Court Opinion

ID: 4277610
Source: CourtListenerOpinion
Date Created: 2018-05-23 14:43:08.68366+00
Date Added: 2024-06-11T14:34:11.068588
License: Public Domain

THE STATE OF SOUTH CAROLINA
                         In The Supreme Court

            The State, Respondent,

            v.

            Stephanie Irene Greene, Appellant.

            Appellate Case No. 2014-000764

                         Appeal from Spartanburg County
                       J. Derham Cole, Circuit Court Judge

                             Opinion No. 27802
                 Heard February 15, 2018 – Filed May 23, 2018

                 AFFIRMED IN PART, VACATED IN PART

            C. Rauch Wise, of Greenwood, for Appellant.

            Attorney General Alan Wilson and Senior Assistant
            Attorney General David Spencer, both of Columbia, and
            Seventh Judicial Circuit Solicitor Barry J. Barnette, of
            Spartanburg, for Respondent.

JUSTICE KITTREDGE: Appellant Stephanie Irene Greene appeals her
convictions and sentences for homicide by child abuse, involuntary manslaughter,
and unlawful conduct toward a child for the death of her infant daughter, Alexis.
Appellant was sentenced to prison for twenty years for homicide by child abuse,
five years concurrent for involuntary manslaughter, and five years concurrent for
unlawful conduct toward a child. We affirm the homicide by child abuse and
unlawful conduct toward a child convictions and sentences, but we vacate the
involuntary manslaughter conviction and sentence.

                                                               I.

Appellant was Alexis's mother; she was Alexis's caretaker during her brief life.
Alexis died from morphine poisoning when she was forty-six days old. Appellant,
a former nurse, was addicted to many drugs. The State contended that Appellant's
morphine addiction (as well as dependence on other drugs) caused Alexis's drug
poisoning through breastfeeding. The jury convicted Appellant on all charges.

This appeal followed. Appellant has raised four issues: (1) whether the trial court
erred in denying her motion for a directed verdict on all charges due to the State's
failure to prove causation; (2) whether the trial court erred in denying her motion
for a directed verdict on the homicide by child abuse charge due to the State's
failure to prove she acted with extreme indifference; (3) whether the trial court
erred in failing to instruct the jury that it could only return a guilty verdict on one
charge; and (4) whether the trial court erred in failing to require the State to open
fully on the law and the facts of the case. We address each of these issues in turn.

                                                               II.

Appellant's first assignment of error is the trial court's failure to grant a directed
verdict on all charges because the State allegedly failed to produce any evidence
that the morphine found in Alexis came from Appellant's breast milk. Appellant
ignores the "synergistic effect" of the morphine poisoning when considered along
with Appellant's abuse of other drugs. We have carefully reviewed the evidence
and, when viewed in a light most favorable to the State as our standard of review
mandates, we find sufficient evidence to present all charges to the jury. State v.
Bennett, 415 S.C. 232, 235, 781 S.E.2d 352, 353 (2016) (noting that when
reviewing the denial of a directed verdict the Court must not weigh the evidence
but must view it in the light most favorable to the State, for the Court is concerned
only with the existence or nonexistence of evidence) (citations omitted).

The State's causation theory was Appellant consumed excessive amounts of central
nervous system depressants, principally morphine,1 while breastfeeding Alexis and
these drugs passed through Appellant's breast milk, resulting in Alexis's death.
                                                            
1
 While the State focused mainly on Alexis's morphine poisoning, the other central
nervous system depressant abused by Appellant was Clonazepam.
The evidence at trial revealed that Appellant continuously took morphine—MS
Contin—and other drugs while pregnant with Alexis and while breastfeeding her.
Moreover, the evidence showed that Appellant took more morphine than her
doctors prescribed. In addition, Appellant exclusively breastfed Alexis until
approximately one week before her death. Appellant told investigators that she
began supplementing with formula due to her new blood pressure medication;
however, Appellant also told investigators that she breastfed Alexis extensively
during the two nights immediately preceding Alexis's death. Thus, sufficient
evidence was shown that Appellant took many drugs, including morphine, and
breastfed Alexis.

In addition, the evidence presented at trial was sufficient to show that the morphine
and Clonazepam found in Alexis came from Appellant's breast milk. Appellant
contends there is no evidence to support a finding that Alexis's drug poisoning was
the result of ingesting morphine through Appellant's breast milk. We disagree, for
we find the evidence, when considered in its entirety, provides a substantial basis
from which a reasonable juror could conclude Appellant's breast milk was the
source of the morphine that killed Alexis. The record includes extensive scientific
evidence on morphine and the synergistic effect when combined with other central
nervous system depressants. This evidence included the varying rates of
metabolism in adults, the absence of metabolism in infants, the transferability of
morphine from a mother to her baby through breast milk, and the risks of infants
ingesting morphine (and other drugs) from their mothers' breast milk.

Dr. David H. Eagerton, an assistant professor of pharmacology and founding
faculty member at the Presbyterian College School of Pharmacy and the former
chief toxicologist at the South Carolina Law Enforcement Division, provided
considerable testimony. Part of that evidence included the warning accompanying
MS Contin, which provides that morphine "passes into the breast milk":

      Dr. Eagerton: "Before taking MS Contin tell your healthcare
          provider if you have a history of it." It gives several histories.
          And then in bold again it says, "Tell your healthcare provider if
          you are pregnant or planning to become pregnant. MS Contin
          may harm your unborn baby. If you're breastfeeding MS Contin
          passes into the breast milk and may harm your baby."

(emphasis added).
Much of the scientific evidence addressed an infant's inability to absorb and
process a drug like morphine:

      The State: And obviously the child died. Obviously, it is consistent
         with that. Through the breastfeeding and everything a child—can
         it metabolize drugs like an adult does?

      Dr. Eagerton: No, they don't.

      The State: If you would, tell the jury about that, especially a six-
         week-[]old.

      Dr. Eagerton: Okay. Typically, whenever—just to kind of back up a
          little bit how—you have to understand what drugs do in your
          body.

          Once—once you take them they don't stay there forever. They go
          through a cycle. And in pharmacology we use the acronym
          ADME absorption. You have to get the drug into your system.
          So how do you get it in there? There's—there's lots of different
          ways. You can—most things we're talking about now is you think
          of it orally. But you can give it, you know, as a shot either just
          under your skin, in your muscle. You can give it [in an] IV
          directly in your veins. You can absorb some drugs through the
          skin, different things like that. So you have different routes of
          administration depending on what you're trying to do and what the
          drug is.

          Once you absorb it it's going to distribute throughout your body
          based on its chemical and physical properties, that is whether it
          likes water or whether it likes fat, or it distributes into one of those
          two areas in the body primarily.

          Certain tissues may pick up drugs preferentially, things like that.
          So it's going to distribute throughout your body.

          Then the next step is metabolism, which is more correctly termed
          biotransformation. Basically, your liver is responsible for that,
          and it has enzymes that develop over time that basically take these
          foreign compounds that you're taking and make it usually more
   water [soluble], and the idea is to make it either less toxic or more
   readily excreted. But the idea i[s] to make it more readily—more
   water [soluble] typically so that it could be more readily excreted
   from your body. And that's the last stage[] of elimination. And
   it's eliminated—it's eliminated—most drugs are going to be once
   they're—especially once they've been metabolized and made more
   water [soluble] they're going to be eliminated throughout the
   water in your body—urine, feces, sweat, saliva, tears, things like
   that is how it's going to be eliminated primarily. There are other
   ways too.

