Litigation-Driven Medical Testimony Is Not “For Medical Diagnosis or Treatment” Under Rule 803(4): A Commentary on United States v. Sharon Keegan

I. Introduction

In United States v. Sharon Elizabeth Keegan, No. 22‑13019 (11th Cir. Dec. 17, 2025), the Eleventh Circuit confronted a recurring but under‑theorized evidentiary problem: when can a party use an examining psychologist or physician as a conduit to introduce that party’s own out‑of‑court narrative under the hearsay exception for statements made for medical diagnosis or treatment, Federal Rule of Evidence 803(4)?

Keegan was charged with producing child pornography involving her fourteen‑year‑old sister, among other offenses. Her defense centered on duress: she claimed that her husband, the co‑defendant, had severely abused her and that this abuse vitiated her mens rea. Rather than testify and face cross‑examination, Keegan attempted to tell her story through an expert psychologist, Dr. Victoria Reynolds, to whom she related detailed allegations of spousal abuse. She sought to admit those statements through Rule 803(4) on the theory that they were “made for . . . medical diagnosis or treatment.”

The district court allowed Dr. Reynolds to testify as an expert about Keegan’s psychological condition, but excluded Keegan’s detailed abuse allegations as hearsay not covered by Rule 803(4), and alternatively under Rule 403. Keegan entered a conditional guilty plea, preserving her right to appeal the exclusion of the statements. The Eleventh Circuit affirmed, holding that statements made to a physician retained principally for litigation, and not for the patient’s own medical care, are not “for” medical diagnosis or treatment within the meaning of Rule 803(4).

In doing so, the court:

Gave a purpose‑based, intent‑focused reading to the word “for” in Rule 803(4);
Re‑anchored the medical‑treatment exception in its traditional “selfish treatment motivation” rationale and in reliability concerns common to the hearsay exceptions;
Explicitly declined to follow the expansive reading of the 1972 Advisory Committee Note to Rule 803(4), relying instead on the rule’s text and the later amendment to Rule 703; and
Created a clear split with earlier decisions from the Second, Fourth, Eighth, and Tenth Circuits that had broadly admitted statements to litigation‑only experts under Rule 803(4).

This commentary analyzes the opinion’s reasoning, its treatment of precedents and Advisory Committee Notes, and its likely impact on the law of hearsay, expert testimony, and criminal defense strategy in the Eleventh Circuit and beyond.

II. Summary of the Opinion

A. Factual Background and Trial Posture

In 2019, Keegan took nude photographs and videos of her fourteen‑year‑old sister and uploaded them to a shared Dropbox account so that her husband could view them—sometimes at his request, sometimes as a “surprise.” An undercover U.K. agent discovered some of these images online, which led to a U.S. investigation, search warrants, and charges against Keegan’s husband. Initially, law enforcement did not suspect Keegan, but her own statements to investigators (admitting she had “accidentally sent maybe four or five photos” of her sister in pink panties) and forensic analysis of her phone uncovered substantial incriminating material.

Both Keegan and her husband were charged with child pornography offenses. The husband pleaded guilty. Keegan pursued a duress‑type theory: she contended she lacked the requisite mens rea because she was acting under the coercive control and abuse of her husband.

Years earlier, in 2018, a hospital physician had diagnosed Keegan with a dissociative disorder. After indictment, Keegan’s counsel retained Dr. Victoria Reynolds, a psychologist who had spent the last decade exclusively as a full‑time expert witness, with no clinical practice. Counsel asked Reynolds to “evaluate the impacts” of Keegan’s alleged abuse “as they relate to her current legal charges.” After two days of interviews, Reynolds arrived at the same dissociative diagnosis and prepared to testify that Keegan’s conduct was the product of “complex and recognizable trauma‑driven adaptations and survival strategies.” Central to that narrative were Keegan’s own detailed descriptions of spousal abuse, which Reynolds intended to recount to the jury.

