Document ID: ./input/supremecourt_opinions/opinions/14pdf/14-7955_aplc.pdf
Page Number: 109.0

Cite as:  576 U. S. ____ (2015) 

13 

SOTOMAYOR, J., dissenting 

effect is apparent in the brain.  See id., at 250. 

These scientific sources also appear to demonstrate that
Dr.  Evans’  spinal-cord  theory—i.e.,  that  midazolam’s 
ceiling  effect  is  limited  to  the  spinal  cord—was  premised 
on a basic misunderstanding of midazolam’s mechanism of 
action.  I say “appear” not because the sources themselves 
are  unclear  about  how  midazolam  operates:  They  plainly 
state  that  midazolam  functions  by  promoting  GABA’s
inhibitory effects on the central nervous system.  See, e.g.,
Stoelting  &  Hillier  140.    Instead,  I  use  “appear”  because
discerning  the  rationale  underlying  Dr.  Evans’  testimony 
is  difficult.  His  spinal-cord  theory  might,  however,  be
explained at least in part by his apparent belief that rather
than  promoting  GABA’s  inhibitory  effects,  midazolam
produces  sedation  by  “compet[ing]”  with  GABA  and  thus
“inhibit[ing]” GABA’s effect.  App. 312–313.2  Regardless, I 
need  not  delve  too  deeply  into  Dr.  Evans’  alternative
scientific reality.  It suffices to say that to the extent that
Dr.  Evans’  testimony  was  based  on  his  understanding  of 
the source of midazolam’s pharmacological properties, that 
understanding was wrong. 

—————— 

2 The  Court  disputes  this  characterization  of  Dr.  Evans’  testimony,
insisting that Dr. Evans accurately described midazolam’s properties in
the  written  report  he  submitted  prior  to  the  hearing  below,  and  sug
gesting that petitioners’ experts would have “dispute[d] the accuracy” of
this  explanation  were  it  in  fact  wrong.    Ante,  at  25.  But  Dr.  Evans’ 
written  report  simply  said  midazolam  “produces  different  levels  of 
central  nervous  system  (CNS)  depression  through  binding  to  [GABA]
receptors.”    App.  293.    That  much  is  true.    Only  after  Drs.  Sasich  and
Lubarsky  testified  did  Dr.  Evans  further  claim  that  midazolam  pro­
duced  CNS  depression  by  binding  to  GABA  receptors  and  thereby 
preventing GABA itself from binding to those receptors—which is where 
he went wrong.  The Court’s further observation that Dr. Lubarsky also
used a variant on the word “inhibiting” in his testimony—in saying that
GABA’s  “ ‘inhibition  of  brain  activity  is  accentuated  by  midazolam,’ ” 
ante, at 25 (quoting App. 232)—is completely nonresponsive.  “Inhibit­
ing” is a perfectly good word; the problem here is the manner in which 
Dr. Evans used it in a sentence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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