The State: Does a six-week-[]old child metabolize at all?

Dr. Eagerton: No, not typically because it take[s] time[] for your
    liver to develop. It takes time for these—the genes that code for
    these enzymes to turn on and be expressed. And you don't—even
    a child doesn't metabolize things the same as an adult.

   Usually you don't—whenever you go through puberty is whenever
   most of the things that are going to turn on for an adult is going to
   turn on.

   And, in fact, it even goes the other way. As you get old, become
   aged, some of these genes can become nonfunctional. Some—you
   may not have the same metabolic capacity.

   Your kidneys may not work as well, things like that. So you have
   to take into consideration age certainly whenever you're looking at
   the effects of drugs and how long they're going to stay in your
   body.

The State: Obviously, the baby Alexis showed signs of this before
   the death.

Dr. Eagerton: Right. The—the lethargy, maybe trouble breathing.
    I—I don't know how to interpret that exactly, but there [were]
    some—there were some symptoms that were conveyed that were
    consistent with morphine toxicity.
              The State: And basically if she was continuously breastfeeding and
                 things like that could she reach a level, especially if she didn't
                 metabolize it nearly as fast as the mother, for example, could it
                 reach the levels of toxicology—toxicity of the level [sic]?

              Dr. Eagerton: Yes. And that's one of the things that if you can't
                  metabolize it, then the drug may build up in your body and you
                  become—you have a toxic dose whenever you wouldn't normally
                  have a tox[ic] dose.

Dr. Eagerton's testimony further included the warning on morphine from
LactMed2:

              Dr. Eagerton: "Epidural morphine given to mothers for post[-]
                  cesarean section analgesia results in trivial amounts of morphine
                  in their colostrum and milk. Intravenous or oral doses of maternal
                  morphine in the immediate postpartum period result in higher
                  milk levels than with epidural morphine. Labor pain medication
                  may delay the onset of lactation. Maternal use of oral narcotics
                  during breastfeeding can cause infant drowsiness, central nervous
                  system depression and even death."

              (emphasis added).

              Dr. Eagerton: "[A]t least some of [the morphine] I believe within a
                  reasonable degree of scientific and medical certainty had to come
                 through the breast milk."

Accepting this evidence as true—as we must under the standard of review—one
may reasonably deduce that morphine ingested through breastfeeding "can cause . .
. death." The evidence, scientific and otherwise, further allows a reasonable juror
to conclude that Appellant's breast milk was the source of the morphine found in
Alexis's body. Thus, the testimony of Dr. Eagerton provides evidence that, if
believed, is sufficient to survive Appellant's directed verdict motion. The State
presented additional evidence.

                                                            
2
 LactMed is a database that provides information and warnings on drugs to which
breastfeeding mothers may be exposed. It is part of TOXNET, a database operated
by the National Institute of Health.
Dr. John D. Wren, a pathologist, performed the autopsy on Alexis. Dr. Wren is an
experienced pathologist, having performed more than four thousand autopsies.
Early in Dr. Wren's testimony, the State established that Alexis's body had no
needle marks. Dr. Wren stated that "the only way this child could have gotten that
much [morphine] would be orally, because I saw no injection sites. . . . The route
of administration had to have been orally." And as Dr. Wren explained, the level
of morphine in Alexis was lethal:

              Dr. Wren: Then you come to morphine. The level was .52 mg per
                  liter, therapeutic level was .10 to .30 mg per liter. And from my
                  references therapeutics [sic] .001 to .200. Toxic is .3 to 2.5. And
                  lethal is .2 to 7.2.

                       Now, you'll notice that some of these overlap. It really depends
                       on how the—how accustomed the body is to that drug.3
                                                            
3
  This is consistent with Dr. Eagerton's testimony that the line dividing toxic and
lethal levels is not an exact demarcation but rather falls within "a range."

Thus, the dissent's misconceptions are twofold. First, the dissent fails to appreciate
that the ranges for toxic and lethal levels of morphine are overlapping and that
Alexis's level fell within the overlapping area. According to the expert testimony
in this case, the level of morphine found in Alexis (.52 mg) could have been
classified in either the toxic level (.3 to 2.5 mg) or lethal level (.2 to 7.2 mg); it is
simply lethal because it caused her death. Therefore, the dissent's attempt to draw
an artificial distinction that there was only evidence showing enough morphine
could pass through the breast milk to be "toxic" but not "lethal" is unavailing.

Second, the dissent fails to recognize the expert testimony that a baby is unable to
metabolize this type of drug and chronic exposure can lead to a higher level of
morphine building up within the body, which can logically result in a lethal level
of morphine. It was not necessary to show Alexis received a lethal level of
morphine from one dose of breast milk in order to prove the State's causation
theory: "the child died as a result of consumption of a controlled substance through
the mother's breast milk." The State provided evidence that Appellant was taking
morphine and breastfeeding Alexis continuously, morphine can pass from a mother
to a baby through breast milk, the level of morphine can build up in a baby due to
the inability to process it, and Alexis died from a lethal level of morphine.
Contrary to the dissent's assertion, nothing more was required for the jury to make
a logical deduction.
                                        ...

         And then in pieds [sic]—I put this in because I had found this
         later—that the levels that produce surgical analgesia in pediatrics
         is .046 to .083, which is 46 to 83. Once again, the level reported
         [in Alexis] is 520. And then of course there's a caveat there.
         Lethal levels may be higher in individuals under chronic opioid
         treatment.

         If you have a person that's under chronic opioid treatment they're
         taking in a lot—a lot often and they're—over a long period of time
         they adjust to the—their body physiology adjusts to that, and they
         can sustain higher levels without it having an effect on them.

         So you have to take into account where the person has a history of
         that—and of course nobody that comes to the morgue is going to
         tell you they're taking morphine, and sometimes the family don't
         tell you either. So we have to take it if they don't have a
         prescription that they're getting it illegal[ly] or they're taking
         something else.

         So based on all of that all of these drugs essentially lead to
         respiratory depression. And so I said based on the history and
         autopsy findings—and I should have put in including toxicology
         results—it was my opinion that this child died as a result of
         respiratory insufficiency secondary to synergistic drug
         intoxication. I could just as easily have said morphine
         intoxication, but lawyers like to split hairs, and so I included them
         all.

         (emphasis added).

Dr. Wren's testimony continued:

      The State: And, Doctor, let me ask you this. Obviously, being a
         young child, six-and-a-half weeks, her metab—the ability to
         metabolize drugs, is it much less than an adult?

      Dr. Wren: That's—that's correct. It builds up.
The State: So it will build up over a period of time if it—if it keeps
   getting the drugs.

Dr. Wren: Yeah. If they can't metabolize it'd have to go somewhere.
    And there's something called intrahepatic circulation. If it's
    excreted into the bile or whatever, it gets into the GI tract, and it's
    reabsorbed and goes back in[,] it just recirculates. It's just not
    eliminated unless she's—has affluent diarrhea or—or urinating all
    of the time.

