                                                                                   [PUBLISH]

                  IN THE UNITED STATES COURT OF APPEALS

                            FOR THE ELEVENTH CIRCUIT           FILED
                             ________________________ U.S. COURT OF APPEALS
                                                                        ELEVENTH CIRCUIT
                                     No. 10-10574                       SEPTEMBER 12, 2011
                               ________________________                     JOHN LEY
                                                                             CLERK
                          D.C. Docket No. 3:08-cr-00136-LC-1

UNITED STATES OF AMERICA,

                                                          lllllllllllllllllllllPlaintiff-Appellee,

                                            versus

DAVID W. WEBB,

                                                        llllllllllllllllllDefendant-Appellant.



                              ________________________

                      Appeal from the United States District Court
                          for the Northern District of Florida
                            ________________________

                                     (September 12, 2011)

Before HULL, BLACK and STAPLETON,* Circuit Judges.

PER CURIAM:

       *
         Honorable Walter K. Stapleton, United States Court of Appeals for the Third Circuit,
sitting by designation.
      Defendant-Appellant David W. Webb (“Webb”) was convicted of 130

counts arising, inter alia, from his wire fraud, health care fraud, and unlawful

dispensing of controlled substances. Webb also was convicted of three counts

charging that a patient’s death resulted from the use of controlled substances

dispensed by Webb or from his health care fraud violation. Webb is serving

concurrent life sentences on the three death-results convictions, and numerous

five, ten, and twenty-year concurrent sentences on his other 127 convictions.

      Webb appeals his 130 convictions, arguing that: (1) the district court gave

erroneous instructions to the jury, (2) he received ineffective assistance of trial

counsel, and (3) the government’s evidence was insufficient to sustain his

convictions. After oral argument and careful review of the briefs and record, we

affirm.

                                      I. INDICTMENT

      On December 22, 2008, a grand jury issued a 131-count indictment1

charging Webb with: (1) conspiring (with his wife, Bonnie Faye Webb (“Faye”))

to defraud a health care benefit program and to commit wire fraud, in violation of

18 U.S.C. §§ 1343, 1347, 1349 (Count 1); (2) defrauding a health care benefit

program, in violation of 18 U.S.C. §§ 1347 and 2 (Counts 2-36); (3) unlawfully

      1
          Webb was acquitted on one count of the indictment.

                                                2
dispensing and causing to be dispensed controlled substances, in violation of 21

U.S.C. §§ 841(a)(1) and 18 U.S.C. § 2 (Counts 39-106; 108-129); and (4)

possessing and using, without lawful authority, a Drug Enforcement

Administration (“DEA”) registration number of another in connection with the

distribution of controlled substances, in violation of 18 U.S.C. §§ 1028(a)(7) and 2

(Counts 130 and 131).

       Count 37 charged Webb with health care fraud, and alleged that his fraud

resulted in death, in violation of 18 U.S.C. §§ 1347 and 2. Count 38 charged

Webb with conspiracy to unlawfully distribute numerous controlled substances,

including oxycodone2 and fentanyl,3 and with death resulting from the use of

oxycodone and fentanyl, all in violation of 21 U.S.C. §§ 841(a)(1), (b)(1)(C), 846.

Count 107 charged Webb with unlawfully dispensing the controlled substances

oxycodone and alprazolam,4 and with death resulting from the use of the

oxycodone, in violation of 21 U.S.C. §§ 841(a)(1), 841(b)(1)(C), 841(b)(2), and 18


       2
        Oxycodone is a powerful pain-reliever derived from opiates like morphine. It comes in
immediate-release forms such as Percocet and continuous-release forms such as OxyContin. See
United States v. Merrill, 513 F.3d 1293, 1300 n.5 (11th Cir. 2008).
       3
         Fentanyl is the drug contained in Duragesic patches. Burnette v. Taylor, 533 F.3d 1325,
1330 n.3 (11th Cir. 2008). Fentanyl is a powerful synthetic opiate analgesic similar to, but more
potent than, morphine.
       4
         Alprazolam is a benzodiazepine that is often used to help reduce anxiety or help people
sleep, and is branded, among other things, as Xanax. See Merrill, 513 F.3d at 1300 n.4.

                                                3
U.S.C. § 2.5 Because defendant Webb challenges the sufficiency of the evidence

at trial, we review the evidence in detail.

                                 II. EVIDENCE AT TRIAL

A. Webb’s Prescribing Practices

      Defendant Webb, a Florida-licensed physician, operated his medical

practice in Destin, Florida, under the name “Doctors on Call.”

      Under Florida law, physicians are allowed to prescribe controlled

medications for pain, but must do so “for a sound medical purpose” and “within

the standard of care of a physician.” The Florida State Board of Medicine has

established seven standards that physicians who prescribe controlled substances

for the treatment of pain must follow, including these five: (1) conducting a

complete medical history and physical examination and documenting them in the

medical record; (2) establishing a written treatment plan with objectives to

determine whether the plan is working; (3) using written drug agreements for

patients deemed at high risk for drug abuse; (4) referral of the patient to expert

doctors “in order to achieve treatment objectives,” especially when the patient has

a history of substance abuse; and (5) keeping complete and accurate records. Fla.

Admin. Code r. 64B8-9.013(3). At trial, witnesses testified that Webb prescribed

      5
          The indictment did not state the names of the victims.

                                                  4
controlled substances for patients whom he saw for less than fifteen minutes, and

that those patients then would go straight to the pharmacy.

      At trial, Dr. Theodore Parran (“Dr. Parran”) was the government’s expert

witness in drug and alcohol dependency. Dr. Parran reviewed 115 to 120 patient

files from Webb’s practice. Based on those files, Dr. Parran concluded that Webb

consistently violated the Florida Board of Medicine’s standards. According to Dr.

Parran, Webb: (1) gave inadequate initial evaluations, including failures to obtain

prior medical records and sub-standard physical exams; and (2) failed to refer

patients to specialists to help manage their pain. Webb also ignored signs of drug

dependency in his patients and continued to prescribe drugs even when patients

were “out of control with their self-taking of the medicine.”

      Dr. Parran’s testimony, along with other testimony and documentary

evidence, indicated that Webb prescribed multiple controlled substances in high

doses, even where doing so made little medical sense. Dr. Parran testified that

when Webb’s patients had pain complaints, Dr. Parran could not recall any who

were not treated with controlled substances, a practice he described as “very

unusual.” The government’s evidence also indicated that even after Webb

discovered some of his patients were addicts, he continued to feed their addictions

by prescribing more controlled substances.

                                         5
       Dr. Parran also opined that Webb’s prescribing practices were “dangerous,”

“[a]bsolutely incredible,” and “clearly inconsistent with the usual course of

medical practice and for other than legitimate medical purposes.” Webb routinely

granted patients’ requests for early refills, even though such requests indicate that

patients are not taking drugs as prescribed. Tellingly in Dr. Parran’s view, Webb

did not question the reasons his patients gave for needing early refills, which

included: (1) a friend having stolen medication; (2) taking too much hydrocodone

for cold sores; and (3) having flushed medication down the toilet. While patients

sometimes legitimately need early refills, when this many patients ask for early

refills it is “a huge red flag.” Instead of granting those patients’ requests, the

better course is often to “ask them to get treatment.”

      Additional testimony and evidence at trial suggested that Webb continued to

give his patients prescriptions for controlled substances even after Webb learned

those patients were obtaining narcotics from other sources or sharing their drugs.

For instance, Webb continued to prescribe multiple controlled substances to

patient Kevin Morris and Morris’s wife, even though Webb knew that Morris

shared medication with his wife. Webb also prescribed 74 Adderall pills rather

than the usual 60 to patient David Lee because Lee “has to pay back some people

who he borrowed medications from.” According to Dr. Parran, prescribing

                                           6
narcotics under these types of circumstances “breaks basic rules of clinical

decision making” because “people getting potentially addicting drugs from

significant others, friends, family, acquaintances, and saying that they like them or

they feel like they’re the thing that works for them” is a major warning sign for

physicians in general.

      Despite warnings from relatives and close friends to Webb and his staff

about various patients’ drug abuse, Webb continued to prescribe those patients

controlled substances. For instance, one patient’s father told Webb that the patient

had entered a drug rehabilitation facility, prompting Webb to note that the patient

“will never get another prescription from our practice.” Webb, however,

prescribed Adderall to that patient less than nine months later. Dr. Parran stated

that he could think of no good reason, aside from terminal illness, to give narcotics

to someone who had been detoxed and was in recovery from an opiate addiction.

