Court Opinion

ID: 6500457
Source: CourtListenerOpinion
Date Created: 2022-07-15 20:00:15.417926+00
Date Added: 2024-06-11T09:17:07.260537
License: Public Domain

United States Court of Appeals
                     For the First Circuit

No. 21-1574

                    UNITED STATES OF AMERICA,

                            Appellee,

                               v.

                         GLENN A. CHIN,

                      Defendant, Appellant.

          APPEAL FROM THE UNITED STATES DISTRICT COURT
               FOR THE DISTRICT OF MASSACHUSETTS

         [Hon. Richard G. Stearns, U.S. District Judge]

                             Before

                       Barron, Chief Judge,
                Lipez and Howard, Circuit Judges.

     James L. Sultan, with whom Rankin & Sultan was on brief, for
appellant.
     Christopher R. Looney, Assistant United States Attorney, with
whom Rachael S. Rollins, United States Attorney, was on brief, for
appellee.

                          July 15, 2022
              BARRON, Chief Judge.       This appeal requires us to revisit

the sentence that Glenn Chin, a former supervising pharmacist at

the New England Compounding Center ("NECC"), received for his

convictions in connection with the criminal investigation into the

deadly nationwide outbreak of fungal meningitis in 2012 that was

traced to the company's shipments of contaminated drugs.                   When we

last considered Chin's sentence, we vacated and remanded it.                    See

United States v. Chin, 965 F.3d 41, 60 (1st Cir. 2020) ("Chin I").

The United States District Court for the District of Massachusetts

resentenced Chin while applying two sentencing enhancements under

the United States Sentencing Guidelines ("Guidelines").                         U.S.

Sent'g       Guidelines   Manual        §§        2B1.1(b)(16)(A),   3A1.1(b)(1)

[hereinafter U.S.S.G].         Chin contends that neither enhancement

applies and thus that his sentence must be vacated once again.                   We

affirm.

                                             I.

              The events at NECC have already been the subject of

several reported decisions by this Court.                 We thus will rehearse

only the facts relevant to Chin's current challenge to certain

aspects of his resentencing.            We refer the reader to Chin's first

appeal, Chin I, 965 F.3d at 45-46, and to the appeal of Barry

Cadden, Chin's boss at NECC, United States v. Cadden, 965 F.3d 1,

7-8   (1st    Cir.   2020),   for   a    more      detailed   discussion   of   the

underlying facts.

                                        - 2 -
              NECC was a pharmacy based in Framingham, Massachusetts,

that specialized in high-risk drug compounding, which refers to a

process in which non-sterile ingredients are combined to create

sterile drugs that are prepared at the request of hospitals and

other healthcare providers.           Chin worked as a licensed pharmacist

at NECC from April 2004 to October 2012.

              In January 2010, Chin was promoted to the role of

supervising pharmacist at NECC, in which he oversaw all drug

production in NECC's two "clean rooms."                 In the fall of 2012, a

number   of    patients    who   had    received        epidural   injections   of

methylprednisolone        acetate      ("MPA")     --    a   steroid   for   pain

relief -- contracted rare fungal infections that were ultimately

traced back to contaminated drugs produced at NECC under Chin's

supervision.     A number of those patients died.

              A federal criminal investigation into NECC's practices

ensued, and in connection with it Chin was charged in December of

2014   with    "racketeering     in    violation    of 18     U.S.C.   § 1962(c);

racketeering     conspiracy      in    violation    of 18    U.S.C.    § 1962(d);

forty-three counts of federal mail fraud in violation of 18 U.S.C.

§ 1341; and thirty-two counts of violating the Federal Food, Drug,

and Cosmetic Act ('FDCA'), see 21 U.S.C. §§ 331(a), 333(a)."                 Chin

I, 965 F.3d at 45.        After a jury trial, Chin was found guilty on

all counts.     Id. at 46.

                                       - 3 -
           Evidence was introduced at trial that showed that Chin

was familiar with Chapter 797 of the United States Pharmacopeia

("USP-797"),    which   sets   forth        standards   governing   sterile

compounding    that   pharmacists    licensed     in    Massachusetts   must

follow. Evidence introduced at trial also supportably showed that,

despite NECC claiming to be USP-797 compliant, Chin knew that NECC

was selling MPA that had not been properly sterilized or tested

for sterility in accordance with USP-797.               And, evidence was

introduced at trial that showed that NECC's clean room became

grossly contaminated with mold and bacteria after Chin instructed

clean room staff to ignore cleaning protocols, and that Chin knew

of this contamination.

           At Chin's sentencing in January 2018, the government,

among other things, requested that the District Court apply the

two Guidelines that set forth the enhancements that are the subject

of Chin's present appeal.       The first enhancement is U.S.S.G.

§ 2B1.1(b)(16)(A), which imposes a two-level increase in the base

offense level of those convicted of certain crimes "[i]f the

offense involved . . . the conscious or reckless risk of death or

serious   bodily   injury."    The    second     enhancement   is   U.S.S.G.

