Source: https://openjurist.org/470/f3d/550/united-states-v-a-mciver
Timestamp: 2018-12-15 21:08:53
Document Index: 150135021

Matched Legal Cases: ['§ 846', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 841', '§ 812', '§ 1308', '§ 1308', '§ 1308', '§ 1308', '§ 704']

470 F3d 550 United States v. A McIver | OpenJurist
470 F. 3d 550 - United States v. A McIver
470 F3d 550 United States v. A McIver
470 F.3d 550
Ronald A. McIVER, Defendant-Appellant, and
All Out Bail Bonding; Giggies Bonding Company, Parties in Interest.
No. 05-4884.
ARGUED: John Philip Flannery, II, Campbell, Miller & Zimmerman, P.C., Leesburg, Virginia, for Appellant. William Corley Lucius, Assistant United States Attorney, Office of the United States Attorney, Greenville, South Carolina, for Appellee. ON BRIEF: Eli D. Stutsman, Portland, Oregon; C. Rauch Wise, Greenwood, South Carolina, for Appellant. Jonathan S. Gasser, United States Attorney, Columbia, South Carolina, for Appellee.
The field of pain management has generated controversy because of its reliance on opiate-based pain medications (opioids), which are also a target of the government's war on drugs. See Diane E. Hoffmann & Anita J. Tarzian, Achieving the Right Balance in Oversight of Physician Opioid Prescribing for Pain: The Role of State Medical Boards, 31 J.L. Med. & Ethics 21, 22-23 (2003). The government has recently become more aggressive in prosecuting doctors who unlawfully distribute opioids and other prescription drugs under the guise of legitimate medical practice. See United States v. Hurwitz, 459 F.3d 463 (4th Cir.2006); United States v. Feingold, 454 F.3d 1001 (9th Cir. 2006); United States v. Williams, 445 F.3d 1302 (11th Cir.2006); United States v. Alerre, 430 F.3d 681 (4th Cir.2005). The charges against Dr. Ronald A. McIver ("Appellant") arose from his prescription of pain medications to patients at a pain clinic. He appeals his conviction for various counts of unlawful distribution of a controlled substance, unlawful distribution of a controlled substance resulting in death, and conspiracy to unlawfully distribute a controlled substance. For the reasons that follow, we affirm.
After trial, the jury convicted Appellant of one count of conspiracy to distribute controlled substances unlawfully in violation of 21 U.S.C. § 846 (2000) (Count 1), six counts of unlawful distribution of a controlled substance in violation of 21 U.S.C. § 841(a)(1) (2000) (Counts 3-5, 13-15), and two counts of unlawful distribution of a controlled substance resulting in the death of Larry Shealy in violation of § 841(a)(1) & (b)(1)(C) (Counts 11, 12).8 The district court sentenced Appellant to 240 months on Counts 1, 3, 4, 5, 13, 14, and 15, and 360 months on Counts 11 and 12, to run concurrently. Appellant timely appealed.
We turn now to a consideration of the facts relevant to this appeal, beginning with those involving the six patients whose experiences underlie Appellant's convictions. In the context of Appellant's challenges to the sufficiency of the evidence, we recite those facts in the light most favorable to the government. United States v. Rahman, 83 F.3d 89, 93 (4th Cir.1996). We then discuss the testimony of the government's expert witness, Dr. Steven Storick, and the district court's jury instruction on the § 841(a)(1) charges.
A. Larry Shealy
B. Barbee Brown
Barbee Brown sought treatment from Appellant primarily for reflex sympathetic dystrophy, a chronic neurological condition that causes severe pain. J.A. 518-19. Appellant knew from the outset that Brown had a history of prescription drug and cocaine abuse. J.A. 207-08, 519. He nevertheless prescribed OxyContin, oxycodone, and, later, methadone in various simultaneous combinations for her. J.A. 518-23. Appellant also allowed Brown to manage her own dosing without specifying a maximum amount. J.A. 208. Brown's father wrote to Appellant to express concern about his daughter's treatment, stating that, since coming to see Appellant, Brown had been in a "drug state," "unstable in her speech and ha[d] threatened to kill" her father. J.A. 233, 520. Appellant continued prescribing opioids to Brown, however, maintaining that, if anything, her dose was too low. J.A. 521.
