United States v. Caputo, Ross A. ( 2008 )


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  •                               In the
    United States Court of Appeals
    For the Seventh Circuit
    ____________
    Nos. 06-3612 & 06-3619
    UNITED STATES OF AMERICA,
    Plaintiff-Appellee,
    v.
    ROSS A. CAPUTO and ROBERT M. RILEY,
    Defendants-Appellants.
    ____________
    Appeals from the United States District Court
    for the Northern District of Illinois, Eastern Division.
    No. 03 CR 126—Ruben Castillo, Judge.
    ____________
    ARGUED SEPTEMBER 10, 2007—DECIDED FEBRUARY 27, 2008
    ____________
    Before EASTERBROOK, Chief Judge, and KANNE and EVANS,
    Circuit Judges.
    EASTERBROOK, Chief Judge. An autoclave sterilizes
    medical instruments quickly and cheaply. But some
    instruments can’t stand the high temperatures and pres-
    sures of an autoclave, so there is a demand for steri-
    lizers that use lower temperatures and non-aqueous
    sterilants. One system in widespread use relies on ethylene
    oxide gas as the sterilant. That gas is toxic and hard to
    handle, however, and Ross Caputo saw a business oppor-
    tunity in these drawbacks. He designed a low-temperature
    2                                   Nos. 06-3612 & 06-3619
    system using a plasma of peracetic acid as the sterilant
    and in 1990 asked the Food and Drug Administration to
    approve this device, which his company AbTox Inc.
    called the Plazlyte.
    Since 1976 it has been unlawful to sell a new medical
    device without the FDA’s approval. The Medical Device
    Amendments to the Food, Drug, and Cosmetic Act have a
    grandfather clause covering devices that had been law-
    fully sold on or before May 28, 1976, or are “substantially
    equivalent” to them. 21 U.S.C. §360c(f)(1)(A)(ii). AbTox
    asked the FDA to approve sales of a Plazlyte as “substan-
    tially equivalent” to units that employ ethylene oxide as
    the sterilant. We refer to “a” Plazlyte rather than “the”
    Plazlyte because AbTox made at least two models. The first
    had an interior volume of one cubic foot and used 10%
    peracetic acid made by mixing water with a solution of
    30% peracetic acid. The water and the 30% solution were
    in separate bottles. This device used a two-cycle proce-
    dure, applying gas plasma twice to sterilize the instru-
    ments. The second model had an interior volume of
    approximately five cubic feet, used 5% peracetic acid
    from a single bottle (no dilution with water from a sec-
    ond bottle), and ran just one cycle, at a different pressure
    from the first model. We call the first model the small
    Plazlyte and the second model the large Plazlyte.
    AbTox submitted the small Plazlyte for approval in 1990.
    It also submitted only those tests that favored the
    device’s effectiveness; others, less helpful to AbTox,
    were concealed (or so a jury could conclude; we re-
    count the evidence in the light most favorable to the
    verdict). The agency’s staff doubted whether the Plazlyte
    was equivalent to ethylene oxide systems and insisted on
    limiting the uses to which it could be put. When the FDA
    Nos. 06-3612 & 06-3619                                      3
    signed off on the small Plazlyte in 1994, it approved the
    device only for use with solid stainless-steel instruments.
    If AbTox wanted to sell the Plazlyte to sterilize instru-
    ments containing interior space that the gas plasma
    might not fully penetrate (such as those with hinges or
    lumens) or instruments made from materials that might
    react chemically with peracetic acid (C2H4O3), an organic
    peroxide, it had to file an application for approval as a
    new device rather than one equivalent to a grandfathered
    device. Any medical instrument containing plastic,
    solder (usually made of lead, tin, or silver), or brass (an
    alloy of copper and zinc) was outside the scope of the
    FDA’s approval.
    A new and expensive machine (Plazlytes sold for
    about $100,000) for sterilizing solid instruments made of
    stainless steel had no prospect in the market. Autoclaves
    are cheaper and don’t require the handling of acids.