§ 3A1.1(b), which imposes a two-level increase in the base offense

level "[i]f the defendant knew or should have known that a victim

of the offense was a vulnerable victim" and an additional two-

                                    - 4 -
level   increase    if   that   enhancement   applies    and   "the    offense

involved a large number of vulnerable victims."

              The District Court declined to apply either enhancement

in sentencing Chin to a term of imprisonment of 96 months, to be

followed by two years of supervised release.            The District Court

determined at Chin's first sentencing that the "conscious or

reckless risk" enhancement did not apply because "the evidence did

not establish a reckless and knowing disregard of a reasonable

certainty of causing death or great bodily harm."              The District

Court determined that the "vulnerable victim" enhancement did not

apply because "here the victims that were identified were the

clinics and the hospitals who purchased the drugs," and "because

we construe 'victim' differently for purposes of sentencing, the

enhancements do not apply on a proximate cause theory to persons

who were not recipients of NECC's representations" -- that is, the

individuals who were ultimately harmed by injections of tainted

pharmaceuticals from NECC.

              The government appealed the sentence that the District

Court had imposed.       It did so, in part, on the ground that the

District Court erred in not applying either enhancement.

              On appeal, this Court rejected the District Court's

basis   for    determining   that   the   "conscious    or   reckless    risk"

enhancement did not apply.          Chin I, 965 F.3d at 53.           We first

explained that the District Court failed to consider whether Chin's

                                    - 5 -
"relevant conduct," rather than the nature of his "offense" alone,

carried with it the risk of death or serious bodily injury.    Id.

at 52–53.     We further explained that the District Court erred

because it

            found   that  Chin    did   not  act   with   a
            "reckless and knowing" state of mind in
            disregarding a "reasonable certainty of
            . . . death or great bodily harm."          The
            sentencing enhancement, however, describes
            the requisite mental state using disjunctive
            language: the enhancement applies so long as
            the defendant acted in spite of either a
            "conscious or reckless risk."         U.S.S.G.
            § 2B1.1(b)(16)(A) (emphasis added). Thus, the
            District Court's finding does not foreclose
            the possibility that Chin's offense involved
            the   mental    state    necessary   for    the
            enhancement's application.       We therefore
            vacate and remand the sentence for the
            District Court to assess whether any of Chin's
            relevant conduct, as defined under U.S.S.G.
            § 1B1.3(a), "involved . . . the conscious or
            reckless risk of death or serious bodily
            injury." Id. § 2B1.1(b)(16).

Id. at 53 (omissions in original).

            Chin I was published on the same day as Cadden, and it

referenced the Cadden opinion in its analysis of the "conscious or

reckless risk" issue. See Chin I, 965 F.3d at 52. Cadden similarly

vacated the District Court's refusal to apply this enhancement to

Cadden and remanded for the court to consider the proper mens rea

for the § 2B1.1(b)(16)(A) enhancement.     We explained that

            the District Court . . . at no point directly
            addressed    in    sentencing    whether    a

                                - 6 -
            preponderance    of    the    evidence    . . .
            established that Cadden's relevant conduct
            associated with the mail fraud involved a
            "conscious or reckless risk of death or
            serious    bodily     injury."         U.S.S.G.
            § 2B1.1(b)(16); Cf. United States v. Lucien,
            347   F.3d   45,    56-57   (2d    Cir.   2003)
            (concluding that a conscious risk is one
            "known to the defendant" while a reckless risk
            is "the type of risk that is obvious to a
            reasonable person and for which disregard of
            said risk represents a gross deviation from
            what a reasonable person would do").

965 F.3d 1, 34–35.

            In Chin I, this Court also rejected the District Court's

basis for determining that the "vulnerable victim" enhancement did

not apply.      We explained in doing so that, "'[t]o come within the

guidelines' definition' of 'victim,' 'one need not be a victim of

the charged offense so long as one is a victim of the defendant's

other relevant conduct.'"           965 F.3d at 54 (alteration in original)

(quoting Cadden, 965 F.3d at 35).                 Moreover, in Chin I, with

respect    to    whether     Chin's       particular    conduct    warranted    the

enhancement, we framed the question on remand with reference to

commentary in the Guidelines.                Specifically, we stated, "[w]e

. . . leave it to the District Court in the first instance to

address,    among    other     things,      whether     [Chin's]    actions     were

analogous       to   those     of     a     fraudster     who      'market[s]    an

ineffective cancer cure,' who the Guidelines indicate would merit

                                          - 7 -
the enhancement, U.S.S.G. § 3A1.1 cmt. n.2."       Chin I, 965 F.3d at

54.

          Following this Court's decisions in Cadden and Chin I,

Cadden was resentenced on July 7, 2021.    Chin was resentenced the

next day by the same judge who had resentenced Cadden and who had

previously sentenced both men.

          At Cadden's resentencing, the District Court observed

that, at the first sentencing, it had treated the applicable mens

rea standard as "not recklessness in the tort law sense but in the

appreciably   stricter   criminal   law   sense,    requiring   actual

knowledge of an impending harm easily preventable."          But, the

District Court noted in resentencing Cadden, "[i]t's clear rather

from the decision in Mr. Cadden's case that the First Circuit has

adopted the Second Circuit's definition [in Lucien, 347 F.3d at

56-57], which is a quite different definition of recklessness."