D. Seth Boyer
E. Kyle Barnes
F. Angela Knight
G. Dr. Steven Storick's Testimony
H. Jury Instructions for § 841(a)(1) Charges
Under § 841(a)(1), the government must prove (1) that Appellant knowingly or intentionally distributed a controlled substance; (2) with knowledge that it was controlled under the law; and (3) that he did so "outside the usual course of professional practice." United States v. Moore, 423 U.S. 122, 124, 96 S.Ct. 335, 46 L.Ed.2d 333 (1975); see also United States v. Tran Trong Cuong, 18 F.3d 1132, 1137 (4th Cir.1994) (setting out elements of § 841(a)(1) charge). With respect to the third element—the only one challenged by Appellant on appeal—the district court instructed the jury extensively prior to its deliberations.9
On appeal, Appellant argues that: (1) the district court's instructions on the § 841(a)(1) charges improperly lowered the government's burden of proof; (2) Dr. Storick's expert testimony constituted inadmissible legal opinions; (3) the district court erred in excluding evidence from Appellant's expert witness, Dr. Thomas Duc; and (4) there was insufficient evidence to support each of his convictions. We consider each argument in turn.
Appellant first argues that by referring to "norms of professional practice" in the jury instructions, the district court improperly allowed the jury to convict on a civil, rather than a criminal, standard of proof. We review the accuracy and adequacy of jury instructions de novo, United States v. Scott, 424 F.3d 431, 434 (4th Cir.2005), and will not reverse a conviction so long as "the instructions, taken as a whole, adequately state the controlling law," United States v. Wills, 346 F.3d 476, 492 (4th Cir.2003) (emphasis added). Because we find that the district court's instructions as a whole adequately articulated a criminal standard of proof, we find no error.
The potential for juries to confuse the civil standard of care applied in medical malpractice cases and the criminal standard of proof applied in § 841(a)(1) prosecutions requires courts to exercise care in setting out the governing standard in the latter circumstance.10 We have previously considered the proper relationship between the standards in two decisions that are relevant to our analysis here, even though neither involved a direct challenge to the propriety of § 841(a)(1) jury instructions.
In Tran Trong Cuong, we addressed a sufficiency of the evidence challenge by Tran, a physician also indicted under § 841(a)(1). Tran's argument in part was that the district court erroneously applied a civil negligence, rather than a criminal, standard of proof during trial. 18 F.3d at 1137. While acknowledging that the district court had, during trial, confused the two standards, we nevertheless concluded that the court's articulation of the criminal standard was correct when it instructed the jury at the close of the case. Id. at 1137-38. The trial court made it clear in its jury charge that the government must "prove beyond a reasonable doubt . . . that the defendant prescribed the drug other than for [a] legitimate medical purpose and not in the usual course of medical practice." Id. at 1137. It then recognized the broad discretion afforded doctors, instructed the jury to consider all of the defendant's actions, and provided specific examples of behavior that tended to denote illegitimacy, such as prescribing drugs without performing physical examinations, or asking patients about the amount or type of drugs they want. Id. at 1137-38. We held that these instructions adequately articulated the government's criminal burden of proof, and did not endorse the use of a negligence standard. Id. Indeed, we concluded that the jury instructions not only captured the criminal standard, but arguably imposed a higher burden on the government than set forth in Moore by additionally requiring proof that Tran had written prescriptions "without a legitimate medical purpose." Id.
With that guidance, we consider the challenge before us, which specifically focuses on the district court's jury instructions. The thrust of Appellant's argument is that the district court erred in telling the jury to consider the extent to which "any violation of professional norms you find to have been committed by the defendant interfered with his treatment of his patients and contributed to an over prescription and/or excessive dispensation of controlled substances." J.A. 1293. Appellant specifically focuses on the district court's use of the phrase "norms of professional practice." However, after reviewing the jury instructions as a whole, as we must, Wills, 346 F.3d at 492, we find multiple reasons to conclude that the instructions here properly set forth the criminal standard required by § 841(a)(1).
