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State of New York

Court of Appeals

OPINION

This opinion is uncorrected and subject to revision 

before publication in the New York Reports.

No. 86 

The People &c.,

 Respondent,

 v.

Stan XuHui Li, 

 Appellant.

Raymond W. Belair, for appellant.

Vincent Rivellese, for respondent.

FAHEY, J.:

Here, the Appellate Division rejected defendant’s challenges to his conviction of 

two counts of manslaughter in the second degree. We affirm the Appellate Division order, 

insofar as appealed from. 
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I.

Defendant, then a physician board-certified in anesthesiology and pain 

management, was accused of running a “pill mill” at his Queens pain management clinic. 

During a lengthy jury trial, the People presented evidence that defendant prescribed 

medically unnecessary high doses of opioids, alprazolam, and other controlled substances 

as a first resort. Defendant generally did not verify the source of the pain complained of 

by the patient for which the patient sought the controlled substances, order diagnostic tests

for objective confirmation of the existence of the pain, or consider other pain management 

treatment options. He conducted little to no physical examination. Defendant often 

prescribed heavy doses of whatever medication his patients requested to alleviate their 

complaints of pain. He required payment in cash and charged extra for, among other things, 

higher doses of opioids. Several of defendant’s former patients testified at trial that they 

were opioid addicts. They testified that they used the drugs defendant prescribed them to 

get high, rather than for legitimate pain management. Indeed, defendant was advised by 

other medical practitioners and patients’ family members that several of his patients were 

addicted to opioids and at risk of dying from opioid abuse. 

Two of defendant’s patients, Joseph Haeg and Nicholas Rappold, died of overdoses 

caused by a combination of oxycodone and alprazolam on December 29, 2009 and 

September 14, 2010, respectively, shortly after filling prescriptions for such drugs issued 

by defendant. Pills from those prescriptions were found in their possession when their 

bodies were discovered. Defendant was charged with two counts of manslaughter in the 

second degree (see Penal Law § 125.15 [1]) for the deaths of Haeg and Rappold, along 
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with multiple other crimes related to Haeg, Rappold, and a number of other patients. 

Defendant was ultimately convicted of 2 counts of manslaughter in the second 

degree, 3 counts of reckless endangerment in the first degree, 3 counts of reckless 

endangerment in the second degree, 170 counts of criminal sale of a prescription, 1 count 

of scheme to defraud in the first degree, 2 counts of grand larceny in the third degree, 9 

counts of falsifying business records in the first degree, and 8 counts of offering a false 

instrument for filing in the first degree. The Appellate Division unanimously affirmed (155 

AD3d 571 [1st Dept 2017]), and a Judge of this Court granted defendant leave to appeal 

(31 NY3d 1119 [2018]). 

On this appeal, defendant challenges only his conviction of two counts of 

manslaughter in the second degree. He raises two contentions. First, defendant argues 

that, as a matter of law, he cannot be convicted of any homicide offense for providing 

controlled substances that result in an overdose death. Second, defendant asserts that his 

conviction on the manslaughter counts is not supported by legally sufficient evidence. 

II.

Defendant is incorrect that, as a matter of law, his conduct may not be prosecuted 

as a homicide offense. He relies heavily on People v Pinckney (38 AD2d 217 [2d Dept 

1972]), where the Appellate Division upheld the dismissal of counts of an indictment 

charging manslaughter in the second degree and criminally negligent homicide after the 

defendant sold heroin to the victim, who later died after injecting it (see id. at 218). The 

Appellate Division reasoned that the legislature had already provided penalties in the Penal 

Law for the sale of dangerous drugs but had not amended the homicide provisions of the 
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Penal Law “to include homicide by the selling of dangerous drugs” (id. at 220-221). 

This Court affirmed the Appellate Division order in Pinckney without opinion (32 

NY2d 749 [1973]). The precedential value of such a ruling is minimal. An affirmance 

without opinion constitutes approval of only the result reached and “does not imply 

approval of everything contained in the opinion of the court below” (People ex rel. Palmer 

v Travis, 223 NY 150, 156 [1918]; see also Matter of Clark, 275 NY 1, 4 [1937]; Rogers 

v Decker, 131 NY 490, 493 [1892]). We disagree with our dissenting colleague that our 

affirmance in Pinckney, which involved an indictment alleging a one-time sale of heroin 

and the instruments for injecting it, forecloses the prosecution of defendant for a homicide

offense under the very different factual circumstances presented here (see dissenting op at 

7-9). 

Subsequent decisions from this Court refute defendant’s assertion that a person who 

provides dangerous drugs that result in death can never, under any circumstances, be 

prosecuted for homicide (see People v Galle, 77 NY2d 953, 955-956 [1991]; People v 

Cruciani, 36 NY2d 304, 305-306 [1975]). Although in those cases, the defendants injected 

the victims with drugs, we did not state that this was a necessary element, as a matter of 

law, for homicide charges to be sustained. Rather, the defendants’ injection of the drugs 

in those cases was one piece of evidence that supported the homicide charges and that 

distinguished those cases from Pinckney (see Cruciani, 36 NY2d at 305-306). 

Insofar as the Appellate Division reasoned in Pinckney that the defendant could not 

be charged with a homicide offense because the legislature had criminalized the sale of 

illegal drugs but had not amended Penal Law article 125 to include a specific reference to 
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death caused by the sale of drugs (see Pinckney, 38 AD2d at 220-221), that rationale was 

flawed. “As a general rule, a statutory prohibition against a particular type of conduct will 

not be deemed to constitute the exclusive vehicle for prosecuting that conduct unless the 

Legislature clearly intended such a result” (People v Duffy, 79 NY2d 611, 614 [1992]). 

There is no basis to conclude that the legislature intended to exclude from the ambit 

of the homicide statutes the prosecution of a defendant who, with the requisite mens rea, 

engages in conduct through the sale or provision of dangerous drugs that directly causes 

the death of a person. The fact that the legislature has separately criminalized the illegal 

sale of controlled substances does not require a different conclusion (see id. at 614-615).1 

We agree with the Appellate Division that “all that was needed for the manslaughter charge 

to be sustained was for the People to satisfy its elements” (155 AD3d at 574). 

