United States v. Kirsten Ball

• Court: Court of Appeals for the Fourth Circuit
• Decided: July 14, 2026
• Docket: 24-4197
• Status: Published

Opinion

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PUBLISHED

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT

No. 24-4197

UNITED STATES OF AMERICA,

Plaintiff – Appellee,

v.

KIRSTEN VAN STEENBERG BALL,

Defendant – Appellant.

Appeal from the United States District Court for the Eastern District of Virginia, at Alexandria. Leonie M. Brinkema, District Judge. (1:23-cr-00080-LMB-1)

Argued: March 20, 2026 Decided: July 14, 2026

Before RICHARDSON, QUATTLEBAUM, and BERNER, Circuit Judges.

Affirmed by published opinion. Judge Richardson wrote the opinion, in which Judges Quattlebaum and Berner joined.

ARGUED: Eugene Joseph Rossi, CARLTON FIELDS, P.A., Washington, D.C., for Appellant. Katherine Elise Rumbaugh, OFFICE OF THE UNITED STATES ATTORNEY, Alexandria, Virginia, for Appellee. ON BRIEF: Jillian A. Blumenthal, CARLTON FIELDS, P.A., Miami, Florida, for Appellant. Jessica D. Aber, United States Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Alexandria, Virginia, for Appellee. USCA4 Appeal: 24-4197 Doc: 46 Filed: 07/14/2026 Pg: 2 of 8

RICHARDSON, Circuit Judge:

Kirsten Ball, a physician, challenges her convictions for the unauthorized

distribution of oxycodone. All agree that her practice was to prescribe large quantities of

oxycodone. The appeal turns on a one-word deletion in the jury instructions that she claims

allowed conviction without the requisite proof that she knew her prescriptions were

unauthorized. She argues that the instructions should have asked whether she knowingly

departed from the course of her professional practice, not merely the course of professional

practice. But she is wrong. The law requires both that the prescriptions fell outside the

objective bounds of professional practice and that she knew it. Read as a whole, the charge

explained just that. We therefore affirm.

I. BACKGROUND

From 2005 to 2022, 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 under 21 U.S.C. § 846, and on twenty counts of distribution of oxycodone

under § 841(a)(1). After a five-day trial, 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. Opening Br. 39. 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).

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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.” J.A.

146, 151, 155–56. The district court noted that although the proposed instructions quoted

the regulatory language interpreting the statute, 1 the use of a possessive pronoun could “get

the jury hung up on this issue of idiosyncratic practice.” J.A. 1099. 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.” 2 J.A. 1660. Ball’s counsel objected to the refusal to give the proposed

instructions and argued that the revised instructions were inconsistent with Ruan.

On direct appeal, Ball contends that the jury instructions incorrectly allowed

conviction “if her medical judgments were contrary to ‘the’ usual practice of medicine in

this country.” Opening Br. 32–33. She argues the proper inquiry post-Ruan was whether

she held the “subjective belief that within her medical practice, she was issuing a

prescription within the bounds for a legitimate medical purpose.” Opening Br. 29 (cleaned

up). That is, so long as she was acting in the usual course of her own professional medical

practice—one that doled out generous quantities of opioids—she could not be found guilty.

We disagree.

1 “A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice.” 21 C.F.R. § 1306.04(a). 2 “Good faith means subjective good intentions and the honest exercise of professional judgment as to the patient’s particular medical needs. It means that the defendant acted in accordance with what she subjectively believed to be proper medical practice.” J.A. 1660–61. 3 USCA4 Appeal: 24-4197 Doc: 46 Filed: 07/14/2026 Pg: 4 of 8

II. DISCUSSION

We review de novo whether the challenged jury instructions correctly stated the law.

United States v. Smithers, 92 F.4th 237, 245 (4th Cir. 2024).

The Controlled Substances Act makes it a crime to “knowingly or intentionally”

prescribe a controlled substance such as oxycodone “[e]xcept as authorized.” 21 U.S.C.

§ 841(a)(1); see also id. § 802(10). By regulation, a prescription is authorized only when

issued “for a legitimate medical purpose by an individual practitioner acting in the usual

course of his professional practice.” 21 C.F.R. § 1306.04(a).

In Ruan, the Supreme Court held that the statute’s “knowingly or intentionally”

mens rea extended to the statute’s “except as authorized” clause. 597 U.S. at 457.

Culpability cannot turn on whether the “hypothetical ‘reasonable’ doctor” would have

known that the conduct was unauthorized. Id. at 465. So careless overprescribing and

other failures to make an “objectively reasonable good-faith effort” to prescribe in an

authorized manner are insufficient to convict. Id. 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. United

States v. Naum, 134 F.4th 234, 239 (4th Cir. 2025) (emphasis added).

