Wyeth v. Levine

(Slip Opinion) OCTOBER TERM, 2008 1

Syllabus

NOTE: Where it is feasible, a syllabus (headnote) will be released, as is
being done in connection with this case, at the time the opinion is issued.
The syllabus constitutes no part of the opinion of the Court but has been
prepared by the Reporter of Decisions for the convenience of the reader.
See United States v. Detroit Timber & Lumber Co., 200 U. S. 321, 337.

SUPREME COURT OF THE UNITED STATES

Syllabus

WYETH v. LEVINE

CERTIORARI TO THE SUPREME COURT OF VERMONT

No. 06–1249. Argued November 3, 2008—Decided March 4, 2009
Petitioner Wyeth manufactures the antinausea drug Phenergan. After
a clinician injected respondent Levine with Phenergan by the “IV
push” method, whereby a drug is injected directly into a patient’s
vein, the drug entered Levine’s artery, she developed gangrene, and
doctors amputated her forearm. Levine brought a state-law damages
action, alleging, inter alia, that Wyeth had failed to provide an ade
quate warning about the significant risks of administering Phener
gan by the IV-push method. The Vermont jury determined that Le
vine’s injury would not have occurred if Phenergan’s label included
an adequate warning, and it awarded damages for her pain and suf
fering, substantial medical expenses, and loss of her livelihood as a
professional musician. Declining to overturn the verdict, the trial
court rejected Wyeth’s argument that Levine’s failure-to-warn claims
were pre-empted by federal law because Phenergan’s labeling had
been approved by the federal Food and Drug Administration (FDA).
The Vermont Supreme Court affirmed.
Held: Federal law does not pre-empt Levine’s claim that Phenergan’s
label did not contain an adequate warning about the IV-push method
of administration. Pp. 6–25.
(a) The argument that Levine’s state-law claims are pre-empted
because it is impossible for Wyeth to comply with both the state-law
duties underlying those claims and its federal labeling duties is re
jected. Although a manufacturer generally may change a drug label
only after the FDA approves a supplemental application, the agency’s
“changes being effected” (CBE) regulation permits certain preap
proval labeling changes that add or strengthen a warning to improve
drug safety. Pursuant to the CBE regulation, Wyeth could have uni
laterally added a stronger warning about IV-push administration,
and there is no evidence that the FDA would ultimately have rejected
2 WYETH v. LEVINE

Syllabus

such a labeling change. Wyeth’s cramped reading of the CBE regula
tion and its broad assertion that unilaterally changing the Phenergan
label would have violated federal law governing unauthorized distri
bution and misbranding of drugs are based on the fundamental mis
understanding that the FDA, rather than the manufacturer, bears
primary responsibility for drug labeling. It is a central premise of the
Food, Drug, and Cosmetic Act (FDCA) and the FDA’s regulations
that the manufacturer bears responsibility for the content of its label
at all times. Pp. 11–16.
(b) Wyeth’s argument that requiring it to comply with a state-law
duty to provide a stronger warning would interfere with Congress’
purpose of entrusting an expert agency with drug labeling decisions
is meritless because it relies on an untenable interpretation of con
gressional intent and an overbroad view of an agency’s power to pre
empt state law. The history of the FDCA shows that Congress did
not intend to pre-empt state-law failure-to-warn actions. In advanc
ing the argument that the FDA must be presumed to have estab
lished a specific labeling standard that leaves no room for different
state-law judgments, Wyeth relies not on any statement by Congress
but on the preamble to a 2006 FDA regulation declaring that state
law failure-to-warn claims threaten the FDA’s statutorily prescribed
role. Although an agency regulation with the force of law can pre
empt conflicting state requirements, this case involves no such regu
lation but merely an agency’s assertion that state law is an obstacle
to achieving its statutory objectives. Where, as here, Congress has
not authorized a federal agency to pre-empt state law directly, the
weight this Court accords the agency’s explanation of state law’s im
pact on the federal scheme depends on its thoroughness, consistency,
and persuasiveness. Cf., e.g., Skidmore v. Swift & Co., 323 U. S. 134.
Under this standard, the FDA’s 2006 preamble does not merit defer
ence: It is inherently suspect in light of the FDA’s failure to offer in
terested parties notice or opportunity for comment on the pre
emption question; it is at odds with the available evidence of Con
gress’ purposes; and it reverses the FDA’s own longstanding position
that state law is a complementary form of drug regulation without
providing a reasoned explanation. Geier v. American Honda Motor
Co., 529 U. S. 861, is distinguished. Pp. 17–25.
___ Vt. ___, 944 A. 2d 179, affirmed.

STEVENS, J., delivered the opinion of the Court, in which KENNEDY,
SOUTER, GINSBURG, and BREYER, JJ., joined. BREYER, J., filed a concur
ring opinion. THOMAS, J., filed an opinion concurring in the judgment.
ALITO, J., filed a dissenting opinion, in which ROBERTS, C. J., and
SCALIA, J., joined.
 Cite as: 555 U. S. ____ (2009) 1

Opinion of the Court

NOTICE: This opinion is subject to formal revision before publication in the
preliminary print of the United States Reports. Readers are requested to
notify the Reporter of Decisions, Supreme Court of the United States, Wash
ington, D. C. 20543, of any typographical or other formal errors, in order
that corrections may be made before the preliminary print goes to press.

SUPREME COURT OF THE UNITED STATES
_________________

No. 06–1249
_________________

WYETH, PETITIONER v. DIANA LEVINE
ON WRIT OF CERTIORARI TO THE SUPREME COURT OF

VERMONT

[March 4, 2009]

JUSTICE STEVENS delivered the opinion of the Court.
Directly injecting the drug Phenergan into a patient’s
vein creates a significant risk of catastrophic conse
quences. A Vermont jury found that petitioner Wyeth, the
manufacturer of the drug, had failed to provide an ade
quate warning of that risk and awarded damages to re
spondent Diana Levine to compensate her for the amputa
tion of her arm. The warnings on Phenergan’s label had
been deemed sufficient by the federal Food and Drug
Administration (FDA) when it approved Wyeth’s new drug
application in 1955 and when it later approved changes in
the drug’s labeling. The question we must decide is
whether the FDA’s approvals provide Wyeth with a com
plete defense to Levine’s tort claims. We conclude that
they do not.
I
Phenergan is Wyeth’s brand name for promethazine
hydrochloride, an antihistamine used to treat nausea. The
injectable form of Phenergan can be administered intra
muscularly or intravenously, and it can be administered
intravenously through either the “IV-push” method,
whereby the drug is injected directly into a patient’s vein,
2 WYETH v. LEVINE

Opinion of the Court

or the “IV-drip” method, whereby the drug is introduced
into a saline solution in a hanging intravenous bag and
slowly descends through a catheter inserted in a patient’s
vein. The drug is corrosive and causes irreversible gan
grene if it enters a patient’s artery.
Levine’s injury resulted from an IV-push injection of
Phenergan. On April 7, 2000, as on previous visits to her
local clinic for treatment of a migraine headache, she
received an intramuscular injection of Demerol for her
headache and Phenergan for her nausea. Because the
combination did not provide relief, she returned later that
day and received a second injection of both drugs. This
time, the physician assistant administered the drugs by
the IV-push method, and Phenergan entered Levine’s
artery, either because the needle penetrated an artery
directly or because the drug escaped from the vein into
surrounding tissue (a phenomenon called “perivascular
extravasation”) where it came in contact with arterial
blood. As a result, Levine developed gangrene, and doc
tors amputated first her right hand and then her entire
forearm. In addition to her pain and suffering, Levine
incurred substantial medical expenses and the loss of her
livelihood as a professional musician.
After settling claims against the health center and
clinician, Levine brought an action for damages against
Wyeth, relying on common-law negligence and strict
liability theories. Although Phenergan’s labeling warned
of the danger of gangrene and amputation following inad
vertent intra-arterial injection,1 Levine alleged that the
——————
1 The warning for “Inadvertent Intra-arterial Injection” stated: “Due

to the close proximity of arteries and veins in the areas most commonly
used for intravenous injection, extreme care should be exercised to
avoid perivascular extravasation or inadvertent intra-arterial injection.
Reports compatible with inadvertent intra-arterial injection of Phener
gan Injection, usually in conjunction with other drugs intended for
intravenous use, suggest that pain, severe chemical irritation, severe
 Cite as: 555 U. S. ____ (2009) 3