III.

We further conclude that defendant’s conviction of two counts of second-degree 

manslaughter is supported by legally sufficient evidence. “A verdict is legally sufficient 

when, viewing the facts in a light most favorable to the People, ‘there is a valid line of 

reasoning and permissible inferences from which a rational jury could have found the 

elements of the crime proved beyond a reasonable doubt’ ” (People v Danielson, 9 NY3d 

342, 349 [2007], quoting People v Acosta, 80 NY2d 655, 672 [1993]). “A sufficiency 

inquiry requires a court to marshal competent facts most favorable to the People and 

 

1 We disagree with defendant that any inferences can be drawn from failed attempts in the 

legislature to amend the homicide statutes (see People v Ocasio, 28 NY3d 178, 183 n 2 

[2016]). 
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determine whether, as a matter of law, a jury could logically conclude that the People 

sustained its burden of proof” (Danielson, 9 NY3d at 349). “This deferential standard is 

employed because the courts’ role on legal sufficiency review is simply to determine 

whether enough evidence has been presented so that the resulting verdict was lawful” 

(Acosta, 80 NY2d at 672). 

Importantly, “[i]n determining the legal sufficiency of the evidence for a criminal 

conviction we indulge all reasonable inferences in the People’s favor, mindful that a ‘jury 

faced with conflicting evidence may accept some and reject other items of evidence’ ” 

(People v Carrel, 99 NY2d 546, 547 [2002], quoting People v Ford, 66 NY2d 428, 437 

[1985]). It is the “province of the jury” to assess witness credibility (People v Calabria, 3 

NY3d 80, 82 [2004]), and we therefore assume on a legal sufficiency review that the jury 

credited the People’s witnesses (see People v Gordon, 23 NY3d 643, 649 [2014]). 

A. Recklessness

To convict defendant of second-degree manslaughter, the People were required to 

prove beyond a reasonable doubt that defendant “recklessly cause[d] the death” of Haeg 

and Rappold (Penal Law § 125.15 [1]). 

“A person acts recklessly with respect to a result or to a 

circumstance described by a statute defining an offense when 

[that person] is aware of and consciously disregards a 

substantial and unjustifiable risk that such result will occur or 

that such circumstance exists. The risk must be of such nature 

and degree that disregard thereof constitutes a gross deviation 

from the standard of conduct that a reasonable person would 

observe in the situation” (Penal Law § 15.05 [3]). 

A conviction for reckless manslaughter “require[s] that there be a ‘substantial and 
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unjustifiable risk’ that death . . . will occur; that the defendant engage in some blameworthy 

conduct contributing to that risk; and that the defendant’s conduct amount to a ‘gross 

deviation’ from how a reasonable person would act” (People v Asaro, 21 NY3d 677, 684 

[2013], quoting Penal Law § 15.05 [3]). The conduct must be “the kind of seriously 

blameworthy carelessness whose seriousness would be apparent to anyone who shares the 

community’s general sense of right and wrong” (Asaro, 21 NY3d at 685 [internal quotation 

marks and citation omitted]). 

The People’s considerable evidence with respect to defendant’s prescribing 

practices on a broader scale, which included testimony from several patients and their 

family members, was relevant as context to assess his mens rea on the manslaughter 

charges with respect to Haeg and Rappold. The People presented evidence that patients 

were not required to make appointments at defendant’s clinic and were required to pay in 

cash. The clinic was open only on weekends, yet defendant wrote over 21,000 

prescriptions for controlled substances between 2008 and 2011, most of those for a 

substance containing oxycodone or alprazolam (Xanax). From January 2008 to January 

2011, defendant increased his prescribing of controlled substances by 683%. On a single 

day in January 2011, for example, defendant saw 94 patients at his clinic. 

Defendant generally charged $100 per office visit, and he increased the charge to 

$150 if a patient returned early for more pills, had a friend or family member pick up the 

prescription, was obtaining prescriptions from other doctors, or wanted a higher daily dose 

of opioids. Patients testified that he generally prescribed whatever they requested, so long 

as they had the requisite cash payment. Physical examinations were either cursory or non-
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existent. Defendant usually did not order diagnostic tests, and if he did, he did not change 

his prescribing practices if a patient failed to comply with tests that he did order. 

The People’s expert, Dr. Gharibo, testified that defendant made no attempt to 

consider non-opioid pain management treatment for his patients, despite his training in 

other pain management options and the addictive nature of the drugs he was prescribing. 

Defendant disregarded warning signs that his patients were abusing their medication and 

were addicted to opioids, such as early visits, obtaining prescriptions from other doctors, 

deterioration in physical appearance, and, in some cases, direct warnings from family 

members and hospitals that defendant’s patients had overdosed. Defendant did not change 

his prescribing practices until law enforcement began investigating him in 2011. 

Defendant altered medical records in response to an investigation request from the New 

York State Health Department’s Office of Professional Medical Conduct. 

According to the People’s witnesses, there was no basis for defendant’s prescription 

of Xanax to a number of patients, including Haeg and Rappold, since that drug had no 

legitimate pain-relieving function. The People’s witnesses also testified about the 

“synergistic respiratory depression” effect of opioids and Xanax when taken together. 

Those witnesses explained that oxycodone has a respiratory depression effect that, if taken 

in large enough doses, will cause a patient to stop breathing entirely. Xanax, also a 

depressant, exacerbated that effect when taken together with oxycodone, such that smaller 

doses of oxycodone could cause respiratory failure. Dr. Gharibo testified that Xanax is 

known to be highly addictive in combination with opioids, that addicts sometimes 

requested the medications together in order to enhance their narcotic highs, and that the 
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combination of opioids and Xanax greatly increased the risk of a fatal overdose. Defendant

was highly trained in pain management and the interaction and potential addictiveness of 

these drugs. Yet he frequently prescribed oxycodone and Xanax together without 

documentation as to why that combination of prescriptions was medically necessary for a 

particular patient. According to Dr. Gharibo, defendant’s prescriptions of high doses of 

opioids and Xanax were not attempts to treat legitimate pain based on reasoned medical 

judgment but rather were designed to create and feed a cycle of craving and addiction. 