One of Webb’s medical assistants also testified that when she expressed her

concerns to Webb, he dismissed her, saying “he did not put the pills in [his

patients’] mouth[s], he just wrote the scripts that they needed.”

      Webb stood out to the pharmacists who filled his prescriptions because of

the “amount and the frequency” of the prescriptions. Unlike other doctors, Webb

kept his patients on pain medications for long periods, and also requested specific

                                          7
brands of pain medicine because they worked better than generics. Dr. Parran

testified, however, that there is no medical reason to prescribe specific brands of

pain medicine rather than generics, and that his understanding is that patients seek

name-brand prescription medicines because those medicines have more street

value. Webb’s patients also brought in prescriptions for early refills more

frequently than other doctors’ patients. One pharmacist testified that some of

Webb’s patients were “drug seekers,” and that she had informed Webb that some

of Webb’s patients were also getting pain medications from other physicians.

      Based on his review of various patients’ files, Dr. Parran concluded that

Webb’s prescription practices were “done in a way that was inconsistent with the

usual course of medical practice and [were] done for other than legitimate medical

purpose.” On cross-examination, Dr. Parran disagreed with Webb’s counsel’s

statement that “a caring doctor . . . would try to do anything they could to relieve

any type of pain that they believe their patient is suffering,” explaining that:

             If in the process . . . of trying to relieve a patient’s pain and
      suffering, a physician receives data, clinical information, calls from
      pharmacists, calls from probation officers, information about overdoses,
      information that patients are out of control with their medicine, running
      out early, seeing multiple different doctors for the same substances,
      using other illicit substances, so if in the process of trying to provide
      care for a patient’s pain and suffering a physician receives data back
      indicating that that patient is out of control with their use and that their
      continued use threatens their health, their life, or their liberty, continuing

                                            8
      to prescribe to that patient in the face of that kind of adverse information
      coming back to the doctor is inconsistent with the practice of medicine.
      That constitutes knowingly doing harm to a patient in an ongoing way.

B. Webb Practices During License Suspension

      The Florida State Board of Medicine suspended Webb’s medical license for

30 days, beginning April 23, 2005, as a penalty for Webb’s inappropriate

prescribing of weight-loss drugs and Viagra over the Internet. During this

suspension, Webb was not allowed to prescribe drugs or bill for office visits.

      Webb arranged for another physician, Dr. Sally Ann Cooper (“Dr. Cooper”),

to cover his practice during three weeks of the suspension. The weekend before

the suspension started, however, Webb phoned in “lots and lots of prescriptions.”

After the suspension began, Webb continued to treat patients and write

prescriptions. When pharmacists refused to fill those prescriptions because

Webb’s license was suspended, he reissued the prescriptions using Dr. Cooper’s

DEA registration number. Some of the prescriptions were dated the week before

Dr. Cooper began to fill in at Webb’s practice. At one point, Webb’s wife Faye

called in some prescriptions. When the pharmacist told Faye that Webb could not

write prescriptions while he was suspended, Faye stated that Webb was not

writing prescriptions and that she was phoning them in. When the pharmacist still

refused to fill the prescription, Faye hung up. Shortly thereafter, Faye called the

                                           9
pharmacy back and gave Dr. Cooper’s name and DEA registration number to

authorize a prescription for a controlled substance. Webb’s practice also called in

other prescriptions using Dr. Cooper’s DEA registration number.

      Dr. Cooper testified that she had not authorized these prescriptions or the

use of her DEA registration number. Dr. Cooper learned that her number had been

used without her authorization when a patient came in for a routine visit and told

Dr. Cooper that her name was on the patient’s prescription bottles despite their

never having met. Further, the bottles “were dated before [Dr. Cooper] had started

working” at Webb’s medical practice. After doing some investigation on her own,

Dr. Cooper filed an official complaint with the Florida State Board of Medicine.

C. Fraudulent Claims to Health Care Benefit Programs

      Evidence introduced at trial indicated that Webb submitted claims for office

visits and procedures during his 30-day suspension and caused pharmacies to

submit claims based on unauthorized prescriptions. In some cases, Dr. Cooper

saw a patient, but Webb submitted the claims under his own name. In another

case, Webb saw a patient on April 25 but backdated the claim to April 22.

      Representatives from Blue Cross/Blue Shield of Florida, TRICARE (the

health benefit plan for armed services members), and companies that contracted

with Medicare and Medicaid testified that the insurers would not pay claims if

                                         10
they knew that the services were provided (or the prescriptions were written) while

a physician’s license was suspended. Webb’s experts agreed that physicians

should not see patients, write prescriptions, or bill for office visits while

suspended from the practice of medicine.

      The insurance company representatives similarly confirmed that their

companies would not pay for medication that was without legitimate medical

purpose. TRICARE’s representative stated that “the fact that the physician is

ordering a service or a prescription drug and that is causing a claim to be

submitted to the U.S. Government, that would be considered the same as saying

that these services are medically necessary to treat the patient.”

D. Death of Patient Victoria Ross

      Before patient Victoria Ross first saw Webb, she ran her own business and

supported her family. Before she first encountered Webb professionally, Ross

took Lortab for her back pain, but neither the medicine nor the pain interfered with

her ability to function.

      Ross’s sons testified at trial that they noticed changes in her appearance and

behavior after she became Webb’s patient and he prescribed her OxyContin. Ross

stopped caring as closely for her son, lost significant amounts of weight, and even

lost her business. These changes were evident not only to Ross’s family, but to

                                           11
outsiders as well.

      According to her husband, Ross eventually became addicted to the

oxycodone Webb prescribed and injected it intravenously. Ross routinely asked

for and received early prescription refills, despite Webb’s notations in Ross’s file

that he would refuse to issue early refills. Over the course of his treating Ross,

Webb became aware that Ross was seeing and getting drugs from other doctors,

but relied on her representations that she would see only Webb going forward.

      Pharmacists also gave Webb indication that his prescription practices might

be contributing to Ross’s misuse of drugs. However, when one pharmacist refused

to fill a prescription because it was too early, Webb called another pharmacy to

have the prescription filled there. Webb also continued to call in prescriptions for

Ross after a pharmacy alerted him to the possibility that Ross may have altered a

prescription for OxyContin. Webb failed to contact a family doctor who a

pharmacy told him was also prescribing OxyContin and Lortab for Ross.

      Although Webb knew that Ross had been hospitalized for endocarditis, a

heart valve infection that can indicate IV drug usage, he did not request medical

records from her hospitalizations. Those records would have revealed that the

cause of Ross’s endocarditis was in fact IV drug usage. However, when Ross got

out of the hospital and asked Webb to prescribe the same drugs she was on prior to

                                          12
her hospitalizations, Webb wrote that he had “‘no problem with that’” because

Ross was a “responsible and compliant patient.”

      After being absent from early 2004, Ross returned to Webb’s office in the

summer of 2004 complaining of increased lower back pain. Webb took no

additional history, but simply prescribed 28 tablets of OxyContin 40 mg, 28 tablets

of Percocet 10 mg, 30 tablets of Xanax 2 mg, the highest available strength, and

30 tablets of Soma. Although he was not referring specifically to Ross, the

government’s expert explained that it is dangerous to prescribe the same amount

of drugs to a patient following a gap between visits without documentation of

“someone else . . . prescribing in the intervening period and the patient still

[having] the same tolerance” because of the risk that “a patient has lost their

tolerance” for the medication, which could cause an accidental overdose.

      Ross filled the August 15 prescriptions on August 15 and 16, 2004. Ross

collapsed on August 25, 2004, and died at the Fort Walton Beach Medical Center

on August 27. The medical examiner determined that the cause of death was

“acute oxycodone intoxication.” Despite the fact that Ross had an unhealthy heart,

the medical examiner determined that an accidental drug overdose was the more

likely cause of death because: (1) of Ross’s long history of drug abuse and (2)

Ross’s heart was restored to a normal rhythm after she collapsed, which is unusual

                                          13
in cases of heart death. Dr. Parran stated that Webb’s prescription practices as to

Ross were “inconsistent with the usual course of medical practice and appear[] to

be for other than legitimate medical purpose and, to within a reasonable degree of

medical certainty, [were] direct contributor[s] to [Ross’s] death.”

E. Death of Patient Terri Morris

      Webb first saw Trebble “Terri” Morris (“Terri”) in 2000. Webb had already

been treating her husband, Kevin Morris (“Kevin”), since August 1999. Kevin

abused the drugs Webb prescribed for him. One of Terri’s previous doctors

testified that he had dismissed her from his practice in the mid-1990s because he

was uncomfortable having her as a patient. The reasons for his discomfort

included Terri’s seeking drugs from emergency rooms, refusing drug rehabilitation

and other forms of help, and inappropriately using narcotics.

