Cam era No ti ce t o t he Co urt” (th e “Not ic e”), al on g wi th an affi da vi t fr om

on e o f th e tr ia l p ro se cu to rs , Ass is ta ntUni te d S ta te s At to rn ey (“ AUSA”) Ben

jamin Bear d. Th e Not ic e rev eal edfor th e fi rs t t im e th atDr. Jo rd an en ga ge d i n c riminal co nduc t b eg in ni ng at a n uns pe ci fie d t im e up t o a ndco nt in ui ng un ti l 2 00 6. Sp eci fic al ly, Dr. Jo rd anha d, o n n in e se parat e o ccas io ns , us eda co un te rfei t b ad ge an d h is Uni te d S ta te s M ars ha l cr ed en ti al s t o p os e as anon -dut y U.S. Mars ha l i n o rd er t o c arry firea rm s o n c omm erci al air pl an es whi le on pe rs on al tra ve l. Onth e n in th fli gh t, a Tran sp orta ti onan d S ecu rit y Adm in is tra ti on (“ TSA”) ag en t d is co ve redDr. Jo rd an ’s pl oy, andsei zedth e weap on s, co un te rfei t b ad ge , an d M ars ha l Se rv ic e cre de nt ia ls . The So ut h Dak ot a U.S. Att orne y ’s Offic e op en edanin ve st ig at io n o f Dr. Jo rd an . Altho ug h Dr. J or da n h aden ga ge d i n si m il ar cr im in al co nduc t atlea steig htti m es be fo re, the reb y co m m it ti ng m ul ti pl e vi ol at io ns of 1 8 U.S.C. § § 9 12 an d 1 00 1 a nd49 U.S.C. § 4 65 05 , th e So ut h Dak ot a U.S. Att orne y

all owe d Dr. J or dan t o e nt er i nt o a“pr e-tria l d iv ers io n a gr eem en t” in whi chDr. Jo rd anpa id$2 ,00 0 a ndag reedno t t o c arry any co nc eal edweap on s ex cep t wh il e o n o ffi ci al bu si ne ss .

44The Not ic e al so setou t the go ve rn m en t’s p os it io n tha t the fai lu re t o d is cl os e

th e in fo rm at io n d idno t v io la te Ign as ia k’s co ns ti tu ti on al rig ht s u nd er Br ady v. Mary la nd , 37 3 U.S. 8 3, 8 3 S . Ct. 1 19 4 (1 96 3) an d Gi gl io v. Un it edSta te s, 4 05 U.S. 15 0, 9 2 S . Ct. 7 63 (19 72 ). Spe ci fic al ly, th e Not ic e av erre d t ha t Ig na si ak co ul d n otm ak e a s uc ces sf ul Brad y cla im be cau se th e p ro se cu to r di d n otpe rs on al ly kn ow ab ou t Dr. J or da n’s co nduc t, o r th e p le a ag reem en t, dur in g Ig na si ak ’s pr os ecu ti on . Sh ortl y aft er the go ve rn m en t fi le d t he Not ic e, Ig na si akfil eda m ot io n t o un se al itto ge th er wi thth e aff id av it . He arg ue d tha t al lo win g t he go ve rn m en t t o

“un il at eral ly” fil e it s n ot ic e u nd er s eal vi ol at es hi s Fi fth Am en dm en t, co m m on la w, andFir stAm en dm en t ri gh ts of a cces s t o c ou rt p ro ceed in gs an d d oc um en ts . The go ve rn m en t fi le d ares po ns e u rg in g a ga in stdi sc lo su re. Init , th e g ov ern m en t ackno wled ge d t ha t o rd in ari ly the re i s a p res um pt io n o f op en ne ss in leg al pr oc eed in gs , bu t as se rte d t ha t i n t hi s ca se th e Dis tri ctCo urt s ho ul d k eep th e Not ic e se al ed , so as t o p ro te ctDr. Jo rd an ’s pri va cy an d p ro te cthi m