With respect to one of defendant’s prescriptions written for a different patient, Dr. Gharibo 

testified that it was “an overdose waiting to happen.” 

Unlike the evidence with respect to some of defendant’s surviving patients, the 

People did not present evidence that defendant was directly informed that the deceased 

patients, Haeg and Rappold, were addicts or had previously overdosed on medications he 

prescribed. Nevertheless, viewing the evidence in the light most favorable to the People, 

as we must, and giving the People the benefit of all reasonable inferences, we conclude 

that a rational jury could have found that defendant was aware of and consciously 

disregarded a substantial and unjustifiable risk that his prescription practices would result 

in the deaths of Haeg and Rappold. 

Dr. Gharibo testified that defendant prescribed opioids to Haeg on the first visit. 

There was no diagnostic workup, no attempt to determine whether non-opioid treatments 

could be effective, and no verification of the information Haeg gave him about receiving 

high doses of opioids from other doctors. Although Haeg gave defendant an MRI from 

2005 showing a central L 5-1 herniation, Dr. Gharibo testified that this was a “general 
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finding” that was “not necessarily diagnostic.” Defendant ordered another MRI for Haeg 

but did not change his prescribing practices after Haeg failed to obtain one. Instead, 

defendant continued to prescribe high doses of short-acting opioids, which Dr. Gharibo 

testified would create a cycle of craving and withdrawal. When Haeg complained of 

increased pain, defendant added a prescription for Percocet (oxycodone and 

acetaminophen), without determining the reason for the increased pain. Defendant also 

prescribed Xanax, an anti-anxiety medication, to Haeg without any indication that Haeg 

suffered from anxiety and without any other documented medical basis. Furthermore, 

Haeg returned early for his medications three times before he overdosed in December 2009, 

which Dr. Gharibo testified should have alerted defendant that Haeg had an addiction and 

was unlikely to take his medications as prescribed. According to Dr. Gharibo, defendant 

created a “prescription regimen to enhance an addict’s high.” On December 26, 2009, 

three days before he was discovered dead from an overdose, defendant prescribed Haeg 

oxycodone, Percocet, and Xanax, among other medications. Dr. Gharibo testified that this 

specific prescription defendant issued to Haeg on December 26, 2009 created a “very high” 

risk that “covered the whole range of morbidity and mortality,” including “overdosing due 

to misusing [the] medication and dying from respiratory death.” In addition, after the 

medical examiner notified defendant of Haeg’s death and requested a copy of defendant’s 

patient file, defendant made several alterations to Haeg’s chart to make it appear as if he 

had taken a more complete patient medical history. 

Rappold first saw defendant in July 2009, complaining of pain due to a fall. 

Defendant did not consider any non-opioid treatments for Rappold, who was then 20 years 
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old, before prescribing a high dose of opioids to him on that first visit. Dr. Gharibo testified 

that defendant conducted only a cursory physical examination, ordered no diagnostic 

testing, and did not diagnose the source of Rappold’s pain. When Rappold returned to 

defendant over a year later, complaining of pain from another fall, defendant again failed 

to order diagnostic tests to objectively assess the complaint of pain and conducted little to 

no physical examination. Instead, defendant prescribed oxycodone and Xanax, without 

any indication that Rappold suffered from anxiety or needed Xanax for any other reason. 

Dr. Gharibo testified that this high-dose prescription was designed to create a cycle of 

craving and not to treat legitimate pain. Rappold returned six days later, complaining that 

he had lost his prescription. Without checking to see whether Rappold had, in fact, filled 

that prescription, defendant prescribed Percocet and Xanax at a decreased dose, with no 

explanation as to the change in prescription. On September 11, 2010, three days before he 

died, Rappold told defendant that the Percocet and Xanax were not working, so defendant 

returned to the earlier prescription, which constituted a significant increase in Rappold’s 

daily dose of oxycodone and Xanax. Dr. Gharibo opined that this prescription created a 

“high probability of overdose and death” even if Rappold took it exactly as prescribed. 

Viewing that evidence in the light most favorable to the People, we conclude that 

the evidence was sufficient to support the jury’s finding that defendant acted recklessly. A 

rational juror could have concluded, based on a valid line of reasoning and permissible 

inferences, that defendant was aware of and consciously disregarded a substantial and 

unjustifiable risk that Haeg and Rappold would take more drugs than prescribed and would 

die by overdose, and, given defendant’s position as their medical doctor, that defendant’s 
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conduct constituted a “gross deviation from the standard of conduct that a reasonable 

person would observe in the situation” (Penal Law § 15.05 [3]). 

We disagree with our dissenting colleague that we have created a rule whereby “a 

reckless doctor is criminally liable for all deaths of patients under his or her care . . . 

irrespective of whether the doctor knew or should have known that the deceased patient 

would abuse the prescription medicine and would die as a result of the abuse” (dissenting 

op at 3). Rather, we agree with the dissent that in order to uphold defendant’s conviction 

of two counts of manslaughter, we must conclude that the People proved, by legally 

sufficient evidence, that defendant was aware of and consciously disregarded a substantial 

and unjustifiable risk that Haeg and Rappold specifically would abuse their medications 

and die as a result. We simply disagree with the dissent that, viewing the evidence in the 

light most favorable to the People, that standard was not met here. As explained, while the 

record here may not contain evidence that defendant was directly told that Haeg and 

Rappold were abusing their prescriptions or previously had come close to death by 

overdose, the record does contain evidence from which the jury could infer that defendant 

was aware of and consciously disregarded a substantial and unjustifiable risk that Haeg and 

Rappold were abusing the prescription drugs that defendant provided and would die as a 

result. We further disagree with the dissent that defendant’s prescribing practices as to 

other patients were irrelevant to his mens rea as it pertained to Haeg and Rappold 

specifically. 