      At her first office visit with Webb, Terri “reported no medical problems,

except for migraines and bipolar or manic depressive disorder . . . and she reported

to be on no medicines.” In addition to other medicines, Webb prescribed five

tablets of OxyContin 20 mg. Pharmacy expert Paul Doering testified that

“OxyContin is a terrible choice” for treating migraine headaches because

OxyContin’s controlled release does not do a good job combating the acute pain

caused by migraines. Dr. Parran opined that prescribing opiates to treat headaches

                                         14
is discouraged because opiates may cause another headache.

      Terri and Kevin both frequently requested early refills. On one occasion, to

justify his early refill, Kevin told Webb that Terri was stealing his medicines.

After the stealing incident, Webb advised Terri and Kevin not to use each other’s

medicines, but continued prescribing them narcotics without mentioning the issue

again. Both Morrises abused the Duragesic (fentanyl) patch that Webb prescribed

Kevin by poking holes in the patch and squeezing the substance into their mouths

to get high. Webb knew that Terri had hepatitis C, which most commonly results

from IV drug abuse, but did not ask Terri how she had contracted the disease.

Despite these signs of drug abuse, Webb continued to prescribe controlled

substances to Terri up until her death on September 9, 2003.

      Terri and Kevin staggered their visits to Webb to ensure that they would

have a steady supply of narcotics. On September 5, 2003, Webb prescribed 30

alprazolam (Xanax), 75 Soma tablets, and 50 Darvocet tablets to Terri. On

September 9, Webb prescribed, inter alia, 15 Duragesic patches to Kevin. When

Kevin found Terri’s dead body, she had one of the Duragesic patches on her body,

and he found several more in the trash with pinpricks in them. Stephen Spinella, a

detective with the Fort Walton Beach Police Department, contacted Webb after

seeing Webb’s name on the pill bottles in Terri’s room. Webb told Detective

                                         15
Spinella that he had no indication that Terri was sharing medications with her

husband, that he had no indication that she was suicidal, and that as far as Webb

knew, Terri took the medications as prescribed.

      The toxicology report done after Terri’s death revealed significant levels of

fentanyl and alprazolam in her blood. The toxicologist testified that the level of

fentanyl in Terri’s blood indicated misuse of the Duragesic patch, was consistent

with ingesting or injecting the patch’s contents, and that putting such a high level

of fentanyl into the body “would be immediately fatal.” Terri’s blood contained

varying amounts of other drugs, and the cause of her death was “complications of

polypharmacy,” or “multiple drug intoxication.”

      Based on his review of the two Morrises’ medical files, Dr. Parran opined

that Webb’s “prescribing appears to have been done inconsistent with the usual

course of medical practice and appears to have been for other than legitimate

medical purpose.” Importantly, “the prescribing played a contributory role in

[Terri Morris’s] death.” Dr. Parran further noted that Terri’s history and behavior

“require[d] intervention and - - and a changing of prescribing at that moment.”

However, Webb’s “prescribing was absolutely unchanged after the husband

reported [Terri’s stealing his medications], up until the time of [Terri’s] death.”

F. Death of Patient Gena Ortega

                                          16
      Webb’s patient Gena Ortega (“Ortega”) was a dental hygienist who had

successfully completed a drug rehabilitation program in 2001. According to

Ortega’s sister-in-law, after she got married Ortega was “a very professional

person, loved her job and neat in her appearance, . . . and . . . seemed to be just in

good general spirits.” After Ortega began seeing Webb, she became moody, had

little energy, and could not hold down a job. Ortega had burn marks on her legs

and on the furniture in her home from where she allowed the cigarettes she was

smoking to drop from her mouth and smolder.

      Webb treated Ortega for back pain intermittently from July 2004 until her

death in April 2007. Ortega’s husband testified that he drove her to two of her

appointments with Webb, during which she was in Webb’s office for less than 15

minutes and went directly to the pharmacy afterwards.

      In December 2004, Ortega told Webb that she had taken too many pills and

therefore had run out of her prescription ten days early, and Webb phoned in a

new prescription for her. On March 23, 2005, Webb noted that Ortega “‘requests

some medication to unwind at the end of the day,’” so Webb prescribed her what

Dr. Parran described as a “whopping” 1 mg dose of Klonopin. Dr. Parran opined

that “[u]nwind at the end of the day is not a diagnosis,” and is “certainly not a

legitimate medical purpose for a Schedule IV benzodiazepine to be prescribed.”

                                          17
Ortega obtained an early refill from Webb in April 2005 and Webb sent her for a

pain consult in May 2005. After a five-month absence, Ortega came back to Webb

in October 2005, and Webb prescribed her Klonopin and Lortab at the same levels

as before.

      According to pharmacy databases in the area where Webb practiced, Webb

continued to prescribe Lortab for Ortega on a monthly basis until April 19, 2007.

That same day, Webb also prescribed generic Soma and Endocet. Ortega died on

April 22, 2007. Among other things, Ortega’s toxicology report showed the

presence of hydrocodone and alprazolam, which resulted in “a synergistic effect.”

The medical examiner concluded that the cause of Ortega’s death was “toxic

effects of hydrocodone and other drugs,” which essentially caused her to

accidentally choke on her own vomit. Dr. Parran testified that Webb’s

“prescribing appeared to be inconsistent with the usual course of medical practice

and appeared to have been for other than legitimate medical purpose and was a

contributing factor to [Ortega’s] death.”

      At the close of the government’s evidence, Webb made a motion for

acquittal, which the district court denied. Webb did not renew this motion at the

close of the evidence.

G. Webb’s Trial Evidence

                                            18
      Webb’s first trial witness was Dr. Richard L. Rauck (“Dr. Rauck”). Dr.

Rauck, an expert in anesthesiology and pain management, testified that Webb was

writing prescriptions appropriate for his patients’ conditions, and that his

prescribing practices were within the professional bounds of medical practice. Dr.

Rauck stated that in cases where he has testified for the Department of Justice that

other doctors conducted themselves outside the bounds of medical practice, it was

his experience that the accused doctors did not treat infections and other

conditions. In Dr. Rauck’s opinion, Webb’s prescribing patterns did not fit with

those of other doctors prosecuted for inappropriately prescribing controlled pain

medications.

      Dr. Rauck further testified that opioids can appropriately be prescribed for

patients with drug abuse histories. Dr. Rauck testified that Webb did refer patients

to pain management clinics for treatment. In his review of Webb’s files, Dr.

Rauck did not see any intent on Webb’s part to get his patients addicted to

narcotics.

      Dr. Rauck testified specifically on each of the three patients in whose deaths

Webb was implicated. He opined that Terri Morris had an extraordinary level of

fentanyl in her system when she died, and that such a high level could not have

come from a prescribed dose. He also noted that Webb did not prescribe fentanyl

                                          19
for Terri, but only for her husband, and testified that it was not unusual for Webb

to have prescribed OxyContin to treat Morris’s headaches.

      As to Gena Ortega, Dr. Rauck testified that she had been on “stable doses of

hydrocodone, so one would not have expected that to have caused her death.” He

stated that the levels of hydrocodone found in her blood at death should not have

been lethal. Dr. Rauck also found it compelling that Ortega had a sixty percent

lesion of one coronary artery and a forty percent lesion of another coronary artery,

which he posited was a possible reason for a cardiac event that could have caused

Ortega’s death.

      Dr. Rauck also reviewed Victoria Ross’s file, which he said demonstrated

“narrowing in [the] coronary arteries” that could possibly have caused her death.

Dr. Rauck opined that Ross “clearly had sustained a miocardial [sic] infarction

rather acutely within days or hours before her ultimate death.” He also testified

that if Ross took her OxyContin as prescribed “it would be hard for [him] to

understand that that would be the cause of death.” Dr. Rauck disagreed with the

medical examiner that acute oxycodone intoxication was likely the cause of Ross’s

death, concluding that her heart condition was a more likely cause.

      Webb testified in his own defense. He stated that he took patients other

doctors were unwilling to see, and that he is very frustrated by his arrest and trial.

                                          20
He also never intended to defraud anyone.

       Webb did not know that Victoria Ross was going to other doctors to get

medicine, and was not treating Ross for her heart problems. Webb prescribed

Ross OxyContin shortly before she died, but did not realize how desperate her

situation was. As to Ortega, she would not have died if she had taken the amount

of drugs Webb prescribed her. Webb never prescribed fentanyl to Terri Morris,

and when he found out that she and her husband were sharing drugs, he would

have had a “very significant conversation” with them (although he did not claim to

remember such a conversation specifically).