The District Court then quoted the definition of recklessness from

Lucien: "the type of risk that is obvious to a reasonable person

and for which disregard of said risk represents a gross deviation

from what a reasonable person would do," Lucien, 347 F.3d at 56-

57.

          In assessing whether the enhancement applied to Cadden,

the District Court found that Cadden "preside[d] over" a "high-

risk enterprise" at NECC and did so

                               - 8 -
           despite warnings, signals, . . . incomplete
           testing, falsification of drug lab cleaning
           reports, . . . the appearance of mold and
           other contaminants in the clean room, and his
           superior knowledge of the risk involved[.] I
           have to conclude that [Cadden's] conduct did
           and does fit within the definition of
           "recklessness."

The District Court then applied the enhancement to Cadden.

           Chin was resentenced by the District Court the day after

Cadden was.    The District Court declared in resentencing Chin, "I

do not want to retread ground that I covered yesterday. . . . . I

assume [the First Circuit's quotation of Lucien in Cadden] meant

they were adopting or at least embracing the Second Circuit's view

of how 'recklessness' would be defined in this case." The District

Court then held the "conscious or reckless risk" enhancement

applicable to Chin.

           In addition, at Cadden's resentencing, the District

Court noted that, in light of the First Circuit's ruling in

Cadden's first appeal, "'victims' [are] defined . . . by the larger

picture of [an offender's] conduct as a whole," and that "any

person who entrusts medical personnel to inject a foreign substance

into their spine by definition fits what I would think, and

ordinary   people   would   think,    is   a   definition   of   being     in   a

vulnerable    position."     The     District    Court   then    applied    the

"vulnerable victim" enhancement to Cadden.

                                   - 9 -
          At Chin's resentencing, the District Court observed that

the "First Circuit['s] . . . expansive view of what constitutes a

'victim' under the Guidelines was pretty clear to me," and that

"vulnerability can . . . refer to one's . . . inability to protect

one's self under the circumstances."          The District Court then held

the "vulnerable victim" enhancement applicable to Chin as well.

          After applying both the "conscious or reckless risk" and

"vulnerable   victim"    enhancements    to    Chin,   the   District   Court

determined that Chin's total offense level was 34.           Given that the

District Court determined that Chin's Criminal History Category

was I, the District Court calculated his Guidelines Sentencing

Range to be a term of imprisonment of 151–188 months.          The District

Court thereafter imposed a 126-month term of imprisonment and two

years of supervised release.       Chin timely appeals. "[W]e review

the District Court's 'factfinding for clear error and afford de

novo consideration to its interpretation and application of the

sentencing guidelines.'"      Chin I, 965 F.3d at 50 (quoting United

States v. Benítez-Beltrán, 892 F.3d 462, 469 (1st Cir. 2018)).

                                   II.

          We start with Chin's challenge to the District Court's

application of the two-level enhancement set forth in U.S.S.G.

§ 2B1.1(b)(16)(A).      We are not persuaded by it.

                                 - 10 -
                                A.

          Chin first argues that the District Court erred in

interpreting § 2B1.1(b)(16)(A).        He contends that is so because

the District Court held the enhancement to apply so long as there

is proof that the offense, including the defendant's relevant

conduct, involved a risk of death or serious bodily injury of which

the defendant should have been aware and thus to apply even in the

absence of proof by a preponderance of the evidence that the

defendant in fact knew of that risk.

          Chin contends in support of that argument that the

District Court based its "should have known" interpretation of the

enhancement solely on our invocation in the course of construing

that same provision of the Guidelines in Cadden of the Second

Circuit's decision in Lucien.        He goes on to contend, however,

that "it is not at all clear from this Court's 'Cf.' citation to

Lucien that it was adopting that particular definition of 'reckless

risk.'"

          Chin further argues that, given that we did not hold in

Cadden that Lucien controls, we must construe the enhancement

afresh.   And, he contends, by virtue of the use of the word

"reckless"   in   § 2B1.1(b)(16)(A),    the   enhancement   is   properly

construed to require proof that a defendant was aware that his

relevant conduct in committing his offense created a risk of death

or serious bodily injury and not merely that he should have known

                               - 11 -
of   that    risk.    He   then    contends       that,   in   consequence,     the

enhancement cannot be applied to him, because the government did

not prove by a preponderance of the evidence that Chin was aware

of any such risk in engaging in the conduct relevant to his

offense.

             We agree with Chin that the "Cf." citation to Lucien in

our Cadden decision, 965 F.3d at 34–35, does not resolve how this

enhancement must be construed.            We did not have occasion in Cadden

to address the meaning of the word "reckless" in the enhancement.

