Opinion ID: 717496
Heading Depth: 3
Heading Rank: 1

Heading: sufficiency of the evidence

Text: 39 In challenging the sufficiency of the evidence, Dumlao bears a heavy burden. United States v. Gutierrez, 978 F.2d 1463, 1468 (7th Cir.1992). Our review in such cases is limited; it is not our function to reweigh the evidence, nor substitute our judgment for the decision of the jury. United States v. Hatchett, 31 F.3d 1411, 1416 (7th Cir.1994). We consider the evidence in the light most favorable to the prosecution, making all reasonable inferences in its favor, and will affirm the conviction so long as any rational trier of fact could have found the essential elements of the crime beyond a reasonable doubt. Jackson v. Virginia, 443 U.S. 307, 319, 99 S.Ct. 2781, 2789, 61 L.Ed.2d 560 (1979). Reversal is warranted only when the record is devoid of any evidence, regardless of how it is weighed, from which a jury could find guilt beyond a reasonable doubt. United States v. Garcia, 35 F.3d 1125, 1128 (7th Cir.1994) (quoting Gutierrez, 978 F.2d at 1468-69). 40
41 We first consider Dumlao's claim that the evidence was insufficient to support her conspiracy conviction. To sustain this conviction, the government must provide substantial evidence that (1) a conspiracy existed and (2) that Dumlao knowingly agreed to join it. United States v. Cabello, 16 F.3d 179, 181 (7th Cir.1994). We stated in United States v. Townsend, 924 F.2d 1385 (7th Cir.1991), that these elements may be proved entirely by circumstantial evidence. Id. at 1390 (citations omitted). The critical question, then, is whether the jury may reasonably infer that the necessary elements existed. Id. 42 Given these standards, there is ample evidence to support such an inference in this case. We have held that transactions in large quantities of drugs, prolonged cooperation between the parties, and [e]vidence that the parties have standardized their transactions with one another are all relevant factors in determining whether a conspiracy exists and whether one has knowingly joined it. See United States v. Kozinski, 16 F.3d 795, 808 (7th Cir.1994). These factors are present here. The jury heard evidence of Dumlao's many suspicious prescribing practices, including supplying quantities of Dilaudid far exceeding the needs of her purported patients. These practices continued over a period of four years. The jury also heard evidence of Dumlao's expensive, standardized charges-allegedly over $300 per prescription--which were always paid in cash, except for one bounced check. 43 Dumlao objects that these indicators are meant to apply only to what would normally be arms-length transactions between independent actors, not ongoing cooperative relationships such as those between a doctor and her patient. We have recognized the underlying rationale for this argument, which is that conspiracies, like business combinations, are often formed to reduce transaction costs. Townsend, 924 F.2d at 1394. It is true that these factors, standing alone, describe professional consultative relationships just as they indicate the possible existence of a conspiracy between people who are otherwise competitors. But this argument ignores the fact that these are relevant factors, not exclusive ones. This is another way of saying that their probative value often depends on context. 44 The jury had many contextual factors to consider in this case, especially as related to whether the interactions could be characterized as part of a doctor-patient relationship. The jury heard of futile attempts by the government to warn Dumlao about specific professional patients; such a warning is enough for most physicians to drop such patients immediately. Moreover, Dumlao claimed that she did not know that the drugs she prescribed were being used for illicit purposes, but yet she required some patients to sign to whom it may concern notes promising that they would not sell their medication. She knew that many patients had severe drug addictions, and also frequently left the date off her prescriptions so they could be filled at any time, thus evading regulatory laws. Aside from these facts, there is even a question as to what extent a doctor-patient relationship existed at all, since Dumlao met many patients only once, and dealt with Sanchez as a go-between thereafter. The jury could reasonably infer that Dumlao was in fact aware of the patients' intentions and the results of her own actions, and thus that an ordinary doctor-patient relationship did not exist. 45 Much evidence against Dumlao was independent of any potential argument about factors drawn from economic theory or the attributes of professional relationships. The jury also heard a recounting of shrill arguments between Sanchez and Dumlao over prescriptions and the payments for them. At times objects were apparently thrown or desks were cleared with a dramatic swipe of an arm. And while Dumlao asserted at trial that she ran a fee for service practice based on consultation time, even a patient/witness, Jeannette Neville, the wife of co-conspirator George Neville, testified that she understood that Dumlao's fees were charged per prescription, not per visit. These things are not features of usual medical practice or indicative of interactions with responsible government officials. As a further anomaly, Sanchez's letters virtually demanded prescriptions and instructed Dumlao in various ways, including the admonition do not play no games. 