       After the defense rested, the district court instructed the jury on all counts.

                              III. JURY INSTRUCTIONS

       Section 841(b)(1)(C) provides for an enhanced penalty for unlawful

dispensing of a controlled substance if death “results from the use of such

substance.” 21 U.S.C. § 841(b)(1)(C). Section 1347(a) provides for an enhanced

penalty for health care fraud “if the violation results in death.” 18 U.S.C.

§ 1347(a).6

       Webb requested a jury instruction on the three death-results Counts—37,



       6
        At the time of trial, § 1347 had the same language, but did not have subsections (a) and
(b). Later legislative changes made what was in § 1347 now § 1347(a) and added subsection (b).

                                               21
38, and 107. Webb’s proposed jury instruction stated that the government must

prove that (1) his conduct “directly” and “in continuous sequence produced[,] or

contributed substantially to producing, the death,” and (2) that “but for” his

conduct, the death would not have occurred. His instruction stated:

            In order to establish that a death “resulted” from the Defendant’s
      conduct, the government must prove beyond a reasonable doubt that the
      Defendant’s conduct directly and in natural and continuous sequence
      produced or contributed substantially to producing the death, so that it
      can be said that “but for” the Defendant’s conduct, the death would not
      have occurred.

      The district court did not give Webb’s proposed instruction but gave

different charges on the counts. We review the district court’s jury instructions

and Webb’s requested instruction in the context of each statute separately. The

principal issue concerns the wording of the jury instruction as to the statutory

terms “results from” contained in § 841(b)(1)(C) (Counts 38 and 107) and “results

in” contained in § 1347(a) (Count 37).

      A.     21 U.S.C. § 841: Counts 38 and 107

      As we noted earlier, Count 38 charged Webb with conspiracy to unlawfully

distribute numerous controlled substances, including oxycodone and fentanyl, and

with death (Terri Morris’s and Victoria Ross’s) resulting from the use of

oxycodone and fentanyl, all in violation of 21 U.S.C. §§ 841(a)(1), (b)(1)(C), and



                                         22
846.7 Count 107 charged Webb with unlawfully dispensing the controlled

substances oxycodone and alprazolam, and with a death (Victoria Ross’s)

resulting from the use of the oxycodone, in violation of 21 U.S.C. §§ 841(a)(1),

(b)(1)(C), (b)(2), and 2.

       We start with the language of the applicable statute. Section 841(a) states

that: “it shall be unlawful for any person knowingly or intentionally . . . to . . .

dispense[] a controlled substance . . . .” 21 U.S.C. § 841(a). Section 841(b)

provides an enhanced penalty “if death . . . results from the use of such substance,”

as follows:

       (b) Penalties
       Except as otherwise provided . . . , any person who violates subsection
       (a) of this section shall be sentenced as follows:
       ...
       such person . . . if death or serious bodily injury results from the use of
       such substance shall be sentenced to a term of imprisonment of not less
       than twenty years or more than life . . . .

21 U.S.C. § 841(b)(1)(C) (emphasis added).

       The dispute in this case centers on whether § 841(b)(1)(C)’s enhanced

penalty requires the jury to find (1) merely that the patient’s use of the controlled

substance (unlawfully prescribed by Webb) was the actual cause of death; or (2)


       7
        The indictment does not specify whose death resulted from the use of which drugs; it
does not even mention the names of the victims. Evidence adduced at trial indicates that Morris
died from the use of fentanyl and Ross died from the use of oxycodone.

                                              23
that Webb’s conduct proximately caused the death or at least that the death was

reasonably foreseeable to Webb.

      As to the § 841offenses (Counts 38 and 107), the district court instructed

there was no foreseeability or proximate cause requirement, and that instead the

government must prove that “but for” (had it not been for) the victim’s ingesting

of the drugs charged in the indictment, the victim would not have died. The

district court’s instruction stated:

            Similarly, as it concerns Counts 38 and 107, the law provides that
      whenever death or serious injury is a result of the victim’s use of a
      controlled substance that has been distributed or dispensed by the
      Defendant, a more serious offense is committed, regardless of whether
      the defendant knew or should have known that death would result.

             There is no requirement that the death resulting from the use of
      the controlled substance dispensed was a reasonably foreseeable event,
      or that the controlled substance was the proximate cause of the death.
      This standard is satisfied upon a finding by you that, but for the victims
      ingesting the controlled substances charged in the indictment, the
      victims would not have died.

      Therefore, you are to determine as follows:

      ...

             Whether in Count 38 the death of Trebble Morris resulted from
      the use of fentanyl and whether the death of Victoria Ross resulted from
      the use of oxycodone that Defendant had caused to be dispensed,
      between in or about December, 2002 and on or about September 13,
      2007.



                                         24
             Whether in Count 107 the death of Victoria Ross resulted from
       the use of oxycodone that the Defendant caused to be distributed or
       dispensed, between on or about August 15, 2004 and on or about August
       16, 2004.

       On appeal, Webb contends that the district court (1) erred in refusing his

requested instruction and (2) should have instructed that, to find Webb responsible

for the deaths, it had to find “proof of actual cause and effect” between Webb’s

own conduct and his patients’ deaths.8 Webb submits that “[l]egal causation

(proximate cause and foreseeability) is a fundamental principle of jurisprudence

and it should have been part of the government’s burden of proof for all three

deaths—Congress has not stated otherwise.”

       We disagree. Rather we join several of our sister circuits and hold that

§ 841(b)(1)(C)’s enhanced penalty requires only proof that the death resulted from

the victim’s use of a controlled substance dispensed by the defendant. See United

States v. De La Cruz, 514 F.3d 121 (1st Cir. 2008); United States v. Houston, 406


       8
         Webb challenges both the failure to give his instruction and the instruction the district
court gave instead. We review a district court’s rejection of a proposed jury instruction for abuse
of discretion. Merrill, 513 F.3d at 1305. “The district court has broad discretion in formulating
jury instructions as long as those instructions are a correct statement of the law.” Id. (quotation
marks omitted). We will reverse the district court’s refusal to incorporate a requested jury
instruction “only if the proffered instruction was substantially correct, the requested instruction
was not addressed in the charges actually given, and failure to give the instruction seriously
impaired the defendant’s ability to present an effective defense.” Id. (quotation marks omitted).
        We review the legal correctness of the jury instruction actually given de novo. United
States v. Prather, 205 F.3d 1265, 1270 (11th Cir. 2000). Jury instructions are subject to harmless
error review. See Davis v. Kemp, 752 F.2d 1515, 1520-21 (11th Cir. 1985) (en banc).

                                                25
F.3d 1121 (9th Cir. 2005); United States v. McIntosh, 236 F.3d 968 (8th Cir.

2001); United States v. Robinson, 167 F.3d 824 (3d Cir. 1999); United States v.

Patterson, 38 F.3d 139 (4th Cir. 1994). We discuss these decisions in depth, as

some focus on foreseeability and others on proximate cause.9

       1.      United States v. Patterson, 38 F.3d 139 (4th Cir. 1994)

       In Patterson, the Fourth Circuit held that reasonable foreseeability is not an

element of the death “results from” sentence enhancement in § 841(b)(1)(C).

Patterson, 38 F.3d at 145. The two defendants in Patterson pled guilty to unlawful

distribution of controlled substances, but reserved the right to contest at

sentencing whether victim Carroll’s death resulted from their distribution of

controlled substances. Id. at 141.10 The sentencing court found that Carroll’s death

resulted from the drugs brought by defendant Patterson to the party. Id. at 141-42.

       On appeal, the defendants argued that the district court erred in not

requiring the government to prove that Carroll’s death was a foreseeable result of

       9
        While Webb has not directed us to any definition of the two terms, foreseeability is
widely defined as an element of proximate cause. See Black’s Law Dictionary 721 (9th ed.
2009) (“Foreseeability, along with actual causation, is an element of proximate cause in tort
law.”).
       10
          Carroll attended a party at Defendant Laythe’s residence. Patterson, 38 F.3d at 142.
Defendant Patterson brought controlled substances to the party, “including Demerol, Mepergan,
morphine sulfate, and Valium, all in tablet or capsule form.” Id. Carroll later took some of the
pills Patterson gave to Laythe, and injected some heroin that Patterson melted down. Id.
Everyone involved went to sleep, and when Patterson and Laythe awoke, they found Carroll
dead. Id.