Our focus there was solely on the District Court's failure to

address Cadden's "relevant conduct" in applying the enhancement

as   § 1B1.1 cmt. n.1(I) of the Guidelines requires, given that the

District     Court   appeared      to    focus    in   assessing    whether     the

enhancement applied on the nature of the offenses of which Cadden

had been convicted.        See Cadden, 965 F.3d at 34; U.S.S.G. § 1B1.1

cmt. n.1(I) (defining "offense"); id. § 1B1.3(a)(1)(A) (setting

forth "relevant conduct" for purposes of computing base offense

level,   offense     characteristics,       and    adjustments).         But,   even

though Cadden's invocation of Lucien is not controlling of the

question     presented     here,    we     nonetheless     conclude      that   the

enhancement is best construed as Lucien construed it.

               The   Guideline     refers    to    a   "conscious   or    reckless

risk."      U.S.S.G. § 2B1.1(b)(16)(A) (emphasis added).              If we were

to read "reckless" in this Guideline itself to require a defendant

                                        - 12 -
to be aware of the risk of death or substantial bodily injury, as

Chin contends we must, the use of the words "conscious or" in that

same Guideline would be superfluous.       See United States v. DeLuca,

17 F.3d 6, 10 (1st Cir. 1994) ("'[A]ll words and provisions of

statutes are intended to have meaning and are to be given effect,

and no construction should be adopted which would render statutory

words or phrases meaningless, redundant or superfluous.'           We think

that    this     principle      is   fully       applicable        to    the

sentencing guidelines    . . . ."    (internal      citations      omitted)

(quoting Lamore v. Ives, 977 F.2d 713, 716–17 (1st Cir. 1992))).

           Nor can this redundancy be avoided, as Chin suggests, by

"requiring the government to prove, at the very least, what amounts

to willful blindness" to prove recklessness.         "Willful blindness

serves as an alternate theory on which the government may prove

knowledge."    United States v. Pérez-Meléndez, 599 F.3d 31, 41 (1st

Cir. 2010).

           In construing the Guideline to require proof only that

the risk would have been obvious to a reasonable person in Chin's

position, we align ourselves not only with the Second Circuit

decision in Lucien, but with the Ninth and Tenth Circuits too.

See United States v. Maestas, 642 F.3d 1315, 1321 (10th Cir. 2011)

("[A]   defendant’s   conduct   involves    a   conscious   risk    if   the

defendant was subjectively aware that his or her conduct created

a risk of serious bodily injury, and a defendant’s conduct involves

                                 - 13 -
a reckless risk if the risk of bodily injury would have been

obvious to a reasonable person."); United States v. Johansson, 249

F.3d 848, 859 (9th Cir. 2001) ("We do not believe that a defendant

can   escape   the    application    of    the   serious   risk   of   injury

enhancement by claiming that he was not aware that his conduct

created a serious risk, that is, a defendant does not have to

subjectively know that his conduct created the risk.").            And while

Chin is right that two courts of appeals have ruled to the contrary

and interpreted § 2B1.1(b)(16)(A) to require actual, subjective

awareness of a risk, see United States v. Mohsin, 904 F.3d 580,

586 (7th Cir. 2018); United States v. McCord, Inc., 143 F.3d 1095,

1098 (8th Cir. 1998), neither of those courts explains how that

interpretation accords with the enhancement's use of the words

"conscious or" before "reckless."          See Johansson, 249 F.3d at 858

("Our     concern    with   the   Eighth     Circuit's   interpretation   of

'reckless' [in       McCord] . . . is that there is no meaningful

distinction between an offense that involves the 'conscious' risk

of injury, and an offense that involves the 'reckless' risk of

injury, if under either prong the defendant must have been aware

of the risk in the first place."); accord Maestas, 642 F.3d at

1320-21.1

      1Chin does also point to the Eleventh Circuit's decision in
United States v. Mateos, 623 F.3d 1350 (11th Cir. 2010), which
applied the enhancement on the ground that the sentencing court
had "f[ound] that a trained nurse, such as [the defendant] . . .,

                                    - 14 -
           Chin     does    point     out    that,      although    neither

§ 2B1.1(b)(16)(A)    nor   its    application   notes    define    the   term

"reckless," a definition of that word does appear elsewhere in the

Guidelines. He then argues that we thus must apply that definition

of "reckless" here.

           Chin has in mind the definition of "reckless" that

appears in the application notes to the Guideline that concerns

involuntary manslaughter.        See U.S.S.G. § 2A1.4.      That Guideline

sets different base offense levels for involuntary manslaughter

depending on whether "the offense involved criminally negligent

conduct; or . . . the offense involved reckless conduct; or . . .

the   offense   involved   the    reckless   operation    of   a   means   of

transportation."    Id.    The application note to that Guideline, in

turn, defines "reckless" as follows:

           "Reckless" means a situation in which the
           defendant was aware of the risk created by his
           conduct and the risk was of such a nature and
           degree that to disregard that risk constituted
           a gross deviation from the standard of care
           that a reasonable person would exercise in
           such a situation.

would be well aware" of the risks associated with her criminal
activity, id. at 1371.    But, as the government observes, this
standard more closely resembles a should-have-known standard than
an actual awareness standard. Moreover, insofar as the Eleventh
Circuit meant to embrace an actual-awareness-of-risk requirement
in Mateos, see id. ("the Guidelines provision focuses on the
defendant's disregard of risk"), it, too, made no attempt to
explain how such a requirement could be reconciled with the
Guideline's text.