The State: So, and the—the mother was taking morphine in this
   situation and breastfeeding. Obviously, the baby was getting
   morphine though the—taking MS Contin actually.

Dr. Wren: At least some, yeah.

The State: Yeah. From there. So the baby would get the morphine
   from the mother.

Dr. Wren: That's correct.

The State: And could then metabolize it as fast as it, you know—in a
   fast way or was constantly getting it from the breast milk, could it
   build up in that body?

Dr. Wren: That's right. I did a couple of calculations. I'm not as
    good in my head as I used to be, but I think I might be correct or
    at least close. I have one reference here if I can find it.

The State: Yes, sir. Take your time.

Dr. Wren: It's from toxnet.

The State: Yes, sir.

Dr. Wren: It says—this is a caveat. "Newborn infants tend to be
    particularly sensitive to the effects of even small doses of
    analgesics. Once the mother's milk come in—comes in it's best to
    provide pain control with a nonnarcotic analgesic and limit
    maternal intake of morphine to a few days at a low dosage with
close infant monitoring. And then if the baby shows signs of
increased sleepiness more than usual, difficulty breastfeeding,
breathing difficulties, a physician should be contacted
immediately."

It goes further to say there's a study here of one mother who was
21 days postpartum, which is about half this one, [who] received
oral morphine, 10 mg every six hours, and for four doses. That's
40 mg. And then five [milligrams] every six hours for two doses.
So that's actually 50 mg total she got in a 24-hour period.

She had a peak morphine of a hundred micrograms per liter after
one hour, and four and a half hours after her first milligram, 5 mg
dose.

Using the peak level from this study an exclusively best—
breastfed infant would receive 15 micrograms per [] daily[,] equal
to about three percent of the maternal daily dose assuming a daily
maternal oral morphine dose of 40 mg.

Okay. So I took 40 mg and took three percent of that. That
comes out to be 1.2 mg.

The baby weighed 3,345 grams, which is 3.345 mg [sic]. And I
was doing this in my head, so I got—took three times 1.2.
That's—well, actually I didn't even do that. I took 1.2 mg and
divided that by the volume of blood in a child that age. The rule
of thumb is 75 to 80 milliliters per kilogram.

Okay. This child weighed, again, 3.345 kilograms, so 3.345 times
75 or 80 comes out to be about .285 liters. 285 milliliters is all the
blood that child had in her body, and that has to go into the tissues
everywhere in the body. So the—the blood—you'll have to take
my word for it. It is hard to get 10 ccs of blood out of a child, an
infant. It is really hard. The younger they are, the harder it is.

And we—a lot of places that do blood toxicology, they want 21
milliliters. They want three 7-milliliter tubes of blood. We can't
get that. So we have to send them small amounts.
          But, at any rate, if you take the 1.2 mg and divide it by two—.285
          you get about 4 mg per liter, which is 4,000 micrograms per liter.
          So that's—that's a good bit of—when we're talking about
          micrograms and milligrams, that's a good bit.

          Then I found another place in the same article where it says that
          an exclusively breastfed infant receives—tells what it receives.
          But it also says the peak morphine in—they did seven women
          who had preterm deliveries, and they—they gave them 60 mg of
          morphine in 24 hours cumulative. And they found out that the
          peak milk morphine varied, was 48 on the average mic—
          micrograms per liter. And the peak six glucuronide metabolite
          was 1,084 mg or micrograms per liter, which is also secreted in
          breast milk.

          And it's thought that that—that active drug, the six—the six
          isomer is actually secreted in the milk too. And in the infant's
          digestive system it's converted back to morphine, and that is
          another source of morphine.

Dr. Wren also re-read portions of the LactMed warning on morphine:

      Dr. Wren: "Maternal use of oral narcotics during breastfeeding can
          cause infant drowsiness, central nervous system depression[,] and
          even death. Newborn instant—infants seem to be particularly
          sensitive to the effects of even small do[s]es of narcotic analgesics
          and limited maternal intake of morphine to a few—to a few days
          at a low dosage with close infant monitoring is best to provide
          pain control and limited maternal intake to a few days at low
          dosage."

The defense stressed the lack of studies and peer-reviewed articles linking drug-
related infant deaths to breastfeeding. Dr. Wren provided a common sense
explanation:

      Dr. Wren: I don't—I don't think anybody in here would subject [a]
          child to an ongoing test like that.

In sum, the State presented evidence that Appellant continuously ingested
substantial doses of morphine and other drugs while pregnant and breastfeeding;
that morphine and other drugs can and do pass from a nursing mother to a
breastfeeding child through breast milk; that infants cannot metabolize morphine
and other drugs effectively; that Alexis exhibited symptoms consistent with
morphine toxicity; and that Alexis's death was caused by respiratory failure
secondary to synergistic drug intoxication.

As noted, we are mandated when reviewing the denial of a directed verdict motion
to view the evidence in a light most favorable to the State. When examined
through the proper lens, the State presented ample evidence that would permit the
jury to logically and reasonably conclude that Appellant's morphine consumption
while breastfeeding "place[d] the child at unreasonable risk of harm," S.C. Code
Ann. § 63-5-70(A)(1) (2010), and constituted "an act or omission by any person
which causes harm to the child's physical health or welfare" resulting in the child's
death, S.C. Code Ann. § 16-3-85 (2015). See State v. McKnight, 352 S.C. 635,
643–44, 576 S.E.2d 168, 172 (2003) (affirming the denial of a directed verdict
motion in a homicide by child abuse action despite an expert's inability to identify
"the exact mechanism" through which the cocaine affected the infant's body).4 
                                                            
4
   We, of course, agree with   the dissent that the "State must prove every element of
the crime charged." We are convinced the State has done so in this case, sufficient
to survive a directed verdict motion. With respect for the dissent, we disagree with
its reliance on the law concerning a jury's consideration of circumstantial evidence.
It is here that the dissent introduces its view that "additional reasoning" is needed.
While the dissent's desired framework may apply to a jury's consideration of
circumstantial evidence, it has no place at the directed verdict stage. The reliance
on McCormick on Evidence section 185 is misplaced, for this section "clarifies the
meaning of relevance[,]" not a trial court's consideration of circumstantial evidence
at the directed verdict stage. Similarly, the case of State v. Logan, cited by the
dissent, addressed a challenge to a circumstantial evidence jury charge. 405 S.C.
83, 747 S.E.2d 444 (2013). Logan does not remotely touch upon a trial court's
consideration of circumstantial evidence at the directed verdict stage. The dissent
conflates the standards that apply to a trial court's consideration of circumstantial
evidence at a directed verdict motion and a jury's consideration of circumstantial
evidence. This conflation of different standards was addressed in Bennett, as the
Court concluded that "the lens through which a court considers circumstantial
evidence when ruling on a directed verdict motion is distinct from the analysis
performed by the jury." State v. Bennett, 415 S.C. 232, 236, 781 S.E.2d 352, 354
(2016). Paradoxically, the dissent does acknowledge that "the State presented
substantial circumstantial evidence to support its theory that Alexis died as a result
                                                               III.

