WASHINGTON — Amid a national crisis of soaring opioid overdoses and deaths, the Supreme Court on Tuesday heard the cases of two doctors accused of operating pill factories, as judges struggled to formulate a legal standard that would separate nontraditional medical practices from drugs. a business.
They analyzed the language of the Controlled Substances Act, remembering lessons learned from grammar teachers as children. They tried analogies, including whether there is ever a bona fide exception to speeding. And they worried about sending doctors to prison for decades over disputes over whether they had violated vaguely defined medical norms.
Doctors were convicted on two occasions of drug trafficking. One of them, Dr. Xiulu Ruan, was charged with running an Alabama clinic with a business partner that filled nearly 300,000 controlled substance prescriptions in just over four years, making her one of the nation’s leading sources of prescriptions for certain types of drugs. fentanyl. drugs.
Another, Dr. Shaquille Kahn, was accused of writing prescriptions in Arizona and Wyoming in exchange for payments roughly matching retail drug prices. Prosecutors said he accepted payment in cash and personal property, including firearms.
The question for the judges was how to read the phrase in the ruling under the Controlled Substances Act. The phrase establishes an exception to the law’s prohibition and punishment for prescriptions that have been “issued for legitimate medical purposes by an individual medical practitioner acting in the course of his professional practice.”
Eric J. Feigin, a federal government lawyer, said the exception describes an objective standard based on established medical regulations that the two physicians ignored.
“They want to be free from any obligation, even making minimal effort to act like doctors when they prescribe dangerous, highly addictive and, in one case, lethal doses of drugs to gullible and vulnerable patients,” he said.
Physicians’ lawyers said the correct standard was subjective and based on whether they acted in good faith, even if their behavior was contrary to accepted medical practice.
“The problem is that medical standards are evolving,” said Lawrence S. Robbins, Dr. Ruan’s attorney. “This is a constantly evolving issue. And that respect for patients, their disease, and their doctors requires subjective standards.”
Bo B. Brindley, Dr. Kahn’s attorney, warned of the “terrible deterrent effect” that could come from turning the DEA into a “de facto national medical board.”
Chief Justice John J. Roberts, Jr. said that subjective understanding is not usually a defense against criminal charges.
The driver stopped because he went 70 mph when the speed limit was 55, may have thought the limit was 70. “You’re still getting a fine, right?” Chief Justice Roberts asked.
Mr. Robbins said different rules apply to serious criminal charges.
“You can’t defend a traffic violation based on your state of mind,” he said, adding that more is required, “when you’re talking about sending doctors or anyone for that matter to prison for decades of mandatory minimums. in prison.”
Judge Amy Coney Barrett offered a closer analogy. Suppose, she said, that the criminal law provides: “Except as permitted by law, you must drive at less than 55 miles per hour.”
Motorists driving much faster to get an injured child to the emergency room may misunderstand, but in good faith, the exception that applies to them, she said.
Judge Brett M. Kavanaugh agreed. “If the law says ‘except where permitted’ and you honestly believe that you are allowed to travel 100 miles to get your child to the hospital, you should be acquitted, right?” he asked.
Judge Kavanaugh then turned to the trial cases of Ruan v. United States, nos. 20-1410, and Kahn v. United States, nos. 21-5261.
“The doctor may have violated this objective standard, but he could legitimately believe that the standard is somewhat different, and therefore, in such circumstances, he should not be sent to 20 years in prison, right?” he asked.
Judge Samuel A. Alito, Jr., drawing on what he learned from “my old English teacher,” said that placing the phrase “knowingly and intentionally” in the statute after the exception cited by doctors meant that it did not apply to exclusion, undermining the doctors’ argument that subjective conscientiousness matters.
According to Judge Alito, the grammatical errors in the doctors’ arguments did not end there. “The problem is that it can change the dialect,” he said. “He can only change the verb.”
Judge Stephen G. Breyer disagreed, remembering his high school days.
“I had another English teacher, Miss Chichester,” he said, “who told us that an adverb can change a verb, an adjective, or another adverb.” (Most authorities would agree that Judge Breuer is absolutely right.)
Chief Justice Roberts said, a little sadly, “I can’t remember my grammar teacher’s name.”