B. Causation

The People also were required to prove that defendant’s conduct was a “sufficiently 
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direct cause” of death, and that there was not “an obscure or merely probable connection” 

between defendant’s conduct and the deaths (People v Stewart, 40 NY2d 692, 697 [1976] 

[emphasis and internal quotation marks omitted]). Defendant’s conduct must “set[ ] in 

motion the events which ultimately result in the victim’s death” (People v Matos, 83 NY2d 

509, 511 [1994]). Nevertheless, defendant’s actions “need not be the sole cause of death,”

and defendant “need not commit the final, fatal act to be culpable for causing death” (id.; 

see Matter of Anthony M., 63 NY2d 270, 280 [1984]). As we recently summarized, a 

defendant’s conduct constitutes a sufficiently direct cause of death when the People prove 

“(1) that defendant’s actions were an actual contributory cause of [the] death, in the sense 

that they forged a link in the chain of causes which actually brought about the death; and 

(2) that the fatal result was reasonably foreseeable” (People v Davis, 28 NY3d 294, 300 

[2016] [internal quotation marks and citations omitted]). 

When Haeg’s body was discovered on December 29, 2009, the police also recovered 

prescription bottles of oxycodone and Percocet, prescribed by defendant on December 26, 

2009, and filled on the same date, with dozens of pills missing from each bottle. Haeg had 

Xanax (among other drugs) in his system, which lowered the amount of oxycodone 

necessary to kill him. The People did not prove that the Xanax Haeg ingested came from 

defendant. Nevertheless, the toxicologist testified that Haeg’s oxycodone levels were so 

high that it was “clearly a fatal dose.” Based on this evidence, a rational juror could 

conclude that defendant’s reckless conduct was an actual contributory cause of Haeg’s 

death. 

The issue is closer with respect to Rappold, but we conclude that the evidence of 
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causation was legally sufficient. The evidence showed that on the night before he died, 

Rappold took Xanax from a bottle prescribed by defendant two days before, and when that 

pill bottle was recovered from his car, more than half of the pills prescribed were gone. 

The People demonstrated that Rappold’s death on September 14, 2010 was caused by

“[a]cute intoxication due to [the] combined effects of alprazolam and oxycodone,” 

meaning that although the substances were not found in his body at “overwhelmingly high 

level[s],” the doses were high enough that, acting synergistically, they depressed his 

respiration and caused his death. Although the People failed to prove that the oxycodone 

that contributed to Rappold’s death came from defendant, the evidence supported a 

conclusion that the Xanax Rappold ingested did. Thus, there is a valid line of reasoning 

and permissible inferences from which the jury could conclude that defendant’s conduct 

was an actual contributory cause of Rappold’s death, in the sense that it “forged a link in 

the chain of causes which actually brought about the death” (Davis, 28 NY3d at 300). As 

noted, defendant’s conduct need not be the sole cause of death (see Matos, 83 NY2d at 

511). 

Defendant’s contention that Haeg’s and Rappold’s ingestion of the prescribed drugs 

in an amount greater than he prescribed was either an intervening cause or unforeseeable 

is without merit. “Even an intervening, independent agency will not exonerate defendant 

unless the death is solely attributable to the secondary agency, and not at all induced by the 

primary one” (Anthony M., 63 NY2d at 280 [internal quotation marks omitted]; see

Stewart, 40 NY2d at 697; People v Kibbe, 35 NY2d 407, 411-413 [1974]). With respect 

to foreseeability, “the People must prove ‘that the ultimate harm is something which should 
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have been foreseen as being reasonably related to the acts of the accused’ ” (Davis, 28 

NY3d at 301, quoting Kibbe, 35 NY2d at 412). 

The fact that Haeg and Rappold took the substances defendant prescribed for them 

in a greater dosage than prescribed is neither an intervening, independent agency nor 

unforeseeable. It is a direct and foreseeable result of defendant’s reckless conduct. As 

explained, viewing the evidence in the light most favorable to the People, a rational juror 

could conclude that defendant was aware of and consciously disregarded a substantial and 

unjustifiable risk that Haeg and Rappold would take the medications he prescribed at a 

higher dose than prescribed in order to attain a narcotic high rather than for legitimate pain 

management, and that they would die as a result. 

Finally, defendant argues that Dr. Gharibo’s testimony was not credible or reliable, 

and that his own expert testified that defendant’s prescriptions were well within the 

therapeutic range of normal dosing, supported by sound medical judgment, and could not 

have caused death if taken as prescribed. Defendant points to evidence, including his own 

testimony, that there was no reason for him to know that Haeg and Rappold were addicted 

to opioids, that they would misuse his prescriptions, or that they would die as a result. 

These arguments, however, pertain to the weight of the evidence presented to the 

jury on the manslaughter counts, an issue that we have no power to review (see Danielson, 

9 NY3d at 349). If the jury’s verdict is supported by legally sufficient evidence, we have 

no power to overturn the conviction on weight grounds, “regardless of our subjective 

assessment of the strength of the People’s case” (People v Delamota, 18 NY3d 107, 116 

[2011]). The Appellate Division rejected defendant’s arguments pertaining to the weight 
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of the evidence (155 AD3d at 578), and defendant does not contend that the Appellate 

Division failed to conduct a weight analysis or applied an incorrect standard (see

Danielson, 9 NY3d at 349; Acosta, 80 NY2d at 672). “[T]he limitations of our Court’s 

jurisdiction prevent us from second-guessing” the Appellate Division’s determination that 

defendant’s conviction on the manslaughter counts was not contrary to the weight of the 

evidence (Delamota, 18 NY3d at 117). 

Accordingly, the order of the Appellate Division insofar as appealed from should 

be affirmed. 
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People v Stan XuHui Li

No. 86

WILSON, J. (dissenting):

The central problem with the majority’s decision is that it contains no limiting 

principle. Dr. Li was grotesquely reckless. I have no quarrel, not even a quibble, with the 

majority’s conclusion that Dr. Li’s prescription practices were reckless, contrary to sound 
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medical practice, and unlawful. Dr. Li was convicted of 170 counts of Criminal Sale of a 

Prescription (Penal Law § 220.65), as well as multiple counts of Reckless Endangerment 

in the First Degree (Penal Law § 120.25) and Second Degree (Penal Law § 120.20), Grand 

Larceny in the Third Degree (Penal Law § 155.31 [1]), Falsifying Business Records in the 

First Degree (Penal Law § 175.10), Offering a False Instrument for Filing in the First 

Degree (Penal Law § 175.35), and a single count of Scheme to Defraud in the First Degree 

(Penal Law § 190.65 [1] [b]). Those add up to 198 separate convictions. No doubt he is a 

criminal. He has not challenged any of those convictions in this appeal. 