The government initially moved to exclude Reynolds’s testimony as irrelevant. The district court denied that broad motion, finding the proposed expert opinion probative of the defense. The government then renewed its challenge, this time focusing narrowly on Keegan’s statements to Reynolds describing her husband’s abuse. The government argued that these statements were hearsay not within Rule 803(4), though they could be referenced as the basis of the expert’s opinion under Rule 703. The district court agreed:

Factually, it found that Keegan’s purpose in speaking with Reynolds was to prepare the psychologist to testify—“to feed [Reynolds] her story in hopes that [the] witness would then be able to tell the same story to the jury”—rather than to obtain diagnosis or treatment.
Legally, it held that Rule 803(4) did not apply, and in the alternative, that Rule 403 barred the statements because their slight probative value was substantially outweighed by unfair prejudice to the government.

Keegan then entered a conditional guilty plea to one count of child pornography production, reserving the right to withdraw the plea if she prevailed on appeal of the evidentiary ruling. On appeal, she argued that:

The district court misinterpreted Rule 803(4) by imposing an unduly narrow, purpose‑based limitation; and
Even if 803(4) was correctly construed, the court erred in excluding the statements under Rule 403.

B. Holding

The Eleventh Circuit (Judge Grant, joined by Judges Newsom and Abudu; Newsom wrote a concurrence) affirmed. The court held:

Rule 803(4) covers only statements that are actually made “for” medical diagnosis or treatment, i.e., where the patient’s purpose is to obtain medical care or evaluation for her own health, not to create evidence for litigation;
Reliability and “selfish treatment motivation” are inherent in Rule 803(4)’s design and must inform its application, even though the rule does not explicitly mention “trustworthiness” as some other Rule 803 exceptions do;
The district court did not clearly err in finding that Keegan’s statements to Reynolds about spousal abuse were not made for diagnosis or treatment but for use in litigation, and therefore did not abuse its discretion in excluding them as hearsay; and
Given that conclusion, the court found it unnecessary to reach the alternative Rule 403 ruling.

In a concurrence, Judge Newsom agreed with the result and reasoning but emphasized an interpretive nuance: even if Keegan’s reading of “for” as permitting dual motives is linguistically plausible, proper textual interpretation must be informed by the broader context and structure of the hearsay rules. In that context, the phrase “made for . . . medical diagnosis” cannot reasonably be read to include statements made for diagnosis that was itself sought as a tool for litigation strategy.

III. Detailed Analysis

A. Precedents and Authorities Cited

1. Historical Background on Hearsay

The majority opinion begins with a historical survey of hearsay doctrine, drawing on classic sources:

Wigmore on Evidence (5th & 6th volumes): The court cites Wigmore’s account of the gradual emergence of a general rule against hearsay from the 1500s through the 1700s, and his discussions of the rationale for exceptions when statements are “practically sufficient” in reliability.
Queen v. Hepburn, 11 U.S. (7 Cranch) 290 (1813) (Marshall, C.J.): Cited for the “intrinsic weakness” of hearsay and its “incompetency to satisfy the mind” of factfinders about facts.
Ellicott v. Pearl, 35 U.S. (10 Pet.) 412 (1836) (Story, J.): Quoted for describing hearsay as “exceedingly infirm, unsatisfactory and intrinsically weak.”
Coleman v. Southwick, 9 Johns. 45 (N.Y. Sup. Ct. 1812): Emphasizes that hearsay deprives the opposing party of the opportunity for cross‑examination, and that a hearsay declarant can hide behind “I was told so” without answering particulars or resolving contradictions.
State v. Medlicott, 9 Kan. 257 (1872): Invoked to emphasize that rules excluding hearsay are designed to guard against the dangers of unsworn, untested declarations.

These authorities serve several purposes:

They re‑center the analysis on the fundamental concern with cross‑examination and reliability;
They link modern Rule 803(4) to a long tradition of cabining exceptions strictly to situations with strong guarantees of trustworthiness; and
They ground the court’s skepticism toward litigation‑oriented medical statements in a historical distrust of hearsay designed to evade cross‑examination.