Opinion of the Court

labeling was defective because it failed to instruct clini
cians to use the IV-drip method of intravenous admini
stration instead of the higher risk IV-push method. More
broadly, she alleged that Phenergan is not reasonably safe
for intravenous administration because the foreseeable
risks of gangrene and loss of limb are great in relation to
the drug’s therapeutic benefits. App. 14–15.
Wyeth filed a motion for summary judgment, arguing
that Levine’s failure-to-warn claims were pre-empted by
federal law. The court found no merit in either Wyeth’s
field pre-emption argument, which it has since abandoned,
or its conflict pre-emption argument. With respect to the
contention that there was an “actual conflict between a
specific FDA order,” id., at 21, and Levine’s failure-to
warn action, the court reviewed the sparse correspondence
between Wyeth and the FDA about Phenergan’s labeling
and found no evidence that Wyeth had “earnestly at
tempted” to strengthen the intra-arterial injection warn
ing or that the FDA had “specifically disallowed” stronger
language, id., at 23. The record, as then developed,
——————
spasm of distal vessels, and resultant gangrene requiring amputation
are likely under such circumstances. Intravenous injection was in
tended in all the cases reported but perivascular extravasation or
arterial placement of the needle is now suspect. There is no proven
successful management of this condition after it occurs. . . . Aspiration
of dark blood does not preclude intra-arterial needle placement, be
cause blood is discolored upon contact with Phenergan Injection. Use of
syringes with rigid plungers or of small bore needles might obscure
typical arterial backflow if this is relied upon alone. When used intra
venously, Phenergan Injection should be given in a concentration no
greater than 25 mg per mL and at a rate not to exceed 25 mg per
minute. When administering any irritant drug intravenously, it is
usually preferable to inject it through the tubing of an intravenous
infusion set that is known to be functioning satisfactorily. In the event
that a patient complains of pain during intended intravenous injection
of Phenergan Injection, the injection should be stopped immediately to
provide for evaluation of possible arterial placement or perivascular
extravasation.” App. 390.
4 WYETH v. LEVINE

Opinion of the Court

“lack[ed] any evidence that the FDA set a ceiling on this
matter.” Ibid.
The evidence presented during the 5-day jury trial
showed that the risk of intra-arterial injection or perivas
cular extravasation can be almost entirely eliminated
through the use of IV-drip, rather than IV-push, admini
stration. An IV drip is started with saline, which will not
flow properly if the catheter is not in the vein and fluid is
entering an artery or surrounding tissue. See id., at 50–
51, 60, 66–68, 75. By contrast, even a careful and experi
enced clinician using the IV-push method will occasionally
expose an artery to Phenergan. See id., at 73, 75–76.
While Phenergan’s labeling warned against intra-arterial
injection and perivascular extravasation and advised that
“[w]hen administering any irritant drug intravenously it is
usually preferable to inject it through the tubing of an
intravenous infusion set that is known to be function-
ing satisfactorily,” id., at 390, the labeling did not con
tain a specific warning about the risks of IV-push
administration.
The trial record also contains correspondence between
Wyeth and the FDA discussing Phenergan’s label. The
FDA first approved injectable Phenergan in 1955. In 1973
and 1976, Wyeth submitted supplemental new drug appli
cations, which the agency approved after proposing label
ing changes. Wyeth submitted a third supplemental
application in 1981 in response to a new FDA rule govern
ing drug labels. Over the next 17 years, Wyeth and the
FDA intermittently corresponded about Phenergan’s label.
The most notable activity occurred in 1987, when the FDA
suggested different warnings about the risk of arterial
exposure, and in 1988, when Wyeth submitted revised
labeling incorporating the proposed changes. The FDA did
not respond. Instead, in 1996, it requested from Wyeth
the labeling then in use and, without addressing Wyeth’s
1988 submission, instructed it to “[r]etain verbiage in
 Cite as: 555 U. S. ____ (2009) 5

Opinion of the Court

current label” regarding intra-arterial injection. Id., at
359. After a few further changes to the labeling not re
lated to intra-arterial injection, the FDA approved Wyeth’s
1981 application in 1998, instructing that Phenergan’s
final printed label “must be identical” to the approved
package insert. Id., at 382.
Based on this regulatory history, the trial judge in
structed the jury that it could consider evidence of Wyeth’s
compliance with FDA requirements but that such compli
ance did not establish that the warnings were adequate.
He also instructed, without objection from Wyeth, that
FDA regulations “permit a drug manufacturer to change a
product label to add or strengthen a warning about its
product without prior FDA approval so long as it later
submits the revised warning for review and approval.”
Id., at 228.
Answering questions on a special verdict form, the jury
found that Wyeth was negligent, that Phenergan was a
defective product as a result of inadequate warnings and
instructions, and that no intervening cause had broken
the causal connection between the product defects and the
plaintiff’s injury. Id., at 233–235. It awarded total dam
ages of $7,400,000, which the court reduced to account for
Levine’s earlier settlement with the health center and
clinician. Id., at 235–236.
On August 3, 2004, the trial court filed a comprehensive
opinion denying Wyeth’s motion for judgment as a matter
of law. After making findings of fact based on the trial
record (supplemented by one letter that Wyeth found after
the trial), the court rejected Wyeth’s pre-emption argu
ments. It determined that there was no direct conflict
between FDA regulations and Levine’s state-law claims
because those regulations permit strengthened warnings
without FDA approval on an interim basis and the record
contained evidence of at least 20 reports of amputations
similar to Levine’s since the 1960’s. The court also found
6 WYETH v. LEVINE

Opinion of the Court

that state tort liability in this case would not obstruct the
FDA’s work because the agency had paid no more than
passing attention to the question whether to warn against
IV-push administration of Phenergan. In addition, the
court noted that state law serves a compensatory function
distinct from federal regulation. Id., at 249–252.
The Vermont Supreme Court affirmed. It held that the
jury’s verdict “did not conflict with FDA’s labeling re
quirements for Phenergan because [Wyeth] could have
warned against IV-push administration without prior
FDA approval, and because federal labeling requirements
create a floor, not a ceiling, for state regulation.” ___ Vt.
___, ___ 944 A. 2d 179, 184 (2006). In dissent, Chief Jus
tice Reiber argued that the jury’s verdict conflicted with
federal law because it was inconsistent with the FDA’s
conclusion that intravenous administration of Phenergan
was safe and effective.
The importance of the pre-emption issue, coupled with
the fact that the FDA has changed its position on state
tort law and now endorses the views expressed in Chief
Justice Reiber’s dissent, persuaded us to grant Wyeth’s
petition for certiorari. 552 U. S. ___ (2008). The question
presented by the petition is whether the FDA’s drug label
ing judgments “preempt state law product liability claims
premised on the theory that different labeling judgments
were necessary to make drugs reasonably safe for use.”
Pet. for Cert. i.
II
Wyeth makes two separate pre-emption arguments:
first, that it would have been impossible for it to comply
with the state-law duty to modify Phenergan’s labeling
without violating federal law, see Fidelity Fed. Sav. &
Loan Assn. v. De la Cuesta, 458 U. S. 141, 153 (1982), and
second, that recognition of Levine’s state tort action cre
ates an unacceptable “obstacle to the accomplishment and
 Cite as: 555 U. S. ____ (2009) 7

Opinion of the Court

execution of the full purposes and objectives of Congress,”
Hines v. Davidowitz, 312 U. S. 52, 67 (1941), because it
substitutes a lay jury’s decision about drug labeling for the
expert judgment of the FDA. As a preface to our evalua
tion of these arguments, we identify two factual proposi
tions decided during the trial court proceedings, empha
size two legal principles that guide our analysis, and
review the history of the controlling federal statute.
The trial court proceedings established that Levine’s
injury would not have occurred if Phenergan’s label had
included an adequate warning about the risks of the IV
push method of administering the drug. The record con
tains evidence that the physician assistant administered a
greater dose than the label prescribed, that she may have
inadvertently injected the drug into an artery rather than
a vein, and that she continued to inject the drug after
Levine complained of pain. Nevertheless, the jury rejected
Wyeth’s argument that the clinician’s conduct was an
intervening cause that absolved it of liability. See App.
234 (jury verdict), 252–254. In finding Wyeth negligent as
well as strictly liable, the jury also determined that Le
vine’s injury was foreseeable. That the inadequate label
was both a but-for and proximate cause of Levine’s injury
is supported by the record and no longer challenged by
Wyeth.2
The trial court proceedings further established that the
critical defect in Phenergan’s label was the lack of an
adequate warning about the risks of IV-push administra
——————
2 The dissent nonetheless suggests that physician malpractice was
the exclusive cause of Levine’s injury. See, e.g., post, at 1 (opinion of
ALITO, J.) (“[I]t is unclear how a ‘stronger’ warning could have helped
respondent”); post, at 16–18 (suggesting that the physician assistant’s
conduct was the sole cause of the injury). The dissent’s frustration with
the jury’s verdict does not put the merits of Levine’s tort claim before
us, nor does it change the question we must decide—whether federal
law pre-empts Levine’s state-law claims.
8 WYETH v. LEVINE