    Caputo understood that AbTox would never be able to
    sell a single unit of the small Plazlyte for the limited use
    approved by the FDA. Caputo (and his assistant Robert
    Riley) did not try. Instead they immediately began pro-
    moting the large Plazlyte as a replacement for ethylene-
    oxide devices, and thus as suitable for general-purpose
    sterilization. It had begun selling the large Plazlyte outside
    the United States in 1993; thus, long before receiving
    the FDA’s approval to sell the small Plazlyte, it knew
    that the small device would never be marketed and that
    the large Plazlyte would be promoted for use with many
    kinds of instruments—though it did not tell the FDA
    these things when negotiating the details of the limited
    use that would be allowed to the small Plazlyte.
    Problems ensued when some hospitals used the Plazlyte
    to sterilize brass instruments employed for procedures
    4                                   Nos. 06-3612 & 06-3619
    in the eye. The Plazlyte left a blue-green residue on some
    of these instruments—and, although the instruments
    were sterile, the residue (copper and zinc acetate) was
    harmful to patients’ eyes. Some patients experienced
    corneal decompensation, a severe condition that entails
    loss of vision.
    In May 1995 the FDA found out what AbTox was telling
    customers and reminded it about the limitations on the
    scope of approval. This notice informed AbTox that the
    Plazlyte as promoted was “misbranded”. AbTox then
    sought the FDA’s approval to sell the large Plazlyte
    to sterilize a wider class of instruments; when the FDA
    rejected AbTox’s request for expedited decision and
    told AbTox that it “may not market this device until
    you have received a letter from the FDA allowing you to
    do so”, AbTox went on promoting the large Plazlyte as
    before. On September 27, 1996, the FDA sent AbTox
    another instruction to stop selling the large Plazlyte; AbTox
    failed to comply (though it did not tell the FDA so). The
    agency never authorized AbTox to sell the large Plazlyte
    for any use.
    The Centers for Disease Control opened an investiga-
    tion to discover what was causing the eye injuries. Mean-
    while, in January 1998, the FDA inspected AbTox’s facili-
    ties and discovered that it was still selling the large
    Plazlyte. The inspectors told AbTox to desist; it didn’t. In
    April 1998 the FDA issued a warning to all hospitals,
    telling them that the large Plazlyte was not an approved
    device and at all events must not be used with any instru-
    ments containing solder, copper, or zinc, or for any oph-
    thalmic instruments. The FDA directed AbTox to recall
    the devices; U.S. marshals seized its inventory; this crimi-
    nal prosecution eventually followed.
    Nos. 06-3612 & 06-3619                                      5
    The prosecutor threw the book at Caputo and Riley. The
    indictment charged them with conspiring to defraud
    the United States, 
    18 U.S.C. §371
    , mail fraud, 
    18 U.S.C. §1341
    , wire fraud, 
    18 U.S.C. §1343
    , lying to federal agents,
    
    18 U.S.C. §1001
    , and the delivery of misbranded devices,
    
    21 U.S.C. §§ 331
    (a) and 333(a)(1). A jury convicted them
    of these charges after an eight-week trial. Caputo has
    been sentenced to 120 months’ imprisonment and Riley
    to 72 months. Both were ordered to make restitution of
    $17.2 million, the list price of all Plazlyte units ever sold.
    Defendants’ lead argument is that the Food, Drug, and
    Cosmetic Act violates the first amendment by restricting
    promotional materials to those uses that the FDA has
    approved. The argument starts from the premise that
    federal law allows customers of any approved medical
    device or drug to put it to any use that the customer
    sees fit. These “off-label uses” being lawful, the argument
    goes, it must also be lawful to tell customers about them.