                                    - 15 -
Id. § 2A1.4 cmt. n.1.          The application note also explains that

"'[c]riminally negligent' means conduct that involves a gross

deviation from the standard of care that a reasonable person would

exercise under the circumstances, but which is not reckless."                    Id.

            But,   the    application        note     that    sets     forth   this

definition of "reckless" in connection with the Guideline that

concerns    involuntary    manslaughter        does    not    purport    to    apply

throughout the Guidelines.           Nor does it even purport to apply to

the Guideline at issue here in particular, which applies to fraud

and certain related offenses.            Thus, the application note does

not, by its terms, require us to apply the definition of "reckless"

that it sets forth here.

            Moreover, it is problematic to apply that definition

here as a textual matter.            The definition of "reckless" in the

involuntary    manslaughter     Guideline      refers    to    a     "risk."     See

U.S.S.G. § 2A1.4 cmt. n.1.             It is thus hard to see how that

definition could have been intended to apply to this Guideline,

because this Guideline itself uses the word "reckless" to modify

the word "risk."    No such awkwardness arises under the involuntary

manslaughter    Guideline;      it    uses   the     adjective     "reckless"     to

describe a defendant's conduct -- either "reckless conduct" or

"reckless    operation    of   a     means   of     transportation,"      U.S.S.G.

§ 2A1.4.    See Maestas, 642 F.3d at 1321 (observing the distinction

                                      - 16 -
between the two Guidelines' respective uses of "reckless conduct"

and "reckless risk"); Johansson, 249 F.3d at 859 ("The Guideline

describes a 'reckless risk,' not a reckless disregard of a known

risk.").2

            Chin   separately   argues    that   --   the   definition   of

"reckless" elsewhere in the Guidelines aside -- the term as it

appears in the enhancement at issue here is best construed to

require the defendant to be aware of the risk of death or serious

bodily injury.     He relies for this contention in part on other

instances in which recklessness has been defined to require a

     2 Chin draws our attention to a case in which this Court
relied on the definition of "reckless" from the involuntary
manslaughter Guideline when interpreting a third Guideline's use
of that word. See United States v. Carrero-Hernández, 643 F.3d
344, 348–50 (1st Cir. 2011). There, this Court was tasked with
interpreting a Guideline that provided for an increased offense
level "if the defendant recklessly created a substantial risk of
death or serious bodily injury to another person in the course of
fleeing from a law enforcement officer," U.S.S.G. § 3C1.2, whose
application note expressly imported the definition of "reckless"
from the Guideline on involuntary manslaughter, id. cmt. n.2; see
also Carrero-Hernández, 643 F.3d at 348. But, even setting aside
the fact that in that case -- unlike this one -- the Guideline in
question expressly incorporated the definition of "reckless" set
out in the application note to § 2A1.4, Carrero-Hernández
illustrates why the text of Chin's enhancement compels a different
construction of the word "reckless." The provision at issue in
Carrero-Hernández, like the involuntary manslaughter Guideline,
used "reckless[]" to describe how an offender engaged in risky
conduct.   See U.S.S.G. § 3C1.2 ("If the defendant recklessly
created a substantial risk . . ."); id. § 2A1.4 ("if the offense
involved reckless conduct . . .").      By contrast, as we have
explained, "reckless" in § 2B1.1(b)(16)(A) describes expressly a
"risk," not the way an offender conducted himself with respect to
that risk. See id. § 2B1.1(b)(16)(A).

                                 - 17 -
defendant's subjective awareness of a risk.                  See Voisine v. United

States, 579 U.S. 686, 694, 699 (2016) (describing reckless conduct

as "acts undertaken with awareness of their substantial risk of

causing injury" and "with conscious disregard of a substantial

risk of harm"); Farmer v. Brennan, 511 U.S. 825, 836–37 (1994)

("The     criminal     law      . . .     generally    permits       a       finding    of

recklessness only when a person disregards a risk of harm of which

he is aware.").

              But, in those instances, the term defines the mens rea

element of a criminal offense, see Voisine, 579 U.S. at 691;

Farmer,    511      U.S.   at   836–37,     which   must     be   proved       beyond   a

reasonable doubt.3         Here, however, the term appears in a sentencing

enhancement, which is subject only to the lower preponderance of

the evidence standard that also applies in the civil context.                          See

United States v. Hernández-Negrón, 21 F.4th 19, 25-26 (1st Cir.

2021).    Thus, the examples of "reckless" being given the stricter

meaning on which Chin relies fail to show that this Guideline is

best construed to incorporate a meaning of "reckless" that is used

to   define    an    element     of   a   crime,    rather    than       a   meaning    of

      3Farmer was a civil Bivens action in which the Court held
that "deliberate indifference," for the purposes of defining a
violation of the Eighth Amendment, see Helling v. McKinney, 509
U.S. 25, 32 (1993), required actual knowledge and disregard of a
risk, rather than merely an objective risk. 511 U.S. at 837, 839–
40.   The Court explained in so holding, however, that it was
"adopt[ing]" what it called "subjective recklessness as used in
the criminal law." Id. at 839–40.