The two counts at issue are for Manslaughter in the Second Degree (Penal Law § 

125.15 [1]), arising from prescriptions Dr. Li issued to Joseph Haeg and Nicholas Rappold, 

who died when they consumed substantially larger doses of controlled substances than 

those prescribed by Dr. Li. The fundamental questions are these: under what circumstances 

has the legislature authorized manslaughter convictions of physicians when (a) a patient 

has disregarded the prescribed dosage, resulting in death; or, more generally, (b) a 

physician has made a reckless decision and a patient has died. Historically, the criminal 

prosecution of medical doctors for homicide has been exceedingly rare (see R. E. Farmer 

and Sarah E. McDowell, Doctors Charged with Manslaughter in the Course of Medical 

Practice, 1795-2005: A Literature Review, 99 J. Royal Socy. Med. 309 [2006] [reporting 

that, in the United Kingdom from 1795-2005, only 85 doctors were charged with 

manslaughter for deaths resulting from their medical practice]). The United States Drug 

Enforcement Agency tracks nationwide criminal convictions of doctors related to the 

distribution of controlled substances. Of the 294 doctors criminally convicted from 2003-
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2018, only two were convicted of homicides and two pled guilty (to involuntary 

manslaughter and negligent homicide, respectively) (see Cases Against Doctors ̧ U.S. 

Department of Justice, Drug Enforcement Administration, Diversion Control Division, 

available at

https://apps2.deadiversion.usdoj.gov/CasesAgainstDoctors/spring/main?execution=e1s1

[last accessed Nov. 19, 2019]).1 The legislature has expressly provided a circumstance in 

which physicians may be charged with second-degree manslaughter: assisted suicide 

(Penal Law § 125.15 [2]). Other instances in which doctors have been charged with 

manslaughter have been ones in which the doctor knew, or should have known, that the 

doctor’s actions would likely result in that specific patient’s death. 

The rule implicitly adopted by the majority is quite different: a reckless doctor is 

criminally liable for all deaths of patients under his or her care where drugs prescribed by 

(or errors made by) the doctor contributed to a patient’s death, irrespective of whether the 

doctor knew or should have known that the deceased patient would abuse the prescription 

medicine and would die as a result of the abuse (or error).

I assume, as the majority does, that given Dr. Li’s prescribing practices and 

thousands of patients, it was foreseeable that some patient(s) of his were likely drug 

 

1 Out of those four cases, the facts are readily available in only one. Dr. Noel Chua was 

convicted of felony murder after one of his patients overdosed and died. Dr. Chua lived 

with that patient, ordered nurses to administer drugs to the patient while the patient was 

high, and was explicitly told by a nurse that the patient was showing signs of addiction (see

Chua v State, 289 Ga 220 [2011]). In another, involving Dr. James Bischoff, although the 

facts are not readily ascertainable, the indictment included a charge of “Robbery with a 

Weapon,” suggesting that his case, too, is not similar to Dr. Li’s. 
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abusers, and a subset of those would die from ingesting drugs he had prescribed. But unlike 

the majority, I do not believe that proposition is sufficient to demonstrate the causation 

necessary to sustain a conviction for manslaughter. Instead, I believe our decisional law 

governing causation requires that Dr. Li had some basis to foresee that his prescriptions to 

Messrs. Haeg and Rappold were likely to cause their deaths. As to certain other of Dr. Li’s 

patients, the record evidence would be sufficient to support a finding of causation – but 

those patients did not die. As to Messrs. Haeg and Rappold, the record evidence is 

insufficient to prove causation because it fails to establish that Dr. Li had reason to foresee 

the risk of their deaths in particular. 

I.

A person is guilty of manslaughter in the second degree when that person 

“recklessly causes the death of another person” (Penal Law § 125.15 [1]). Here, 

“recklessly” is indisputably satisfied; the difficult issue resides in “causes.” To cause the 

death of another under New York law, a defendant’s actions must be ‘“a sufficiently direct 

cause’ of the death so that the fatal result was reasonably foreseeable” (People v 

Hernandez, 82 NY2d 309, 314 [1993], quoting People v Kibbe, 35 NY2d 407, 412 [1974]). 

A defendant’s recklessness may be established, at least in part, by proof of the defendant’s 

reckless conduct in circumstances other than the specific conduct resulting in the injury. 

Proof of causation, however, is distinct from recklessness because foreseeability must be 

established as to the specific fatal result occasioning the charge of manslaughter. In People 

v Roth, a petroleum transport company and two of its managers were indicted for seconddegree manslaughter, criminally negligent homicide, reckless endangerment and several 
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other crimes, resulting from an explosion that killed an employee (80 NY2d 239 [1992]). 

The “Appellate Division affirmed the dismissal of the homicide charges, the reckless 

endangerment charge and the charge of endangering public health, safety or the 

environment” (id. at 243). We affirmed the dismissal of the reckless manslaughter and 

criminally negligent homicide charges but reinstated the reckless endangerment charge. 

Although all of those charges required the same proof of recklessness, we explained that 

the manslaughter and criminally negligent homicide charges were legally unsupportable 

for lack of causation:

“the People were also required to submit proof from which the Grand Jury could 

conclude that the actual cause of the explosion was foreseeable. For purposes of 

criminal liability, it was not enough to show that, given the variety of dangerous 

conditions existing at the site, an explosion was foreseeable; instead, the People 

were required to show that it was foreseeable that the explosion would occur in the 

manner that it did. It was error, therefore, to instruct the Grand Jury that the 

defendants could be indicted ‘if you find that they recklessly created unsafe 

conditions that led to [the victim’s] death by a foreseeable event, namely, the 

explosion.’ Moreover, even if the Grand Jury had been properly instructed in this 

regard, the indictment on these charges could not stand”

(id. at 244 [internal citations omitted]). We reinstated the reckless endangerment charge 

because, unlike the manslaughter and criminally negligent homicide charges, “there is no 

requirement that the defendants’ reckless conduct cause injury or death” (id. at 245). 