fro m an y po te nt ia l re ta li at io n. Th es e co nc ern s, the go ve rn m en t s ub m it te d, warran te d se al in g t he in fo rm at io n abo utDr. Jo rd an ’s pre vi ou s co nduc t. In de ed , “ [o ]n ba la nc e, if

th e u nd ers ig ne d e rredin fil in g u nd er s eal , no pre jud ic e h as be encau se d an y on e, in cl ud in g t he witne ss ; wh erea s, i f itha d b eenm ad e a p ub li c rec or d 45im

pr op erl y , th enth e witne ss wou ldha ve be enha rm ed , forno go odpu rp os e.” The Dis tri ctCo urt s umm ari ly den ie d t he m ot io n t o u ns eal , “ [f]or re as on s p res en te d i n th e Gov ern m en t’s re sp on se .” W e rejectth is arg um en t m ad e b y th e g ov ern m en t, an d t he refo re we re ve rs e th e Dis tri ctCo urt ru li ng on th is is su e. In s ho rt, o urag reem en t wi th th e 2 5 go ve rn m en t s ta rts an d e nd s wi thth ei r ob se rv at io n t ha t the re ex is ts a pr es um pt io n of op enne ss inall leg al pro ceed in gs . Uni te d S ta te s v . Ocho a-Vas qu ez, 4 28 F.3d 10 15 , 10 29 –3 0 (1 1t h C ir. 2 00 5) . Butth e g ov ern m en t’s ar gu m en t m in im iz es what is at s ta ke when th atpre su m pt io n o f op enne ss is ov erco m e. Fi rs t, the va lu e o f op enne ss in cri m in al pro ceed in gs ex te nd s fa r be y on d ju st th e in te res ts of a ny part ic ul ar d efen da nt . Rath er, we h av e ex pl ai ne d t ha t: In ba la nc in g th e publ ic in te res t in acce ss in g cou rt do cu m en ts ag ai ns t a pa rty’ s in te res t in ke ep in g th e in fo rm at io n co nf id en ti al , co urts co ns id er, am on g ot he r fact or s, whe th er al lo win g acce ss wo u l d im pa ir co urt fu nc ti on s or harm le gi ti m at e p r i v a c y in te res ts , th e de gr ee of an d li ke li ho od of in

jury if m ad e publ ic , th e rel iabi li ty of th e in fo rm at io n, whe th er th ere wi l l b e a n op po rtu ni ty to res po nd to th e in fo rm at io n, whe th er th e in fo rm at io n co nc ern s publ ic of fic ia ls or publ ic co nc e rn s , an d th e av ai labi li ty of a le ss on ero us al te rn at iv e to se al in g th e do cu m en ts .

This Court “revie w[s] for a buse of discr etion the re fusal of a district court to unseal 2 5 court doc uments.” Romero v. Dr ummond Co., Inc., 480 F .3d 1234, 1242 (11th Cir. 2007).

46Ro m ero , 48 0 F .3dat 1 24 6. Th us , whi le itis tru e th atDr. Jo rd an ’s pri va cy

in te res ts si t o n o ne si de of t he ba la nc e, itis “ th e in te res t o f th e p ub li c in acce ss in g th e in fo rm at io n” th atres ts on th e o th er. Id . And , inth is cas e, th e p ub li c h as a gr eatin te res t i n l earn in g t he co nt en ts of the Not ic e—n am el y , lea rn in g t he hi gh ly
m at eri al factth atDr. Jo rd an , a rep eatgo ve rn m en t ex pe rt wi tn es s, ab us edhi s go ve rn m en t au th or it y

an d c omm it te d a ct s wh ic h c ou ldha ve be ench arg edas fel on ie s. To say tha t the de fen se wou ldha ve pre ferr edto us e th is in fo rm at io n t o di sc red itDr. Jo rd an ’s tes ti m on y is alm os t ce rta in ly an und ers ta te m en t. Perh ap s i ro ni cal ly, by argu in g tha t the re was no Brady vi ol at io n i n thi s ca se be cau se th e AUSA pr os ecu ti ng Ign as iak was un aware of Dr. J or dan’s h is to ry , itis actua ll y th e g ov ern m en t tha t m os t p ers ua si ve ly hig hl ig ht s t he va lu e inun se al in g th e Not ic e. In de ed , sh ou ldth e Not ic e rem ai n s eal ed , th e si gn ifi can t l ik el ih oo d i s th atin th e n ex t CS A pro se cu ti on in whi ch Dr. Jo rd antes ti fie s as anex pe rt, b ot h th e p ro se cu ti ng AUSA andth e d efen se co un se l wi ll ag ai n b e u na ware o f th e hi gh ly relev an t i m