Opinion of the Court

tion. Levine also offered evidence that the IV-push
method should be contraindicated and that Phenergan
should never be administered intravenously, even by the
IV-drip method. Perhaps for this reason, the dissent
incorrectly assumes that the state-law duty at issue is the
duty to contraindicate the IV-push method. See, e.g., post,
at 8, 25. But, as the Vermont Supreme Court explained,
the jury verdict established only that Phenergan’s warn
ing was insufficient. It did not mandate a particular
replacement warning, nor did it require contraindicating
IV-push administration: “There may have been any num
ber of ways for [Wyeth] to strengthen the Phenergan
warning without completely eliminating IV-push admini
stration.” ___ Vt., at ___, n. 2, 944 A. 2d, at 189, n. 2. We
therefore need not decide whether a state rule proscribing
intravenous administration would be pre-empted. The
narrower question presented is whether federal law pre
empts Levine’s claim that Phenergan’s label did not con
tain an adequate warning about using the IV-push method
of administration.
Our answer to that question must be guided by two
cornerstones of our pre-emption jurisprudence. First, “the
purpose of Congress is the ultimate touchstone in every
pre-emption case.” Medtronic, Inc. v. Lohr, 518 U. S. 470,
485 (1996) (internal quotation marks omitted); see Retail
Clerks v. Schermerhorn, 375 U. S. 96, 103 (1963). Second,
“[i]n all pre-emption cases, and particularly in those in
which Congress has ‘legislated . . . in a field which the
States have traditionally occupied,’ . . . we ‘start with the
assumption that the historic police powers of the States
were not to be superseded by the Federal Act unless that
was the clear and manifest purpose of Congress.’ ” Lohr,
518 U. S., at 485 (quoting Rice v. Santa Fe Elevator Corp.,
331 U. S. 218, 230 (1947)).3
——————
3 Wyeth argues that the presumption against pre-emption should not
 Cite as: 555 U. S. ____ (2009) 9

Opinion of the Court

In order to identify the “purpose of Congress,” it is ap
propriate to briefly review the history of federal regulation
of drugs and drug labeling. In 1906, Congress enacted its
first significant public health law, the Federal Food and
Drugs Act, ch. 3915, 34 Stat. 768. The Act, which prohib
ited the manufacture or interstate shipment of adulter
ated or misbranded drugs, supplemented the protection
for consumers already provided by state regulation and
common-law liability. In the 1930’s, Congress became
increasingly concerned about unsafe drugs and fraudulent
marketing, and it enacted the Federal Food, Drug, and
Cosmetic Act (FDCA), ch. 675, 52 Stat. 1040, as amended,
21 U. S. C. §301 et seq. The Act’s most substantial innova
tion was its provision for premarket approval of new
drugs. It required every manufacturer to submit a new
drug application, including reports of investigations and
specimens of proposed labeling, to the FDA for review.
Until its application became effective, a manufacturer was

——————
apply to this case because the Federal Government has regulated drug
labeling for more than a century. That argument misunderstands the
principle: We rely on the presumption because respect for the States as
“independent sovereigns in our federal system” leads us to assume that
“Congress does not cavalierly pre-empt state-law causes of action.”
Medtronic, Inc. v. Lohr, 518 U. S. 470, 485 (1996). The presumption
thus accounts for the historic presence of state law but does not rely on
the absence of federal regulation.
For its part, the dissent argues that the presumption against pre
emption should not apply to claims of implied conflict pre-emption at
all, post, at 21, but this Court has long held to the contrary. See, e.g.,
California v. ARC America Corp., 490 U. S. 93, 101–102 (1989); Hills
borough County v. Automated Medical Laboratories, Inc., 471 U. S. 707,
716 (1985); see also Rush Prudential HMO, Inc. v. Moran, 536 U. S.
355, 387 (2002). The dissent’s reliance on Buckman Co. v. Plaintiffs’
Legal Comm., 531 U. S. 341 (2001), see post, at 21, and n. 14, is espe
cially curious, as that case involved state-law fraud-on-the-agency
claims, and the Court distinguished state regulation of health and
safety as matters to which the presumption does apply. See 531 U. S.,
at 347–348.
10 WYETH v. LEVINE

Opinion of the Court

prohibited from distributing a drug. The FDA could reject
an application if it determined that the drug was not safe
for use as labeled, though if the agency failed to act, an
application became effective 60 days after the filing.
FDCA, §505(c), 52 Stat. 1052.
In 1962, Congress amended the FDCA and shifted the
burden of proof from the FDA to the manufacturer. Before
1962, the agency had to prove harm to keep a drug out of
the market, but the amendments required the manufac
turer to demonstrate that its drug was “safe for use under
the conditions prescribed, recommended, or suggested in
the proposed labeling” before it could distribute the drug.
§§102(d), 104(b), 76 Stat. 781, 784. In addition, the
amendments required the manufacturer to prove the
drug’s effectiveness by introducing “substantial evidence
that the drug will have the effect it purports or is repre
sented to have under the conditions of use prescribed,
recommended, or suggested in the proposed labeling.”
§102(d), id., at 781.
As it enlarged the FDA’s powers to “protect the public
health” and “assure the safety, effectiveness, and reliabil
ity of drugs,” id., at 780, Congress took care to preserve
state law. The 1962 amendments added a saving clause,
indicating that a provision of state law would only be
invalidated upon a “direct and positive conflict” with the
FDCA. §202, id., at 793. Consistent with that provision,
state common-law suits “continued unabated despite . . .
FDA regulation.” Riegel v. Medtronic, Inc., 552 U. S. ___,
___ (2008) (slip op., at 8) (GINSBURG, J., dissenting); see
ibid., n. 11 (collecting state cases). And when Congress
enacted an express pre-emption provision for medical
devices in 1976, see §521, 90 Stat. 574 (codified at 21
U. S. C. §360k(a)), it declined to enact such a provision for
prescription drugs.
In 2007, after Levine’s injury and lawsuit, Congress
again amended the FDCA. 121 Stat. 823. For the first
 Cite as: 555 U. S. ____ (2009) 11

Opinion of the Court

time, it granted the FDA statutory authority to require a
manufacturer to change its drug label based on safety
information that becomes available after a drug’s initial
approval. §901(a), id., at 924–926. In doing so, however,
Congress did not enact a provision in the Senate bill that
would have required the FDA to preapprove all changes to
drug labels. See S. 1082, 110th Cong., 1st Sess., §208,
pp. 107–114 (2007) (as passed) (proposing new §506D).
Instead, it adopted a rule of construction to make it clear
that manufacturers remain responsible for updating their
labels. See 121 Stat. 925–926.
III
Wyeth first argues that Levine’s state-law claims are
pre-empted because it is impossible for it to comply with
both the state-law duties underlying those claims and its
federal labeling duties. See De la Cuesta, 458 U. S., at
153. The FDA’s premarket approval of a new drug appli
cation includes the approval of the exact text in the pro
posed label. See 21 U. S. C. §355; 21 CFR §314.105(b)
(2008). Generally speaking, a manufacturer may only
change a drug label after the FDA approves a supplemen
tal application. There is, however, an FDA regulation that
permits a manufacturer to make certain changes to its
label before receiving the agency’s approval. Among other
things, this “changes being effected” (CBE) regulation
provides that if a manufacturer is changing a label to “add
or strengthen a contraindication, warning, precaution, or
adverse reaction” or to “add or strengthen an instruction
about dosage and administration that is intended to in
crease the safe use of the drug product,” it may make the
labeling change upon filing its supplemental application
with the FDA; it need not wait for FDA approval.
§§314.70(c)(6)(iii)(A), (C).
Wyeth argues that the CBE regulation is not implicated
in this case because a 2008 amendment provides that a
12 WYETH v. LEVINE