As was the case in Tran Trong Cuong, 18 F.3d at 1137, and Alerre, 430 F.3d at 687, the court below cabined both its overall § 841(a)(1) instruction, as well as its specific instructions on the third element, within the requirement of proof "beyond a reasonable doubt." J.A. 1290, 1292. This statement clearly articulated the proper criminal burden for the government and precluded conviction on a lesser civil standard of proof.
The court then properly defined the scope of unlawful conduct under § 841(a)(1) by explaining that the government had to prove that Appellant used "his authority to prescribe controlled substances . . . not for treatment of a patient, but for the purpose of assisting another in the maintenance of a drug habit or" some other illegitimate purposes, such as his own "personal profit." J.A. 1292; see Alerre, 430 F.3d at 690-91. This instruction set the proper threshold for conviction by placing unlawful conduct beyond the bounds of any legitimate medical practice, including that which would constitute civil negligence. See Tran Trong Cuong, 18 F.3d at 1137; cf. Alerre, 430 F.3d at 690 (setting forth the standard for medical malpractice in South Carolina). In other words, the district court ensured that the jury could only convict Appellant for conduct that was exclusively criminal in nature.
Significantly, in order to satisfy this definition of unlawful conduct, the district court required the prosecution to prove, not only that Appellant acted "outside the course of professional practice," as required by Moore, 423 U.S. at 124, 96 S.Ct. 335, but also that he acted "for other than a legitimate medical purpose," J.A. 1292 (emphasis added). This additional requirement arguably benefitted Appellant by placing an even heavier burden on the government than otherwise required to establish criminal liability. See Alerre, 430 F.3d at 690-91; Tran Trong Cuong, 18 F.3d at 1138.
As in Tran Trong Cuong, 18 F.3d at 1138, and Alerre, 430 F.3d at 691 n. 9, the court next stated that so long as Appellant acted in good faith, he acted lawfully. J.A. 1291-92; see 430 F.3d at 692, 18 F.3d at 1138. The significance of this distinction is manifest: good faith is a defense to a charge under § 841(a)(1), but not to a claim of medical malpractice. See Hurwitz, 459 F.3d at 480 ("good faith generally is relevant in a § 841 case against a registered physician"); Pleasants v. Alliance Corp., 209 W.Va. 39, 49 n. 27, 543 S.E.2d 320 (2000) (collecting cases rejecting use of subjective good faith jury instructions in medical malpractice actions). The inclusion of a good faith instruction is therefore a plainspoken method of explaining to the jury a critical difference between the two standards.
Finally, the court instructed the jury on the difference between civil and criminal violations. J.A. 1293. The court indicated that "a violation of a professional norm does not in and of itself establish a violation of [a] criminal law," but could support a conviction based on its "extent and severity." Id. While this instruction allowed the jury to consider civil violations, it properly explained that such evidence is not inexorably indicative of unlawfulness. See Alerre, 430 F.3d at 691. The district court then concluded by describing the concept of medical malpractice and the civil standard of care before categorically stating that a criminal standard governed resolution of this case.11 J.A. 1293-96 ("[Malpractice or negligence] is not what we're talking about . . . . We're talking about whether or not this physician prescribed a controlled substance outside the bounds of his professional medical practice.").
These instructions, taken as a whole, set the proper threshold for conviction, mandating application of a criminal standard of proof and precluding conviction on a lower civil standard. The fact that the district court may have invoked language, taken in isolation, suggestive of a civil standard, would not alone lower the government's burden of proof. Indeed, it would be difficult, if not impossible, to purge an instruction under § 841(a)(1) of all references to permissible standards or norms of care, since the third element of § 841(a)(1) requires a determination of whether the defendant's conduct is outside the usual course of professional conduct.