Appellant argues that, even if causation was shown, the trial court erred in failing
to direct a verdict on the homicide by child abuse charge because the State did not
prove she acted with extreme indifference.

"A person is guilty of homicide by child abuse if the person . . . causes the death of
a child under the age of eleven while committing child abuse or neglect, and the
death occurs under circumstances manifesting an extreme indifference to human
life." S.C. Code Ann. § 16-3-85(A)(1) (2015). For purposes of this statute, we
have previously defined "extreme indifference" as "a mental state akin to intent
characterized by a deliberate act culminating in death." McKnight v. State, 378
S.C. 33, 48, 661 S.E.2d 354, 361 (2008) (quoting State v. Jarrell, 350 S.C. 90, 98,
564 S.E.2d 362, 367 (Ct. App. 2002)).

In this case, sufficient evidence was presented to show that Appellant was addicted
to prescription drugs—including morphine—and Appellant knew she should use
caution in taking morphine while pregnant or breastfeeding but elected to take it in
excessive amounts without a doctor's supervision ensuring Alexis's safety.5

The testimony at trial revealed that Appellant began receiving prescription drugs
due to injuries sustained in a car accident in 1998. In January 2006, Appellant was
pregnant and began seeing Dr. Kooistra to treat a seizure disorder. Notably, Dr.
Kooistra did not prescribe any pain medications for Appellant while she was
pregnant and tried "to avoid prescribing medications of any sort during
pregnancy." In November 2007, Appellant began seeing Dr. Kovacs and receiving
                                                            
of ingesting morphine from [Appellant's] breast milk." The dissent circumvents
this undeniable finding by parsing selected portions of the testimony favorable to
Appellant and recasting that evidence as the "proper lens." The State must present
evidence from which a jury can fairly and logically deduce that the defendant
committed the offense charged, and at the directed verdict stage, the evidence must
be viewed in a light most favorable to the State, not the defendant.
5
 In addition, the toxicology report revealed that Alexis tested positive for
Klonopin (Clonazepam), for which Appellant had a prescription. The pill bottle
for this drug, found in Appellant's room on the morning of Alexis's death,
specifically instructed, "Do not use if pregnant or suspect you are pregnant or are
breastfeeding."
prescriptions for various narcotics. Unbeknownst to Dr. Kovacs, Appellant
continued to receive other pain prescriptions from Dr. Kooistra. In March 2010,
when Appellant realized that she was pregnant with Alexis, she did not notify
either prescribing doctor. In April 2010, Appellant requested to switch her
prescription patch—Duragesic—to MS Contin pills, which Dr. Kovacs prescribed
as she was unaware that Appellant was pregnant. Dr. Kovacs testified that she
would not have prescribed morphine to Appellant had she known of the pregnancy.
In addition, Dr. Bridges, Appellant's O.B.G.Y.N. physician, testified that she and
her colleagues were unaware that Appellant was taking morphine prior to the birth,
during delivery, and postpartum.

Throughout her pregnancy, Appellant failed to disclose that she was pregnant to
the doctors prescribing morphine to her and failed to disclose that she was taking
morphine to her prenatal doctors. In addition, she routinely omitted the fact that
she was taking morphine from the paperwork that she submitted to her doctors.
The testimony at trial was that, at the very least, the drug should only be taken
under a doctor's supervision so the baby's health could be monitored.
Nevertheless, Appellant failed to disclose this important information to any of her
doctors.

The morphine addiction and concealment continued after Alexis's birth. In
October 2010, Appellant told Dr. Kovacs that she had missed her appointments
since receiving the MS Contin prescription in April because she had been so
depressed that she could not leave the house—her pregnancy and Alexis's recent
birth were never mentioned. One of the State's experts, Dr. Eagerton, testified that
the use of morphine during lactation is not recommended. Moreover, in response
to whether "the doctors definitely need to know about this," Dr. Eagerton stated,
"Absolutely." Again, Dr. Kovacs testified that she would not have given Appellant
the medication had she known about the pregnancy and Dr. Bridges testified that
no mention of morphine was made during Appellant's postpartum visit. Due to her
nondisclosure, the record reveals that Appellant received an additional prescription
for MS Contin and continued to breastfeed Alexis.

The morning of Alexis's death, Appellant omitted morphine from the list of her
current prescriptions that she provided to the investigators, despite their specific
inquiry upon finding the pill bottle in her bedroom. At that time, Appellant only
admitted to taking morphine while pregnant with Alexis. When initially
questioned by law enforcement, Appellant lied about her morphine addiction. It
was only after the autopsy and toxicology reports were finalized and Appellant was
interviewed again by Investigator Gary that she told the truth and acknowledged
her addiction. Specifically, Investigator Gary testified that Appellant "finally
admitted she just didn't tell [the doctors] because she was afraid they'd take off
[sic] her off the morphine."

Thus, viewing the evidence in the light most favorable to the State, the jury could
conclude Appellant acted with extreme indifference in taking the morphine and
breastfeeding her child, resulting in Alexis's death.

                                                               IV.

Appellant argues alternatively that if the homicide by child abuse conviction
stands, the multiple convictions and sentences for the remaining offenses cannot
stand and should be vacated. Concerning the involuntary manslaughter conviction
and sentence, we agree. As explained below, we find nothing in South Carolina's
homicide statutes or law that reflects a legislative intent to deviate from the
overwhelmingly prevailing view that the homicide of one person by one defendant
is limited to one homicide punishment—one homicide, one homicide punishment.
Concerning the unlawful conduct toward a child charge, we reject Appellant's
challenge and affirm, for that entirely separate offense was complete prior to
Alexis's death.

                                                               A.

Multiple offenses, including multiple homicide offenses, may be prosecuted in a
single trial, but principles inherent in double jeopardy and due process preclude
multiple punishments for the same offense.6 See, e.g., State v. Cavers, 236 S.C.
305, 311–12, 114 S.E.2d 401, 404 (1960) ("It was within the province of the jury
to find whether appellant's conduct was negligent or reckless, or neither; if
negligent, it would have supported a verdict of guilty of manslaughter, the court
having eliminated murder and voluntary manslaughter; if reckless, it sustains the
verdict of guilty of reckless homicide, and that finding by the jury is implicit in the
verdict. The jury were instructed that they could not find appellant guilty on both
                                                            
6
  U.S. Const. amend. V ("No person shall . . . be subject for the same offence to be
twice put in jeopardy of life or limb . . . ."); U.S. Const. amend. XIV ("[N]or shall
any State deprive any person of life, liberty, or property, without due process of
law"); S.C. Const. art. I, § 3 ("[N]or shall any person be deprived of life, liberty, or
property without due process of law . . . ."); S.C. Const. art. I, § 12 ("No person
shall be subject for the same offense to be twice put in jeopardy of life or liberty
. . . .").
counts. To sustain this point of appellant would require the court, instead of the
jury, to determine whether his conduct was negligent or reckless, if either, which,
under the evidence in this case, would be an invasion by the court of the province
of the jury. The State cannot be required to elect between counts in an indictment
when they charge offenses of the same character and refer to the same transaction,
whether or not one charges a common law offense and another a statutory offense."
(citations omitted)); see also Ball v. United States, 470 U.S. 856, 859, 861 (1985)
("It is clear that a convicted felon may be prosecuted simultaneously for violations
of §§ 922(h) and 1202(a) involving the same firearm. This Court has long
acknowledged the Government's broad discretion to conduct criminal prosecutions,
including its power to select the charges to be brought in a particular case. . . . To
say that a convicted felon may be prosecuted simultaneously for violation of §§
922(h) and 1202(a), however, is not to say that he may be convicted and punished
for two offenses. Congress can be read as allowing charges under two different
statutes with conviction and sentence confined to one. Indeed, '[a]ll guides to
legislative intent,' United States v. Woodward, 469 U.S. 105, 109, 105 S. Ct. 611-
613, 83 L. Ed. 2d 518 (1985), show that Congress intended a felon in [the
defendant's] position to be convicted and punished for only one of the two
offenses." (citations omitted)).

