Supreme Court Sides With Doctors Accused of Running Pill Mills

WASHINGTON — The Supreme Court on Monday sided with two doctors convicted of illegally dispensing drugs without a legitimate medical purpose.

The ruling was unanimous, though the justices disagreed on the precise rationale. They were united, however, in saying that prosecutors needed to prove more than that the doctors had violated objective standards.

Justice Stephen G. Breyer, writing for six members of the court, said that, so long as doctors were authorized to dispense controlled substances, prosecutors “must prove beyond a reasonable doubt that the defendant knew that he or she was acting in an unauthorized manner, or intended to do so.”

The doctors in the two cases were convicted of unlawful drug distribution under the Controlled Substances Act. One, Dr. Xiulu Ruan, was accused of running a clinic in Alabama with a business partner that issued nearly 300,000 prescriptions for controlled substances in a little more than four years, making it one of the nation’s leading sources of prescriptions for some kinds of fentanyl drugs.

The other, Dr. Shakeel Kahn, was accused of writing prescriptions in Arizona and Wyoming in exchange for payments that roughly tracked the street prices of the drugs. Prosecutors said he had accepted payment in cash and personal property, including firearms.

The question for the justices was how to read a phrase in a regulation under the act. The phrase set out an exception to the law’s prohibition for prescriptions that were “issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice.”

Lawyers for the government argued that the exception described an objective standard rooted in established medical norms, while the doctors’ lawyers said that their clients’ subjective understandings and good faith must play a role.

Justice Breyer sided with the second view, writing that he rejected the government’s argument that “requiring it to prove that a doctor knowingly or intentionally acted not as authorized will allow bad-apple doctors to escape liability by claiming idiosyncratic views about their prescribing authority.”

The Supreme Court sent the case back to the appeals courts to consider whether the juries in the two cases had been properly instructed and, if not, whether the errors were harmless.

Justice Samuel A. Alito Jr., writing for three members of the court, agreed with Justice Breyer’s bottom line but not his reasoning.

“A doctor who makes negligent or even reckless mistakes in prescribing drugs is still ‘acting as a doctor’ — he or she is simply acting as a bad doctor,” Justice Alito wrote.

“The same cannot be said, however, when a doctor knowingly or purposefully issues a prescription to facilitate ‘addiction and recreational abuse,’” he wrote, quoting an earlier decision.

Justice Alito said he would allow doctors who act “in subjective good faith in prescribing drugs” to invoke the exception to the law.

Kate Nicholson, executive director of the National Pain Advocacy Center, which filed a brief supporting the doctors, said the decision “protects providers from being afraid of unwarranted prosecution and people in pain from being given access to care.”

Abbe Gluck, a law professor at Yale, said the decision on Monday was “a victory for physicians prescribing innovative treatments that they believe serve legitimate medical purposes and should counteract concerns that the court would issue a ruling that would chill physician prescribing and needed pain treatments.”

She cautioned against overreading the decisions, Ruan v. United States, No. 20-1410, and Kahn v. United States, No. 21-5261.

“Some may wonder why alleged ‘pill mill’ operators appear to get off the hook, but the court didn’t say that,” Professor Gluck said. “What the court said is that juries must scrutinize whether charged physicians actually believed their behavior was legitimate rather than using an objective standard of a hypothetical reasonable physician. That may make prosecutions of some outliers difficult, but good government lawyering should smoke out dishonest doctors who are not acting as doctors at all.”

Jan Hoffman contributed reporting.