Albert C. Miller appeals from his convictions for practicing medicine without a license. He urges that he did not knowingly and intelligently waive his Sixth Amendment right to counsel, and that the record contains insufficient evidence to support his convictions. We affirm the judgment of the district court.
I. Background Facts and Proceedings.
Miller was charged by a trial information with seven counts of practicing medicine without a license. Counts I through VI involved violations of sections 147.2 and 147.103A(1) of the Iowa Code, 1991 (as amended). Count VII involved a violation of Iowa Code sections 147.2 and 147.86 (1991).
Several persons testified at trial describing treatments they received from Miller in his home for various ailments. His usual method of treatment was to put a lock of the person's hair or a photograph of the person into a machine called a radionics device. After recording numerous readings from the device on a chart, he would treat the person by administering mild electric shocks from a "function generator," massaging the person's feet or neck, or placing large magnets next to the person. In addition, he often sold or recommended natural vitamins or nutrients to the people who visited him. Although Miller did not charge for the treatments, he consistently accepted donations of $10 for each treatment. He did not have any license to practice medicine, osteopathy, or surgery.
Dr. John Renner, M.D., Director of the Consumer Health Information Research Institute, testified as an expert witness for the State. He found the various treatments and vitamins given by Miller to his patients, while not necessarily harmful, were generally not medically useful. In his opinion the primary danger was not from the medicine itself, but from the fact it delayed appropriate, potentially beneficial, medical treatment.
On July 14, 1994, the jury returned verdicts finding Miller guilty on all seven counts. He was sentenced to a term of incarceration not to exceed five years on six counts. On the seventh count, he was sentenced to four months in the county jail. All the sentences were suspended and Miller was placed on probation for five years.
II. Waiver of Right to Counsel.
The Sixth and Fourteenth Amendments to the federal constitution guarantee state criminal defendants the right to have the assistance of counsel. Faretta v. California, 422 U.S. 806, 807, 95 S.Ct. 2525, 2527, 45 L.Ed.2d 562, 566 (1975). A defendant can waive the right to counsel and assert a right of self-representation as long as the waiver is voluntary, knowing, and intelligent. Id. at 835, 95 S.Ct. at 2541, 45 L.Ed.2d at 581; State v. Hutchison, 341 N.W.2d 33, 41 (Iowa 1983). The defendant's election to proceed without counsel must be clear and unequivocal. State v. Spencer, 519 N.W.2d 357, 359 (Iowa 1994), cert. denied, ___ U.S. ___, 115 S.Ct. 642, 130 L.Ed.2d 548 (1994); Faretta, 422 U.S. at 835, 95 S.Ct. at 2541, 45 L.Ed.2d at 582.
The Supreme Court has imposed "rigorous restrictions on the information that must be conveyed to a defendant, and the procedures that must be observed, before permitting him to waive his right to counsel at trial." Patterson v. Illinois, 487 U.S. 285, 298, 108 S.Ct. 2389, 2398, 101 L.Ed.2d 261, 276 (1988).
Faretta, 422 U.S. at 835, 95 S.Ct. at 2541, 45 L.Ed.2d at 582 (citation omitted).
Because Miller's constitutional right to counsel is at issue, our review is de novo of the totality of the facts and circumstances. Spencer, 519 N.W.2d at 359. We examine the record as a whole to determine whether Miller knowingly and intelligently waived his right to counsel. Id. at 360.
At Miller's arraignment on May 9, 1994 the following colloquy occurred:
Shortly after this exchange, Miller answered all questions for the remainder of the proceedings with the response, "I stand mute." At the conclusion of the proceedings the court recommended that Miller seek the assistance of legal counsel:
Two days later Miller filed a "Notice and Demand for Counsel of Choice" which demanded the court "recognize his Right to Counsel or co-counsel who is not a member of the State Bar Association and who is not a licensed attorney." The court responded with the following calendar entry:
After disposing of other matters, the court again addressed the defendant:
The court then explained court proceedings:
After the State gave Miller a box containing copies of all documents seized from his house, Miller again raised the counsel issue:
On June 29, 1994 Miller filed a "Waiver of Speedy Trial and Motion for Continuance" which contained the following statements:
4. The Accused understands that he has a right to defend himself. Faretta v. California, 422 U.S. [at 806, 95 S.Ct. at 2527]. The Accused also understands that the court should make exceptions for the Accused, since his is compelled to defend himself. Haines v. Kerner, 404 U.S. [at 519, 92 S.Ct. at 595].
The motion to continue was denied and trial commenced on July 14, 1994. Miller had not filed an application for appointment of counsel.
We believe that the district court adequately advised Miller of his right to counsel, explained the nature of the charges, and warned of the ramifications of self-representation. The court several times told Miller that if he wanted court-appointed counsel he would have to file an application and affidavit showing he was indigent. The court even had the clerk mail him an affidavit. Despite these admonitions, Miller had not filed an application for counsel at the time of trial.
We also believe Miller was competent to make the choice of self-representation. See Spencer, 519 N.W.2d at 361. He was sixty-five years old at the time of trial and had been self-employed in the water treatment business. Although Miller lacks a formal education beyond the eighth grade, he appeared to be intelligent, articulate, and an adequate advocate throughout the proceedings as illustrated by using cross-examination of the State's witnesses to, in effect, testify on the merits of his case. He filed a total of fourteen pro se pleadings in the case; four of the pleadings addressed the right to counsel.
