From January 2011 to May 2015, Dr. Xiulu Ruan operated a clinic with Dr. John Couch, where they issued over 475,000 prescriptions for opioids.

The judge disagreed and informed the jury that the doctors could be held guilty if their prescribing practices deviated from medical norms to the extent that they were unrecognizable as medicine.

As in Ruan v. United States, the trial judge told the jury that the "good faith" argument could not stand if Kahn's actions were outside the bounds of standard medical practice.

The court rejected the government's "mens rea" standard in which the government argued that the statute should be read as requiring an "objectively reasonable good-faith effort," stating that such an interpretation would put the burden on the defendant to prove that their mental state was that of a "hypothetical 'reasonable' doctor."

Breyer cited Elonis v. United States against the government's requirement for the accused to prove he is "reasonable."