                                          - 18 -
"reckless" that is traditionally used in the civil context, which

is the one the Second Circuit attributes to it in Lucien, 347 F.3d

at 56-57.        See Safeco Ins. Co. of Am. v. Burr, 551 U.S. 47, 68

(2007) ("While 'the term recklessness is not self-defining,' the

common law has generally understood it in the sphere of civil

liability    as    conduct   violating       an    objective      standard:      action

entailing 'an unjustifiably high risk of harm that is either known

or so obvious that it should be known.'" (quoting Farmer, 511 U.S.

at 836)); see also id. at 68 n.18 ("Unlike civil recklessness,

criminal recklessness also requires subjective knowledge on the

part of the offender.").

            We do not mean to suggest that the word "reckless" in a

Guideline    necessarily     incorporates          the    traditional     common-law

understanding of the term in the civil context.                     But, given the

use   of   the    words   "conscious    or    reckless"      to    modify   risk    in

§ 2B1.1(b)(16)(A), the text requires us to construe "reckless"

here to refer to that standard.

                                         B.

            Chin argues in the alternative that the record fails to

show by a preponderance of the evidence that his relevant conduct

satisfied the objective standard for recklessness, even if that

standard is the applicable one under this Guideline. Specifically,

he    contends     that   "[w]hile     [he]       was    aware    that   there    were

deficiencies in testing and the condition of the compounding lab

                                     - 19 -
. . ., it would have required rank speculation to foresee that

those   shortcomings   would    cause    the   vials   of    MPA    to   become

contaminated with fungus, leading to a scourge of serious illness

and death."   We are not persuaded.

           The District Court did not expressly set forth findings

about the nature of the risk of which Chin should have been aware

from his relevant conduct in committing his offense.               However, we

may look to the record of the sentencing hearing to ascertain the

District Court's reasoning.     Cf. United States v. Montero-Montero,

817 F.3d 35, 37 (1st Cir. 2016) ("To be sure, a sentencing court's

rationale sometimes may be inferred from the sentencing colloquy

and the parties' arguments (oral or written) in connection with

sentencing.").

           Notably,    before     applying       the       § 2B1.1(b)(16)(A)

enhancement to Chin, the District Court explained that it "d[id]

not want to retread ground that [it] covered yesterday."                  It is

thus evident that the District Court was relying on the same

rationale for applying this enhancement to Chin that it had relied

on the day before in applying the enhancement to Cadden.                 And, at

Cadden's   resentencing,   it   had     explained   that    the    enhancement

applied to Cadden because Cadden "preside[d] over" a "high-risk

enterprise" at NECC

           despite warnings, signals, . . . incomplete
           testing, falsification of drug lab cleaning
           reports, . . . the appearance of mold and

                                 - 20 -
           other contaminants in the clean room, and his
           superior knowledge of the risk involved.

           Of course, the record in Chin's case must provide support

for the District Court's decision to apply the enhancement to him

based on this same rationale.      But, reviewing the District Court’s

factfinding for clear error, Chin I, 965 F.3d at 50, we conclude

that the record here supportably shows that Chin knew in 2012 that

NECC's clean room was grossly contaminated after his staff's

failure to adhere to cleaning protocols, that he knew that NECC

was selling MPA that was not properly sterilized or tested for

sterility despite claiming that it was USP-797 compliant, and that

he instructed NECC technicians to mislabel untested drugs with the

lot numbers of older lots that NECC had tested.               And, as the

government points out, the record also supportably shows that Chin

was required to follow USP-797 standards, the purpose of which "is

to describe conditions and practices to prevent harm, including

death,    to    patients   that   could    result   from   . . . microbial

contamination."      Thus, the District Court did not clearly err in

finding that Chin should have been aware of the risk of death or

serious bodily injury that his conduct in committing his offense

posed, given the evidence supportably showing that he breached

USP-797        standards   that    exist      in    part    to    "prevent

. . . death . . . to patients."

                                  - 21 -
                                         III.

             We next address Chin's contention that the District

Court erred in applying an enhancement to his sentence that

provides for a two-level increase "[i]f the defendant knew or

should have known that a victim of the offense was a vulnerable

victim."     U.S.S.G. § 3A1.1(b)(1).4            The application note further

explains that the enhancement "applies to offenses involving an

unusually vulnerable victim."            Id. § 3A1.1 cmt. n.2.       To apply the

"vulnerable    victim"     enhancement,          "the   sentencing      court   must

determine that (1) 'the victim of the crime was vulnerable, that

is, . . . the victim had an "impaired capacity . . . to detect or

prevent crime;"' and (2) 'the defendant knew or should have known

of the victim's unusual vulnerability.'"                United States v. Stella,

591   F.3d   23,    29   (1st    Cir.    2009)    (quoting     United    States   v.

Donnelly, 370 F.3d 87, 92 (1st Cir. 2004)).