                                                26
the defendants’ distribution of controlled substances before applying the enhanced

penalty in § 841(b)(1)(C). Id. at 142-43. The defendants argued that “(1) the

statute imposes a ‘reasonable foreseeability of death’ requirement, and (2) the

Government failed to provide sufficient evidence to prove that the death of Carroll

was, in fact, a reasonably foreseeable consequence of their actions.” Id. at 145.

      Rejecting this claim, the Fourth Circuit concluded that “because we find that

§ 841(b)(1)(C) imposes no reasonable foreseeability requirement, we need not

address the question whether Carroll’s death was reasonably foreseeable” to the

defendants. Id. The Fourth Circuit explained that “the plain language of

§ 841(b)(1)(C) does not require, nor does it indicate, that prior to applying the

enhanced sentence, the district court must find that death resulting from the use of

a drug distributed by a defendant was a reasonably foreseeable event.” Id.

Instead, “[t]he statute puts drug dealers and users on clear notice that their

sentences will be enhanced if people die from using the drugs they distribute.” Id.

      The Fourth Circuit concluded that: “Where serious bodily injury or death

results from the distribution of certain drugs, Congress has elected to enhance a

defendant’s sentence regardless of whether the defendant knew or should have

known that death would result.” Id. The Fourth Circuit refused to “second-guess

[Congress’s] unequivocal choice.” Id.

                                          27
      2.     United States v. Robinson, 167 F.3d 824 (3d Cir. 1999)

      The Third Circuit concluded that § 841(b)(1)(C) does not require proof that

a defendant’s actions are the proximate cause of a victim’s death. Robinson, 167

F.3d at 826. Defendant Robinson delivered heroin to Bungar, who delivered it to

Allison, who died of a heroin overdose. Id. at 826-27. The jury convicted

Robinson of conspiring to distribute heroin. The sentencing court “concluded that

Robinson distributed heroin that resulted in Allison’s . . . death,” and imposed the

mandatory minimum 20-year sentence in § 841(b)(1)(C). Id. at 827.

      On appeal, defendant Robinson contended that § 841(b)(1)(C) “requires a

20-year mandatory minimum only if a court finds that the distribution of the

substance was in the common law sense the proximate cause of death or serious

bodily injury.” Id. at 826. In other words, “even though Robinson acknowledges

that a user of the heroin he supplied died from its use, he challenges the sentence

because the district court did not make a finding that his conduct was a proximate

cause of the user’s death.” Id.

      Looking to Patterson for guidance, the Third Circuit stated “the [Fourth

Circuit] explained that the ‘statute puts drug dealers and users on clear notice that

their sentences will be enhanced if people die from using the drugs they

distribute.’” Id. at 830 (quoting Patterson, 38 F.3d at 145). After quoting the

                                          28
Fourth Circuit’s explanation that “it would ‘not second-guess [Congress’s]

unequivocal choice,’” id. (quoting Patterson, 38 F.3d at 145), the Third Circuit

said that “[w]e will not either.” Id. Instead, “[w]here, as here, Congress’ language

is ‘plain and unambiguous,’ we simply apply the language of the statute as

written.” Id. at 830-31.

       The Third Circuit added that “[i]n the circumstances, it would be sophistry

to say that Allison’s death did not result from the use of the heroin delivered

pursuant to the conspiracy.” Id. at 831. The Third Circuit emphasized that “we

are applying a statute dealing with a discrete problem, the distribution of

controlled substances, products which Congress recognized will in some cases

cause death or serious bodily injury.” Id. “Congress recognized that the risk is

inherent in the product and thus it provided that persons who distribute it do so at

their peril.” Id.

       In sum, “[i]t is obvious Congress intended in such a case that the 20-year

mandatory minimum would apply if death or serious bodily injury resulted from

the use of the substance without regard for common law proximate cause

concepts.” Id. Although acknowledging that there might be some limiting

principles on application of the enhancement, the Third Circuit stated that “[i]f

section 841(b)(1)(C) is not to be applied as presently written, Congress and not

                                         29
this court should narrow its application.” Id. at 832.

       3.      United States v. McIntosh, 236 F.3d 968 (8th Cir. 2001)

       In McIntosh, the Eighth Circuit similarly concluded that the enhanced

penalty in § 841(b)(1)(A) did not have a foreseeability or a proximate cause

requirement.11 McIntosh, 236 F.3d at 972. Defendants McIntosh and McMillan

conspired to produce methamphetamine. Id. at 970. McIntosh shared his

methamphetamine with Jean Creswell, who lived with him, and with her niece

Amy Creswell. Id. Some of this methamphetamine eventually reached Jessica

Smith, Jean’s fourteen-year-old daughter, even though McIntosh had specifically

instructed his friends not to give Jessica methamphetamine. Id. Jessica died after

using the methamphetamine. Id.12

       The district court determined that: “1) Jessica’s death resulted from the use

of methamphetamine; 2) the methamphetamine used by Jessica . . . came from

       11
         The relevant wording of § 841(b)(1)(A), which applies to different controlled
substances, is the same as the enhanced penalty in § 841(b)(1)(C):
       (1)(A) In the case of a violation of subsection (a) . . .
       ...
       such person shall be sentenced to a term of imprisonment which . . . if death or
       serious bodily injury results from the use of such substance shall be not less than 20
       years or more than life . . . .
21 U.S.C. § 841(b)(1)(A) (emphasis added).
       12
         McIntosh pled guilty to conspiracy to manufacture methamphetamine. McIntosh, 236
F.3d at 970. His plea agreement “left open for the district court’s determination at sentencing
whether McIntosh was subject to an enhanced sentence because of Jessica’s death.” Id. at 970-
71.

                                                 30
either Amy Cresswell, Jean Creswell, or McMillan;[] and 3) regardless of which of

the three supplied the methamphetamine, it ‘originally came’ from McIntosh.” Id.

at 971. The district court also found that the “government failed to prove that

McIntosh directly furnished Jessica with methamphetamine nor [sic] that he had

any knowledge she was being supplied with the drug by the others.” Id.

      Despite the latter two findings, “the district court concluded McIntosh was

subject to the enhancement because he played a part in manufacturing the drug

[Jessica] did use,” and sentenced him to twenty years’ imprisonment. Id. On

appeal, McIntosh contended that § 841(b)(1)(A) permits a sentence enhancement

only if death “was a reasonably foreseeable result of, or was proximately caused

by, a defendant’s conduct,” and that he did not proximately cause Jessica’s death

and could not reasonably have foreseen it. Id.

      The Eighth Circuit explained that “[t]he starting point for ascertaining the

intended meaning of any statute is the language of the statute itself.” Id. The

statute’s “language is unambiguous and . . . giving effect to its plain meaning

prohibits us from superimposing upon the statute a foreseeability or proximate

cause requirement.” Id. at 972. The Eighth Circuit “decline[d] to hinder

Congress’s will, apparent from the face of the statute, through a judicial

pronouncement that the statute requires more than it says.”

                                         31
Id.

        The Eighth Circuit agreed with the Third and Fourth Circuits’ conclusions

“that Congress intended § 841(b)(1)(A)’s enhancement to apply without regard to

the principles of proximate cause or the foreseeability of death or serious bodily

injury.” Id. at 972-73. The Eighth Circuit acknowledged that “[o]ur conclusion

that the statute imposes strict liability upon McIntosh for Jessica’s death vitiates

[McIntosh’s] argument” that the enhanced sentence only applies if the defendant

intends to cause death or knowingly risks death. Id. at 974.13

        4.      United States v. De La Cruz, 514 F.3d 121 (1st Cir. 2008)

        In De La Cruz, the First Circuit also concluded that § 841(b)(1)(A)’s

enhanced penalty does not require the government to prove foreseeability. De La

Cruz, 514 F.3d at 138. A jury convicted defendant De La Cruz of conspiracy to

distribute heroin and possession with intent to distribute heroin, in violation of 21

U.S.C. §§ 841(a)(1), 846. Id. at 125. De La Cruz sold heroin to Tracy, who sold



        13
           Other circuits have also opined that § 841(b)(1)(C) (or provisions with similar language)
creates a strict liability regime. See United States v. Carbajal, 290 F.3d 277, 283 (5th Cir. 2002)
(interpreting sentencing guideline with similar “death . . . resulted from” language to
§ 841(b)(1)(C) and determining that it “is a strict liability provision that applies without regard
for common law principles of proximate cause or reasonable foreseeability”); United States v.
Rebmann, 226 F.3d 521, 522, 525 (6th Cir. 2000) (indicating in dicta that § 841(b)(1)(C) “[o]n
its face, . . . is, in effect, a strict liability statute with respect to the injury or death of another
arising out of the distribution of drugs”), overruled on other grounds by United States v.
Leachman, 309 F.3d 377, 385 n.9 (6th Cir. 2002).