Opinion of the Court

manufacturer may only change its label “to reflect newly
acquired information.” 73 Fed. Reg. 49609. Resting on
this language (which Wyeth argues simply reaffirmed the
interpretation of the regulation in effect when this case
was tried), Wyeth contends that it could have changed
Phenergan’s label only in response to new information
that the FDA had not considered. And it maintains that
Levine has not pointed to any such information concerning
the risks of IV-push administration. Thus, Wyeth insists,
it was impossible for it to discharge its state-law obliga
tion to provide a stronger warning about IV-push admini
stration without violating federal law. Wyeth’s argument
misapprehends both the federal drug regulatory scheme
and its burden in establishing a pre-emption defense.
We need not decide whether the 2008 CBE regulation is
consistent with the FDCA and the previous version of the
regulation, as Wyeth and the United States urge, because
Wyeth could have revised Phenergan’s label even in accor
dance with the amended regulation. As the FDA ex
plained in its notice of the final rule, “ ‘newly acquired
information’ ” is not limited to new data, but also encom
passes “new analyses of previously submitted data.” Id.,
at 49604. The rule accounts for the fact that risk informa
tion accumulates over time and that the same data may
take on a different meaning in light of subsequent devel
opments: “[I]f the sponsor submits adverse event informa
tion to FDA, and then later conducts a new analysis of
data showing risks of a different type or of greater severity
or frequency than did reports previously submitted to
FDA, the sponsor meets the requirement for ‘newly ac
quired information.’ ” Id., at 49607; see also id., at 49606.
The record is limited concerning what newly acquired
information Wyeth had or should have had about the risks
of IV-push administration of Phenergan because Wyeth
did not argue before the trial court that such information
was required for a CBE labeling change. Levine did,
 Cite as: 555 U. S. ____ (2009) 13

Opinion of the Court

however, present evidence of at least 20 incidents prior to
her injury in which a Phenergan injection resulted in
gangrene and an amputation. See App. 74, 252.4 After
the first such incident came to Wyeth’s attention in 1967,
it notified the FDA and worked with the agency to change
Phenergan’s label. In later years, as amputations contin
ued to occur, Wyeth could have analyzed the accumulating
data and added a stronger warning about IV-push admini
stration of the drug.
Wyeth argues that if it had unilaterally added such a
warning, it would have violated federal law governing
unauthorized distribution and misbranding. Its argument
that a change in Phenergan’s labeling would have sub
jected it to liability for unauthorized distribution rests on
the assumption that this labeling change would have
rendered Phenergan a new drug lacking an effective appli
cation. But strengthening the warning about IV-push
administration would not have made Phenergan a new
drug. See 21 U. S. C. §321(p)(1) (defining “new drug”); 21
CFR §310.3(h). Nor would this warning have rendered
Phenergan misbranded. The FDCA does not provide that
a drug is misbranded simply because the manufacturer
has altered an FDA-approved label; instead, the misbrand
ing provision focuses on the substance of the label and,
among other things, proscribes labels that fail to include
“adequate warnings.” 21 U. S. C. §352(f). Moreover,
because the statute contemplates that federal juries will
resolve most misbranding claims, the FDA’s belief that a
drug is misbranded is not conclusive. See §§331, 332,
334(a)–(b). And the very idea that the FDA would bring
an enforcement action against a manufacturer for

——————
4 Levine also introduced evidence that Pfizer had withdrawn Vistaril,
another antinausea drug, from intravenous use several decades earlier
because its intravenous injection had resulted in gangrene and ampu
tations. See App. 79.
14 WYETH v. LEVINE

Opinion of the Court

strengthening a warning pursuant to the CBE regulation
is difficult to accept—neither Wyeth nor the United States
has identified a case in which the FDA has done so.
Wyeth’s cramped reading of the CBE regulation and its
broad reading of the FDCA’s misbranding and unauthor
ized distribution provisions are premised on a more fun
damental misunderstanding. Wyeth suggests that the
FDA, rather than the manufacturer, bears primary re
sponsibility for drug labeling. Yet through many amend
ments to the FDCA and to FDA regulations, it has re
mained a central premise of federal drug regulation that
the manufacturer bears responsibility for the content of its
label at all times. It is charged both with crafting an
adequate label and with ensuring that its warnings re
main adequate as long as the drug is on the market. See,
e.g., 21 CFR §201.80(e) (requiring a manufacturer to re
vise its label “to include a warning as soon as there is
reasonable evidence of an association of a serious hazard
with a drug”); §314.80(b) (placing responsibility for post
marketing surveillance on the manufacturer); 73 Fed. Reg.
49605 (“Manufacturers continue to have a responsibility
under Federal law . . . to maintain their labeling and
update the labeling with new safety information”).
Indeed, prior to 2007, the FDA lacked the authority to
order manufacturers to revise their labels. See 121 Stat.
924–926. When Congress granted the FDA this authority,
it reaffirmed the manufacturer’s obligations and referred
specifically to the CBE regulation, which both reflects the
manufacturer’s ultimate responsibility for its label and
provides a mechanism for adding safety information to the
label prior to FDA approval. See id., at 925–926 (stating
that a manufacturer retains the responsibility “to main
tain its label in accordance with existing requirements,
including subpart B of part 201 and sections 314.70 and
601.12 of title 21, Code of Federal Regulations (or any
successor regulations)” (emphasis added)). Thus, when
 Cite as: 555 U. S. ____ (2009) 15

Opinion of the Court

the risk of gangrene from IV-push injection of Phenergan
became apparent, Wyeth had a duty to provide a warning
that adequately described that risk, and the CBE regula
tion permitted it to provide such a warning before receiv
ing the FDA’s approval.
Of course, the FDA retains authority to reject labeling
changes made pursuant to the CBE regulation in its re
view of the manufacturer’s supplemental application, just
as it retains such authority in reviewing all supplemental
applications. But absent clear evidence that the FDA
would not have approved a change to Phenergan’s label,
we will not conclude that it was impossible for Wyeth to
comply with both federal and state requirements.
Wyeth has offered no such evidence. It does not argue
that it attempted to give the kind of warning required by
the Vermont jury but was prohibited from doing so by the
FDA.5 See Tr. of Oral Arg. 12–13; see also Brief for United
States as Amicus Curiae 25. And while it does suggest
that the FDA intended to prohibit it from strengthening
the warning about IV-push administration because the
——————
5 The record would not, in any event, support such an argument. In
1988, Wyeth did propose different language for Phenergan’s warning
about intra-arterial injection, adapted from revisions the FDA proposed
in 1987. See App. 339–341, 311–312. When the FDA approved Wyeth’s
application, it instructed Wyeth to retain the wording in its current
label. During the trial court proceedings, Levine indicated that the
language proposed in 1988 would have more strongly warned against
IV-push administration. But the trial court and the Vermont Supreme
Court found that the 1988 warning did not differ in any material
respect from the FDA-approved warning. See ___ Vt. ___, ___, 944
A. 2d 179, 189 (2006) (“Simply stated, the proposed warning was
different, but not stronger. It was also no longer or more prominent
than the original warning . . .”); App. 248–250. Indeed, the United
States concedes that the FDA did not regard the proposed warning as
substantively different: “[I]t appears the FDA viewed the change as
non-substantive and rejected it for formatting reasons.” Brief for
United States as Amicus Curiae 25; see also ___ Vt., at ___, 944 A. 2d,
at 189.
16 WYETH v. LEVINE

Opinion of the Court

agency deemed such a warning inappropriate in reviewing
Phenergan’s drug applications, both the trial court and the
Vermont Supreme Court rejected this account as a matter
of fact. In its decision on Wyeth’s motion for judgment as
a matter of law, the trial court found “no evidence in this
record that either the FDA or the manufacturer gave more
than passing attention to the issue of” IV-push versus IV
drip administration. App. 249. The Vermont Supreme
Court likewise concluded that the FDA had not made an
affirmative decision to preserve the IV-push method or
intended to prohibit Wyeth from strengthening its warn
ing about IV-push administration. ___ Vt., at ___, 944
A. 2d, at 188–189. Moreover, Wyeth does not argue that it
supplied the FDA with an evaluation or analysis concern
ing the specific dangers posed by the IV-push method. We
accordingly cannot credit Wyeth’s contention that the FDA
would have prevented it from adding a stronger warning
about the IV-push method of intravenous administration.6
Impossibility pre-emption is a demanding defense. On
the record before us, Wyeth has failed to demonstrate that
it was impossible for it to comply with both federal and
state requirements. The CBE regulation permitted Wyeth
to unilaterally strengthen its warning, and the mere fact
that the FDA approved Phenergan’s label does not estab
lish that it would have prohibited such a change.