Appellant further argues that Dr. Storick's testimony combined with the instructions on the third element to lower the government's burden. At trial, Dr. Storick opined that Appellant acted "outside the course of legitimate medical practice," "inappropriate[ly]" or "with no legitimate reason." J.A. 523, 527, 543. Appellant argues that the confluence of this testimony and the court's instructions regarding the "norms of professional practice" effectively allowed the jury to convict based on a civil standard of proof. We find this argument unpersuasive for two reasons.
First, as we recognized in Alerre and noted above, evidence regarding a departure from a generally recognized standard-of-care is not inherently impermissible. 430 F.3d at 691. To the contrary, such evidence may support an inference that a physician is acting as a dealer of drugs rather than a provider of care.12 Id. Indeed, it is the extent and severity of departures from the professional norms that underpin a jury's finding of criminal violations. See id. ("[E]vidence that a physician consistently failed to follow generally recognized procedures tends to show that in prescribing drugs he was not acting as a healer but as a seller of wares.")
Second, even if we assume that Dr. Storick suggested a lower burden to the jury, the district court's jury charge negated any such testimony by articulating the proper standard. Again, our decision in Tran Trong Cuong is instructive. The district court there made statements at trial that unambiguously indicated that a civil standard of proof governed the case, commenting, for example, that the governing standard was (1) "whether a reasonably prudent physician would do it," (2) "whether it is within the standard of care of a family practitioner," and (3), "like you use in a civil case, whether [care was comparable to that provided] in the usual course of treating a patient by the average family practitioner." 18 F.3d at 1137. We concluded, nonetheless, that the satisfactory definition included in the jury instructions cured the prior misstatements. Id. at 1138. Such a conclusion is consistent with our general presumption that "a properly instructed jury [acts] in a manner consistent with the instructions." Alerre, 430 F.3d at 692; see Jones v. United States, 527 U.S. 373, 394, 119 S.Ct. 2090, 144 L.Ed.2d 370 (1999) ("[J]urors are presumed to have followed . . . instructions.").
As discussed above, the district court here instructed the jury that the government had to satisfy a criminal standard of proof to convict Appellant. J.A. 1291-96. We presume that the jury followed these instructions and ignored any suggestion to the contrary. See Jones, 527 U.S. at 394, 119 S.Ct. 2090; Alerre, 430 F.3d at 692. We discern nothing in the record that rebuts this presumption. Accordingly, we find no error.
Appellant next asserts error in the admission of Dr. Storick's expert testimony that Appellant treated certain patients outside the course of legitimate medical practice. Appellant argues that this testimony embraced inadmissible legal conclusions. We review this argument for plain error because Appellant did not object to the testimony at trial. United States v. Ellis, 121 F.3d 908, 918 (4th Cir.1997). To reverse on plain error review, we "must `(1) identify an error, (2) which is plain, (3) which affects substantial rights, and (4) which seriously affect[s] the fairness, integrity or public reputation of judicial proceedings.'" Id. (quoting United States v. Brewer, 1 F.3d 1430, 1434 (4th Cir.1993)) (alterations in original). Because we conclude that Dr. Storick's testimony was admissible, there was no error and Appellant cannot satisfy this standard.
Rule 704(a) allows the admission of expert testimony that "embraces an ultimate issue to be decided by the trier of fact." Fed.R.Evid. 704(a). In other words, questions of fact that are committed to resolution by the jury are the proper subject of opinion testimony. Id. However, opinion testimony that states a legal standard or draws a legal conclusion by applying law to the facts is generally inadmissible.13 See United States v. Barile, 286 F.3d 749, 760 (4th Cir.2002); Okland Oil Co. v. Conoco, Inc., 144 F.3d 1308, 1328 (10th Cir.1998). The line between a permissible opinion on an ultimate issue and an impermissible legal conclusion is not always easy to discern. Barile, 286 F.3d at 760. We identify improper legal conclusions by determining whether "the terms used by the witness have a separate, distinct and specialized meaning in the law different from that present in the vernacular." Id. For example, courts have held inadmissible testimony that a defendant's actions constituted "extortion," DiBella v. Hopkins, 403 F.3d 102, 121 (2d Cir.2005); that a dog bite constituted "deadly force," Miller v. Clark County, 340 F.3d 959, 963 n. 7 (9th Cir.2003); that defendants held a "fiduciary" relationship to plaintiffs, Christiansen v. Nat'l Sav. & Trust Co., 683 F.2d 520, 529 (D.C.Cir.1982); and that a product was "unreasonably dangerous," Strong v. E.I. DuPont de Nemours Co., 667 F.2d 682, 685-86 (8th Cir.1981). Dr. Storick's testimony, however, does not involve terms with similar legal significance.