While the South Carolina legislature has manifestly authorized multiple homicide
charges for a single homicide, we find no expression of legislative intent
authorizing multiple homicide punishments for a single homicide committed by a
single defendant. As a result, absent legislative intent to the contrary, we follow
the prevailing rule—one homicide is limited to one homicide punishment per
defendant. See Ervin v. State, 991 S.W.2d 804 (Tex. Crim. App. 1999) (collecting
cases from various jurisdictions supporting that one person causing one death
should result in one murder or homicide conviction); see also People v. Lowe, 660
P.2d 1261, 1271 n.11 (Colo. 1983), abrogated on other grounds by Callis v.
People, 692 P.2d 1045 (Colo. 1984) (collecting "[c]ases holding that a person may
be convicted of only one homicide offense for the killing of one person"). "It
would be a strange system of justice that would permit the defendant to be
sentenced to two . . . sentences for the killing of one person." People v. Hickam,
684 P.2d 228, 231 (Colo. 1984) (quoting Lowe, 660 P.2d at 1270–71).
"[C]onviction of both charges, arising from the slaying of the same person amounts
to piling punishment upon punishment. Fundamental fairness precludes such a
practice." Loscomb v. State, 45 Md. App. 598, 613, 416 A.2d 1276, 1285 (1980).
                                         B.

              Homicide by Child Abuse and Involuntary Manslaughter

Appellant was indicted on both homicide by child abuse and involuntary
manslaughter charges as a result of Alexis's death.

The homicide by child abuse statute reflects the legislature's intent to define and
target a specific societal problem—child abuse resulting in death, which further
explains why multiple homicide offenses may be prosecuted in a single trial. The
statute defines in detail the elements of homicide by child abuse: "caus[ing] the
death of a child under the age of eleven while committing child abuse or neglect"
where "the death occurs under circumstances manifesting an extreme indifference
to human life." S.C. Code Ann. § 16-3-85(A)(1) (2015). Conversely, the now
codified common law offense of involuntary manslaughter is defined in broad
terms, covering unintentional killings from both unlawful conduct that does not
naturally tend to place another in danger of death or serious bodily harm and
lawful conduct that recklessly places another in danger of harm. See, e.g., State v.
Sams, 410 S.C. 303, 309, 764 S.E.2d 511, 514 (2014) ("Involuntary manslaughter
is defined as the unintentional killing of another without malice while engaged in
either (1) the commission of some unlawful act not amounting to a felony and not
naturally tending to cause death or great bodily harm, or (2) the doing of a lawful
act with a reckless disregard for the safety of others."); S.C. Code Ann. § 16-3-60
(2015).

In McKnight v. State, 378 S.C. 33, 51–52, 661 S.E.2d 354, 363 (2008), we applied
the Blockburger "same-elements" test and held that involuntary manslaughter is
not a lesser included offense of homicide by child abuse. See Blockburger v.
United States, 284 U.S. 299 (1932). In McKnight, we stated a defendant charged
with homicide by child abuse was not entitled to a jury charge on involuntary
manslaughter because "the elements of involuntary manslaughter will never be
included in the greater offense of homicide by child abuse." Id. at 52, 661 S.E.2d
at 363. The lawful-conduct-in-a-criminally-negligent-manner prong could not
apply because child abuse is not lawful. Id. at 51–52, 661 S.E.2d at 363. Further,
the unlawful-conduct version of involuntary manslaughter could not apply because
"child abuse could never be defined as an unlawful activity not tending to cause
death or great bodily harm." Id. at 52, 661 S.E.2d at 363 (internal quotation marks
omitted).
This issue is presented to us in an unusual posture. While both homicide charges
were properly presented to the jury, the jury was not instructed in accordance with
Appellant's proper request—Appellant could not be found guilty of both homicide
by child abuse and involuntary manslaughter. In this situation, the jury should
have been instructed that, depending on their view of the evidence, they could find
Appellant not guilty of both homicide offenses, guilty of homicide by child abuse,
or guilty of involuntary manslaughter—but may not find Appellant guilty of both
homicide charges. The State erroneously contends both homicide convictions and
punishments should stand.

The flaw in the State's argument on appeal is best understood by reviewing its
theory of criminal liability as the trial unfolded. After indicting Appellant on
varying homicide charges (which as a matter of law could not be premised on one
theory of liability), the State ultimately elected to pursue a single theory of
liability—Alexis's death from morphine poisoning was caused by the morphine in
Appellant's breast milk—and the trial court instructed the jury, "That applies to
each of the separate charges." The jury could have accepted Appellant's view of
the evidence and found Appellant not guilty of homicide by child abuse.
Specifically, the jury could have concluded the State failed to prove Appellant
"committed a deliberate or intentional act under circumstances revealing an
extreme indifference to human life."7 In that scenario, the jury may have
nevertheless found Appellant guilty of involuntary manslaughter.8 But the jury's
guilty verdict on Count One in the indictment—homicide by child abuse—
precluded a guilty verdict on the charged offense of involuntary manslaughter in

                                                            
7
    This language is from the trial court's jury charge on homicide by child abuse.
8
  The trial court's charge on involuntary manslaughter included the instruction,
"Unintentional means that the defendant did not intend to kill the child nor did the
defendant intend to inflict serious bodily harm or injury to the deceased child." A
finding that Appellant's conduct satisfied this standard would be consistent with
Appellant's argument that it is safe for breastfeeding mothers to take morphine.
However, it would be inconsistent with a finding that Appellant "committed a
deliberate or intentional act under circumstances revealing an extreme indifference
to human life."
Count Two. Thus, under these circumstances, a conviction and sentence for each
homicide charge cannot stand.9

The situation here should be contrasted with a homicide that would properly fall
within multiple homicide statutes. In that situation, a jury may properly return a
guilty verdict on more than one homicide charge. In State v. Easler, 327 S.C. 121,
489 S.E.2d 617 (1997), this Court affirmed convictions and sentences for two
homicide charges—felony driving under the influence causing death and reckless
homicide—arising out of a motor vehicle accident that killed one person and
seriously injured another. The evidence and theory of criminal liability satisfied
the elements of both homicide statutes. Easler, however, went further and
affirmed multiple punishments for the single homicide committed by one
defendant, and this was error. We overrule Easler to the extent it authorizes
multiple homicide punishments involving only one homicide.