2. Modern Hearsay Doctrine and Exceptions

The court references several modern authorities to situate Rule 803(4) within the broader scheme of hearsay exceptions:

Fed. R. Evid. 801(c), 802, 803, 807: The court restates the basic definition of hearsay as an out‑of‑court statement offered for its truth and notes the general rule of inadmissibility in Rule 802, followed by enumerated exceptions (Rule 803) and the residual exception (Rule 807), which explicitly requires “sufficient guarantees of trustworthiness.”
Mattox v. United States, 156 U.S. 237 (1895): Quoted regarding the rationale for dying declarations—impending death is presumed to induce truthfulness.
White v. Illinois, 502 U.S. 346 (1992): Cited to classify statements made for medical treatment as among the nation’s “firmly rooted” hearsay exceptions and to emphasize that some exceptions, such as medical statements and excited utterances, are inherently reliable even without explicit trustworthiness language.
Idaho v. Wright, 497 U.S. 805 (1990): Cited for the proposition that patients are “highly unlikely to lie” to their doctors because treatment effectiveness depends on accurate information.
Palmer v. Hoffman, 318 U.S. 109 (1943): Used to contrast inherently trustworthy business records with those created primarily for litigation, and to show that explicit trustworthiness language was necessary in Rule 803(6) because not all business records are inherently reliable.
United States v. Williams, 865 F.3d 1328 (11th Cir. 2017): Provides the abuse‑of‑discretion standard for evidentiary rulings and the rule that legal errors in such rulings are per se abuses of discretion.
City of Tuscaloosa v. Harcros Chems., 158 F.3d 548 (11th Cir. 1998); United States v. Byrom, 910 F.2d 725 (11th Cir. 1990): Establish clear‑error review for factual findings underlying evidentiary rulings.

3. Treatise Authorities on Rule 803(4)

The court relies heavily on leading evidence treatises:

McCormick on Evidence § 277: Provides the key phrase “selfish treatment motivation,” which the court adopts. The idea is that patients are motivated to be truthful when speaking to medical providers because their own health is at stake.
Weinstein’s Federal Evidence § 803.06[1]: Describes the “guarantee of credibility” that arises when a patient’s desire to heal encourages accurate statements to a physician.
Wigmore on Evidence § 1720: Warns against admitting patient statements whose “real use and predominating effect would be that of hearsay testimony of the patient,” a warning the court uses to justify limiting Rule 803(4) to genuine medical‑care statements.

4. Rule 703 and Basis‑of‑Opinion Evidence

Crucially, the court invokes the 2000 amendment to Rule 703 and the scholarship surrounding it:

Fed. R. Evid. 703: Post‑2000, it clarifies that inadmissible facts or data reasonably relied upon by an expert may be disclosed to the jury only “to help the jury evaluate the opinion” and, if they would otherwise be inadmissible, only if their probative value in evaluating the opinion substantially outweighs their prejudicial effect.
Henderson v. Ford Motor Co., 72 F.4th 1237 (11th Cir. 2023): Cited for the proposition that hearsay relied on by an expert under Rule 703 is admissible only as the basis of the expert’s opinion, not as substantive evidence.
United States v. Kent, 93 F.4th 1213 (11th Cir. 2024): Referenced for distinguishing between using a statement as substantive evidence versus as the basis of an expert’s opinion.
Paul W. Kaufman & Christopher J. Merken, “Toward a Presumptive Admission of Medical Records Under Federal Rule of Evidence 803(4),” 64 B.C. L. Rev. 567 (2023): The court quotes this article for the insight that Rule 703 now demands the very jury distinction (between basis and substantive use) that the 1972 Advisory Committee Note to Rule 803(4) disparaged as unrealistic.
Ronald L. Carlson & Paul R. Rice articles on expert testimony: Cited in the Rule 703 advisory history to highlight the debate over whether juries can meaningfully distinguish an expert’s opinion from its factual bases.

5. Circuit Precedents on Rule 803(4) from Other Circuits

The court explicitly declines to follow older cases from other circuits that broadly applied Rule 803(4) to litigation‑only examinations:

O’Gee v. Dobbs Houses, Inc., 570 F.2d 1084 (2d Cir. 1978);
United States v. Iron Shell, 633 F.2d 77 (8th Cir. 1980);
Morgan v. Foretich, 846 F.2d 941 (4th Cir. 1988);
United States v. Farley, 992 F.2d 1122 (10th Cir. 1993).

These decisions, relying heavily on the 1972 Advisory Committee Note, treated Rule 803(4) as having abolished “the common‑law distinction between the doctor who is consulted for the purpose of treatment and an examination for the purpose of diagnosis only,” and allowed statements to litigation‑oriented experts to come in as substantive evidence.