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. See 597 U.S. at 467

(“[T]he regulation defining the scope of a doctor’s prescribing authority does so by

reference to objective criteria such as ‘legitimate medical purpose’ and ‘usual course’ of

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‘professional practice.’” (quoting § 1306.04(a)); Smithers, 92 F.4th at 246 (“[A]cting

outside the ‘bounds of medical practice’ is a purely objective standard.”); Naum, 134 F.4th

at 243. 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. 3 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.” Opening Br. 24 (emphasis in original). 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, 21 C.F.R. § 1306.04(a)

(emphasis added). Same boundary, no possessive. Had “his professional practice” meant

the doctor’s own idiosyncratic practice, the regulation would not have stripped the

3 Even so, objective standards bear on the subjective inquiry. A doctor who professes “idiosyncratic views” about the scope of his prescribing authority will only “escape liability” if the jury believes that he actually held those views. Ruan, 597 U.S. at 466. And “the more unreasonable a defendant’s asserted beliefs or misunderstandings are, especially as measured against objective criteria, the more likely the jury will find that the Government has carried its burden of proving knowledge.” Id. at 467 (cleaned up) (citing Cheek v. United States, 498 U.S. 192, 203–04 (1991)). A jury may accept that a doctor held some objectively unreasonable notions about prescribing, but is unlikely to accept that a doctor truly believed he could dispense drugs like candy on a street corner. 5 USCA4 Appeal: 24-4197 Doc: 46 Filed: 07/14/2026 Pg: 6 of 8

possessive when marking that line. The Supreme Court likewise treats the phrases with

and without the possessive pronoun as interchangeable. See United States v. Moore, 423

U.S. 122, 141 (1975); Ruan, 597 U.S. at 478–79 (Alito, J., concurring). 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. Compare 21 C.F.R. § 1306.04, with

§ 1306.06 (“A prescription for a controlled substance may only be filled by a pharmacist,

acting in the usual course of his professional practice . . . .” (emphasis added)), and 21

U.S.C. § 802(21) (defining “practitioner” to include various scientific and medical

professionals who may handle “a controlled substance in the course of professional practice

or research”). Thus, “grammatically speaking, her practice does not mean her idiosyncratic

practice. Her practice is the medical field she’s in.” J.A. 2201 (emphasis added). This

humble pronoun cannot save Ball.

The instructions tracked the correct standard. They told the jury to convict if “the

defendant knowingly or intentionally distributed the substance not for a legitimate purpose

or outside the usual course of professional medical practice.” J.A. 1654. That instruction

was not a model of clarity. Read alone, its placement of “knowingly or intentionally” could

leave the jury uncertain whether those terms modified only the act of distribution or also

the prescription’s lack of authorization. See Smithers, 92 F.4th at 246–48; Naum, 134 F.4th

at 239.

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But we do not read instructions one sentence at a time. United States v. Sanders,

146 F.4th 372, 377–78 (4th Cir. 2025). Rather, we ask whether the charge as a whole, read

in the context of the entire record, accurately and fairly states the controlling law. Id.;

Smithers, 92 F.4th at 248. Here, the overall charge resolved any ambiguity, providing what

the instructions in Smithers and Naum did not. 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. J.A. 1655–56. It charged that “good faith is a

complete defense,” and—unlike the objective good-faith instruction we faulted in

Smithers, 92 F.4th at 249–50—it defined good faith as “subjective good intentions”

measured by “what she subjectively believed to be proper medical practice.” J.A. 1660–

61. 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.” J.A. 1659. And

it forbade the jury from inferring knowledge “from proof of a mistake, negligence,

carelessness or a belief in an inaccurate proposition.” J.A. 1662. Taken together, those

instructions required the subjective finding that Ruan demands.

That repeated subjective language is what the jury instructions in Smithers and

Naum lacked. In Smithers, the offense instruction permitted conviction on an objective

finding that the physician acted beyond the bounds of medical practice, and nothing in the

rest of the charge required more; the good-faith instruction compounded the error by

defining good faith as compliance with generally accepted standards. 92 F.4th at 246–50.

Similarly, in Naum, the instructions required the jury to find only that the defendant

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“knowingly and intentionally” wrote prescriptions, but not that he knew such conduct fell

outside the objective bounds of professional medical practice. 134 F.4th at 239–40. Here,

by contrast, the court expressly directed the jury to decide what Ball knew and intended,

defined good faith by what she subjectively believed, and prohibited conviction for mere

negligence or mistake. 4 The charge therefore did not leave the jury free to convict merely

because a reasonable physician would have recognized the prescriptions as unauthorized.

Read in their entirety, the instructions captured Ruan’s framework: Professional

standards objectively define the scope of authorization, but the Government still must

prove that the defendant subjectively appreciated that her prescriptions fell outside those

bounds. 5

* * *

Professional standards determine whether a prescription is unauthorized. And a

defendant’s knowledge or intent determines whether an unauthorized prescription is

criminal. Because the charge required the jury to find both, Ball’s conviction is

AFFIRMED.

4 Other circuits have upheld charges containing comparable subjective-knowledge requirements. See United States v. Hofschulz, 105 F.4th 923, 929 (7th Cir. 2024); United States v. Lamartiniere, 100 F.4th 625, 636–37, 649 (5th Cir. 2024). 5 Ball separately contends the district court abused its discretion in declining to give the parties’ jointly proposed instructions. Reversal on that ground requires a proposed instruction that was (1) correct, (2) not substantially covered by the charge as given, and (3) directed at a point so important that its omission seriously impaired the defense. United States v. Sonmez, 777 F.3d 684, 688 (4th Cir. 2015). Ball’s challenge fails for the reasons already given: The instructions as given substantially covered the subjective-knowledge requirement, and the only “point” that Ball says she was barred from pressing—that the jury had to find she knew her prescriptions were unauthorized measured against her own practice—is not the law. 8