Appellant argues that the district court erred by excluding testimony from his expert witness, Dr. Thomas Duc. During direct examination, Appellant's attorney asked Dr. Duc whether a minority group of doctors who treat pain aggressively with opioids acted "within the bounds of medical practice." J.A. 1085. The government raised an objection to this testimony, which the district court sustained, on the grounds that it called for a legal conclusion. Id. Even if the district court's exclusion of this testimony were improper, any such error was harmless because of the examination that followed. See United States v. Pendergraph, 388 F.3d 109, 112 (4th Cir.2004) (recognizing that error in exclusion of evidence is harmless if it does not substantially sway the judgment).
Finally, Appellant argues that there was insufficient evidence to support each of his convictions. A "jury's verdict must be upheld on appeal if there is substantial evidence in the record to support it." United States v. Wilson, 198 F.3d 467, 470 (4th Cir.1999). In making this determination, "we view the evidence in the light most favorable to the government and inquire whether there is evidence that a `reasonable finder of fact could accept as adequate and sufficient to support a conclusion of a defendant's guilt beyond a reasonable doubt.'" Id. (quoting United States v. Burgos, 94 F.3d 849, 862 (4th Cir.1996) (en banc)). We now turn to an analysis of each claim.
Appellant argues that the government did not present sufficient evidence on Count 1 to prove either that he entered into an illicit agreement with his patients to distribute controlled substances unlawfully or that he did so knowingly. Proof of each was a necessary element of the conspiracy charge against him. United States v. Cropp, 127 F.3d 354, 361 (4th Cir.1997); United States v. Clark, 928 F.2d 639, 641-42 (4th Cir.1991). There is ample evidence, however, to support each element.
With respect to the first element, "it is not necessary to prove a formal agreement to establish a conspiracy in violation of federal law; a tacit or mutual understanding among or between the parties will suffice." United States v. Depew, 932 F.3d 324, 326 (4th Cir.1991). There was evidence that many of Appellant's patients were drug addicts who sought treatment from him with the express purpose of obtaining drugs and, further, that he prescribed drugs in quantities greater than he had reason to believe, or that tests revealed, his patients were using. See J.A. 134-35, 176, 248, 354, 356, 523, 527, 529, 533-34, 538-40, 543, 687. Viewed in a light most favorable to the government, this evidence supports a conclusion that McIver tacitly agreed with his patients to provide opioid prescriptions without legitimate medical reasons for doing so.
The government can satisfy the knowledge requirement by showing either that Appellant actually knew of the conspiracy, Cropp, 127 F.3d at 361, or that he was willfully blind to it by "purposely clos[ing] his eyes to avoid knowing what was taking place around him." United States v. Ruhe, 191 F.3d 376, 384 (4th Cir.1999) (quoting United States v. Schnabel, 939 F.2d 197, 203 (4th Cir.1991)). The government presented a plethora of evidence that demonstrates that Appellant either knew of the conspiracy, or, at the very least, was willfully blind to the unlawfulness of his actions.
Appellant challenges the sufficiency of the evidence on the third element of the § 841(a)(1) charges, whether he prescribed substances "outside the usual course of professional practice."16 See Alerre, 430 F.3d at 690 (quoting Moore, 423 U.S. at 124, 96 S.Ct. 335).
