Criminal – Doctor convicted of unauthorized distribution of oxycodone

Where the district court accurately instructed the jury on the mens rea required to convict someone for the unauthorized distribution of oxycodone, a doctor’s convictions were affirmed.

Background

From 2005 to 2022, Kirsten Ball practiced medicine from her home office as a licensed physician. In April 2023, she was indicted on one count of conspiracy to distribute oxycodone and on 20 counts of distribution of oxycodone. A jury convicted her of conspiracy and all but one count of distribution.

Ball does not dispute that the government presented sufficient evidence showing that her prescriptions deviated from standard medical practice. Her appeal instead turns on whether the jury instructions accurately stated the law—specifically, the mens rea required for conviction—following the Supreme Court’s decision in Ruan v. United States, 597 U.S. 450 (2022).

The parties’ joint proposed instructions defined the substantive offenses as requiring proof that Ball knew she was acting outside the “course of her professional practice.” The district court noted that although the proposed instructions quoted the regulatory language interpreting the statute, the use of a possessive pronoun could “get the jury hung up on this issue of idiosyncratic practice.” So the district court removed the word “her” in four instances. It retained instructions that negligence was insufficient for a criminal conviction, and that “good faith is a complete defense to each charge.”

Analysis

In Ruan, the Supreme Court held that the statute’s “knowingly or intentionally” mens rea extended to the statute’s “except as authorized” clause. Culpability cannot turn on whether the “hypothetical ‘reasonable’ doctor” would have known that the conduct was unauthorized.

So careless overprescribing and other failures to make an “objectively reasonable good-faith effort” to prescribe in an authorized manner are insufficient to convict. Instead, the government must prove that the defendant “subjectively believed his conduct was outside the bounds of professional practice” or intended to prescribe beyond what the profession allows.

But Ruan did not make the authorization inquiry wholly subjective. Whether a prescription was issued for a legitimate medical purpose in the usual course of professional practice is an objective question governed by professional standards. What Ruan made subjective is the physician’s mens rea: The government must prove that the physician knew the prescription fell outside those objective bounds of medical practice or that he intended that result. Ball’s contrary reading collapses those distinct inquiries by allowing each physician’s personal habits to define the scope of federal prescribing authority.

Ball seeks support for her preferred instructions in the regulation’s use of the possessive pronoun. She argues that the pronoun requires the defendant’s subjective knowledge to be measured against the “usual course of that specific doctor’s professional practice.”

But the pronoun drops out later in the same subsection. There, the regulation clarifies that “[a]n order purporting to be a prescription issued not in the usual course of professional treatment . . . is not a prescription within the meaning and intent of” the statute. Same boundary, no possessive. Had “his professional practice” meant the doctor’s own idiosyncratic practice, the regulation would not have stripped the possessive when marking that line. The Supreme Court likewise treats the phrases with and without the possessive pronoun as interchangeable.

Parallel provisions in the statutory and regulatory text confirm that the possessive refers to the antecedent profession, not to any particular individual. The regulation specifies that the objective standards must accord with those of an “individual practitioner,” rather than, for example, the particular pharmacist or institutional practitioner.

Thus, “grammatically speaking, her practice does not mean her idiosyncratic practice. Her practice is the medical field she’s in.” This humble pronoun cannot save Ball. The instructions tracked the correct standard.

The court told the jury that the government had to prove that, when Ball issued the prescriptions, “she knew she was acting, or she intended to act,” without authorization. It charged that “good faith is a complete defense,” and defined good faith as “subjective good intentions” measured by “what she subjectively believed to be proper medical practice.”

It distinguished civil medical negligence from criminal conduct, explaining that the latter demanded “proof beyond a reasonable doubt that the doctor knowingly or intentionally acted outside the bounds of professional medical practice.” And it forbade the jury from inferring knowledge “from proof of a mistake, negligence, carelessness or a belief in an inaccurate proposition.” Taken together, those instructions required the subjective finding that

Ruan demands.

Affirmed.

United States v. Ball, Case No. 24-4197, July 14, 2026. 4th Cir. (Richardson), from EDVA at Alexandria (Brinkema). Eugene Joseph Rossi for Appellant. Katherine Elise Rumbaugh for Appellee. VLW 026-2-263. 8 pp.

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