It is because of this rule—one homicide, one homicide punishment—that even
were we to accept the State's argument that the involuntary manslaughter guilty
verdict should stand, an additional sentence for Alexis's death could not stand. The
fact that Appellant received a concurrent five-year sentence for involuntary
manslaughter does not change the result. The concurrent sentence likely reflects
the learned trial judge's inherent understanding that a consecutive sentence could
not be imposed. Yet the conviction itself is considered a punishment and that, too,
must be vacated. Ball v. United States, 470 U.S. 856, 864–65 (1985) ("The second
conviction, whose concomitant sentence is served concurrently, does not evaporate
simply because of the concurrence of the sentence. The separate conviction, apart
from the concurrent sentence, has potential adverse collateral consequences that
may not be ignored. . . . Thus, the second conviction, even if it results in no greater
sentence, is an impermissible punishment.").

                                                               V.

Appellant's final challenge is the claim of error in the trial court's refusal to
"require the State to open fully on the law and the facts of the case [in closing
argument] and replying only to new arguments of defense counsel." We affirm
pursuant to Rule 220, SCACR, and the following authority: State v. Beaty, Op.
                                                            
9
  This is the very argument made by defense counsel to the trial court, as he
argued, "it's very inconsistent for the jury to have found that, one, [Appellant] was
simply negligent, or, two, grossly negligent, or, three, extreme indifference,
because there are different standards requiring different—different things."
No. 27693 (S.C. Sup. Ct. filed Apr. 25, 2018) (Shearouse 2018 Adv. Sh. No. 17 at
57).

                                       VI.

In sum, the homicide by child abuse and unlawful conduct toward a child
convictions and sentences are affirmed; the involuntary manslaughter conviction
and sentence is vacated; and we find no error in the order and manner of closing
arguments.

AFFIRMED IN PART, VACATED IN PART.

BEATTY, C.J., HEARN and JAMES, JJ., concur. FEW, J., concurring in
part and dissenting in part in a separate opinion.
JUSTICE FEW: I concur in sections III, IV, and V of the majority opinion. I
also concur with the conclusion the majority reaches in section II that Greene's
conviction for unlawful conduct toward a child must be affirmed. I disagree,
however, that we may affirm Greene's homicide convictions. On this point, for the
reasons I will explain, I dissent.

                                                               I.

The State argues it is not required to prove scientific facts with expert testimony as
we require civil plaintiffs to do. The State is mistaken. The State must prove
every element of the crime charged, State v. Attardo, 263 S.C. 546, 550, 211
S.E.2d 868, 870 (1975), and when establishing any one element requires the State
to prove a fact that is beyond the common understanding of lay people, the State
must prove that fact by expert testimony, see Graves v. CAS Medical Systems, Inc.,
401 S.C. 63, 80, 735 S.E.2d 650, 659 (2012) ("In some design defect cases, expert
testimony is required . . . because the claims are too complex to be within the ken
of the ordinary lay juror."); Watson v. Ford Motor Co., 389 S.C. 434, 445, 699
S.E.2d 169, 175 (2010) (stating "expert evidence is required where a factual issue
must be resolved with scientific, technical, or any other specialized knowledge");
see also Green v. Lilliewood, 272 S.C. 186, 192, 249 S.E.2d 910, 913 (1978)
(holding that unless the subject is a matter of common knowledge, expert
testimony is required to establish that a defendant failed to conform to a required
standard of care in a medical malpractice case); Kemmerlin v. Wingate, 274 S.C.
62, 65, 261 S.E.2d 50, 51 (1979) (holding in a public accounting malpractice
action: "Since this is an area beyond the realm of ordinary lay knowledge, expert
testimony usually will be necessary to establish both the standard of care and the
defendant's departure therefrom.").

                                                               II.

The State's theory of how Greene caused Alexis's death was narrow:10 Greene took
morphine and other medications while breastfeeding, the morphine passed through

                                                            
10
  In all prosecutions for homicide, the State must prove the defendant caused the
death of the victim. See State v. McIver, 238 S.C. 401, 406, 120 S.E.2d 393, 395
(1961) ("In a homicide case, the corpus delicti consists of two elements—the death
of the person killed, and its causation by the criminal act of another."). McIver was
a manslaughter case, 238 S.C. at 403, 120 S.E.2d at 393, and the causation element
Greene's breast milk, and Alexis died as a result of morphine intoxication.11 The
trial court charged the jury,

                             The State has the burden of proving these crimes, but it
                             involves the ingestion of the controlled substance by the
                             child through the child's mother's breast milk. That's the
                             State's allegation and theory in the case, that the child
                             died as a result of consumption of a controlled substance
                             through the mother's breast milk. That applies to each of
                             the separate charges.

The State had no difficulty proving Greene was taking morphine while
breastfeeding, and that Alexis died from morphine intoxication. The issue,
therefore, is whether the State proved the morphine that killed Alexis came from
Greene's breast milk.

              A.             Circumstantial Evidence of Causation

On this point, as the majority has explained in detail, the State presented
substantial circumstantial evidence, which we view in the light most favorable to
the State. State v. Pearson, 415 S.C. 463, 470, 783 S.E.2d 802, 806 (2016).
The majority has recited the strongest circumstantial evidence in the record that
supports the State's theory of causation, but to be fair, there is even more than what
the majority has included. In fact, the circumstantial evidence that Alexis died
from ingesting morphine through Greene's breast milk appears overwhelming, until
we pose the scientific question of whether it is even possible for enough morphine
to pass through breast milk to kill a child.

 

                                                            
is specifically included in the statute governing homicide by child abuse, S.C.
Code Ann. § 16-3-85(A) (2015).
 
11
  The State began the trial with alternative theories of causation. The first theory
was that Greene administered morphine directly to Alexis. At the conclusion of all
evidence, however, the State elected not to proceed on the basis of a direct transfer
of morphine, and the trial court directed a verdict for Greene on that theory.
 
      B.     Circumstantial Evidence Cases

The use of circumstantial evidence to prove guilt in criminal trials contemplates
that "even if the circumstances depicted are accepted as true, additional reasoning
is required to reach the desired conclusion." Kenneth S. Broun et al., McCormick
on Evidence § 185, at 397 (Hornbook Series, 7th ed. 2014). In State v. Logan, 405
S.C. 83, 747 S.E.2d 444 (2013), we described the "evaluation of circumstantial
evidence" and stated it "requires jurors to find that the proponent of the evidence
has connected collateral facts in order to prove the proposition propounded—a
process not required when evaluating direct evidence." 405 S.C. at 97, 747 S.E.2d
at 451; see also 405 S.C. at 97-98, 747 S.E.2d at 451 ("Analysis of circumstantial
evidence is plainly a more intellectual process."). In every circumstantial evidence
case in which this Court affirmed the sufficiency of the evidence, the "additional
reasoning" required to "connect[] collateral facts in order to prove the proposition
propounded" was such that a lay juror could readily conduct the reasoning and
make the connection. In those cases, the "intellectual process" through which the
jury could reasonably infer the guilt of the defendant from the circumstances
proven by the State involved a chain of inferences that lay jurors were fully
capable of navigating.