——————
6 The dissent’s suggestion that the FDA intended to prohibit Wyeth

from strengthening its warning does not fairly reflect the record. The
dissent creatively paraphrases a few FDA orders—for instance by
conflating warnings about IV-push administration and intra-arterial
injection, see, e.g., post, at 9, 11–12, 15–16—to suggest greater agency
attention to the question, and it undertakes a study of Phenergan’s
labeling that is more elaborate than any FDA order. But even the
dissent’s account does not support the conclusion that the FDA would
have prohibited Wyeth from adding a stronger warning pursuant to the
CBE regulation.
 Cite as: 555 U. S. ____ (2009) 17

Opinion of the Court

IV
Wyeth also argues that requiring it to comply with a
state-law duty to provide a stronger warning about IV
push administration would obstruct the purposes and
objectives of federal drug labeling regulation. Levine’s tort
claims, it maintains, are pre-empted because they inter
fere with “Congress’s purpose to entrust an expert agency
to make drug labeling decisions that strike a balance
between competing objectives.” Brief for Petitioner 46.
We find no merit in this argument, which relies on an
untenable interpretation of congressional intent and an
overbroad view of an agency’s power to pre-empt state law.
Wyeth contends that the FDCA establishes both a floor
and a ceiling for drug regulation: Once the FDA has ap
proved a drug’s label, a state-law verdict may not deem
the label inadequate, regardless of whether there is any
evidence that the FDA has considered the stronger warn
ing at issue. The most glaring problem with this argu
ment is that all evidence of Congress’ purposes is to the
contrary. Building on its 1906 Act, Congress enacted the
FDCA to bolster consumer protection against harmful
products. See Kordel v. United States, 335 U. S. 345, 349
(1948); United States v. Sullivan, 332 U. S. 689, 696
(1948). Congress did not provide a federal remedy for
consumers harmed by unsafe or ineffective drugs in the
1938 statute or in any subsequent amendment. Evidently,
it determined that widely available state rights of action
provided appropriate relief for injured consumers.7 It may
——————
7 Although the first version of the bill that became the FDCA would
have provided a federal cause of action for damages for injured consum
ers, see H. R. 6110, 73d Cong., 1st Sess., §25 (1933) (as introduced),
witnesses testified that such a right of action was unnecessary because
common-law claims were already available under state law. See
Hearings on S. 1944 before a Subcommittee of the Senate Committee
on Commerce, 73d Cong., 2d Sess., 400 (1933) (statement of W. A.
Hines); see id., at 403 (statement of J. A. Ladds) (“This act should not
18 WYETH v. LEVINE

Opinion of the Court

also have recognized that state-law remedies further
consumer protection by motivating manufacturers to
produce safe and effective drugs and to give adequate
warnings.
If Congress thought state-law suits posed an obstacle to
its objectives, it surely would have enacted an express pre
emption provision at some point during the FDCA’s 70
year history. But despite its 1976 enactment of an express
pre-emption provision for medical devices, see §521, 90
Stat. 574 (codified at 21 U. S. C. §360k(a)), Congress has
not enacted such a provision for prescription drugs. See
Riegel, 552 U. S., at ___ (slip op., at 14) (“Congress could
have applied the pre-emption clause to the entire FDCA.
It did not do so, but instead wrote a pre-emption clause
that applies only to medical devices”).8 Its silence on the
issue, coupled with its certain awareness of the prevalence
of state tort litigation, is powerful evidence that Congress
did not intend FDA oversight to be the exclusive means of
ensuring drug safety and effectiveness. As Justice
O’Connor explained in her opinion for a unanimous Court:
“The case for federal pre-emption is particularly weak
where Congress has indicated its awareness of the opera
tion of state law in a field of federal interest, and has
nonetheless decided to stand by both concepts and to
tolerate whatever tension there [is] between them.” Bo
nito Boats, Inc. v. Thunder Craft Boats, Inc., 489 U. S. 141,
166–167 (1989) (internal quotation marks omitted); see
also supra, at 8 (discussing the presumption against pre
——————
attempt to modify or restate the common law with respect to personal
injuries”).
8 In 1997, Congress pre-empted certain state requirements concerning

over-the-counter medications and cosmetics but expressly preserved
product liability actions. See 21 U. S. C. §§379r(e), 379s(d) (“Nothing in
this section shall be construed to modify or otherwise affect any action
or the liability of any person under the product liability law of any
State”).
 Cite as: 555 U. S. ____ (2009) 19

Opinion of the Court

emption).
Despite this evidence that Congress did not regard state
tort litigation as an obstacle to achieving its purposes,
Wyeth nonetheless maintains that, because the FDCA
requires the FDA to determine that a drug is safe and
effective under the conditions set forth in its labeling, the
agency must be presumed to have performed a precise
balancing of risks and benefits and to have established a
specific labeling standard that leaves no room for different
state-law judgments. In advancing this argument, Wyeth
relies not on any statement by Congress, but instead on
the preamble to a 2006 FDA regulation governing the
content and format of prescription drug labels. See Brief
for Petitioner 8, 11, 42, 45, and 50 (citing 71 Fed. Reg.
3922 (2006)). In that preamble, the FDA declared that the
FDCA establishes “both a ‘floor’ and a ‘ceiling,’ ” so that
“FDA approval of labeling . . . preempts conflicting or
contrary State law.” Id., at 3934–3935. It further stated
that certain state-law actions, such as those involving
failure-to-warn claims, “threaten FDA’s statutorily pre
scribed role as the expert Federal agency responsible for
evaluating and regulating drugs.” Id., at 3935.
This Court has recognized that an agency regulation
with the force of law can pre-empt conflicting state re
quirements. See, e.g., Geier v. American Honda Motor Co.,
529 U. S. 861 (2000); Hillsborough County v. Automated
Medical Laboratories, Inc., 471 U. S. 707, 713 (1985). In
such cases, the Court has performed its own conflict de
termination, relying on the substance of state and federal
law and not on agency proclamations of pre-emption. We
are faced with no such regulation in this case, but rather
with an agency’s mere assertion that state law is an obsta
cle to achieving its statutory objectives. Because Congress
has not authorized the FDA to pre-empt state law directly,
cf. 21 U. S. C. §360k (authorizing the FDA to determine
the scope of the Medical Devices Amendments’ pre-emption
20 WYETH v. LEVINE

Opinion of the Court

clause),9 the question is what weight we should accord the
FDA’s opinion.
In prior cases, we have given “some weight” to an
agency’s views about the impact of tort law on federal
objectives when “the subject matter is technica[l] and the
relevant history and background are complex and exten
sive.” Geier, 529 U. S., at 883. Even in such cases, how
ever, we have not deferred to an agency’s conclusion that
state law is pre-empted. Rather, we have attended to an
agency’s explanation of how state law affects the regula
tory scheme. While agencies have no special authority to
pronounce on pre-emption absent delegation by Congress,
they do have a unique understanding of the statutes they
administer and an attendant ability to make informed
determinations about how state requirements may pose an
“obstacle to the accomplishment and execution of the full
purposes and objectives of Congress.” Hines, 312 U.S, at
67; see Geier, 529 U. S., at 883; Lohr, 518 U. S., at 495–
496. The weight we accord the agency’s explanation of
state law’s impact on the federal scheme depends on its
thoroughness, consistency, and persuasiveness. Cf.
United States v. Mead Corp., 533 U. S. 218, 234–235
(2001); Skidmore v. Swift & Co., 323 U. S. 134, 140 (1944).
Under this standard, the FDA’s 2006 preamble does not
merit deference. When the FDA issued its notice of pro
——————
9 For similar examples, see 47 U. S. C. §§253(a), (d) (2000 ed.) (au

thorizing the Federal Communications Commission to pre-empt “any
[state] statute, regulation, or legal requirement” that “may prohibit or
have the effect of prohibiting the ability of any entity to provide any
interstate or intrastate telecommunications service”); 30 U. S. C.
§1254(g) (2006 ed.) (pre-empting any statute that conflicts with “the
purposes and the requirements of this chapter” and permitting the
Secretary of the Interior to “set forth any State law or regulation which
is preempted and superseded”); and 49 U. S. C. §5125(d) (2000 ed. and
Supp. V) (authorizing the Secretary of Transportation to decide
whether a state or local statute that conflicts with the regulation of
hazardous waste transportation is pre-empted).
 Cite as: 555 U. S. ____ (2009) 21