This evidence amply supports a finding that McIver's actions went beyond the legitimate practice of medicine and were "no different than [those of] a large-scale pusher," Tran Trong Cuong, 18 F.3d at 1138, and is thus sufficient to support each of McIver's § 841(a)(1) convictions.
In order to prove Counts 11 and 12, the government had to establish that McIver unlawfully distributed drugs to Shealy that resulted in his death. § 841(b)(1)(C). McIver argues only that the government did not present sufficient evidence to demonstrate that Shealy died from the drugs that he prescribed. Again, we disagree.
Oxycodone is a potent and addictive opioid that is classified as a Schedule II drug under the Controlled Substances ActSee 21 U.S.C. § 812 (2000); 21 C.F.R. § 1308.12(b)(1) (2004). It is marketed in instant-release form under trade names such as Roxicodone, Roxicet, OxyIR, and OxyFAST, and in a controlled-release form as OxyContin.
Dilaudid is the trade name for a medication that contains hydromorphone, a potent and addictive opioid that is classified as a Schedule II narcotic. § 1308.12(b)(1)
Methadone is a potent and addictive synthetic opioid that is used to treat pain and addiction to other opioids. It is classified as a Schedule II narcotic. § 1308.12(b)(1)
Morphine is one of the most powerful and addictive opioids. It is classified as a Schedule II narcotic. § 1308.12(b)(1)
InAlerre we pointed out that, "[i]n contrast to the criminal standard, a medical malpractice plaintiff in South Carolina must show in a civil case (1) `the generally recognized practices and procedures that would be exercised by competent practitioners in a defendant doctor's field of medicine under the same or similar circumstances,' and (2) `that the defendant doctor departed from the recognized and generally accepted standards, practices, and procedures.'" 430 F.3d at 690 (citing Gooding v. St. Francis Xavier Hosp., 326 S.C. 248, 487 S.E.2d 596, 599 (1997)).
While not directly relevant to the distinction between a civil and criminal standard of proof, we further note that the court here mirrored the instructions in bothTran Trong Cuong, 18 F.3d at 1137-38, and Alerre, 430 F.3d at 691 n. 9, by instructing the jury to base its decision on all of Appellant's actions and the surrounding circumstances. J.A. 1291. Appellant thus received the benefit of court-sanctioned deference to his professional judgment.
We entrust to the district court the task of ensuring that such evidence is sufficiently constrained as to not confuse a jurySee Fed.R.Evid. 403 (requiring exclusion of confusing evidence); Alerre, 430 F.3d at 691 n. 10 (noting that "undue emphasis on standard-of-care evidence might, in certain circumstances, confuse a jury."). Based on the record before us, we find nothing improper with the evidence admitted at trial.
We have previously recognized that in certain circumstances, such as cases involving specialized industries, "opinion testimony that arguably states a legal conclusion is helpful to the jury, and thus, admissible."United States v. Barile, 286 F.3d 749, 760 n.7 (4th Cir.2002) (quoting Weinstein's Federal Evidence § 704.04[2][a] (2d ed.2001)). Because we conclude that Dr. Storick's testimony did not embrace improper legal conclusions, we need not confront the question of whether his testimony falls under this exception.
This issue is a question of fact that is entrusted to the jury,see Tran Trong Cuong, 18 F.3d at 1137-38 (approving instructions given to jury on this issue); United States v. Kaplan, 895 F.2d 618, 623-24 (9th Cir.1990) (treating issue as question for jury); Oregon v. Ashcroft, 192 F.Supp.2d 1077, 1090 n. 15 (D.Or.2002) (recognizing issue as a question of fact for jury), and, therefore, is the proper subject of expert testimony, see Fed.R.Evid. 704(a).
We note as well that experts inTran Trong Cuong and Alerre testified similarly, and that the defendant in Tran Trong Cuong relied on the opinions of two physicians that his prescription practices were "within the state of the art" or "the medical standard." 430 F.3d at 686, 18 F.3d at 1135.