The Eleventh Circuit respectfully parts ways with these decisions, emphasizing that:

They predate the 2000 amendment to Rule 703;
They do not seriously engage the text and purpose of Rule 803(4); and
They give too much weight to the 1972 Note, which the Eleventh Circuit views as both atextual and undermined by subsequent rule amendments.

6. Deference to District Courts

The opinion stresses the role of trial judges in evaluating purpose and context:

United States v. Shamsid‑Deen, 61 F.4th 935 (11th Cir. 2023): Cited for the proposition that district courts, “immersed in the case as it unfolds,” are well positioned to resolve evidentiary questions based on procedural and factual detail.

B. The Court’s Legal Reasoning

1. Textual Focus on “for” in Rule 803(4)

Rule 803(4) provides, in relevant part, that the following is not excluded by the rule against hearsay:

“A statement that: (A) is made for—and is reasonably pertinent to—medical diagnosis or treatment; and (B) describes medical history; past or present symptoms or sensations; their inception; or their general cause.”

The core interpretive question is the meaning of “made for . . . medical diagnosis or treatment.” Starting with ordinary dictionary definitions, the court finds that “for” denotes “the object, aim, or purpose of an action or activity,” and “connotes intent.” Thus, for a statement to be within Rule 803(4), obtaining a medical diagnosis or treatment must be the declarant’s purpose or aim in making the statement.

Importantly:

This focus is on the declarant’s purpose, not merely the fact that a medical professional was involved or that a diagnosis resulted.
The court emphasizes the link between purpose (“for”) and the functional justification of the exception—reliability founded on a “selfish treatment motivation.”

2. Reliability and the “Selfish Treatment Motivation”

The opinion re‑situates Rule 803(4) within the broader logic of the hearsay exceptions. The key steps in the court’s reasoning are:

Hearsay exceptions are justified by reliability. The court draws on Wigmore and Supreme Court cases like White and Wright to assert that hearsay exceptions admit statements made in contexts that provide “substantial guarantees of . . . trustworthiness.”
Rule 803(4) is premised on a patient’s incentive to tell the truth when seeking care. The patient’s desire to obtain effective medical diagnosis or treatment—what McCormick calls “selfish treatment motivation”—is what ensures reliability.
Statements to litigation‑only experts may lack that reliability. When a party consults a doctor or psychologist solely (or essentially) to prepare for litigation, the natural incentive is not necessarily to be candid for health reasons, but to craft a narrative advantageous in court.

Although Rule 803(4) lacks an explicit “trustworthiness” clause (unlike Rules 803(6) and 803(8)), the court reasons that reliability is no less central:

In contexts such as excited utterances (Rule 803(2)), reliability is inherent in the circumstances of the statement, and thus need not be expressly referenced.
For medical diagnosis/treatment statements, the guarantee of credibility is likewise built in when the statement is truly made to seek care, but not when the doctor is effectively a litigation consultant.

3. Limiting the Advisory Committee’s 1972 Note

A key doctrinal move is the court’s treatment of the 1972 Advisory Committee Note to Rule 803(4). The Note had asserted that:

Statements to a doctor “consulted only for the purpose of enabling him to testify” are admissible under Rule 803(4);
This breaks from “conventional doctrine,” under which such statements were not admissible as substantive evidence but could be referenced to explain the basis of the expert’s opinion; and
The reason for this break was skepticism that juries could maintain a distinction between basis‑of‑opinion use and substantive truth.

The Eleventh Circuit declines to follow this Note, for two reasons:

Notes are not binding and can be outdated. While Advisory Committee Notes are usually entitled to “great weight,” they are not law and may be discounted when later developments undermine their rationale.
The Note’s central assumption has been repudiated by the 2000 amendment to Rule 703. Rule 703 now explicitly requires juries to distinguish between inadmissible information used only as the basis of an expert’s opinion and information that is admissible as substantive evidence. In other words, the Rule now demands exactly the jury distinction that the 1972 Note to Rule 803(4) declared unrealistic.

Given this mismatch, the court concludes that the Note’s rationale and its broad endorsement of admitting statements to litigation‑only physicians as substantive evidence should not control contemporary interpretation of Rule 803(4). Instead, courts must return to the text of the rule and its underlying reliability rationale.