    Until the last 30 years, such an argument would have
    been laughed out of court. Valentine v. Chrestensen, 
    316 U.S. 52
     (1942), had held that “commercial speech”—that
    is, speech promoting a product for sale—is not part of
    the “freedom of speech” as that term was understood in
    1789. But the Court overruled Valentine in Virginia Board of
    Pharmacy v. Virginia Citizens Consumer Council, Inc., 
    425 U.S. 748
     (1976), holding that the government cannot regulate
    by ensuring ignorance among consumers. If it is lawful to
    sell a product then, the Court held, it must be lawful to
    inform consumers that the product is available to buy.
    Consumers themselves must decide what to do; the
    Constitution forecloses an enforced ignorance based on a
    paternalistic view that informed consumers will make
    mistakes. See also, e.g., Greater New Orleans Broadcasting
    6                                   Nos. 06-3612 & 06-3619
    Ass’n, Inc. v. United States, 
    527 U.S. 173
     (1999); Rubin v.
    Coors Brewing Co., 
    514 U.S. 476
     (1995); Bolger v. Youngs
    Drug Products Corp., 
    463 U.S. 60
     (1983); R.H. Coase, Adver-
    tising and Free Speech, 6 J. Legal Studies 1 (1977).
    For a time judges thought the Supreme Court’s new
    understanding inapplicable to drugs (and, by implica-
    tion, medical devices): Federal law allows vendors to tell
    customers about all lawfully available drugs and devices,
    after all, and thus avoids the precise problem presented
    by Virginia Citizens Consumer Council. But federal law
    does prohibit manufacturers from alerting consumers to
    lawful off-label uses, and Thompson v. Western States
    Medical Center, 
    535 U.S. 357
     (2002), held that this limit is
    unconstitutional in at least some applications. A federal
    law allowed pharmacists to compound some drugs that
    had been approved for stand-alone sales, creating sub-
    stances that had not been subjected to the normal testing.
    The legislation granting pharmacists this compounding
    privilege attached conditions to the way they could
    promote the compounded drugs. The Court held these
    limits unconstitutional: if the compounded drug could
    be sold, the Court held, then it could be freely promoted
    for every lawful use. Western States Medical Center estab-
    lishes that drugs are not a special case for first-amendment
    analysis. (The Court once held that gambling is a special
    case, see Posadas de Puerto Rico Associates v. Tourism Co. of
    Puerto Rico, 
    478 U.S. 328
     (1986), but the status of that rule
    is doubtful. See 44 Liquormart, Inc. v. Rhode Island, 
    517 U.S. 484
    , 508–14 (1996) (plurality opinion).) The Court
    suggested in Western States Medical that Congress either
    adopt a substantive rule prohibiting compounding
    (or, here, prohibiting off-label uses) or allow the FDA to
    supply warnings via its own speech. Compelling private
    Nos. 06-3612 & 06-3619                                      7
    persons to toe the government’s line, or shut up, is uncon-
    stitutional, the Court held. This is the doctrine that Caputo
    and Riley propose to invoke in their defense.
    Whether Virginia Citizens Consumer Council and Western
    States Medical Center apply to promotion by a product’s
    manufacturer, which struck a bargain with the FDA in
    the approval process by promising to limit its promo-
    tion—a bargain that the private litigants in the earlier cases
    had not struck—is a difficult question. The doctrine of
    unconstitutional conditions places limits on the promises
    that an agency may extract from those who seek approval.
    And if a given use is lawful, and thus can be written
    about freely in newspapers or blogs, and discussed
    among hospitals that already have purchased a Plazlyte,
    doesn’t it make a good deal of sense to allow speech by
    the device’s manufacturer, which after all will have the
    best information? Why privilege speech by the unin-
    formed? The manufacturer has an incentive to slant the
    speech in its favor and may withhold bad news, but many
    listeners (especially professionals such as physicians)
    understand this and can discount appropriately. That, at
    any rate, is the anti-paternalist view of Virginia Citizens
    Consumer Council and the cases that followed in its wake.