46 Finally, in addition to all these factors, Dumlao's acceptance of Sanchez's many government agent notes and letters easily permits an inference of Dumlao's awareness of the scheme. The many typographical errors aside, merely the content of Sanchez's letters to Dumlao was a glaring indication that something--really, everything--was amiss. The government argued that in view of her long years of education and experience, as well as her ethical and legal responsibilities related to the distribution of narcotics, a physician in Dumlao's position would not be so easily deceived. Moreover, the jury also heard that Dumlao had little to say about these letters in her defense. Referring specifically to the error-filled letters on direct examination, her attorney asked her: Did that signal anything to you? Did that make you suspicious at all? This was Dumlao's reply: 47 Well, knowing the person that has written the letter and how thorough she was, and this as far as she was--I am convinced as far as she but a list a lot as far as their personality, type A, and having believed her story because some of the persons that she mentioned were family members of previous patients I had. It was easy for me to connect what they were working on. 48 And when she writes the letter--and I am thinking more of the patient that is involved for one thing. At the same time I did notice a few misspellings, but that didn't basically--have worked in America I have seen some grammatical errors for English-speaking people. It's common. Because myself I come from a foreign country. Grammatically we are--because it's not our language, they are emphasizing quite a lot. 49 So even a medical person may misspell vomiting with two Ts instead of one. It's not surprising for me, for a patient for me to misspell certain words, and that was the explanation for that. 50 The finder of fact believed another explanation, and we will not question what was in effect their determination of credibility. Viewing all these factors in the light most favorable to the government, we find that a rational jury could reasonably infer, beyond a reasonable doubt, that a conspiracy existed and that Dumlao knowingly joined it. 51
52 Dumlao also appeals her conviction on thirteen counts of knowingly or intentionally acquiring or obtaining a controlled substance by misrepresentation, fraud, deception, or subterfuge in violation of the Controlled Substances Act, 42 U.S.C. § 843(a)(3). First, like her defense to the conspiracy charge, Dumlao argues that she was not aware that she was unlawfully issuing prescriptions, and thus did not have the requisite intent and knowledge to perpetrate a fraud upon pharmacies. In sum, Dumlao claims she was not the source of the fraud, but its victim--merely the conduit for the misrepresentations. This is a variation of the argument addressed above in the conspiracy context, and goes no further here. The jury found otherwise, and had a rational basis for doing so. 53 Dumlao next argues that the evidence offered to prove some of these counts was insufficient. Seven of the thirteen counts were based on prescriptions for six patients, none of whom testified at trial. Citing the Fourth Circuit's decision in United States v. Tran Trong Cuong, 18 F.3d 1132 (4th Cir.1994), Dumlao claims that the lack of testimony from these patients is impermissible because it invites the jury to find guilt by association or pattern, rather than consider each count independently. 54 In Tran Trong Cuong, the government attempted to prosecute a physician for over 130 counts of distribution of a controlled substance. The evidence for eighty of these counts, however, consisted merely of copies of the prescriptions and an expert's testimony and exhibit summarizing a fraction of the patients' files. 18 F.3d at 1141. None of the twenty patients who received the prescriptions testified. Id. Finding this to be a classic example of 'overkill' by the prosecution, the Fourth Circuit reversed Tran's convictions on the eighty counts for insufficiency of the evidence. Id. at 1142. 55 In a more recent case, however, the Fourth Circuit emphasized that the presence or absence of witness testimony is not the only criterion of sufficiency. In United States v. Singh, 54 F.3d 1182 (4th Cir.1995), the court stated that [i]n Tran Trong Cuong, we reversed the convictions, not because the victims did not testify, but rather because their lack of testimony was not replaced by any substantive evidence. Singh, 54 F.3d at 1188. Indeed, while witness testimony is important, it is difficult to see why it should be the touchstone in such determinations, especially given the fact that many patients in this case had terminal illnesses or suffered from a variety of other misfortunes which might have precluded availability. 56 In any event, unlike Tran Trong Cuong, there was plenty of substantive evidence regarding these counts without witness testimony. Much of this information was individual and particularized. In addition to the copies of the specific prescriptions, the government produced Dumlao's medical files on the patients in question. Furthermore, the government's expert reviewed all of these files and concluded that none contained adequate justification for a Dilaudid prescription--indeed, he noted some files contained information making such a prescription improper. Moreover, as a general factor, the jury was aware that all of these nontestifying patients were associated with Sanchez and her scheme to obtain Dilaudid. With these additional items of information, the jury was not asked to infer guilt on these counts merely from the other improper prescriptions. Accordingly, we find the evidence sufficient to support the convictions rendered.