## Facts

- Dr. L. Stan Naramore, a Kansas physician, was charged in 1994 for conduct during treatment of two hospital patients in August 1992: Ruth Leach (attempted murder) and Chris Willt (premeditated first-degree murder).
- Ruth Leach, age 78, had terminal cancer and significant pain; a nurse suggested stronger pain relief.
- Naramore discussed increasing pain medication with Leach’s son, warning that additional medication could depress breathing and might cause death; the son agreed to proceed for pain relief.
- Naramore administered fentanyl; Leach’s breathing slowed, and Naramore mentioned reversal with Narcan but prepared morphine.
- After the son objected to accelerating death and threatened to hold Naramore responsible, Naramore withdrew from Leach’s care.
- Chris Willt, obese and diabetic, was brought to the hospital after being found slumped over; Norcuron, a paralytic that prevents spontaneous breathing, was administered to facilitate intubation.
- Naramore stated Willt was brain-dead and recovery was hopeless; hospital staff observed limb/facial movement and thought Willt might be attempting to breathe when ventilation was paused.
- Naramore interpreted the movements as seizure activity; a second physician, Dr. Ernest Cram, was consulted and initially found no pulse, respiration, or reflexes.
- After learning Norcuron had been given and checking its effects, Cram agreed with Naramore’s assessment; ventilation was discontinued and Willt was pronounced dead with no observed neurological, respiratory, or cardiac activity.
- At trial, expert testimony conflicted: several physicians supported that Naramore’s actions were within acceptable medical practice, while State experts characterized the care as outside accepted practice and indicative of wrongful intent.
- A jury convicted Naramore of attempted murder (Leach) and intentional and malicious second-degree murder (Willt); he appealed.

## Issues

1. Whether the evidence, viewed favorably to the State, was sufficient to prove beyond a reasonable doubt that Naramore intended to kill Leach and intentionally and maliciously caused Willt’s death.
2. What level and type of proof are required to impose criminal liability on a physician for acts arising from medical treatment, as distinct from malpractice or professional discipline.
3. Whether the jury was adequately instructed on specialized medical concepts central to the case, including palliative care for terminal patients and reasonable resuscitation/withdrawal-of-support decisions.
4. Whether circumstantial evidence and disputed expert opinions supported guilt where the evidence also supported reasonable, medically grounded theories of innocence.

## Decision

- The Kansas Court of Appeals reversed both convictions.
- The court held the evidence was insufficient to establish the required criminal intent and causation beyond a reasonable doubt in the context of contested medical judgment and expert disagreement.
- The court stated jurors ordinarily lack general knowledge about palliative care and reasonable resuscitation or life-support decisions, and appropriate instructions should be given when such issues are central.
- Applying the circumstantial-evidence standard, the court concluded the State’s theories did not exclude reasonable interpretations consistent with legitimate palliative treatment for Leach and good-faith medical judgment (even if mistaken) for Willt.

## Legal Principles

- Criminal guilt must be proved beyond a reasonable doubt; on appellate review, the question is whether a rational factfinder could find guilt beyond a reasonable doubt when evidence is viewed in the State’s favor.
- For acts arising from medical treatment, proof sufficient for malpractice or licensure discipline (e.g., negligence or deviation from a professional standard) does not itself establish criminal intent or malice.
- Circumstantial evidence may support a conviction, but the circumstances must be inconsistent with any reasonable theory of innocence supported by the evidence; the State need not disprove merely hypothetical innocence lacking substantial evidentiary support.
- When a case turns on specialized medical matters such as palliative care and resuscitation/withdrawal-of-support decisions, the trial court should instruct the jury on those concepts because they are not within ordinary juror knowledge.

## Conclusion

The court reversed the attempted murder and second-degree murder convictions because the record, dominated by competing expert testimony and medical facts compatible with accepted end-of-life care and good-faith clinical judgment, did not prove the required criminal intent and malice beyond a reasonable doubt and warranted proper guidance to jurors on specialized medical issues.


State v. Naramore, 25 Kan. App. 2d 302, 965 P.2d 211 (Kan. Ct. App. 1998)