                                                  32
some of that heroin to Flynn, who sold some to Wallace. Wallace later died in his

home of heroin use. Id. at 126. At trial, the district court instructed the jury that

it:

              [M]ust find, beyond a reasonable doubt, that Wallace ingested
              heroin, that this heroin was a “but for” cause of Wallace’s death,
              and that this heroin was distributed as part of the conspiracy
              charged in Count One and passed through Defendant’s hands as
              part of the distribution charged in Count Two.

Id. at 137.

      On appeal, De La Cruz argued that the jury should have been instructed

that, before finding him eligible for the enhanced penalty, it had to find that

Wallace’s death was foreseeable to him. Id. at 136. Rejecting De La Cruz’s

claim, the First Circuit noted that “[n]othing in the language of the statute suggests

that a death must be foreseeable before the enhanced penalty provision applies.”

Id. at 137. Instead, “[w]hat is required under the death-enhancing statute is that

the government prove cause-in-fact, that is, that the decedent’s death was caused

in fact by his or her use of drugs that were distributed either by the defendant

himself or by others in a conspiracy of which the defendant was a part.” Id. at

138. In De La Cruz’s case, “the district court properly instructed the jury about

the required proof of cause-in-fact, and-following the court’s instructions-the jury

specifically found that Wallace died as a result of ingesting heroin that was

                                          33
distributed during the course of the charged offenses by Defendant [De La Cruz]

to Wallace through Tracy and Flynn.” Id.; see United States v. Hatfield, 591 F.3d

945, 947-48 (7th Cir. 2010) (discussing different types of causation and noting the

“parties agree that the statutory term ‘results from’ required the government to

prove that ingestion of the defendants’ drugs was a ‘but for’ cause of the deaths

and the bodily injury” and “[t]he death or injury need not have been

foreseeable”).14

       5.      United States v. Houston, 406 F.3d 1121 (9th Cir. 2005)

       In Houston, the Ninth Circuit concluded that proximate cause is not a

required element of § 841(b)(1)(C)’s enhanced penalty. Houston, 406 F.3d at

1122-23. The jury convicted defendant Houston of distributing methadone to

Bradford, who died. Id. at 1121. The district court instructed the jury that “the

Government was required to prove beyond a reasonable doubt that ‘the



       14
          The error alleged in Hatfield was not that the district court charged the statutory
language that the government must prove the victim died “as a result of ingesting a controlled
substance . . . distributed by the defendants.” 591 F.3d at 947. The error was the added part of
the charge which stated the controlled substances had to have been “a factor that resulted in
death” and “although they need not be the primary cause of death . . . they must at least have
played a part in the death.” Id. (quotation marks omitted). The Seventh Circuit concluded that:
                 The defendants’ objection to the instruction was well taken. All that would
        have been needed to satisfy it was to eliminate the addition to the statutory language,
        which was a good deal clearer than the addition and probably clear enough.
        Elaborating on a term often makes it less rather than more clear . . . .
Id. at 949.

                                                34
defendant’s act was a proximate cause of . . . Bradford’s death.’” Id. at 1123.

      The Ninth Circuit determined that “[t]o the extent that this instruction

suggested that Bradford’s death had to have been a foreseeable result of

[defendant] Houston’s act, the instruction required the Government to prove more

than the statute requires, and was therefore in error.” Id. (footnote omitted). The

Ninth Circuit reasoned that “[t]he addition of proximate cause as an element

necessary for invoking the twenty-year minimum sentence described in

§ 841(b)(1)(C) is inconsistent with the statutory language, our circuit’s related

precedent, and the conclusions of every other federal court of appeals to consider

the issue.” Id. The Ninth Circuit cited Patterson, McIntosh, and Robinson to

support its conclusion that neither foreseeability nor proximate cause is required to

support the enhanced penalty in § 841(b)(1)(C). See Houston, 406 F.3d at 1124.

      The Ninth Circuit added that, (1) “[a]ll that is necessary under the statutory

language is that ‘death ... results’ from the offense described in § 841(a)(1),” and

(2) “[c]ause-in-fact is required by the ‘results’ language, but proximate cause, at

least insofar as it requires that the death have been foreseeable, is not a required

element.” Id. at 1125. The Ninth Circuit determined that the district court

erroneously instructed the jury that proximate cause was a required element of

§ 841(b)(1)(C), but found the error harmless and upheld defendant Houston’s

                                          35
conviction and sentence. Id. at 1125-26.

       With this background, we turn to the jury instructions at Webb’s trial.

       6.    Jury Instruction at Webb’s Trial

       “The starting point for all statutory interpretation is the language of the

statute itself . . . .” Med. Transp. Mgmt. Corp. v. Comm’r, 506 F.3d 1364, 1367

(11th Cir. 2007) (quotation marks omitted); Harris v. Garner, 216 F.3d 970, 972

(11th Cir. 2000) (en banc) (“[C]ourts should always begin the process of

legislative interpretation . . . with the words of the statutory provision.”). “[O]ur

task is to determine whether the language at issue has a plain and unambiguous

meaning with regard to the dispute in the case. Our inquiry must cease if the

statutory language is unambiguous and the statutory scheme is coherent and

consistent.” Med. Transp. Mgmt. Corp., 506 F.3d at 1368 (quotation marks and

citation omitted).

      Here, § 841(b)(1)(C) imposes an enhanced penalty whenever “death or

serious bodily injury results from the use of” the controlled substance. 21 U.S.C.

§ 841(b)(1)(C). We agree with our sister circuits that the plain and unambiguous

language of § 841(b)(1)(C) contains no foreseeability or proximate cause

requirement. De La Cruz, 514 F.3d at 138; Houston, 406 F.3d at 1122; McIntosh,

236 F.3d at 972; Robinson, 167 F.3d at 826; Patterson, 38 F.3d at 145. The

                                          36
government is not required to prove a defendant’s conduct proximately caused the

victim’s death or that the death was reasonably foreseeable to the defendant.

Rather, under § 841(b)(1)(C), the government must prove only that the death

“results from” the victim’s use of a controlled substance charged in the indictment.

We apply the language of the statute as written. The statute requires a cause-in-fact

connection between the victim’s ingestion of the drugs and death. It does not

require that the defendant’s conduct proximately cause the death.

      Accordingly, in Webb’s case, we find no error in the district court’s jury

instruction regarding § 841(b)(1)(C), nor any error in the district court’s refusal of

Webb’s requested instruction. The district court properly instructed that the

§ 841(b)(1)(C) standard was satisfied upon a finding that, but for the victims

ingesting the controlled substances charged in the indictment, the victims would

not have died. This “but for” charge told the jury it had to find “but for” (had it not

been for) the victim’s ingestion, no death would have occurred. The statutory term

“results from” is a cause-in-fact requirement that was met by the “but for” charge.

Thus, as to § 841(b)(1)(C), the district court’s jury instructions were correct, and

Webb’s requested instructions were not.

B.    18 U.S.C. § 1347: Count 37

      Count 37 charged Webb with healthcare fraud and with a death (Gena

                                          37
Ortega’s) resulting from that fraud, in violation of 18 U.S.C. §§ 1347 and 2. Webb

once again argues that foreseeability and proximate cause are required elements of

§ 1347(a)’s enhanced penalty. We turn to the language of the statute. Section

1347(a) provides for an enhanced penalty for health fraud “if the violation results

in death,” as follows:

      (a) Whoever knowingly and willfully executes, or attempts to execute, a
      scheme or artifice- -
            (1) to defraud any health care benefit program; or
            (2) to obtain, by means of false or fraudulent pretenses,
            representations, or promises, any of the money or property owned
            by, or under the custody or control of, any health care benefit
            program,

      in connection with the delivery of or payment for health care benefits,
      items, or services, shall be . . . imprisoned not more than 10 years . . . .
      [I]f the violation results in death, such person shall be . . . imprisoned for
      any term of years or for life . . . .

18 U.S.C. § 1347(a) (emphasis added).

      As to the § 1347(a) offense in Count 37, the district court instructed the jury

that a more serious offense is committed when death (1) is a result of the victim’s

use of a controlled substance and (2) is connected to the delivery of, or payment

for, healthcare services in furtherance of the defendant’s scheme to defraud, (3)

regardless of whether Webb knew or should have known that death would result.