4. Interplay with Rule 703: Basis vs. Substantive Evidence

The opinion carefully separates two distinct questions:

Can the expert rely on the statements? Yes. Under Rule 703, an expert may base her opinion on inadmissible hearsay if experts in the field reasonably rely on such information. The government conceded that Reynolds could rely on Keegan’s statements as part of the basis for her diagnosis.
Can the statements themselves be admitted as substantive evidence for their truth? Not necessarily. That requires a hearsay exception (such as Rule 803(4)), or another independent ground of admissibility.

This distinction is crucial in practice. Under the Eleventh Circuit’s approach:

The expert may testify that she diagnosed Keegan with a dissociative disorder and may explain that she relied on Keegan’s descriptions of past abuse as part of the basis for that diagnosis (subject to appropriate limiting instructions under Rule 703).
The jury may not, however, treat Keegan’s out‑of‑court abuse narrative, as recounted by Reynolds, as independent proof that the abuse occurred, unless a hearsay exception like Rule 803(4) applies.

By insisting on this separation, the court prevents parties from “end‑running” the hearsay rules by converting their own narratives into admissible “medical statements” simply by reciting them to a hired expert witness.

5. Application to Keegan’s Statements

The court applies its interpretation of Rule 803(4) to the facts with a strong dose of deference to the district court’s factual findings:

Timing: Keegan consulted Reynolds only after indictment and after spending four months in jail—suggesting a litigation‑driven motive, not ongoing clinical care.
Retainer Letter: Defense counsel explicitly requested that Reynolds evaluate the impact of alleged abuse “as they relate to [Keegan’s] current legal charges,” focusing the engagement on litigation rather than treatment.
Expert’s Role: Reynolds had spent a decade as a full‑time expert witness without doing clinical work, reinforcing that her function was forensic, not therapeutic.
Prior Diagnosis: Keegan had already received the same diagnosis (dissociative disorder) from a hospital physician years earlier—without sharing allegations of spousal abuse. If her goal was merely to inform the jury she had such a diagnosis, her existing medical record would have sufficed; she did not need a new diagnosis predicated on a more elaborate narrative of abuse.

From these facts, the district court inferred—and the Eleventh Circuit found no clear error in the inference—that Keegan’s primary (indeed exclusive) purpose in making the statements to Reynolds was to prepare a trial narrative, not to seek medical diagnosis or treatment for her own health. As the opinion puts it, “the medical diagnosis was not ‘the object, aim, or purpose’” of Keegan’s statements.

Thus, the statements were not made “for” medical diagnosis or treatment as required by Rule 803(4), and the district court did not abuse its discretion in excluding them as inadmissible hearsay.

6. The Concurring Opinion: Textualism in Context vs. Literalism

Judge Newsom’s concurrence focuses on interpretive method. He acknowledges that, taken in isolation, Keegan’s argument has textual plausibility: a person can do something “for” more than one reason, and she did want a diagnosis (even if also for litigation). On a purely semantic level, Rule 803(4) does not expressly exclude dual‑purpose statements.

However, he distinguishes between:

“Sterile semantics”—what might be linguistically possible in a decontextualized setting; and
“Proper textualism”—which seeks the ordinary meaning of the phrase “made for . . . medical diagnosis” as used in the real‑world context of a set of hearsay rules designed to admit only reliably trustworthy statements.

In that context, he argues, no reasonable reader would understand Rule 803(4) to cover a statement made to obtain a medical diagnosis that was itself sought with an eye toward litigation and not for its own therapeutic value. Because such statements do not carry the presumption of reliability that undergirds the hearsay exceptions, they fall outside the ordinary meaning of the rule, properly understood.

The concurrence thus reinforces the majority’s bottom line but underscores that good textual interpretation must incorporate context, manifest purpose, and structure—not just dictionary definitions.

C. Impact and Implications

1. Narrowing Rule 803(4) in the Eleventh Circuit

Within the Eleventh Circuit (Alabama, Florida, Georgia), Keegan significantly narrows the circumstances in which statements to medical professionals—especially forensic or litigation‑consulting experts—can be admitted under Rule 803(4). Key practical consequences include:

Purpose inquiry is now central. Litigants seeking to invoke Rule 803(4) must be prepared to show that the declarant’s purpose in making the statement was to obtain medical diagnosis or treatment, not merely to bolster a litigation position.
Engagement letters and timing will be scrutinized. Courts will look to when and why the expert was retained, the expert’s practice (clinical vs. purely forensic), and whether the same diagnosis or treatment could have been (or was) obtained in a non‑litigation setting.
Defendants cannot insulate themselves from cross‑examination by “laundering” their narrative through experts. Attempts to substitute an expert’s repetition of a defendant’s story for the defendant’s own testimony now face heightened skepticism under 803(4).