    Yet if a manufacturer’s promise to the FDA to avoid
    speech about off-label uses is unenforceable, the FDA
    may respond by withholding any approval of drugs or
    devices that have questionable additional uses. AbTox’s
    small Plazlyte would not have been approved at all,
    had the FDA anticipated that approval would enable
    AbTox to tout it (or its larger brother) for use with brass
    ophthalmic instruments. Other firms, with no desire to
    promote off-label uses (or, at least, no desire to pay for
    the expensive tests needed to persuade the FDA to sanc-
    8                                  Nos. 06-3612 & 06-3619
    tion wider use), would be made worse off by their
    inability to strike deals allowing the FDA to approve a
    subset of all possible uses. Consumers who could benefit
    from drugs or devices that would be excluded from the
    market by the FDA’s response to a broad privilege to
    tout off-label uses also would be made worse off. Doubt-
    less the first amendment differs from Bentham’s felicific
    calculus, but a court should hesitate before extending
    an ahistorical reading of the Constitution in a way that
    injures the very audience that is supposed to benefit from
    free speech.
    Fortunately, we need not decide today whether a seller
    of drugs or medical devices has a constitutional right to
    promote off-label uses. Virginia Citizens Consumer Council
    and its successors rest on the assumption that the law
    allows the activity that the speaker seeks to promote.
    Here that assumption holds only if AbTox lawfully
    could sell the large Plazlyte for the (approved) use
    with solid stainless-steel instruments. Unless the
    machine itself could be sold lawfully, there were no
    lawful off-label uses to promote. And the jury found, by
    its verdicts on both the fraud-on-the-United-States
    count and the misbranded-device counts, that the large
    Plazlyte could not lawfully be sold. The jury concluded
    not only that Caputo and Riley had lied to the agency
    when seeking approval of the small Plazlyte but also
    that the large Plazlyte differed enough from the small
    one that new approval was essential. For current pur-
    poses it is enough to concentrate on the latter conclusion.
    (Defendants insisted at oral argument that the jury
    could have convicted, under the instructions given,
    without finding either lies to the FDA or sale of a never-
    approved device. We have reviewed the instructions and
    Nos. 06-3612 & 06-3619                                     9
    conclude that, to convict on all counts as it did, the jury
    had to find both.)
    Once the FDA certifies a medical device under the
    grandfather clause, the seller may make modifications to
    that device without obtaining fresh approval. The line
    between a “modification” (no approval needed) and a
    new device (which must be submitted independently
    for approval) is drawn in 
    21 C.F.R. §807.81
    . There are
    two principal inquiries: first, whether the changes “signifi-
    cantly affect the safety or effectiveness of the device” and,
    second, whether there is a “major change or modification
    in the intended use of the device.” 
    21 C.F.R. §807.81
    (a)(3).
    We doubt that the large Plazlyte could be described as
    a “modification” of the small one; recall that the large
    device had been placed on sale outside the United States
    in 1993, the year before the FDA approved the small
    device. “Modification” suggests a change in an approved
    device, not a different device that was already on sale
    before the approval. But suppose that this is wrong, and
    suppose further that the large Plazlyte was as safe as the
    small one notwithstanding the difference in the concen-
    tration and number of applications of the sterilant. There
    remains the rule that a “major change or modification
    in the intended use of the device” requires fresh approval.
    Promoting the large Plazlyte as suitable for use with
    all medical instruments is a major change in intended
    use, compared with using it for solid stainless-steel instru-
    ments alone. This expansion of use caused the copper
    and zinc acetates that injured patients. So the large
    Plazlyte, with its expanded “intended use”, was not
    covered by the FDA’s approval of the small Plazlyte and
    could not lawfully be sold at all. That knocks out the
    premise of Virginia Citizens Consumer Council and similar
    cases. There was no lawful activity for speech to promote.