The court’s instruction stated:



                                           38
             As it pertains to Count 37, the law provides that whenever death
      or serious injury is a result of the victim’s use of a controlled substance
      and is connected to the delivery of, or payment for, health care benefits,
      items, or services in furtherance of the Defendant’s scheme to defraud,
      a more serious offense is committed, regardless of whether the Defendant
      knew or should have known that death would result.

      ...

            Therefore, you are to determine as follows:

            Whether in Count 37 the death of Gena Ortega resulted from the
            use of controlled substances in connection with the health care
            fraud violation charged in Count 37, on May 10, 2007.

Webb argues this instruction was erroneous.

      Similar to § 841(b)(1)(C), Congress did not insert a foreseeability or

proximate cause requirement into § 1347(a)’s penalty enhancement. Examining the

statutory language, we see no principled way to distinguish between the “results in”

language in § 1347(a) and the “results from” language in § 841(b)(1)(C), which we

already have determined does not contain proof of foreseeability or proximate

cause as required elements of the enhanced penalty. Rather, the results language in

each statute requires nothing more than a causal connection factually.

      The lack of foreseeability or proximate cause language in § 1347(a) is telling

because Congress has included such language in numerous other criminal statutes,

including statutes where the required connection is between the defendant’s offense



                                          39
conduct and death or bodily injury. See 18 U.S.C. § 247(d)(2) (setting enhanced

punishment for damaging religious property or obstructing free exercise where

“bodily injury results to any person, including any public safety officer performing

duties as a direct or proximate result of conduct prohibited by this section, and the

violation is by means of fire or an explosive” (emphasis added)); id. § 247(d)(3)

(setting enhanced punishment “for damaging religious property or obstructing free

exercise where “bodily injury results to any person, including any public safety

officer performing duties as a direct or proximate result of conduct prohibited by

this section” (emphasis added)); id. § 844(d) (setting enhanced punishment for

importation, manufacture, or distribution of explosive materials, where “personal

injury results to any person, including any public safety officer performing duties

as a direct or proximate result of conduct prohibited by this subsection” (emphasis

added)); id. § 844(f)(2) (setting enhanced punishment for importation,

manufacture, or distribution of explosive materials “and as a result of such conduct,

directly or proximately causes personal injury or creates a substantial risk of injury

to any person” (emphasis added)); id. § 844(f)(3) (setting enhanced punishment for

importation, manufacture, or distribution of explosive materials “and as a result of

such conduct, directly or proximately causes the death of any person” (emphasis

added)); id. § 844(i) (setting enhanced punishment for damaging or destroying, by

                                          40
means of fire or an explosive, any building, vehicle, or other real or personal

property “if personal injury results to any person, including any public safety

officer performing duties as a direct or proximate result of conduct prohibited by

this subsection” (emphasis added)); id. §§ 2248(b)(3)(F), 2259(b)(3)(F),

2264(b)(3)(F), 2327(b)(3) (mandating restitution for losses “suffered by the victim

as a proximate result of the offense” (emphasis added));15 id. § 3286(b) (permitting

charges on terrorism offenses at any time “if the commission of such offense

resulted in, or created a foreseeable risk of, death or serious bodily injury”

(emphasis added)); id. § 3663A(a)(2) (mandating restitution for persons

“proximately harmed as a result of the commission of an offense” (emphasis

added)); id. § 3771(e) (defining “crime victim” as, inter alia, “a person directly and

proximately harmed as a result of the commission of a Federal offense” (emphasis

added)); see also id. § 38(b)(2) (setting enhanced penalty for fraud related to

aircraft parts where “the part to which the offense is related is the proximate cause

of a malfunction or failure that results in serious bodily injury” (emphasis added));

id. § 38(b)(3) (setting enhanced penalty for fraud related to aircraft parts where “the



       15
         Cf. United States v. McDaniel, 631 F.3d 1204, 1208-09 (11th Cir. 2011) (construing 18
U.S.C. § 2259—and rejecting the government’s argument that proximate cause is not
required—“because it is contrary to the plain language of section 2259, which covers, inter alia,
‘losses suffered by the victim as a proximate result of the offense’” (quoting § 2259(b)(3)(F))).

                                               41
part to which the offense is related is the proximate cause of a malfunction or

failure that results in the death of any person” (emphasis added)).

      As the Fourth Circuit noted in Patterson, “Congress understands how to

place a reasonable foreseeability requirement into a sentencing enhancement

provision and has explicitly done so in the past.” Patterson, 38 F.3d at 145 n.7

(discussing 21 U.S.C. § 848(m)(4)). As this Court has emphasized, “[w]here

Congress knows how to say something but chooses not to, its silence is

controlling.” In re Griffith, 206 F.3d 1389, 1394 (11th Cir. 2000) (en banc)

(alteration in original and quotation marks omitted).

      We recognize that the cause-in-fact connection in § 841(b)(1)(c) is between

the use of the controlled substance and the death, and in § 1347(a), between the

defendant’s conduct and the death. However, there still is no foreseeability or

proximate cause language in either statute. At bottom, § 1347(a) does not require

the exacting legal proximate cause as formulated by Webb in his proposed charge.

And there was no error in the district court’s charge that the enhancement may

apply “regardless of whether the Defendant knew or should have known that death

would result.”

      We also recognize Webb relies on United States v. Martinez, 588 F.3d 301

(6th Cir. 2009), where the defendant Martinez was convicted of, inter alia, two

                                         42
counts of health care fraud resulting in the death of two patients, in violation of 18

U.S.C. § 1347. 588 F.3d at 306.16 The district court instructed the jury that, to

convict Martinez of fraud resulting in death, it had to find that Martinez’s fraud

was the “proximate cause of the death of the two patients” before imposing the

enhanced penalty under § 1347. Id. at 318. Martinez argued “that the Government

failed to show that a rational jury could find that he caused their deaths.” Id. at

317. Thus, the Sixth Circuit examined “the standard of causation required to show

that such fraud ‘result[ed] in death’” to determine “whether there [was] sufficient

evidence to support [Defendant] Martinez’s conviction as to these two counts.” Id.

(first alteration in original).

       The Sixth Circuit first noted that “[s]ection 1347 does not indicate the level

of causation required to support application of its enhanced penalties, but other

federal statutes elevate punishment when certain willful crimes ‘result in death.’”

Id. After reviewing several similar statutes and circuit-level decisions interpreting

them, the Sixth Circuit concluded “that proximate cause is the appropriate standard

to apply in determining whether a health care fraud violation ‘results in death.’” Id.

        16
         Martinez, an anesthesiologist, ran a pain-management clinic in Parma, Ohio. At trial,
the government’s theory was that Martinez “engaged in fraud and endangered his patients by
omitting physical examinations, ignoring ‘red flags’ of painkiller addiction, giving appreciably
more injections than were medically necessary or advisable, and providing at-risk patients with
treatments that would leave them dependent on him for pain-suppressant prescriptions.”
Martinez, 588 F.3d at 307.

                                               43
at 318-19. The Sixth Circuit’s conclusion, however, was based on these three

factors: (1) the “fundamental principle of criminal law” that “a person is held

responsible for all consequences proximately caused by his criminal conduct”; (2)

“Congress was aware of principles of legal causation when it determined that a

health care fraud violation [that] results in death warrants an enhanced penalty”;

and (3) notably, “the parties [did] not challenge the district court’s determination

that proximate cause is the appropriate standard of causation.” Id. at 318

(alteration and quotation marks omitted). Upholding Martinez’s convictions and

the enhanced penalties, the Sixth Circuit found sufficient evidence demonstrated

that Martinez (1) committed health care fraud in hurriedly giving patients injections

and prescriptions and (2) that his actions proximately caused his two patients’

deaths. Id. at 322-323. Ultimately, Martinez is materially distinguishable because

the parties there did not “challenge the district court’s determination that proximate

cause is the appropriate standard of causation” and, as the evidence was sufficient

to support Martinez’s convictions even under the more stringent proximate cause

standard, the level of causation required by the statute was not dispositive in any

event. Id. at 318.17


        17
           In United States v. Rebmann, the Sixth Circuit stated in dicta that § 841’s death-
resulting sentence enhancement imposes strict liability. 226 F.3d 521, 525 (6th Cir. 2000) (“On
its face, [21 U.S.C. § 841(a)(1)] is, in effect, a strict liability statute with respect to the injury or

                                                   44
      Finally, although it may have been more prudent to charge exactly defendant

Webb’s “violation results in death” language of the statute, the district court did in

fact charge that the death must be “connected to the delivery of, or payment for,

health care benefits, items, or services in furtherance of the Defendant’s scheme to

defraud.” (Emphasis added). Furthermore, there was overwhelming evidence (1)

that the type of heath care fraud here involved Webb’s prescribing controlled

substances for other than legitimate medical purposes, and having pharmacies

submit claims for reimbursement to health insurers on the basis of his

prescriptions; and (2) that Ortega’s death stemmed from taking those prescribed

drugs for which reimbursement was sought. Accordingly, given the overwhelming

evidence in this case, the particular type of health care fraud involved and its direct

connection with the charged death, we conclude any claimed error in the § 1347(a)

charge was harmless. In some cases the § 1347(a) health care fraudulent conduct

may be far too attenuated from the fact of the patient’s death to impose liability on

the defendant. See Houston, 406 F.3d at 1124 n.5. That is not the case here.