In Pearson, for example, the State proved the following circumstances: the
suspects fled the victim's home in the victim's stolen El Camino, and Pearson's
fingerprint was found in the truck's bed where the victim saw one of the suspects
sitting; Pearson lied about ever having been to the victim's house when he had
previously done considerable landscaping work there; and Pearson lied about
knowing the co-defendant whose DNA was found on the duct tape on the victim's
head. 415 S.C. at 465-69, 473-74, 783 S.E.2d at 803-05, 808. From those
circumstances, a lay juror could readily conclude through a chain of non-scientific
inferences that Pearson was one of the people who robbed and beat the victim. We
found "the evidence could induce a reasonable juror to find Pearson guilty." 415
S.C. at 474, 783 S.E.2d at 808.

In State v. Bennett, 415 S.C. 232, 781 S.E.2d 352 (2016), the State proved the
following circumstances: Bennett's blood was found on the floor directly beneath
the spot from which a television was stolen from a public building; his fingerprint
was found on another television the suspects had attempted to steal from the
"community room" of the building; and though Bennett "was known to frequent"
the room in which his blood was found, "[t]estimony suggested Bennett would
have no reason to be in the community room." 415 S.C. at 234-35, 237, 781
S.E.2d at 353, 354. From those circumstances, a lay juror could readily conclude
through a chain of non-scientific inferences that Bennett committed the burglary,
malicious injury, and larceny. We found "the evidence could induce a reasonable
juror to find Bennett guilty." 415 S.C. at 237, 781 S.E.2d at 354.

In Pearson, Bennett, and every other case in which this Court found the State's
presentation of purely circumstantial evidence sufficient to survive a motion for
directed verdict, a jury was fully capable of performing the "additional reasoning
. . . required to reach the desired conclusion" by using its common knowledge,
experience, and understanding.12 In each of those cases, therefore, we focused
only on the State's proof of collateral facts or circumstances—not on the inferences
to be drawn from those facts or circumstances—and we found the State's proof of
the circumstances sufficient to support the fact inferred.

              C.             The Circumstantial Evidence Standard

In Bennett, we reiterated that when reviewing the sufficiency of circumstantial
evidence, "The Court's review is limited to considering the existence or
nonexistence of evidence, not its weight." 415 S.C. at 235, 781 S.E.2d at 353
(citing State v. Cherry, 361 S.C. 588, 593, 606 S.E.2d 475, 478-79 (2004)). We
criticized the court of appeals in Bennett for considering a "plausible alternative
theory" because doing so is "contrary to our jurisprudence and misapprehends the
court's role" compared to the role of the jury. 415 S.C. at 236, 781 S.E.2d at 354.
We held "the trial court . . . must submit the case to the jury if there is 'any
substantial evidence which reasonably tends to prove the guilt of the accused, or
from which his guilt may be fairly and logically deduced.'" 415 S.C. at 236-37,
781 S.E.2d at 354 (quoting State v. Littlejohn, 228 S.C. 324, 329, 89 S.E.2d 924,
926 (1955)).

In this case, the State presented substantial circumstantial evidence to support its
theory that Alexis died as a result of ingesting morphine from Greene's breast milk,
and abandoned any alternative theory of causation. Therefore, under Bennett and
the long line of cases upon which it relies, our task is limited to the second step in
the Bennett/Littlejohn analysis. The question before us under that second step is
                                                            
12
  See generally Holland v. Georgia Hardwood Lumber Co., 214 S.C. 195, 204, 51
S.E.2d 744, 749 (1949) (discussing circumstantial evidence in a workers'
compensation case, and stating, "The facts and circumstances shown should be
reckoned with in the light of ordinary experience, and such conclusions deduced
therefrom as common sense dictates.").
whether a reasonable jury could "fairly and logically" conclude from the
circumstances proven that the State established the causation element under its
theory. This, in turn, requires us to determine if the chain of inferences the jury
must follow to reach this conclusion may be completed by the jury using its
common knowledge, experience, and understanding, or whether expert testimony
should be required.

Greene argues the jury could not fairly and logically complete this second step
because, in the course of its analysis, the jury would necessarily consider whether
it is even possible that a breastfeeding mother can transmit morphine through her
breast milk in sufficient concentration to cause the death of a child. Green argues
the means of answering this question are beyond the common knowledge,
experience, and understanding of a lay juror. Therefore, Greene argues, expert
testimony was required to establish the causal connection between morphine in the
mother's breast milk and Alexis's death. Specifically, Greene argues the State was
required to present an expert opinion that morphine—by itself or synergistically
with other drugs—passed through her breast milk to kill Alexis.

I agree with Greene. In reaching this conclusion, I find it particularly important
that the State's own expert witnesses refused to state the morphine that killed
Alexis came from Greene's breast milk, or even whether that was possible. The
reader may repeatedly scour the majority's outstanding recitation of the State's
expert testimony—or the record from which it came—but will not find any
testimony that comes close to such a statement. In fact, as I will explain, the
State's two experts openly avoided answering this question. In addition, the
circumstances proven at trial, considered in the light most favorable to the State,
include the fact that reliable medical organizations and journals have stated it can
be "safe" to take morphine while breastfeeding a child. Finally, the record in this
case does not include even one instance documented in medical literature of a
lethal level of morphine in a child that resulted from a breastfeeding mother taking
morphine.

      D.     Expert Testimony on Causation

The State presented the testimony of two experts. David H. Eagerton, Ph.D., is an
assistant professor of pharmacology and founding faculty member at the
Presbyterian College School of Pharmacy and the former chief toxicologist at the
South Carolina Law Enforcement Division. His doctoral degree is in
pharmacology, and he is board certified in forensic toxicology. Dr. Eagerton gave
an extensive explanation of the numerous drugs found in Alexis's body after her
death, including what he considered to be a lethal level of morphine, and how the
combination of those drugs can work synergistically to increase the toxic effects of
the drugs in the blood. He explained how drugs are absorbed into the body and
that infants do not metabolize quickly because their liver has not yet developed. At
one point, Dr. Eagerton testified a six-week old child like Alexis typically does not
metabolize "at all."

The State then asked, "If she was continuously breastfeeding . . . could [Alexis]
reach a level, especially if she didn't metabolize it nearly as fast as the mother,
could it reach the levels of toxicology -- toxicity of the level?" Dr. Eagerton
answered, "Yes." Dr. Eagerton went on to explain Alexis showed symptoms that
were "consistent with morphine toxicity." He testified morphine may build up in a
child's body to become "toxic." But Dr. Eagerton distinguished "toxic" from
"lethal." Toxic means it will make you sick; lethal means it will kill you. There
was never any dispute that morphine in breast milk could make a child sick. In
fact, the label on the package states morphine "passes into the breast milk and may
harm your baby."

On cross-examination, Dr. Eagerton acknowledged several articles in the medical
literature that list morphine as "safe to take while breastfeeding," and conceded
"based upon [his] research" he was not aware of any documentation in the medical
literature "that ever says a mother taking morphine can create a toxic level of
morphine in the child through breast milk." Counsel showed Dr. Eagerton a 2012
article from the journal Clinical Toxicology entitled, "Is Maternal Opioid Use
Hazardous to Breastfed Infants," and the following dialogue took place,

             Q:     Look on page six of this journal. And this is a
                    peer-reviewed journal, correct?