    10                                   Nos. 06-3612 & 06-3619
    Caputo and Riley try to avoid this conclusion by arguing
    that the Due Process Clause of the fifth amendment
    disabled the FDA from keeping the large Plazlyte off the
    market. The line between new and modified devices is too
    vague to be enforceable, the argument goes. We grant that
    phrases such as “significantly affect” and “major
    change . . . in the intended use” are not self-defining. But
    then no legal phrase is. Think of “material” (as in “material
    misrepresentations are forbidden”), a staple of legal
    discourse, or “unreasonable” (as in “unreasonable
    danger to the health and safety of park users”, a phrase
    deemed adequately specific in Thomas v. Chicago Park
    District, 
    534 U.S. 316
    , 324 (2002)). The Supreme Court has
    rejected vagueness challenges to the antitrust laws,
    see Nash v. United States, 
    229 U.S. 373
     (1913), which must
    be an order of magnitude more ambulatory than
    §807.81(a)(3), and has held that a rule cannot be deemed
    unconstitutionally vague if it suggests a metric for decision.
    See United States v. Powell, 
    423 U.S. 87
     (1975). Section
    807.81(a)(3) tells us what dimensions of difference mat-
    ter, even though it does not give an exact answer to the
    question “how much is too much”? (The statute in Powell,
    which forbade the mailing of a firearm capable of being
    concealed on the person, also omitted a quantitative
    rule, but the Court held that its qualitative approach
    suffices.)
    The uncertainty that is inevitable in legal standards (as
    opposed to numerical rules) often is offset by notice, so
    that people need not guess what is required of them. The
    FDA gave AbTox notice, and to spare. It published in
    March 1993 (before the small Plazlyte was approved) a
    “Guidance” stating that any change in the sterilant or
    chamber size of a sterilizer creates a new device that
    Nos. 06-3612 & 06-3619                                   11
    requires new approval. It sent letters, which AbTox
    ignored. (The letters not only called attention to the 1993
    Guidance but also restated the FDA’s view of AbTox’s
    duties under the statute and regulation.) It sent an inspec-
    tion team, whose directions AbTox spurned. There was
    no such notice in United States v. Prigmore, 
    243 F.3d 1
     (1st
    Cir. 2001), a decision on which defendants heavily rely.
    (And Prigmore did not hold the statute or regulations
    unconstitutionally vague, either, though it did remand
    for a new trial with jury instructions adequate to pin
    down the meaning of the rules at issue there.)
    To say that the FDA showered interpretations and advice
    on Caputo and Riley is not to say that the published
    “Guidance” has the effect of a regulation, let alone that
    AbTox was legally bound to comply with the letters. Only
    the statute, regulations, and formal directives of the
    agency (as opposed to its staff) have legal force. The
    agency did not issue its cease-and-desist and recall orders
    until April 1998. Until then Caputo and Riley were at
    liberty to chart their own course, as their own legal advis-
    ers counseled them. When they did this, however, they
    took a risk and could not then say “we didn’t know” or
    “the regulation left us scratching our heads.” The agency
    comprehensively alerted AbTox, Caputo, and Riley to its
    view of their legal obligations, and an agency’s inter-
    pretation of its own regulations, no less than a judicial
    opinion, may disambiguate them. When Caputo and
    Riley chose to go their own way, the question on the table
    for the court became simply who is right about the mean-
    ing of the legal rules, not whether adequate notice
    was given.
    Note that Caputo and Riley have not made an advice-of-
    counsel defense, though no one gets into a multi-million-
    12                                   Nos. 06-3612 & 06-3619
    dollar medical-device business without legal counsel.
    Perhaps they lied to their lawyers about what they
    were doing and thus cannot present a defense that de-
    pends on candor to counsel; or perhaps they decided to
    avoid asking for advice about §807.81(a)(3) for fear of
    what the answer would be; finally, they may have
    asked and received a reply that they did not follow. The
    attorney-client privilege prevents us from knowing which.
    Defendants did, however, argue that they acted “in
    good faith.” They complain about the adequacy of the
    instructions on this subject. That the district judge gave
    any such instruction at all was unduly favorable to the
    defense. This was at heart a fraud prosecution (and for
    most counts nothing but a fraud prosecution), and there
    is no “good faith defense” to fraud. A person who tells a
    material lie to a federal agency can’t say “yes, but I
    thought it would all work out to the good” or some such
    thing. Intentional deceit on a material issue is a crime,
    whether or not the defendant thought that he had a good
    excuse for trying to deceive the federal agency or the
    potential customers.
