Background
Kirsten Ball, a licensed physician who practiced from her home office from 2005 to 2022, was indicted in April 2023 on one count of conspiracy to distribute oxycodone and twenty counts of distribution of oxycodone in violation of the Controlled Substances Act. The Government presented undisputed evidence that Ball’s prescriptions deviated substantially from standard medical practice—she issued large quantities of oxycodone outside conventional medical bounds. After a five-day trial, a jury convicted her of conspiracy and all but one distribution count.
Ball did not challenge the factual record on appeal. Instead, she argued that jury instructions violated the Supreme Court’s decision in Ruan v. United States, 597 U.S. 450 (2022), which holds that prosecutors must prove a defendant subjectively knew his or her conduct was unauthorized. The district court had removed the possessive pronoun “her” from proposed jury instructions that would have asked whether Ball knew she was acting outside “the course of her professional practice,” substituting instead “the course of professional practice.” Ball contended this omission allowed conviction without proving she knew her prescriptions were unauthorized.
The Court’s Holding
The Fourth Circuit affirmed the conviction, holding that the jury instructions, read as a whole, properly implemented Ruan’s framework. The court rejected Ball’s grammatical argument about the possessive pronoun. The regulation defining prescribing authority uses both possessive and non-possessive phrasings interchangeably to refer to the objective standards of the profession, not to any individual physician’s idiosyncratic practice. The court noted that to accept Ball’s reading “collapses [distinct] inquiries by allowing each physician’s personal habits to define the scope of federal prescribing authority.”
Critically, the court held that Ruan requires a two-part inquiry: (1) professional standards objectively determine whether a prescription falls outside authorized bounds, and (2) the government must prove the defendant subjectively knew it fell outside those objective bounds. The district court’s charge, examined in its entirety, satisfied both requirements. The instructions repeatedly invoked subjective knowledge (“she knew she was acting, or she intended to act” without authorization), defined good faith as “subjective good intentions” measured against “what she subjectively believed to be proper medical practice,” and prohibited conviction based on negligence, mistake, or carelessness. By contrast, the court noted that in prior Fourth Circuit cases (Smithers and Naum), similar instructions had failed to include this subjective language and therefore fell short of Ruan’s demands.
Key Takeaways
- Post-Ruan, prosecutors in controlled substances cases must prove defendants subjectively knew their conduct was unauthorized, not merely that a reasonable physician would have known.
- Professional standards set objective boundaries on prescribing authority; subjective knowledge of violating those boundaries is a separate, necessary element of the crime.
- A possessive pronoun in jury instructions or regulations does not permit each physician to define her own scope of authority—it refers to the medical profession generally.
- Jury instructions are reviewed holistically for whether they, taken together and in context, accurately convey the required mens rea, not sentence-by-sentence.
Why It Matters
This decision provides crucial guidance for prosecutors and defense counsel in opioid-distribution cases arising under the Controlled Substances Act. After Ruan, a substantial number of convictions faced challenge on jury-instruction grounds. Ball clarifies that instructions need not be perfect or use exact statutory language, provided they convey the two-step framework: objective professional boundaries plus subjective knowledge of violation. This affects not only appellate review of conviction challenges but also strategic trial decisions about proposed jury instructions.
The decision also rejects a potentially expansive reading of “professional practice” that would have turned it into a purely subjective standard rooted in each physician’s personal habits or beliefs. Such a reading would have made it nearly impossible to prosecute physicians who claimed (even implausibly) to follow their own medical philosophy, undermining the Controlled Substances Act’s regulatory scheme. The Fourth Circuit’s holding preserves room for good-faith medical disagreement while maintaining that actual knowledge remains a requirement for criminal liability.