Opinion of the Court

posed rulemaking in December 2000, it explained that the
rule would “not contain policies that have federalism
implications or that preempt State law.” 65 Fed. Reg.
81103; see also 71 id., at 3969 (noting that the “proposed
rule did not propose to preempt state law”). In 2006, the
agency finalized the rule and, without offering States or
other interested parties notice or opportunity for com
ment, articulated a sweeping position on the FDCA’s pre
emptive effect in the regulatory preamble. The agency’s
views on state law are inherently suspect in light of this
procedural failure.
Further, the preamble is at odds with what evidence we
have of Congress’ purposes, and it reverses the FDA’s own
longstanding position without providing a reasoned expla
nation, including any discussion of how state law has
interfered with the FDA’s regulation of drug labeling
during decades of coexistence. The FDA’s 2006 position
plainly does not reflect the agency’s own view at all times
relevant to this litigation. Not once prior to Levine’s
injury did the FDA suggest that state tort law stood as an
obstacle to its statutory mission. To the contrary, it cast
federal labeling standards as a floor upon which States
could build and repeatedly disclaimed any attempt to pre
empt failure-to-warn claims. For instance, in 1998, the
FDA stated that it did “not believe that the evolution of
state tort law [would] cause the development of standards
that would be at odds with the agency’s regulations.” 63
id., at 66384. It further noted that, in establishing “mini
mal standards” for drug labels, it did not intend “to pre
clude the states from imposing additional labeling re
quirements.” Ibid.10
——————
10 See also 44 Fed. Reg. 37437 (1979) (“It is not the intent of the FDA

to influence the civil tort liability of the manufacturer”); 59 Fed. Reg.
3948 (1994) (“[P]roduct liability plays an important role in consumer
protection”); Porter, The Lohr Decision: FDA Perspective and Position,
52 Food & Drug L. J. 7, 10 (1997) (former chief counsel to the FDA
22 WYETH v. LEVINE

Opinion of the Court

In keeping with Congress’ decision not to pre-empt
common-law tort suits, it appears that the FDA tradition
ally regarded state law as a complementary form of drug
regulation. The FDA has limited resources to monitor the
11,000 drugs on the market,11 and manufacturers have
superior access to information about their drugs, espe
cially in the postmarketing phase as new risks emerge.
——————
stating that the FDA regarded state law as complementing the agency’s
mission of consumer protection).
11 In 1955, the same year that the agency approved Wyeth’s Phener

gan application, an FDA advisory committee issued a report finding
“conclusively” that “the budget and staff of the Food and Drug Admini
stration are inadequate to permit the discharge of its existing responsi
bilities for the protection of the American public.” Citizens Advisory
Committee on the FDA, Report to the Secretary of Health, Education,
and Welfare, H. R. Doc. No. 227, 84th Cong., 1st Sess., 53. Three recent
studies have reached similar conclusions. See FDA Science Board,
Report of the Subcommittee on Science and Technology: FDA Science
and Mission at Risk 2, 6 (2007), online at http://www.fda.gov/ohrms/
dockets/ac/07/briefing/2007-4329b_02_01_FDA%20Report%20on%20Sci
ence%20and%20Technology.pdf (all Internet materials as visited Feb.
23, 2009, and available in Clerk of Court’s case file) (“[T]he Agency
suffers from serious scientific deficiencies and is not positioned to meet
current or emerging regulatory responsibilities”); National Academies,
Institute of Medicine, The Future of Drug Safety: Promoting and
Protecting the Health of the Public 193–194 (2007) (“The [FDA] lacks
the resources needed to accomplish its large and complex mission . . . .
There is widespread agreement that resources for postmarketing drug
safety work are especially inadequate and that resource limitations
have hobbled the agency’s ability to improve and expand this essential
component of its mission”); GAO, Drug Safety: Improvement Needed in
FDA’s Postmarket Decision-making and Oversight Process 5 (GAO–06–
402, 2006), http://www.gao.gov/new.items/d06402.pdf (“FDA lacks a
clear and effective process for making decisions about, and providing
management oversight of, postmarket safety issues”); see also House
Committee on Oversight and Government Reform, Majority Staff
Report, FDA Career Staff Objected to Agency Preemption Policies 4
(2008) (“[T]he Office of Chief Counsel ignored the warnings from FDA
scientists and career officials that the preemption language [of the 2006
preamble] was based on erroneous assertions about the ability of the
drug approval process to ensure accurate and up-to-date drug labels”).
 Cite as: 555 U. S. ____ (2009) 23

Opinion of the Court

State tort suits uncover unknown drug hazards and pro
vide incentives for drug manufacturers to disclose safety
risks promptly. They also serve a distinct compensatory
function that may motivate injured persons to come for
ward with information. Failure-to-warn actions, in par
ticular, lend force to the FDCA’s premise that manufac
turers, not the FDA, bear primary responsibility for their
drug labeling at all times. Thus, the FDA long maintained
that state law offers an additional, and important, layer of
consumer protection that complements FDA regulation.12
The agency’s 2006 preamble represents a dramatic change
in position.
Largely based on the FDA’s new position, Wyeth argues
that this case presents a conflict between state and federal
law analogous to the one at issue in Geier. There, we held
that state tort claims premised on Honda’s failure to
install airbags conflicted with a federal regulation that did
not require airbags for all cars. The Department of
Transportation (DOT) had promulgated a rule that pro
vided car manufacturers with a range of choices among
passive restraint devices. Geier, 529 U. S., at 875. Reject
ing an “ ‘all airbag’ ” standard, the agency had called for a
gradual phase-in of a mix of passive restraints in order to
spur technological development and win consumer accep
tance. Id., at 879. Because the plaintiff’s claim was that
car manufacturers had a duty to install airbags, it pre
sented an obstacle to achieving “the variety and mix of
devices that the federal regulation sought.” Id., at 881.
——————
12 See generally Brief for Former FDA Commissioners Drs. Donald
Kennedy and David Kessler as Amici Curiae; see also Kessler &
Vladeck, A Critical Examination of the FDA’s Efforts To Preempt
Failure-To-Warn Claims, 96 Geo. L. J. 461, 463 (2008); Bates v. Dow
Agrosciences LLC, 544 U. S. 431, 451 (2005) (noting that state tort suits
“can serve as a catalyst” by aiding in the exposure of new dangers and
prompting a manufacturer or the federal agency to decide that a
revised label is required).
24 WYETH v. LEVINE

Opinion of the Court

Wyeth and the dissent contend that the regulatory
scheme in this case is nearly identical, but, as we have
described, it is quite different. In Geier, the DOT con
ducted a formal rulemaking and then adopted a plan to
phase in a mix of passive restraint devices. Examining
the rule itself and the DOT’s contemporaneous record,
which revealed the factors the agency had weighed and
the balance it had struck, we determined that state tort
suits presented an obstacle to the federal scheme. After
conducting our own pre-emption analysis, we considered
the agency’s explanation of how state law interfered with
its regulation, regarding it as further support for our
independent conclusion that the plaintiff’s tort claim
obstructed the federal regime.
By contrast, we have no occasion in this case to consider
the pre-emptive effect of a specific agency regulation
bearing the force of law. And the FDA’s newfound opin
ion, expressed in its 2006 preamble, that state law “frus
trate[s] the agency’s implementation of its statutory man
date,” 71 Fed. Reg. 3934, does not merit deference for the
reasons we have explained.13 Indeed, the “complex and
extensive” regulatory history and background relevant to
this case, Geier, 529 U. S., at 883, undercut the FDA’s
recent pronouncements of pre-emption, as they reveal the
longstanding coexistence of state and federal law and the
FDA’s traditional recognition of state-law remedies—a
recognition in place each time the agency reviewed
Wyeth’s Phenergan label.14
——————
13 The United States’ amicus brief is similarly undeserving of defer
ence. Unlike the Government’s brief in Geier v. American Honda Motor
Co., 529 U. S. 861 (2000), which explained the effects of state law on the
DOT’s regulation in a manner consistent with the agency’s prior
accounts, see id., at 861, the Government’s explanation of federal drug
regulation departs markedly from the FDA’s understanding at all times
relevant to this case.
14 Wyeth’s more specific contention—that this case resembles Geier
 Cite as: 555 U. S. ____ (2009) 25

Opinion of the Court

In short, Wyeth has not persuaded us that failure-to
warn claims like Levine’s obstruct the federal regulation
of drug labeling. Congress has repeatedly declined to pre
empt state law, and the FDA’s recently adopted position
that state tort suits interfere with its statutory mandate is
entitled to no weight. Although we recognize that some
state-law claims might well frustrate the achievement of
congressional objectives, this is not such a case.
V
We conclude that it is not impossible for Wyeth to com
ply with its state and federal law obligations and that
Levine’s common-law claims do not stand as an obstacle to
the accomplishment of Congress’ purposes in the FDCA.
Accordingly, the judgment of the Vermont Supreme Court
is affirmed.
It is so ordered.