             A:     That's right.

             ....

             Q:     Look there if you would on this highlighted
                    portion . . . [and] read that to us.

             A:     "The medical literature describes scant evidence of
                    opioid toxicity in breastfed infants."

             Q:     Do you have any evidence that's contrary to that?
                             A:             No, sir. . . .

                             ....

                             Q:             So there is scant evidence?

                             A:             That is correct.

                             Q:             Which is pretty close to none.

                             A:             Yes, sir.

                             ....

                             Q:             So you are in no position to say then that that
                                            number[13] came through breast milk?

                             A:             I don't believe I've said one way or the other.
                                            Nobody's asked me.

                             Q:             But you don't have any basis for saying that it
                                            came through breast milk?

                             A:             Had to get into the baby somehow.

                             Q:             That's not my question. You have no basis for
                                            saying that number came into the baby through
                                            breast milk?

                             A:             I don't know that I'd say I have no basis. I'd say
                                            the basis is the mother is taking . . . morphine. She
                                            is breastfeeding. We know that based on the
                                            literature we've already talked about that at least
                                            small amounts certainly do pass through into the
                                                            
13
  The question refers to the number 0.52 mg/L, the concentration of morphine
measured in Alexis's blood after her death. Dr. Eagerton testified he considered
that a lethal level of morphine.
                                            breast milk. So I don't think I have a basis to say
                                            that it didn't, or at least some of it.

The strongest testimony Dr. Eagerton gave on the causation question came when
he read from the LactMed database14 on the TOXNET internet site maintained by
the National Institutes of Health in its National Library of Medicine. He testified,
"Maternal use of oral narcotics during breastfeeding can cause infant drowsiness,
central nervous system depression and even death." However, Dr. Eagerton was
careful never to say that the morphine that came from Greene's breast milk killed
Alexis—that it was "lethal." In fact, he was specifically asked, "So, you cannot
make a conclusion today as to how that morphine got into the baby?" He replied,
"No, sir. I think I can make a conclusion . . . at least some of it . . . had to come
through the breast milk." When pressed as to whether morphine could get to a
specific toxicity level from breastfeeding, however, he stated, "Like I said earlier, I
can't quantitate how much."

The State's other expert was John David Wren, M.D., the pathologist who
performed the autopsy. Dr. Wren testified Alexis had lethal levels of morphine,
"It's lethal in the brain, it's lethal in the liver, it's lethal in the blood." He explained,
"it was my opinion that this child died as a result of respiratory insufficiency
secondary to synergistic drug intoxication. I could just as easily have said
morphine intoxication." However, Dr. Wren testified, "It's not my opinion that it
was from milk or anything else. I just know that it was there." On cross-
examination, Dr. Wren testified, "I don't know how it got there. It's unquestionably
there. And you can argue any mechanism you want, but it's there, period."

              E.             The "Proper Lens"15

This case is different from Logan, Bennett, and every other circumstantial evidence
case this Court has decided. The majority's suggestion that I have "conflated" the
roles of judge and jury ignores that difference. None of those previous cases
involved scientific questions, so the lay jury was fully capable of making all the
necessary inferences on its own, "fairly and logically." Bennett, 415 S.C. at 237,
781 S.E.2d at 354. The issue before the Court in those cases, therefore, arose only
                                                            
14
   The LactMed database contains information on drugs and other chemicals to
which breastfeeding mothers may be exposed.
 
15
   The term "proper lens" is taken from the majority opinion, slip op. at 12.
 
under the first step of the Bennett/Littlejohn analysis—whether the circumstantial
evidence met the "any substantial evidence" standard. That is not the issue we face
in this case. As I have stated, the circumstantial evidence in this case that Alexis
died from ingesting morphine through Greene's breast milk appears overwhelming.

The issue in this case arises under the second step of the Bennett/Littlejohn
analysis—whether the "additional reasoning" required to infer from the
circumstances proven that the morphine that killed Alexis came from Greene's
breast milk required the jury to answer a scientific question beyond its common
knowledge, experience, or understanding. It is the same question we addressed in
Graves, Watson, Green, and Kemmerlin. Although Watson, Green, and
Kemmerlin were not circumstantial evidence cases, Graves was a circumstantial
evidence case. In this respect, this case is identical to Graves. We said in
Graves—just like I say here—this case is not about the State's proof of sufficient
circumstances, or "what quantum of circumstantial evidence . . . is necessary" to
present a jury question. 401 S.C. at 80, 735 S.E.2d at 658.

In Graves, we first found the plaintiffs failed to present admissible testimony of an
expert on the existence of a defect in a products liability case. 401 S.C. at 75-78,
735 S.E.2d at 656-57. We then turned to whether the plaintiffs nevertheless
presented sufficient circumstantial evidence to reach a jury. We stated "the Graves
have no direct evidence," and "[t]hus, the question is whether the record contains
sufficient circumstantial evidence of a defect required to survive summary
judgment." 401 S.C. at 79, 735 S.E.2d at 658. Focusing on the second part of the
Bennett/Littlejohn analysis for circumstantial evidence, we stated "we need not
determine what quantum of circumstantial evidence of a design defect is necessary
to withstand summary judgment because the lack of expert testimony is . . .
dispositive." 401 S.C. at 80, 735 S.E.2d at 658. "In some design defect cases," we
held, "expert testimony is required . . . because the claims are too complex to be
within the ken of the ordinary lay juror." 401 S.C. at 80, 735 S.E.2d at 659 (citing
Watson, 389 S.C. at 445, 699 S.E.2d at 175).

Thus, as in Graves, the "proper lens" invoked by the majority forces us to examine
whether the State has satisfied the second prong of the Bennett/Littlejohn analysis.
Through this lens we must determine whether a lay juror can comprehend the
scientific possibility that morphine—even acting synergistically with other drugs—
may pass through a mother's breast milk in sufficient quantity to kill a child.
Greene's counsel repeatedly pressed both Dr. Eagerton and Dr. Wren as to whether
there is any scientific documentation supporting the theory that this is even
possible. At one point, Dr. Eagerton responded, "I don't believe I've seen any
literature that says that. But for everything there's got to be a first." Dr. Wren
responded, "No. But, . . . there is a first time for everything."

These answers demonstrate the narrow point upon which I would reverse Greene's
homicide convictions. If medical and scientific professionals have nothing more
definitive to say as to whether the factual premise of the State's theory is even
possible, then we should not permit a lay jury to base a verdict in a criminal trial
on the premise. One day there may be a "first" who says morphine can do what the
State argues it did here, but it should be a medical or scientific professional, not a
jury in a criminal case.

                                         III.

I agree with the majority that Greene's conviction for unlawful conduct toward a
child must be affirmed, and that under any circumstance both convictions for
homicide cannot stand. However, I would find the trial court erred in not directing
a verdict on the homicide charges because the State failed to present evidence of
causation "sufficient to allow a reasonable juror to find the defendant guilty
beyond a reasonable doubt." Bennett, 415 S.C. at 237, 781 S.E.2d at 354.