Although recklessness – including the foreseeability of some explosion – was sufficiently 

proved for all three counts, causation was not for the manslaughter and criminally negligent 

homicide charges. Likewise, to uphold Dr. Li’s manslaughter convictions, more than his 

rampant recklessness must be proved. There must also be sufficient evidence from which 
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the jury could have found that Dr. Li’ s treatment of Messers. Haeg and Rappold was the 

direct and reasonably foreseeable cause of their deaths. 

The standard to prove causation for manslaughter is different from, and more 

demanding than, the standard to prove causation in tort. As we explained in People v 

Warner-Lambert Co. (51 NY2d 295 [1980]): “[w]e subscribe to the requirement that the 

defendants’ actions must be a sufficiently direct cause of the ensuing death before there 

can be any imposition of criminal liability, and recognize, of course, that this standard is 

greater than that required to serve as a basis for tort liability” (id. at 306; see also Roth, 80 

NY2d at 244). In the criminal context, a general foreseeable risk and an action that ignites 

a chain of causation, resulting in death, are not sufficient to prove that a defendant caused 

a specific reckless homicide (see Warner-Lambert, 51 NY2d at 305-06). Instead, the 

“actual immediate, triggering cause” of the specific victim’s death must be foreseeable for 

a defendant to be found guilty of manslaughter in the second degree (id. at 307).

Our prior cases in which a defendant was found guilty of second-degree 

manslaughter when the defendant had provided drugs causing an overdose, though not 

involving doctors, satisfy that heightened standard of causation. In People v Cruciani, we 

upheld the manslaughter conviction of a defendant who directly injected his girlfriend with 

heroin, causing her death, when the evidence established that the defendant knew his 

girlfriend was “completely bombed out on downs,” knew she had lost her capacity to “walk 

or talk straight,” and acknowledged his injection created a substantial possibility that she 

would die (36 NY2d 304, 305 [1975]). The defendant could foresee that his actions would 
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be the immediate and triggering cause of his girlfriend’s death (see also People v Galle, 77 

NY2d 953 [1991]). Analogously, if Messrs. Haeg or Rappold had walked into Dr. Li’s 

office, and Dr. Li had fed them an overdose of Oxycodone and/or Xanax, causation would 

be firmly established. But under the rationale advanced by the majority here, every heroin 

dealer may be convicted of manslaughter for the deaths of all users overdosing from drugs 

supplied by that dealer. That, of course, is not the law, even though, just as Dr. Li should 

have known that some patients of his would overdose given his reckless prescription 

practices, heroin dealers know that some customers, too, will overdose. 

The majority’s treatment of a case involving a heroin dealer, People v Pinckney (38 

AD2d 217 [2d Dept 1972], affd, 32 NY2d 749 [1973]), is flawed. The Appellate Division 

held that a heroin dealer could not be prosecuted for manslaughter when one of his 

customers died from an overdose of the drugs he provided, using paraphernalia he also 

provided. Although we affirmed Pinckney, the majority notes that our summary 

affirmance has “minimal” precedential value and ‘“does not imply approval of everything 

contained in the opinion of the court below’” (majority op at 4 [internal citation omitted]). 

Nevertheless, our summary affirmance in Pinckney poses a severe problem for the majority

and cannot be brushed aside.

CPL 470.05 (2) states: “[f]or purposes of appeal, a question of law with respect to 

a ruling or instruction of a criminal court during a trial or proceeding is presented when a 

protest thereto was registered, by the party claiming error, at the time of such ruling or 

instruction or at any subsequent time when the court had an opportunity of effectively 
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changing the same.” In Pinckney, the defendant made only two arguments in the court of 

instance. First, he argued that the facts in the indictment did not meet the legal definition 

of recklessness, and second, he argued that “the legislature intended that manslaughter in 

the second degree and criminal negligent homicide should not apply in this type of case” 

(Affidavit of Edward S. Panzer in Support of Motion, Record on Appeal at 15). Because 

we are powerless to decide a criminal appeal on an issue not raised in the court of instance,

our summary affirmance in Pinckney must have adopted one or the other of those grounds.

If Pinckney’s holding rests on the lack of specific legislative action, it applies here 

as well, because the legislature has enacted no homicide statutes specifically related to the 

reckless prescription of medicines. If, instead, it rests on the indictment’s failure to 

establish recklessness, that too would bar Dr. Li’s manslaughter convictions. The 

indictment in Pinckney charged that the defendant: “wilfully [sic], wrongfully and 

unlawfully did recklessly cause the death of one Francis John Muthig . . . by then and there 

selling to and providing said Francis John Muthig with a quantity of the narcotic drug 

Heroin which said Francis John Muthig immediately, with the instruments furnished to him 

by said William L. Pinckney, prepared for injection and did inject into his body, as a direct 

result of which said Francis John Muthig thereafter, on the 5th day of April, 1970, died, 

the said William L. Pinckney knowing the said Heroin to be a dangerous drug” (Indictment, 

Record on Appeal at 7). If that indictment is insufficient to charge Mr. Pinckney with 

manslaughter, Dr. Li cannot be convicted of it either.
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The majority’s treatment of Pinckney is also instructive as to its view of the legal 

standard for causation. In Pinckney, both the Appellate Division majority and concurrence 

noted that prior cases upheld manslaughter convictions for the sale of a poison because the 

“obvious result of its use is death, [which] was known to the seller at the time of the sale” 

(id. at 219-20, citing People v Licenziata, 199 App Div 106 [2d Dept 1921] and People v 

Voelker, 220 App Div 528 [4th Dept 1927]). The Appellate Division then distinguished 

those cases from the case of a defendant whose sale of heroin resulted in a user’s death. 