             Chin   does   not    dispute       that    the   patients    who   were

administered NECC drugs are "victims" in the relevant sense.                      See

United States v. Bradley, 644 F.3d 1213, 1288 (11th Cir. 2011)

(concluding that "recipients of recycled blood-derivatives are

      4U.S.S.G. § 3A1.1(b)(2) provides, "[i]f (A) subdivision (1)
applies; and (B) the offense involved a large number of vulnerable
victims, increase the offense level determined under subdivision
(1) by 2 additional levels."     The District Court applied this
enhancement at Chin's resentencing. Chin does not argue that the
District Court erred in applying the additional enhancement in
§ 3A1.1(b)(2) if the District Court properly applied the
enhancement in § 3A1.1(b)(1).

                                        - 22 -
'vulnerable victims'" where owner of pharmaceutical wholesaler's

fraudulent billing scheme caused AIDS and hemophilia patients to

be treated with recycled blood derivatives); United States v.

Milstein, 401 F.3d 53, 74 (2d Cir. 2005) (affirming application of

"vulnerable victims" enhancement where defendant "distribute[d]

counterfeit and misbranded drugs to doctors, pharmacists, and

pharmaceutical wholesalers, knowing that those customers would

distribute      the    drugs    to    women     with    fertility      problems       and

to Parkinson's        disease patients");        see        also   United    States    v.

Sidhu, 130 F.3d 644, 655 (5th Cir. 1997) ("[A] physician's patients

can be victimized by a fraudulent billing scheme directed at

insurers or other health care providers.").                    But, he still argues

that neither prong of the enhancement is satisfied here. Reviewing

the   District        Court's   factfinding       for        clear   error    and     its

interpretation of the Guidelines de novo, Chin I, 965 F.3d at 50,

we do not agree.

                                           A.

              Chin contends that the victims here -- i.e., the patients

harmed   by     contaminated     NECC     drugs        --    "were   not     'unusually

vulnerable'" merely because they were members of "a generic class

of all medical patients."            He further contends that such a finding

would be inconsistent with the intent and purpose of the Guideline,

which he says is meant to punish "defendants who exploit the

particular weaknesses of society's most vulnerable members."                          To

                                        - 23 -
the extent Chin contends that the District Court erred in its

interpretation and application of the Guideline, we disagree under

de novo review.    To the extent he challenges the District Court's

factual finding that the victims at issue were in fact "unusually

vulnerable," we discern no clear error.

           The District Court did not find, as Chin suggests, that

these   victims   were   unusually      vulnerable    merely    because   they

belonged to "a generic class of all medical patients."                 Rather,

the District Court supportably found that they were unusually

vulnerable   because     their   pain    led   them   to    "entrust   medical

personnel to inject a foreign substance into their spine[s],"

recognizing that "vulnerability can equally refer to one's . . .

inability to protect one's self under the circumstances." Applying

the enhancement based on particularized class characteristics such

as these is consistent with our precedent.            Although we have said

that the sentencing court should focus "on the victim's individual

characteristics" in applying this enhancement, "above and beyond

mere membership in a large class," see United States v. Feldman,

83 F.3d 9, 15 (1st Cir. 1996), we have also made clear that "this

is in no way a fixed rule," United States v. Gill, 99 F.3d 484,

486-87 (1st Cir. 1996).     Indeed, "[i]n some cases the inference to

be drawn from the class characteristics may be so powerful that

there can be little doubt about unusual vulnerability of class

members within the meaning of section 3A1.1."              Id. at 487 (citing

                                  - 24 -
United States v. Echevarria, 33 F.3d 175, 180-81 (2d Cir. 1994)

(upholding enhancement as applied to unlicensed doctor based on

group     determination          of   vulnerability     of     medical    patients),

superseded by regulation on other grounds as stated in United

States v. Hussey, 254 F.3d 428, 433 n.3 (2d Cir. 2001), and United

States v. Bachynsky, 949 F.2d 722, 735 (5th Cir. 1991) (same, as

applied to physician making false diagnoses)).                  Thus, reviewing de

novo,    we   conclude       that     the   District    Court    did     not    err   in

interpreting the Guideline.

              Nor do we find any clear error in the District Court's

application of the Guideline to Chin.              Indeed, we have upheld the

application     of    the     enhancement     in   similar      circumstances:         in

Stella, we held that victims' "illnesses" can distinguish them

from     members     of    the    "general    public"     for    purposes      of     the

vulnerable-victim           enhancement,      insofar     as     their       need     for

medication vitiates their ability to "help themselves" or "to

detect or prevent against the [relevant harm]."                    591 F.3d at 30

(quoting the sentencing court's findings).                   Cf. Bradley, 644 F.3d

at 1289 (concluding that victims "were vulnerable due to their

medical condition -- AIDS and hemophilia"); Milstein, 401 F.3d at

74 (concluding that "women with fertility problems and . . .

Parkinson's     disease patients"           constituted      vulnerable      victims).

Here, the patients receiving MPA injections into their spine were

in   a   similarly        "unusually    vulnerable"     position,      see     U.S.S.G.

