The New York Court of Appeals has ruled that doctors can face homicide charges, in certain instances, if the drugs they prescribe are used by one of their patients during a fatal overdose on the medication. It is the first New York high court decision to rely on the legal theory in a homicide case.

The decision, which was nearly unanimous, means the manslaughter conviction of Dr. Stan XuHui Li of Queens over the deaths of two of his patients will be allowed to stand. 

Associate Justice Eugene Fahey wrote for the majority that, given the facts of the case, a jury was correct in finding Li guilty on the charges of manslaughter in 2014 after two of his patients, Joseph Haeg and Nicholas Rappold, died of opioid overdoses.

"We conclude that a rational jury could have found that defendant was aware of and consciously disregarded a substantial and unjustifiable risk that his prescription practices would result in the deaths of Haeg and Rappold," Fahey wrote.

Li was accused by prosecutors from the New York City Office of the Special Narcotics Prosecutor of running what's known as a "pill mill," an office where the physician drives business by prescribing a disproportionate amount of addictive drugs.

Special Narcotics Prosecutor Bridget Brennan said the decision Tuesday was nine years in the making, from their investigation into Li to his trial and the resulting appeals.

"Today's Court of Appeals decision makes clear that those who recklessly cause a death can be held criminally responsible, even if their conduct is disguised as a medical practice," Brennan said. "We hope this brings a sense of justice and closure to the patients and families who suffered as a result of Dr. Stan XuHui Li's conduct."

In the decision Tuesday, the Court of Appeals laid out the facts of the case brought by prosecutors, who portrayed Li's practice as one influenced by profit, rather than treatment.

His office, in Flushing, was only open one day a week, on the weekend, and didn't require appointments to be seen. Prosecutors said he saw as many as 90 patients in a single day and charged a base fee of $100 per visit. Payments were only allowed in cash.

When patients showed up seeking a prescription for a controlled substance, Li "generally did not verify the source of the pain," and "conducted little to no physical examination," Fahey wrote in the court's decision Tuesday.

"Defendant often prescribed heavy doses of whatever medication his patients requested to alleviate their complaints of pain," Fahey wrote.

Investigators from the Office of the Special Narcotics Prosecutor found that, over three years alone, Li had written more than 21,000 prescriptions for controlled substances. He charged patients an extra fee if they came back to him before their prescription ran out.

Haeg and Rappold, Li's patients, both died of overdoses caused by a combination of oxycodone and alprazolam, or Xanax, both of which were prescribed by Li. Pills from those prescriptions were found with both patients when their bodies were discovered. 

Li was charged with manslaughter over the deaths, as well as 196 other charges, most of which were for the criminal sale of a prescription. He also faced charges of reckless endangerment, grand larceny, and others.

After a trial by jury, Li was convicted and sentenced to a combined 10 to 20 years in prison. The manslaughter charges, alone, accounted for five to 15 years of that sentence. 

Li was unsuccessful in getting that outcome reversed on appeal before the Appellate Division, First Department in Manhattan last year. The appellate court ruled that prosecutors had met their burden to convict Li of manslaughter.

"At bottom, all that was needed for the manslaughter charge to be sustained was for the People to satisfy its elements," the First Department wrote.

Among those elements, Fahey wrote in Tuesday's decision, was whether Li had acted recklessly, and whether those actions could have led to the death of his patients. Based on the facts of the case, Fahey wrote that Li was culpable. 

"Viewing that evidence in the light most favorable to the People, we conclude that the evidence was sufficient to support the jury's finding that defendant acted recklessly," Fahey wrote.

Li's attorneys had argued before the Court of Appeals last month that he couldn't face homicide charges because the drugs he prescribed, when used as directed, would not have killed either Haeg or Rappold. They also argued that Li couldn't have known they would abuse the drugs.

Fahey found that argument unconvincing in Tuesday's decision, saying the jury could have inferred, from the facts of the case, that both patients may have abused drugs.

"The fact that Haeg and Rappold took the substances defendant prescribed for them in a greater dosage than prescribed is neither an intervening, independent agency nor unforeseeable," Fahey wrote. "It is a direct and foreseeable result of defendant's reckless conduct."

Associate Justice Rowan Wilson, the lone dissenting judge in the case, wrote that the court's other six judges had created a rule Tuesday that could be interpreted broadly, rather than used in a limited circumstance like the one before them.

Wilson, however, was not kind to Li in his dissent, calling him "grotesquely reckless."

"I have no quarrel, not even a quibble, with the majority's conclusion that Dr. Li's prescription practices were reckless, contrary to sound medical practice, and unlawful," Wilson wrote. "No doubt he is a criminal."

The last line referred to the countless other charges, aside from manslaughter, on which Li was convicted. He hadn't challenged those, instead throwing his full weight behind having the manslaughter conviction reversed. Those charges carried the heaviest sentence.

But instead of aligning with the majority's new rule established Tuesday, Wilson said he would rather have the state Legislature decide when doctors should face homicide charges.

"Exactly how far today's decision expands the homicide liability for doctors is unclear," Wilson wrote. "If a doctor recklessly prescribes drugs that interact and cause a death, will that be considered manslaughter?"

Li was represented before the Court of Appeals by Raymond Belair, a member at Belair & Evans in Manhattan. Belair, like Wilson, warned of the new rule established through the court's decision Tuesday.

"We had hoped to prevail, among many other grounds , on the fact that Dr. Li had no reason to believe that his prescriptions would likely cause the deaths of these two specific patients," Belair said. "However, at this point our options are few. The new rule announced today for New York physicians is very troubling."

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