——————
because the FDA determined that no additional warning on IV-push
administration was needed, thereby setting a ceiling on Phenergan’s
label—is belied by the record. As we have discussed, the FDA did not
consider and reject a stronger warning against IV-push injection of
Phenergan. See also App. 249–250 (“[A] tort case is unlikely to obstruct
the regulatory process when the record shows that the FDA has paid
very little attention to the issues raised by the parties at trial”).
 Cite as: 555 U. S. ____ (2009) 1

BREYER, J., concurring

SUPREME COURT OF THE UNITED STATES
_________________

No. 06–1249
_________________

WYETH, PETITIONER v. DIANA LEVINE
ON WRIT OF CERTIORARI TO THE SUPREME COURT OF

VERMONT

[March 4, 2009]

JUSTICE BREYER, concurring.
I write separately to emphasize the Court’s statement
that “we have no occasion in this case to consider the pre
emptive effect of a specific agency regulation bearing the
force of law.” Ante, at 24. State tort law will sometimes
help the Food and Drug Administration (FDA) “uncover
unknown drug hazards and [encourage] drug manufactur
ers to disclose safety risks.” Ante, at 23. But it is also
possible that state tort law will sometimes interfere with
the FDA’s desire to create a drug label containing a spe
cific set of cautions and instructions. I also note that some
have argued that state tort law can sometimes raise prices
to the point where those who are sick are unable to obtain
the drugs they need. See Lasagna, The Chilling Effect of
Product Liability on New Drug Development, in The Li
ability Maze 334, 335–336 (P. Huber & R. Litan eds.
1991). The FDA may seek to determine whether and
when state tort law acts as a help or a hindrance to
achieving the safe drug-related medical care that Congress
sought. Medtronic, Inc. v. Lohr, 518 U. S. 470, 506 (1996)
(BREYER, J., concurring in part and concurring in judg
ment); cf. Bates v. Dow Agrosciences LLC, 544 U. S. 431,
454–455 (2005) (BREYER, J., concurring). It may seek to
embody those determinations in lawful specific regulations
describing, for example, when labeling requirements serve
as a ceiling as well as a floor. And it is possible that such
2 WYETH v. LEVINE

BREYER, J., concurring

determinations would have pre-emptive effect. See Lohr,
supra, at 505 (opinion of BREYER, J.) (citing Hillsborough
County v. Automated Medical Laboratories, Inc., 471 U. S.
707 (1985)). I agree with the Court, however, that such a
regulation is not at issue in this case.
 Cite as: 555 U. S. ____ (2009) 1

THOMAS, J., concurring in judgment

SUPREME COURT OF THE UNITED STATES
_________________

No. 06–1249
_________________

WYETH, PETITIONER v. DIANA LEVINE
ON WRIT OF CERTIORARI TO THE SUPREME COURT OF

VERMONT

[March 4, 2009]

JUSTICE THOMAS, concurring in the judgment.
I agree with the Court that the fact that the Food and
Drug Administration (FDA) approved the label for peti
tioner Wyeth’s drug Phenergan does not pre-empt the
state-law judgment before the Court. That judgment was
based on a jury finding that the label did not adequately
warn of the risk involved in administering Phenergan
through the IV-push injection method. Under federal law,
without prior approval from the FDA, Wyeth could have
“add[ed] or strengthen[ed]” information on its label about
“a contraindication, warning, precaution, or adverse reac
tion,” 21 CFR §314.70(c)(6)(iii)(A) (2008), or “about dosage
and administration that is intended to increase the safe
use of the drug product,” §314.70(c)(6)(iii)(C), in order to
“reflect newly acquired information,” including “new
analyses of previously submitted data,” about the dangers
of IV-push administration of Phenergan, 73 Fed. Reg.
49603, 49609 (2008). It thus was possible for Wyeth to
label and market Phenergan in compliance with federal
law while also providing additional warning information
on its label beyond that previously approved by the FDA.
In addition, federal law does not give drug manufacturers
an unconditional right to market their federally approved
drug at all times with the precise label initially approved
by the FDA. The Vermont court’s judgment in this case,
therefore, did not directly conflict with federal law and is
2 WYETH v. LEVINE

THOMAS, J., concurring in judgment

not pre-empted.
I write separately, however, because I cannot join the
majority’s implicit endorsement of far-reaching implied
pre-emption doctrines. In particular, I have become in
creasingly skeptical of this Court’s “purposes and objec
tives” pre-emption jurisprudence. Under this approach,
the Court routinely invalidates state laws based on per
ceived conflicts with broad federal policy objectives, legis
lative history, or generalized notions of congressional
purposes that are not embodied within the text of federal
law. Because implied pre-emption doctrines that wander
far from the statutory text are inconsistent with the Con
stitution, I concur only in the judgment.
I

A

In order “to ensure the protection of our fundamental
liberties,” Atascadero State Hospital v. Scanlon, 473 U. S.
234, 242 (1985) (internal quotation marks omitted), the
“Constitution establishes a system of dual sovereignty
between the States and the Federal Government.” Greg
ory v. Ashcroft, 501 U. S. 452, 457 (1991). The Framers
adopted this “ ‘constitutionally mandated balance of pow
er,’ ” Atascadero State Hospital, supra, at 242, to “reduce
the risk of tyranny and abuse from either front,” because a
“federalist structure of joint sovereigns preserves to the
people numerous advantages,” such as “a decentralized
government that will be more sensitive to the diverse
needs of a heterogeneous society” and “increase[d] oppor
tunity for citizen involvement in democratic processes,”
Gregory, supra, at 458. Furthermore, as the Framers
observed, the “compound republic of America” provides “a
double security . . . to the rights of the people” because
“the power surrendered by the people is first divided
between two distinct governments, and then the portion
allotted to each subdivided among distinct and separate
 Cite as: 555 U. S. ____ (2009) 3

THOMAS, J., concurring in judgment

departments.” The Federalist No. 51, p. 266 (M. Beloff ed.,
2d ed. 1987).
Under this federalist system, “the States possess sover
eignty concurrent with that of the Federal Government,
subject only to limitations imposed by the Supremacy
Clause.” Tafflin v. Levitt, 493 U. S. 455, 458 (1990). In
this way, the Supremacy Clause gives the Federal Gov
ernment “a decided advantage in [a] delicate balance”
between federal and state sovereigns. Gregory, 501 U. S.,
at 460. “As long as it is acting within the powers granted
it under the Constitution, Congress may impose its will on
the States.” Ibid. That is an “extraordinary power in a
federalist system.” Ibid.
Nonetheless, the States retain substantial sovereign
authority. U. S. Const., Amdt. 10 (“The powers not dele
gated to the United States by the Constitution, nor prohib
ited by it to the States, are reserved to the States respec
tively, or to the people”); see also Alden v. Maine, 527 U. S.
706, 713 (1999); Printz v. United States, 521 U. S. 898,
918–922 (1997); New York v. United States, 505 U. S. 144,
155–156 (1992); Gregory, supra, at 457–459; Tafflin, su
pra, at 458. In accordance with the text and structure of
the Constitution, “[t]he powers delegated by the proposed
constitution to the federal government, are few and de
fined” and “[t]hose which are to remain in the state gov
ernments, are numerous and indefinite.” The Federalist
No. 45, at 237–238. Indeed, in protecting our constitu
tional government, “the preservation of the States, and the
maintenance of their governments, are as much within the
design and care of the Constitution as the preservation of
the Union and the maintenance of the National govern
ment.” Texas v. White, 7 Wall. 700, 725 (1869), quoted in
New York v. United States, supra, at 162.
As a result, in order to protect the delicate balance of
power mandated by the Constitution, the Supremacy
Clause must operate only in accordance with its terms.
4 WYETH v. LEVINE