                                         - 25 -
§ 3A1.1 cmt. n.2, by virtue of their physical condition and the

circumstances of the procedure.    Thus, we discern no error in the

District Court's application of the enhancement.

                                  B.

          Chin also argues that the record fails to show that Chin

knew or should have known of the victims' unusual vulnerability.

In support of this contention, Chin appears to argue that the "knew

or should have known" requirement in § 3A1.1(b) per se precludes

the enhancement's application to him because he was merely a

supplier of medical products to health care facilities and thus

stood at a remove from the patients who were harmed by the

contaminated drugs that NECC compounded.      But, insofar as Chin in

pressing this contention is making a legal argument about the

proper construction of the Guideline, such that our review is de

novo, see Chin I, 965 F.3d at 50, we must reject the contention.

          Nothing in the text of the provision supports the per se

exclusion of medical suppliers.        Thus, nothing in the text bars

the application of the enhancement to a medical supplier who knew

or should have known that he was distributing unsafe drugs that

would be used by vulnerable patients.        See Bradley, 644 F.3d at

1289; Milstein, 401 F.3d at 74; see also United States v. Moran,

778 F.3d 942, 952–53, 978–79 (11th Cir. 2015) (applying "vulnerable

victim" enhancement to defendant CEO of medical facility who was

not directly involved in patient care).       Rather, the text merely

                              - 26 -
provides that the enhancement applies to an offender who "knew or

should have known that a victim of the offense was a vulnerable

victim."   U.S.S.G. § 3A1.1(b).

           Chin next argues that the enhancement may not be applied

to him by referencing the application note to it.         The application

note explains that "[t]he adjustment would apply, for example, in

a fraud case in which the defendant marketed an ineffective cancer

cure." U.S.S.G. § 3A1.1 cmt. n.2. Chin contends that, in addition

to the fact that he was not himself "a health care provider," he

also is not analogous to a fraudster who marketed an ineffective

cancer cure.      And that is so, Chin contends, because NECC had

previously sold lots of MPA without incident, and the record fails

to show by a preponderance of the evidence that he "kn[e]w that

any of the drugs he compounded were contaminated." He thus appears

to be contending that, absent a showing by a preponderance of the

evidence of his intent to defraud the victims, there can be no

finding that Chin knew or should have known that the victims were

vulnerable.

           But,   even   if   we   understand   this   argument   to   be   a

contention about the proper way to construe the Guideline, such

that our review is de novo rather than for clear error, Chin I,

965 F.3d at 50, we reject it.       The text of the Guideline provides

no basis for concluding that the "knew or should have known"

standard may be satisfied only by a finding that the defendant

                                   - 27 -
intended to defraud his victims.             Nor does the application note,

in giving an example of how the Guideline could be satisfied,

purport to suggest that there is a requirement to prove an intent

to defraud.        Instead, the Guideline merely requires that it be

shown by a preponderance of the evidence that, in engaging in the

conduct relevant to his offense, Chin knew or should have known

that vulnerable patients would be using the unsafe drugs he

produced at NECC.

            Finally, Chin appears to be arguing that, even if the

Guideline    may    be    applied   to   a   medical    supplier    who   was    not

defrauding patients, the District Court clearly erred in finding

that   he   "knew    or    should   have     known"    that   the   victims     were

vulnerable.     Here, his assertion is that there is an absence of

record evidence of his individualized knowledge of both who the

end users of NECC drugs would be and that the drugs that NECC

shipped were contaminated.          But, we cannot agree.

            The District Court supportably found that "[e]vidence

introduced at trial, including internal NECC emails, brought home

the certainty that Chin and other of the coconspirators were fully

aware of the risks involved in the distribution of defective

drugs."     Chin's resume advertised his "[k]nowledge of USP[-]797,"

and the first sentence of the introduction to USP-797 reads, "[t]he

objective of this chapter is to describe conditions and practices

to prevent harm, including death, to patients that could result

                                     - 28 -
from . . . microbial contamination . . . ."         And, Chin himself

concedes in his brief to us that he "was aware that there were

deficiencies in testing and the condition of the compounding lab

and that all the USP-797 protocols were not being strictly adhered

to."       Indeed, evidence was presented at trial that tended to show

that Chin was aware of the particularly grave risks associated

with injecting contaminated medication into a patient's spinal

fluid, as opposed to other routes of drug administration.5       Thus,

the District Court did not clearly err in concluding that Chin

knew or should have known that downstream recipients of MPA from

NECC were particularly vulnerable.

                                     IV.

              For the foregoing reasons, we affirm Chin's sentence.

       An NECC compounding technician testified that Chin, when
       5

training him in clean-room sanitation practices, "stressed that
with the injectable drugs [there] was even more a need to be
vigilant in terms of cleanliness because you're bypassing the
immune system, basically injecting it right into the cerebral
spinal fluid, whatever it is, and it's going to go straight up
into their brain."     Additionally, the second sentence of the
introduction to USP-797 explains that "[c]ontaminated [compounded
sterile preparations] are potentially most hazardous to patients
when administered into body cavities, central nervous and vascular
systems, eyes, and joints and when used as baths for live organs
and tissues."

                                  - 29 -