    The district judge did not abuse his discretion—the right
    standard, see General Electric Co. v. Joiner, 
    522 U.S. 136
    (1997)—in keeping out of evidence the proposed “expert”
    testimony that defendants wanted to introduce. The
    “expert” would have testified about the meaning of the
    statute and regulations. That’s a subject for the court, not
    for testimonial experts. See Bammerlin v. Navistar Interna-
    tional Transportation Corp., 
    30 F.3d 898
    , 900 (7th Cir. 1994).
    The only legal expert in a federal courtroom is the
    judge. An advice-of-counsel defense might have got
    something along these lines in through the back door, but
    as we have explained no such defense was made.
    Nos. 06-3612 & 06-3619                                13
    It came out after the trial that the jury’s foreman had
    six misdemeanor convictions related to his use of heroin
    and alcohol, to which he had been addicted. The district
    judge held a hearing and concluded that this juror
    had believed that questions asking the venire whether
    anyone had been convicted of a crime sought informa-
    tion about federal crimes only, and he had not been
    convicted of a federal crime. The judge credited that
    explanation, found that the juror had committed an
    “honest mistake,” and added that, had the juror re-
    vealed his convictions, they would not have supported
    a challenge for cause. The juror testified, and the judge
    found, that he had broken his heroin addiction through a
    methadone program, had been “clean” for a year before
    trial, and had been forthright about his problems when
    asked; it was a newspaper report, based on that candor,
    that led to the discovery after the end of the trial. The
    district judge applied the right legal standard, see
    McDonough Power Equipment, Inc. v. Greenwood, 
    464 U.S. 548
     (1984); United States v. Warner, 
    498 F.3d 666
    , 684–88
    (7th Cir. 2007), and did not abuse his discretion in con-
    cluding that defendants are not entitled to a new trial.
    After all, it is usually the prosecutor who wants to ex-
    cuse potential jurors with criminal records, lest they
    sympathize unduly with others facing the ordeal of a
    prosecution and at risk of imprisonment. Caputo and
    Riley do not give any reason for thinking that this juror
    would have been slanted in the prosecutor’s favor.
    Riley contends that his conviction on Count 9, which
    charged him with making two false statements to an
    employee of the FDA, in violation of 
    18 U.S.C. §1001
    ,
    should be reversed because the instructions allowed the
    jury to convict if either of two statements was false,
    14                                   Nos. 06-3612 & 06-3619
    while the evidence shows that one statement at most
    was false. As a matter of law, one false statement is enough
    for a conviction, so Riley’s line of argument fails under
    Griffin v. United States, 
    502 U.S. 46
     (1991), which holds
    that a conviction is proper if the evidence established
    beyond a reasonable doubt any of the ways in which
    the crime might have been committed. Griffin holds that
    a jury may be relied on to accept the supported possi-
    bility and discard the unsupported one. (When the in-
    struction contains a legal error, then the jury’s fact-finding
    ability may lead it astray, but Riley does not contend
    that the instruction allowed the jury to convict him on
    Count 9 on a factually substantiated but legally incorrect
    theory.)
    A brief discussion of sentencing brings this opinion to a
    close. The district court calculated the loss at roughly
    $17 million, the list price for all Plazlyte devices that
    AbTox delivered. Application Note 3(F)(v) to U.S.S.G.
    §2B1.1 says that defendants who sell goods without
    required approvals receive no credit for their value, if any,
    to the customers. List price thus was the right starting
    point. Defendants say, however, that some machines
    were sold at a discount and a few given away as demon-
    strators, and that the judge should have used actual
    transactions prices rather than list prices. That’s true in
    principle, but defendants don’t say that using transac-
    tions prices would have reduced the loss below $7 million.