2. A Circuit Split and Potential for Supreme Court or Rulemaking Intervention

By explicitly declining to follow O’Gee, Iron Shell, Morgan, and Farley, the Eleventh Circuit has staked out a conflicting approach on the admissibility of statements made to doctors retained solely for trial. While those older cases are decades old and may be ripe for reconsideration in light of the 2000 amendment to Rule 703, they remain good law in their respective circuits unless and until overruled.

This divergence:

Creates a doctrinal split over the scope of Rule 803(4);
Raises the prospect that the Supreme Court could eventually resolve the question; and
May spur the Advisory Committee on Evidence Rules to consider updating the text of Rule 803(4) or revising its 1972 Note to reflect current doctrine and Rule 703’s framework.

3. Effects on Criminal Defense and Prosecution Strategies

The decision has clear implications for both sides in criminal cases:

For defendants:
- Using expert witnesses to convey their own narratives without testifying themselves will be harder. Courts will examine whether post‑indictment consultations with experts are truly medical or primarily forensic.
- Defendants with existing clinical diagnoses (e.g., from hospital or treating physicians) may be more inclined to rely on those records and treating providers, who can more readily satisfy the “selfish treatment motivation” criterion.
- Defense counsel will need to think more carefully about whether and how to instruct experts to recount the defendant’s statements, and whether such evidence can be admitted under Rule 703 (with limiting instructions) rather than Rule 803(4).
For prosecutors:
- They can invoke Keegan to challenge defense efforts to introduce elaborate backstory narratives (e.g., abuse, coercion) through retained experts as substantive evidence rather than as mere basis‑of‑opinion material.
- However, the same logic may boomerang against prosecution‑retained experts or forensic interviewers in cases involving child victims, domestic violence, or sexual assault, where the line between treatment and litigation preparation is sometimes blurred.

4. Implications for Victim and Child‑Witness Statements

Although Keegan is a defendant‑focused case, its logic is neutral and applies equally to prosecution‑sponsored experts. In some jurisdictions, statements made by child victims of abuse to “forensic interviewers” or SANE (Sexual Assault Nurse Examiner) nurses are admitted under Rule 803(4) on the theory that they are reasonably pertinent to diagnosis or treatment.

Under Keegan’s framework, courts in the Eleventh Circuit may need to:

Examine whether the primary purpose of such examinations is medical (e.g., assessing and treating trauma, physical injuries, or mental health) or evidentiary (collecting statements for prosecution);
Distinguish between portions of the interviews necessary for diagnosis/treatment and those that are primarily investigative or forensic; and
Consider whether parts of such interviews might be admissible only under Rule 703 (as basis‑of‑opinion material) rather than under Rule 803(4) as substantive proof.

While the opinion does not directly address Confrontation Clause issues, the narrowing of Rule 803(4) may indirectly affect the range of out‑of‑court statements that can be admitted consistency with both the hearsay rules and the Sixth Amendment.

5. Strengthening the Basis/Substance Divide in Expert Testimony

Keegan reinforces a trend toward enforcing the distinction between:

What an expert may rely on in forming an opinion (Rule 703); and
What the jury may consider as independent proof of facts (hearsay rules like Rule 803(4)).

By rejecting the 1972 Note’s skepticism about jurors’ ability to keep these concepts separate, the Eleventh Circuit aligns with Rule 703’s post‑2000 architecture and supports the use of careful limiting instructions:

Juries may hear that “the expert considered X” without treating X as fact unless a separate hearsay exception validates X as substantive evidence.
This distinction constrains the risk that experts will be used as vehicles for introducing large volumes of otherwise inadmissible hearsay under the guise of explaining “bases” of opinions.

IV. Complex Concepts Simplified

A. Hearsay and Why It Is Disfavored

Hearsay is an out‑of‑court statement offered in court to prove that what it says is true. For example, if a witness testifies, “My neighbor told me she saw Bill start the fire,” that is hearsay if offered to prove Bill started the fire, because the neighbor is not in court to be cross‑examined.