Pinckney pointed out that, as to heroin, “[a]lthough it is a matter of common knowledge 

that the use of heroin can result in death, it is also a known fact that an injection of heroin 

into the body does not generally cause death” (Pinckney, 38 AD2d at 220; see also id. at 

223-24 [Shapiro, J., concurring]). The same is true of opioids other than heroin, 

particularly when prescribed by a doctor: they can, but do not usually, result in death. 

Presumably, the majority’s reason for brushing Pinckney aside is to adopt a different rule 

of causation, one in which the reckless distribution of a dangerous drug is itself sufficient 

to establish causation – including foreseeability – from deaths resulting from a defendant’s 

distribution of that drug. Otherwise, Dr. Li could not be convicted of manslaughter. 

That said, I do agree with the majority that oversight or physical administration of 

the fatal drugs is not “a necessary element, as a matter of law, for homicide charges to be 

sustained” (majority op at 4). For example, evidence regarding some of Dr. Li’s other 

patients was sufficient to allow a trier of fact to find that Dr. Li’s continued prescription of 

controlled substances to those patients would foreseeably result in a substantial risk of their 
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deaths. One patient explicitly told Dr. Li that she was addicted to Oxycodone and Xanax; 

that same patient’s mother also called Dr. Li and implored him not to prescribe Soma to 

her daughter because it “was something that really could end her life” (SA.1342). As to 

certain other patients, Dr. Li knew they had previously overdosed on the same drugs he 

was prescribing; that knowledge would have allowed a trier of fact to conclude that Dr. Li 

could foresee that those patients would overdose again, with the attendant risk of death.2 

Had Mr. Rappold, or his mother, alerted Dr. Li to the fact that a few months before his 

death, Mr. Rappold had successfully completed an opioid detoxification program that 

administered Suboxone to him, that information would have been evidence suggesting that 

a foreseeable result of Dr. Li’s subsequent provision of opioids to Mr. Rappold was his 

death. However, the record contains no evidence that Dr. Li was aware of that information. 

Such examples are not exhaustive but serve to demonstrate that the heightened standard of 

causation for criminal liability can be met in circumstances where the defendant, doctor or 

otherwise, does not directly administer the lethal dosage.

By contrast, Dr. Li’s prescriptions to Messrs. Haeg and Rappold were not 

foreseeably the direct cause of their deaths. Mr. Haeg originally came to Dr. Li with an 

MRI showing a central L 5-1 herniation and complaining of chronic back pain that had 

 

2 The majority’s statement that “[w]ith respect to one of defendant’s prescriptions written 

for a different patient, Dr. Gharibo testified that it was ‘an overdose waiting to happen,”’

(majority op at 9), refers to a patient whose prescriptions included not just Xanax and 

Oxycontin, but Oxycodone, Opana and a Duragesic patch (containing fentanyl, a synthetic 

opiate).
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persisted for 17 years, treated by opioids from his prior doctors. Dr. Li prescribed pain 

medication to Mr. Haeg at the same level Mr. Haeg said he had been receiving from his 

prior doctor – a far from fatal dosage if taken as instructed. In sharp contrast to certain 

other of Dr. Li’s patients described above, Dr. Li had received no information to suggest 

that Mr. Haeg would not take his medication as instructed. Mr. Haeg’s early visits for 

medication, alone, did not indicate that his prescriptions would be the immediate and 

triggering cause of his death, and on the two occasions (September 26, 2009 and December 

5, 2009) that Mr. Haeg returned early, Dr. Li wrote prescriptions for 84 pills instead of the 

usual 120. 

As to Mr. Rappold, Dr. Li conducted an introductory physical examination of his 

new patient, who complained of pain from a fall, and prescribed him pain medication 

within accepted therapeutic bounds. When Mr. Rappold returned early, explaining that he 

had lost his prescription, Dr. Li issued him a prescription with a sharply reduced dose. Dr. 

Li did not return Mr. Rappold’s prescription to its original dosage until Mr. Rappold told 

Dr. Li that the pain medications were no longer working. Again, there was no indication 

that Mr. Rappold would not take his prescriptions as instructed and no evidence to suggest 

that those prescriptions would foreseeably result in Mr. Rappold’s death. Indeed, the 

evidence at trial suggested that Mr. Rappold had ingested drugs from multiple sources on 

the night he died, further attenuating the claim that Dr. Li caused his death. No record 

evidence indicates that Dr. Li had reason to believe Mr. Rappold was obtaining drugs from

others, likely illegally.
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II.

Our several cases relied on by the majority to describe the causation requirement 

for homicide do not support the conclusion that, absent some reason for a physician to 

believe that a patient will radically disregard prescribed dosages, liability for homicide 

attaches if the patient dies as a result of an overdose. In People v Stewart (40 NY2d 692 

[1976]), the defendant stabbed his victim in the stomach; the question was whether the 

victim, who died during surgery, died as a result of the stab wound or as a result of a heart 

attack occurring when the surgeons decided to repair a hernia unrelated to the stab wound. 

There, we expressly stated that “something more is required” than proving that the 

defendant’s conduct “forged a link in the chain of causes which actually brought about the 

death,” namely, “the defendant’s actions must be a sufficiently direct cause of the ensuing 

death before there can be any imposition of criminal liability” (id. at 697 [emphasis 

original]). We vacated the defendant’s conviction for manslaughter, reducing it to assault.

People v Matos (83 NY2d 509 [1994]), holds that the felony murder rule applies to 

a defendant whose rooftop flight from the police resulted in the falling death of a pursuing 

officer because “it should also be foreseeable that someone might fall while in hot pursuit 

across urban roofs in the middle of the night” (id. at 512). Matter of Anthony M. (63 NY2d 

270 [1984]), held that defendants could be held to have caused the cardiac-arrest deaths of 

their assault victims, who had no prior history of cardiac trouble, where medical evidence 

supported the conclusion that the stress of the assaults caused the fatal heart attacks days 

later. People v Davis (28 NY3d 294 [2016]), is the same: death by cardiac arrest following 
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an assault. Those cases are fundamentally different from Dr. Li’s. Unlike the defendants 

in those cases, Dr. Li had no reason to foresee that Messrs. Haeg or Rappold would so 

substantially deviate from the prescribed dosages as to cause their deaths. 