    A loss from $7 million through $20 million produces the
    same offense level; there’s accordingly no need to deter-
    mine with precision where within that span the loss falls.
    (Despite United States v. Demaree, 
    459 F.3d 791
     (7th Cir.
    2006), which was released a month before defendants
    were sentenced and holds that judges must use the Guide-
    Nos. 06-3612 & 06-3619                                    15
    lines in force on the date of sentencing, the district judge
    used the 1997 version in which loss from $10 million
    through $20 million produced the same number of levels.
    That error was favorable to defendants, and as the prosecu-
    tor has not taken a cross-appeal we need not discuss
    it further.)
    Finding actual transactions prices was unnecessary to
    know the “loss” for the purpose of §2B1.1, which does not
    require more than an estimate. Restitution, by con-
    trast, requires an exact figure; it is a substitute for civil
    damages, though limited to direct losses rather than
    consequential damages. See United States v. Behrman,
    
    235 F.3d 1049
     (7th Cir. 2000); United States v. Havens,
    
    424 F.3d 535
    , 537 (7th Cir. 2005). So the restitution for a
    Plazlyte with a list price of $100,000 but sold at a $20,000
    discount is $80,000, not $100,000. And the restitution for
    a machine given away as a demonstrator is nothing.
    Likewise restitution for a machine that was invoiced at
    $100,000, but never paid for in light of the recall (defen-
    dants say that there were several in this category), is zero.
    The district court must determine these figures one cus-
    tomer at a time and not use the list-price shortcut that
    is suitable when the only question is whether loss falls
    within widely spaced bounds.
    Defendants propose a further adjustment for the value
    the buyers obtained from the Plazlyte sterilizers. Some
    hospitals may have used them principally for the ap-
    proved purpose and found them entirely satisfactory;
    others may have put them to off-label uses that did not
    cause problems. But if a court is going to deduct for
    the value of the machines in use, it should order restitu-
    tion for the cost of compensating injured patients, the cost
    to hospitals and the Centers for Disease Control of investi-
    16                                   Nos. 06-3612 & 06-3619
    gating the mysterious eye injuries, and so on; one can’t
    have the subtractions for productive use without the
    additions for harms caused by off-label uses. Defendants
    do not propose to make restitution for these harms, so
    they can’t obtain subtractions either.
    There remains one problem: What of the machines that
    remained in service after the recall? A recall notice is (from
    a customer’s perspective) an option rather than a com-
    mand. Some hospitals returned their Plazlyte machines;
    others junked them; but a few kept them and continued
    using them, even purchasing extra sterilant from AbTox
    to extend their lives. (The FDA allowed AbTox to sell
    the peracetic acid to hospitals that certified their aware-
    ness of the recall and the reasons behind it.) These cus-
    tomers evidently believed that the machines were valu-
    able—and, if hospitals took care to avoid certain kinds of
    instruments, they continued to be safe. We think that no
    restitution is owed to customers that, with full knowledge,
    continued to operate Plazlyte machines for longer than
    was necessary to replace them. (Hospitals that retained
    the Plazlyte sterilizers only until they could secure
    new, approved equipment should be grouped with hospi-
    tals that returned them in the recall.) In principle hospitals
    that kept their machines in long-term service are entitled
    to compensation for a reduction in the value that Plazlyte
    sterilizers would have on resale (not only because of
    the blow to their reputation but also because spare parts
    will be hard to come by), but unless that value (or its
    proxy, the reduction in the machines’ expected useful lives)
    can be determined, the judge should assume that the
    hospitals that kept their Plazlyte machines for more than
    a year after the recall notice will use them until they
    wear out.
    Nos. 06-3612 & 06-3619                                17
    The judgment of the district court is affirmed except
    with respect to restitution. The award of restitution is
    vacated and the case remanded for calculation, using
    the principles in this opinion, of the amount that defen-
    dants owe to each of AbTox’s customers.
    USCA-02-C-0072—2-27-08