Case Explained: UNITED STATES OF AMERICA Plaintiff – v. KIRSTEN VAN STEENBERG BALL Defendant –

Court: United States Court of Appeals for the Fourth Circuit

Filed: 2026-07-14

The Fourth Circuit affirmed Kirsten Ball’s convictions for conspiracy to distribute and distribution of oxycodone, rejecting her argument that jury instructions failed to account for the Supreme Court’s decision in *Ruan v. United States*. The court held that while *Ruan* requires the government to prove a physician subjectively knew their conduct was unauthorized, the scope of what constitutes “unauthorized” prescribing remains an objective standard based on the usual course of professional medical practice, not the defendant’s personal or idiosyncratic habits. The court applied the standard of review de novo for jury instructions and interpreted 21 U.S.C. § 841(a)(1) alongside 21 C.F.R. § 1306.04(a). The opinion clarified that *Ruan* mandates a two-part inquiry: an objective determination of whether the prescriptions fell outside the bounds of professional practice, and a subjective determination that the defendant knew they were acting outside those bounds. The court found that although the district court deleted the possessive pronoun “her” from the phrase “course of her professional practice,” the instructions as a whole accurately stated the law. The charge explicitly required the government to prove Ball knew she was acting without authorization, defined good faith as subjective belief in proper medical practice, and instructed the jury that negligence or mistake was insufficient for criminal conviction. Consequently, the judgment of the District Court for the Eastern District of Virginia is affirmed, and Ball’s convictions stand.

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