pe ach m en t ev id en ce co nt ai ne d i n t he Not ic e. Andin th atcas e, as in th is on e, sh ou ldth e trut h e ve r co m e to li gh t, the go ve rn m en t co ul d a ga in po in t t o i ts own ig no ran ce an d c la im imm un it y fro m Brad y erro r. Sta te d t hi s way, we wou ldha ve ex pe ct edth e g ov ern m en t t o c on de m n, ra th er tha n c on do ne , su ch a pr ob le m at ic ou tc om e. 47Bu t i ns te adth e g ov ern m en t as se rts th atDr. Jo rd an ’s pri va cy in te res t ou twei gh s t he publ ic ’s rig htto kn ow t he ex te ntof Dr. J or da n’s i nv ol ve m en t wi th th e g ov ern m en t. To b e su re, i n s om e cas es a party m ay ov erco m e th e p res um

pt io n of op enne ss if i t ca n s ho w “ anov erri di ng in te res t b as edon fin di ng s t ha t cl os ur e is es se nt ia l t o p res erv e h ig he r va lu es an d i s n arro wly ta il or edto serve th atin te res t.” Pres s- Ent erp ris e Co . v. Supe rio r Co urt o f Cal ifo rn ia , 46 4 U.S. 5 01 , 51 0, 1 04 S. Ct. 81 9, 8 24 (19 84 ). Ind eed , th e g ov ern m en t co rrec tl y po in ts to two cat eg or ie s o f witne ss es who se pri va cy

in te res ts are u nd ers ta nd ab ly param ou nt : v ic ti m s i n s ex cri m e cas es an d c riminal in fo rm an ts . Dr. Jo rd anis ne it he r. Rathe r, he is anex pe rt witne ss who , at a r at e o f $3 00 /h ou r, vo lunt ari ly accep te d e m pl oym en t wh ic h requi redhi m

to tes ti fy ag ai ns t Ig na si ak . Ind eed , Dr. Jo rd antes ti fie d t ha t h e h as be enpa id“ aro un d” $3 0,0 00 forhi s s erv ic e as th e g ov ern m en t’s ex pe rt i n thi s an d ot he r cas es . Whi le th e fac t o f hi s p ai d s ta tu s d oe s n otm ak e h im am en ab le to an y so rt o f un fai r orimm at eri al ch arac te r at ta ck , itdo es gre at ly redu ce, i f no t al to ge th er ev is cera te , hi s ex pe ct at io n t o k eep im pe ach m en t ev id en ce p riv at e. The go ve rn m en t i s t hu s ri gh t tha t co urts sh ou ldpro te ctwitne ss es li ke Dr. Jo rd anfro m

“un warra nt edin va si on ” in to th ei r pr iv acy. Bu t we cann otag ree t ha t i m pe ach m en t ev id en ce co nc ern in g ahi gh ly com pe ns at edan d v ol un taril y

ap pe ari ng ex pe rt witne ss is eit he r “ un warra nt ed ” o r an“ in va si on ” in to th atwitne ss ’s pri va cy . 48V. CONCLUSIO N

Fo r al l the reas on s ab ov e, we rev ers e Ig na si ak ’s con vi ct io ns an d re m an d t hi s cas e to th e Dis tri ctCo urt fo r fu rth er p ro ceed in gs . W e fu rth er v acat e th e Dis tri ct Co urt’s o rd er s eal in g t he go ve rn m en t’s n ot ic e fi le d und er s eal reg ard in g Dr. Jo rd an . REVERSED, VACATED, a nd REMANDED.

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