Hearsay is generally excluded because:

The original speaker is not under oath;
The opponent cannot cross‑examine the original speaker;
The jury cannot observe the original speaker’s demeanor; and
Memories can be faulty, statements can be taken out of context, or motives can be suspect.

However, some hearsay is admitted under carefully defined exceptions where circumstances indicate a high level of reliability—for example, dying declarations, present‑sense impressions, and statements for medical diagnosis or treatment.

B. Rule 803(4): Statements for Medical Diagnosis or Treatment

Rule 803(4) allows hearsay statements that:

Are made for medical diagnosis or treatment (i.e., with the purpose of getting medical help or evaluation), and
Describe medical history, symptoms, or the general cause of the condition.

The underlying idea is that people will usually tell the truth to doctors because their health depends on it. This self‑interest in getting proper care makes the statements more reliable than typical hearsay.

Keegan clarifies that this exception does not apply when:

The person is talking to a doctor or psychologist primarily to prepare testimony for a lawsuit or criminal trial, and
Any “diagnosis” obtained is really a tool for litigation rather than for medical care.

C. Rule 703: Expert Opinions and Their Bases

Rule 703 governs what experts (such as doctors, psychologists, engineers) may rely on to form their opinions and what they may tell the jury about those bases. Experts can rely on information that would not itself be admissible—like hearsay—as long as experts in the field reasonably rely on such information.

But there is an important distinction:

Expert reliance: The expert may consider hearsay in forming an opinion.
Substantive use: The jury cannot automatically treat that hearsay as independent proof of the facts stated unless a hearsay exception applies.

After the 2000 amendments, Rule 703 expects juries to understand this difference, often with help from limiting instructions. Keegan leans on this structure to say: you cannot simply bypass the hearsay rules by putting your story into a medical expert’s mouth.

D. Duress and Mens Rea (Briefly)

Keegan’s defense theory was that she lacked the necessary mens rea (criminal intent) because her husband’s abuse placed her under duress. Roughly speaking:

Mens rea refers to the state of mind required for a crime (e.g., intentionally, knowingly, recklessly).
Duress is a defense arguing that a defendant committed a crime because of unlawful threats or coercion, such that the law should excuse or mitigate the conduct.

Her abuse narrative was therefore central to the case. The evidentiary question was not whether she could present any evidence related to mental health or abuse, but whether she could do so via her own hearsay statements filtered through an expert and protected from cross‑examination.

V. Conclusion

United States v. Keegan establishes an important and carefully reasoned limitation on the medical‑treatment hearsay exception in Rule 803(4) within the Eleventh Circuit. The key takeaways are:

Purpose matters. Statements to medical professionals are admissible under Rule 803(4) only when made for the purpose of medical diagnosis or treatment—rooted in the patient’s “selfish treatment motivation”—and not when made primarily (or solely) to generate evidence for litigation.
Reliability remains central. Even where the rule text does not mention “trustworthiness,” the hearsay exceptions are anchored in reliability concerns that must inform how courts apply terms like “for medical diagnosis or treatment.”
Advisory Notes are subordinate to text and later amendments. The court declines to follow the 1972 Advisory Committee Note to Rule 803(4) where its rationale conflicts with the structure of Rule 703 as amended and where it attempts to expand the exception beyond its traditional, reliability‑based justifications.
Expert testimony is not a hearsay escape hatch. Parties may not circumvent cross‑examination by telling their stories to hired experts and then invoking Rule 803(4) to introduce those stories as substantive evidence.
A circuit split emerges. By rejecting the broader, Note‑driven approach of several other circuits, the Eleventh Circuit has created a divergence that may invite reconsideration by those circuits, intervention by the Supreme Court, or revision of the rules or Advisory Committee Notes.

In the broader legal context, Keegan signals a renewed judicial insistence on aligning hearsay doctrine with its historical foundations: exceptions are to be applied narrowly, grounded in specific, well‑understood guarantees of trustworthiness, and not repurposed to serve as conduits for self‑serving litigation narratives.

Litigation-Driven Medical Testimony and Rule 803(4): Commentary on United States v. Keegan