Although the majority asserts that “a rational juror could conclude that defendant 

was aware of and consciously disregarded a substantial and unjustifiable risk that Haeg and 

Rappold would take the medications he prescribed at a higher dose than prescribed in order 

to attain a narcotic high rather than for legitimate pain management, and that they would 

die as a result” (majority op at 15), the majority does not specify on what evidence a rational 

juror could so conclude. There are only two possibilities: either it is the overall evidence 

of Dr. Li’s reckless pain management practice in general – which means the majority has 

adopted a rule that if a doctor’s recklessness makes it foreseeable that some patients may 

die from an overdose, causation is established as to any death resulting from any patient’s 

overdose — or else something about Dr. Li’s practice with regard to Messrs. Haeg and

Rappold in particular demonstrates specific foreseeability as to their deaths. 

If it is the latter, the evidence is not sufficient to establish causation. Taking Mr. 

Haeg, as to whom the majority says the evidence of recklessness is stronger, most of what 

the majority describes (majority op at 9-10) does not show any reasonable foreseeability 

of prescription abuse, much less death. For example, Dr. Li’s failure to verify 

independently the doses prescribed by Mr. Haeg’s former doctors, or his failure to reduce 

Mr. Haeg’s dosages when Mr. Haeg did not provide the updated MRI that Dr. Li requested, 

do not bear on the question of foreseeability of death. Presumably, a doctor who prescribes 
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Xanax to a patient without an indication that the patient has anxiety is not liable for 

manslaughter if the patient takes an overdose of Xanax, although perhaps the majority’s 

new rule is otherwise. 

The sole item cited by the majority that appears to bear on foreseeability is Dr. 

Gharibo’s testimony that the prescription given to Mr. Haeg “three days before he was 

discovered dead from an overdose...created a ‘very high’ risk that ‘covered the whole 

range of morbidity and mortality,’ including ‘overdosing due to misusing the medication 

and dying from respiratory death”’ (majority op at 10). But that is not what Dr. Gharibo 

testified. Instead, the majority has taken his statement that the prescribed dosages created 

a “very high risk, highly addictive, inappropriate misprescribing ... driven to prescribe to 

create addiction and potentially even create diversion and death to the individual as well as 

to the people around them” (SA.0906) – which makes a clear distinction between the “very 

high risk” (that Dr. Li would create an addiction) and the less foreseeable result (that he 

could “potentially even create diversion and death”) – and appended it to Dr. Gharibo’s 

assessment of the general risk faced by opioid addicts. That generalized risk includes a 

smörgåsbord of catastrophes ranging from “falling and injuring themselves and getting hurt 

in a whole variety of ways, whether it’s injuring their foot or hand or getting hit by a car, 

to overdosing due to misusing their medication and dying from respiratory death.” Dr. 

Gharibo’s testimony as to the litany of doom that might befall any opioid addict – from 

stubbing one’s toe to death – demonstrates the lack of foreseeability of any particular result 
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within that range. His testimony does not meet the standard for causation as set forth in 

Warner-Lambert and Roth. 

The majority has extended homicide liability to physicians by blurring recklessness 

into causation: if a doctor is generally reckless in prescribing drugs, it is foreseeable that 

some patient may die; if it is foreseeable that some patient may die, causation is established 

when any patient dies from an overdose of the prescribed drug(s). In applying a standard 

under which doctors can be found guilty of manslaughter if they maintain reckless 

prescription practices and a patient takes an overdose, the majority creates a novel and 

unwelcome extension of criminal liability for physicians. 

III

The result here (holding a reckless doctor liable for homicide as a result of a 

patient’s death) is inconsistent with the way errors – even grossly negligent, fatal errors –

by doctors have been historically addressed. The state licenses doctors to make sure they 

are at least minimally competent, withdraws licensure if a doctor proves incompetent, and 

subjects all doctors, good and bad, to tort liability under well-established law governing 

medical malpractice.3 Doctors can also be found guilty of crimes other than manslaughter, 

 

3

In 2018, New York courts awarded $685,317,000.00 in damages in 1,535 successful 

medical malpractice suits (2019 Medical Malpractice Payout Report: A complete analysis 

of medical malpractice payouts as recorded by the National Practitioner Data Bank [a 

computer database of the United States Department of Health and Human Services],

presented by LeverageRx, LeverageRx, available at 

https://www.leveragerx.com/malpractice-insurance/2019-medical-malpractice-report/

[last accessed Nov. 19, 2019]).
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including crimes that the legislature specifically targeted at the criminal sale of 

prescriptions for which Dr. Li has been convicted. 

Exactly how far today’s decision expands the homicide liability for doctors is 

unclear. If a doctor recklessly prescribes drugs that interact and cause a death, will that be 

considered manslaughter? If a doctor relies on a patient’s self-report of medical history or 

allergies and the patient dies, will that be deemed reckless and also sufficient to establish 

causation because the doctor acted without independently verifying the information, 

justifying a manslaughter charge? We have previously recognized the impropriety in 

conflating the causation element required in typical homicides with the causation element 

required in commercial situations resulting in death (see People v DaCosta, 6 NY3d 181, 

186 [2006]). I would tread much more gingerly in advancing homicide liability against 

doctors than does the majority, leaving the legislature to determine, prospectively, what 

criminal penalties should attach to what kinds of reckless conduct by doctors, instead of 

attempting to apply to the medical profession causation rules developed in cases involving 

garden-variety assaults and burglaries. To some extent, the legislature has already done 

so, as evidenced by the myriad other crimes of which Dr. Li was tried and convicted, 

convictions he has not appealed to this court.

* * * * * * * * * * * * * * * * *

Order insofar as appealed from affirmed. Opinion by Judge Fahey. Chief Judge DiFiore 

and Judges Rivera, Stein, Garcia and Feinman concur. Judge Wilson dissents in an 

opinion.

Decided November 26, 2019