                          IV. INEFFECTIVE ASSISTANCE

A.     Ineffective Assistance Principles


death of another arising out of the distribution of drugs.”), overruled on other grounds by United
States v. Leachman, 309 F.3d 377, 385 n.9 (6th Cir. 2002). Martinez does not mention Rebmann
or discuss the other circuits’ decisions dealing with the similar enhanced penalty under § 841.

                                               45
      Webb also claims that his trial counsel’s performance was deficient in that

trial counsel failed to make appropriate motions for acquittal at the close of

evidence. He argues that the evidence was insufficient to sustain his convictions,

and that the motions for acquittal would have been granted. We review Webb’s

insufficiency of the evidence claim but through the lens of his ineffective

assistance claim.18

      In order to prevail on an ineffective assistance claim, a defendant must

demonstrate both that (1) “counsel’s performance was deficient,” and (2) “the

deficient performance prejudiced the defense.” Strickland v. Washington, 466 U.S.

668, 687, 104 S. Ct. 2052, 2064 (1984). We may consider the prongs of the

Strickland test in either order, and the defendant must show that both prongs are

satisfied in order to demonstrate a Sixth Amendment violation. See Holladay v.

Haley, 209 F.3d 1243, 1248 (11th Cir. 2000) (“[T]he court need not address the

performance prong if the defendant cannot meet the prejudice prong, or vice

versa.”(citation omitted)).

      Given the overwhelming evidence outlined in detail above, we conclude that

the government presented sufficient evidence to sustain all of Webb’s convictions


       18
        Because the record is adequately developed by virtue of the trial transcript, we review
Webb’s ineffective assistance claim in this direct appeal. See United States v. Patterson, 595
F.3d 1324, 1328 (11th Cir. 2010).

                                               46
and that motions for acquittal, even if made, would have failed.19 Accordingly, we

need not reach the performance prong, as, in any event, Webb suffered no prejudice

from his counsel’s performance in not making motions for acquittal at the close of

the evidence.

                                     V. CONCLUSION

      For all of these reasons, we affirm Webb’s convictions and sentences.

      AFFIRMED.




       19
         “The evidence is sufficient to support a conviction if, after viewing the evidence in the
light most favorable to the prosecution, any rational trier of fact could have found the essential
elements of the crime beyond a reasonable doubt.” United States v. Klopf, 423 F.3d 1228, 1236
(11th Cir. 2005) (quotation marks omitted). “In determining whether sufficient evidence
supports a defendant’s conviction, we view the evidence in the light most favorable to the
government and draw all reasonable inferences and credibility choices in favor of the jury’s
verdict.” United States v. Chirinos, 112 F.3d 1089, 1095 (11th Cir. 1997).

                                               47
STAPLETON, Circuit Judge, concurring and dissenting:

      With one exception, I concur in all of the conclusions reached by my

colleagues. In particular, I agree that the enhanced penalties provided by 21 U.S.C.

§ 841(b)(1)(C) are to be imposed whenever, following an unlawful distribution of a

controlled substance, the use of that substance becomes a but/for cause of a death

or serious injury without regard to whether the death or injury was reasonably

foreseeable to the defendant. As all of the courts of appeals which have considered

the issue have concluded, that is what the literal text of the statute indicates and

that literal reading is entirely consistent with the context in which the statute is

found. As my colleagues acknowledge,

      [W]e are [here] applying a statute dealing with a discrete problem, the
      distribution of controlled substances, products which Congress
      recognized will in some cases cause death or serious bodily injury. In
      short, Congress recognized that the risk is inherent in the product and
      thus it provided that persons who distribute it do so at their peril. It is
      obvious Congress intended in such a case that the 20-year mandatory
      minimum would apply if death or serious bodily injury resulted from
      the use of the substance without regard for common law proximate
      cause concepts.

United States v. Robinson, 167 F.3d 824, 831 (3d Cir. 1999) (footnote omitted).

      Section 1347 of Title 18 of the United States Code, however, does not deal

with a discrete problem arising from products involving an inherent risk of serious




                                           48
injury or death.1 Rather, it provides an enhanced penalty for health care fraud if the

fraudulent scheme of the defendant resulted in death or serious bodily injury.

Section 1347 thus applies to a wide variety of economically motivated health care

activities and focuses on the relationship between the defendant’s conduct and the

consequences thereof. For this reason, I agree with the conclusion of the Sixth

Circuit Court of Appeals in United States v. Martinez, 588 F.3d 301, 318-19 (6th

Cir. 2009), “that proximate cause is the appropriate standard to apply in

determining whether a health care fraud violation ‘results in death.’”

      The Martinez Court is the only court of appeals that has previously addressed

the causal connection required by § 1347. It correctly points out that this section is

not unlike a number of other statutes which impose enhanced punishment when the

conduct constituting the defendant’s violation “results” in death or serious bodily

injury, citing in particular the Civil Rights Act, 18 U.S.C. §§ 241, 242 and 245, and

       1
           Section 1347(a) provides:

       Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice –
               (1) to defraud any health care benefit program; or
               (2) to obtain, by means of false or fraudulent pretenses, representations, or
       promises, any of the money or property owned by, or under the custody or control
       of, any health care benefit program,

in connection with the delivery of or payment for health care benefits, items, or services, shall be
fined under this title or imprisoned not more than 10 years, or both. If the violation results in
serious bodily injury (as defined in section 1365 of this title), such person shall be fined under
this title or imprisoned not more than 20 years, or both; and if the violation results in death, such
person shall be fined under this title, or imprisoned for any term of years or for life, or both.

                                                 49
the Fair Housing Act, 42 U.S.C. § 3631(a).2 Based on its review of the case law, the

Martinez Court found it to be a generally applicable “fundamental principle of

criminal law” that a “person is held responsible for all consequences proximately

caused by his conduct.” Id. at 315 (quoting United States v. Wiegand, No. 93-1735,

1994 U.S. App. LEXIS 37209, at *7 (6th Cir. 1994)). Moreover, the Court reasoned

that “when the Congress provided that [a violation] resulting in death may be

punished by life imprisonment, [a court] must consider it to have been fully

cognizant of the principles of legal causation.” Id. (quoting United States v. Marler,

756 F.2d 206, 216 (1st Cir. 1985)).

      Nothing in the text or context of section 1347 or its legislative history

counsels against giving the concept of injury resulting from the statutory violation

its traditional scope, and I would do so.

      Contrary to the Government’s suggestion, I am unable to conclude that the

       2
         The Martinez Court cited several cases from other circuits addressing analogous statutes.
See United States v. Marler, 756 F.2d 206, 215-16 (1st Cir. 1985) (holding that 18 U.S.C. §
242’s requirement for enhanced punishment is met when the defendant’s willful violation of the
civil rights statute is a “proximate cause” of the victim’s death, and that proximate cause can be
demonstrated where death was the “natural and foreseeable” result of the defendant’s conduct);
United States v. Woodlee, 136 F.3d 1399, 1405 (10th Cir. 1998) (holding that “the bodily injury
element of the felony crime is justified if injury was a foreseeable result of the” defendant’s
violation of 18 U.S.C. § 245(b)); United States v. Harris, 701 F.2d 1095, 1101 (4th Cir 1983)
(holding that the “if death results” language of 18 U.S.C. § 241 requires only that death is
foreseeable and naturally results from violating the statute”); United States v. Guillette, 547 F.2d
743, 749 (2d Cir. 1976) (holding that life imprisonment may be imposed if death results from
violations of 18 U.S.C. § 241 when the defendant’s violation of that statute is a proximate cause
of the victim’s death).

                                                50
District Court’s erroneous charge was harmless beyond a reasonable doubt.

      Accordingly, I would reverse Appellant’s conviction on Count 37 and affirm

on all other counts.




                                       51
