The Supreme Court is hearing the case of doctors accused of running pill factories

WASHINGTON – The Supreme Court ruled Tuesday amid a national crisis of rising opioid overdoses and deaths looked at the cases of two doctors accused of operating pill mills as judges struggle to formulate a legal standard that would separate unconventional medical practices from drug trafficking.

They analyzed the language of the Controlled Substances Act and recalled lessons learned from childhood grammar teachers. They tried analogies, including whether there is ever a bona fide exception to speeding. And they worried about sending doctors to jail for decades over disputes over whether they had violated ill-defined medical norms.

The doctors in the two cases were convicted of unlawful drug distribution. one, dr Xiulu Ruan, was accused of running a clinic in Alabama with a business partner who had issued nearly 300,000 prescriptions for controlled substances in just over four years, making him one of the nation’s top sources for prescriptions for some types of fentanyl drugs .

The other, dr. Shakeel Kahn, has been accused of writing prescriptions in Arizona and Wyoming for payments that roughly matched the drug’s street prices. Prosecutors said he accepted cash and personal property, including firearms.

The question for the judges was how to read a sentence in a regulation under the Controlled Substances Act. The sentence provided an exception to the law’s prohibition and penalties for prescriptions “prepared for a legitimate medical purpose by an individual physician acting in the ordinary course of his profession.”

Eric J. Feigin, a federal government attorney, said this exception describes an objective standard rooted in established medical norms that the two doctors ignored.

“They want to be free from any obligation to make even minimal efforts to behave like doctors when prescribing dangerous, highly addictive and in one case fatal doses of drugs to trusting and vulnerable patients,” he said.

Lawyers for the doctors said the proper standard is a subjective one that focuses on whether they acted in good faith, even when their behavior conflicted with generally accepted medical practices.

“The problem is that medical standards are evolving,” said Lawrence S. Robbins, an attorney for Drs. Ruan. “It’s a constantly evolving matter. And this respect for patients and their illness and their doctors requires a subjective standard.”

Beau B. Brindley, an attorney for Dr. Kahn warned of a “terrible chilling effect” that would result if the Drug Enforcement Administration were transformed into “a de facto national medical association.”

Chief Justice John G. Roberts Jr. said that subjective understanding generally does not create a defense against criminal charges.

A motorist who pulled over for driving 70 mph when the speed limit was 55 may have believed the speed limit was 70. “You still get the ticket, right?” Chief Justice Roberts asked.

Mr Robbins said different rules apply to serious criminal charges.

“You cannot defend traffic violations on the basis of your state of mind,” he said, adding that more is needed “if you are talking about sending doctors or anyone for that matter to prison for the mandatory minimum of decades in prison.” “

Judge Amy Coney Barrett suggested what she suggested as a closer analogy. Assuming, she said, that a criminal law dictates, “Except where permitted by law, you must drive less than 55 miles per hour.”

Drivers who drive much faster to get an injured child to an emergency room could mistakenly but in good faith understand that the exception applies to them.

Judge Brett M. Kavanaugh agreed. “If the law says ‘except as authorized’ and you sincerely believe you’re legal to drive 100 to take your child to the hospital, you should be acquitted, right?” he asked.

Judge Kavanaugh then turned to the cases pending before the court, Ruan v. United States, No. 20-1410, and Kahn v. United States, No. 21-5261.

“The doctor may have violated that objective standard but would have reasonably thought the standard was slightly different and so shouldn’t be sent to prison for 20 years in the circumstances, should he?” he asked.

Judge Samuel A. Alito Jr., relying on what he learned from “my old English teacher,” said the placement of the phrase “knowingly and intentionally” in the statute after the exception the doctors relied on meant that this is not the case apply to the exception and invalidate the doctors’ argument that subjective good faith counts.

The grammatical errors in the doctors’ arguments didn’t stop there, Judge Alito said. “The problem is what an adverb can change,” he said. “It can only modify a verb.”

Judge Stephen G. Breyer disagreed, recalling his own school days.

“I had another English teacher, Ms. Chichester,” he said, “who told us an adverb could modify a verb, an adjective, or some other adverb.” (Most authorities would agree that Judge Breyer is exactly right.)

Sounding a little rueful, Chief Justice Roberts said, “I don’t remember the name of my grammar teacher.”

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