We reject Miller's argument that his case was too complicated to allow self-representation. See id. at 359; cf. State v. Hindman, 441 N.W.2d 770, 772 (Iowa 1989) ("Where the offense is readily understood by laypersons and the penalty is not unduly severe, the duty of inquiry which is imposed upon the court is only that which is required to assure an awareness of right to counsel and a willingness to proceed without counsel in face of such awareness."). He had prior experience with the justice system involving similar charges and procedures. In 1993 he was found guilty by an Illinois jury on thirteen of fifteen counts of unlawful practice of medicine without a license. In that trial, Miller was represented by counsel. He was certainly aware of the dangers and disadvantages of self-representation when he elected to represent himself before our Iowa courts.
It is clear that Miller was not interested in representation by a licensed attorney, but desired to be represented by unlicensed counsel instead. In his "Brief in Support of Notice and Demand for Counsel of Choice," he argues explicitly and at length that he is entitled to representation by unlicensed counsel. When he was advised, correctly, that he could not be represented by unlicensed counsel, he clearly and unequivocally chose to represent himself. Consequently, we hold that Miller knowingly and intelligently waived his right to counsel.
III. Sufficiency of Evidence.
We must uphold the jury's verdict unless the record lacks substantial evidence to support the charges. State v. Liggins, 524 N.W.2d 181, 186 (Iowa 1994). Substantial evidence is evidence which could convince a rational jury the defendant is guilty of the crimes charged beyond a reasonable doubt. Id. We consider all of the evidence in the record, not just the evidence supporting the verdict, in the light most favorable to the State. State v. Robinson, 288 N.W.2d 337, 340 (Iowa 1980).
Miller was charged with practicing medicine and osteopathic medicine in violation of Iowa Code section 147.2. Two separate instructions were given to the jury defining the practice of medicine and osteopathic medicine. One instruction, which was patterned after Iowa Administrative
The other instruction provided that the following "persons shall be deemed to be engaged in the practice of medicine and osteopathic medicine":
1. Persons who publicly profess to be physicians or who publicly profess to assume the duties incident to the practice of medicine and osteopathic medicine.
2. Persons who prescribe, or prescribe and furnish medicine for human ailments.
This instruction is based on Iowa Code section 148.1 and states the definition which has been used in our previous cases. See Iowa Code § 147.2 (unlicensed "person shall not engage in the practice of medicine ... as defined in the following chapters of this title"); see also, e.g., State v. Robinson, 236 Iowa 752, 753, 19 N.W.2d 214, 215 (1945); State v. Hueser, 205 Iowa 132, 134, 215 N.W. 643, 643 (1927). The instruction based on the Iowa Administrative Code, although a more specific definition, is neither inconsistent nor an incorrect statement of the law. 1978 Op.Iowa Att'y Gen. 874; see State v. Hughey, 208 Iowa 842, 846, 226 N.W. 371, 373 (1929) (upholding jury instruction providing that "the duties incident to the practice of medicine and surgery" include "the holding out of one's self as a physician").
Miller argues that he did not publicly profess to be a physician or publicly profess to assume the duties incident to the practice of medicine and osteopathic medicine. He emphasizes that he never advertised nor described himself as a doctor; he would sometimes recommend that his customers consult a licensed physician or chiropractor; and he only met people in his home, not in an office.
We conclude there is sufficient evidence to conclude that Miller publicly professed to assume the duties incident to the practice of medicine and osteopathic medicine. We have defined the "duties incident to the practice of medicine" to include diagnosing patients' ailments and prescribing the proper treatment. Hughey, 208 Iowa at 846-47, 226 N.W. at 373. See State v. Heath, 125 Iowa 585, 590, 101 N.W. 429, 431 (1904) (applying statute to persons administering "magnetic treatments"); State v. Edmunds, 127 Iowa 333, 338, 101 N.W. 431, 433 (1904) (similar statutes "have been held to apply to magnetic healers"). Witnesses testified that they were treated by Miller for various ailments including arthritis, rash, infection, headaches, constipation, and neck, shoulder, and back pain. Although he may not have referred to himself as a doctor, he led his customers to believe that he could diagnose and treat their ailments. Even though Miller did not formally advertise his treatments, he gained a large local customer base by means of referral from one customer to another. The fact that Miller would sometimes recommend that his customers consult a licensed physician or chiropractor does not detract from the fact that he would diagnose and treat their physical conditions, at least up to a certain point.
We also conclude there was sufficient evidence that Miller routinely prescribed and furnished medicine. Miller argues that he sold or recommended only natural vitamins or nutrients. His defense, through the testimony of a witness, was the vitamins and nutrients were not medicines, but food.
We have broadly construed the statutory words "prescribe and furnish medicine" to include administering any substance or remedy in the treatment of an ailment or disease. See State v. Bresee, 137 Iowa 673, 677-78, 114 N.W. 45, 47 (1907); see also Hueser, 205 Iowa at 135, 215 N.W. at 644 (upholding the definition of prescribe as the "designation of a remedy for an ailment or disease after having, by investigation, observation, or an inquiry, ascertained the apparent nature thereof"); Webster's Third New International Dictionary 1402 (1971) (defining medicine
Id. We believe Miller's actions of selling or recommending natural vitamins to his customers constitutes furnishing a substance or remedy for treating their ailments.
We conclude there is sufficient evidence to convince a rational jury beyond a reasonable doubt that Miller was guilty of practicing medicine and osteopathic medicine without a license.