THOMAS, J., concurring in judgment

The clause provides:
“This Constitution, and the Laws of the United States
which shall be made in Pursuance thereof; and all
Treaties made, or which shall be made, under the Au
thority of the United States, shall be the supreme Law
of the Land; and the Judges in every State shall be
bound thereby, any Thing in the Constitution or Laws
of any state to the Contrary notwithstanding.” Art.
VI, cl. 2.
With respect to federal laws, then, the Supremacy Clause
gives “supreme” status only to those that are “made in
Pursuance” of “[t]his Constitution.” Ibid.; see 3 J. Story,
Commentaries on the Constitution of the United States
§1831, p. 694 (1833) (hereinafter Story) (“It will be ob
served, that the supremacy of the laws is attached to those
only, which are made in pursuance of the constitution”).
Federal laws “made in Pursuance” of the Constitution
must comply with two key structural limitations in the
Constitution that ensure that the Federal Government
does not amass too much power at the expense of the
States. The first structural limitation, which the parties
have not raised in this case, is “the Constitution’s confer
ral upon Congress of not all governmental powers, but
only discrete, enumerated ones.” Printz, supra, at 919; see
also United States v. Morrison, 529 U. S. 598, 618, n. 8
(2000); New York v. United States, supra, at 155–157;
McCulloch v. Maryland, 4 Wheat. 316, 405 (1819) (“This
government is acknowledged by all to be one of enumer
ated powers”).1
——————
1 This structural limitation may be implicated in a pre-emption case if

the federal law at issue is beyond the scope of Congress’ enumerated
powers. Expansion of congressional power through an “increasingly
generous . . . interpretation of the commerce power of Congress,” for
example, creates “a real risk that Congress will gradually erase the
diffusion of power between State and Nation on which the Framers
 Cite as: 555 U. S. ____ (2009) 5

THOMAS, J., concurring in judgment

The second structural limitation is the complex set of
procedures that Congress and the President must follow to
enact “Laws of the United States.” See INS v. Chadha,
462 U. S. 919, 945–946 (1983) (setting forth the Constitu
tion’s Bicameral and Presentment Clauses, Art. I, §7, cls.
2–3, which “prescribe and define the respective functions
of the Congress and of the Executive in the legislative
process”). “[T]he Framers were acutely conscious that the
bicameral requirement and the Presentment Clauses
would serve essential constitutional functions,” Chadha,
462 U. S., at 951, by allowing the passage of legislation
only after it has proceeded through “a step-by-step, delib
erate and deliberative process,” id., at 959, that was
“finely wrought and exhaustively considered” by the
Framers, id., at 951. The Supremacy Clause thus requires
that pre-emptive effect be given only those to federal
standards and policies that are set forth in, or necessarily
follow from, the statutory text that was produced through
the constitutionally required bicameral and presentment
procedures. See 3 J. Story §1831, at 694 (Actions of the
Federal Government “which are not pursuant to its consti
tutional powers, but which are invasions of the residuary
authorities of the smaller societies,” are not “the supreme
law of the land. They will be merely acts of usurpation,
and will deserve to be treated as such”).
B
In light of these constitutional principles, I have become
“increasing[ly] reluctan[t] to expand federal statutes
beyond their terms through doctrines of implied pre
——————

based their faith in the efficiency and vitality of our Republic.” Garcia

v. San Antonio Metropolitan Transit Authority, 469 U. S. 528, 583–584
(1985) (O’Connor, J., dissenting); see also Marbury v. Madison, 1
Cranch 137, 176 (1803) (“The powers of the legislature are defined, and
limited; and that those limits may not be mistaken, or forgotten, the
constitution is written”).
6 WYETH v. LEVINE

THOMAS, J., concurring in judgment

emption.” Bates v. Dow Agrosciences LLC, 544 U. S. 431,
459 (2005) (THOMAS, J., concurring in judgment in part
and dissenting in part). My review of this Court’s broad
implied pre-emption precedents, particularly its “purposes
and objectives” pre-emption jurisprudence, has increased
my concerns that implied pre-emption doctrines have not
always been constitutionally applied. Under the vague
and “potentially boundless” doctrine of “purposes and
objectives” pre-emption, Geier v. American Honda Motor
Co., 529 U. S. 861, 907 (2000) (STEVENS, J., dissenting),
for example, the Court has pre-empted state law based on
its interpretation of broad federal policy objectives, legisla
tive history, or generalized notions of congressional pur
poses that are not contained within the text of federal law.
See, e.g., Pharmaceutical Research and Mfrs. of America v.
Walsh, 538 U. S. 644, 678 (2003) (THOMAS, J., concurring
in judgment) (referring to the “concomitant danger of
invoking obstacle pre-emption based on the arbitrary
selection of one purpose to the exclusion of others”);
Crosby v. National Foreign Trade Council, 530 U. S. 363,
388–391 (2000) (SCALIA, J., concurring in judgment) (criti
cizing the majority’s reliance on legislative history to
discern statutory intent when that intent was “perfectly
obvious on the face of th[e] statute”); Geier, supra, at 874–
883 (relying on regulatory history, agency comments, and
the Government’s litigating position to determine that
federal law pre-empted state law).
Congressional and agency musings, however, do not
satisfy the Art. I, §7 requirements for enactment of federal
law and, therefore, do not pre-empt state law under the
Supremacy Clause. When analyzing the pre-emptive
effect of federal statutes or regulations validly promul
gated thereunder, “[e]vidence of pre-emptive purpose
[must be] sought in the text and structure of the [provi
sion] at issue” to comply with the Constitution. CSX
Transp., Inc. v. Easterwood, 507 U. S. 658, 664 (1993); see
 Cite as: 555 U. S. ____ (2009) 7

THOMAS, J., concurring in judgment

also New York v. FERC, 535 U. S. 1, 18 (2002) (“[A] federal
agency may pre-empt state law only when and if it is
acting within the scope of its congressional delegated
authority . . . [for] an agency literally has no power to act,
let alone pre-empt the validly enacted legislation of a
sovereign State, unless and until Congress confers power
upon it” (internal quotation marks omitted; second altera
tion in original)); Camps Newfound/Owatonna, Inc. v.
Town of Harrison, 520 U. S. 564, 617 (1997) (THOMAS, J.,
dissenting) (noting that “treating unenacted congressional
intent as if it were law would be constitutionally dubi
ous”). Pre-emption analysis should not be “a freewheeling
judicial inquiry into whether a state statute is in tension
with federal objectives, but an inquiry into whether the
ordinary meanings of state and federal law conflict.”
Bates, supra, at 459 (THOMAS, J., concurring in judgment
in part and dissenting in part) (internal quotation marks
and citation omitted); see also Geier, supra, at 911
(STEVENS., J., dissenting) (“[P]re-emption analysis is, or at
least should be, a matter of precise statutory [or regula
tory] construction rather than an exercise in free-form
judicial policymaking” (internal quotation marks omit
ted)). Pre-emption must turn on whether state law con
flicts with the text of the relevant federal statute or with
the federal regulations authorized by that text. See Foster
v. Love, 522 U. S. 67, 71 (1997) (finding that conflict pre
emption question “turn[ed] entirely on the meaning of the
state and federal statutes” at issue before the Court); see
also New York v. FERC, supra, at 19.
II
This Court has determined that there are two categories
of conflict pre-emption, both of which Wyeth contends are
at issue in this case. First, the Court has found pre
emption “where compliance with both federal and state
regulations is a physical impossibility for one engaged in
8 WYETH v. LEVINE

THOMAS, J., concurring in judgment

interstate commerce.” Florida Lime & Avocado Growers,
Inc. v. Paul, 373 U. S. 132, 142–143 (1963). Second, the
Court has determined that federal law pre-empts state
law when, “under the circumstances of [a] particular case,
[state] law stands as an obstacle to the accomplishment
and execution of the full purposes and objectives of Con
gress.” Hines v. Davidowitz, 312 U. S. 52, 67 (1941).2
A
Wyeth first contends that “it would have been impossi
ble for it to comply with the state-law duty to modify
Phenergan’s labeling without violating federal law.” Ante,
at 6 (opinion for the Court by STEVENS, J.). But, as the
majority explains, the text of the relevant federal statu
tory provisions and the corresponding regulations do not
directly conflict with the state-law judgment before us.
This Court has used different formulations of the stan
dard to be used in deciding whether state and federal law
conflict, and thus lead to pre-emption, under the “impossi
bility” doctrine. See, e.g., Geier, supra, at 873 (“a case in
which state law penalizes what federal law requires”);
American Telephone & Telegraph Co. v. Central Office
Telephone, Inc., 524 U. S. 214, 227 (1998) (AT&T) (when
state-law claims “directly conflict” with federal law), cited
in Geier, supra, at 874 (describing AT&T as a “cas[e]
involving impossibility”); Florida Lime & Avocado Grow
ers, supra, at 142–143 (“where compliance with both fed
——————
2 The majority’s pre-emption analysis relies in part on a presumption

against pre-emption. Ante, at 8, and n. 3 (opinion of STEVENS, J.).
Because it is evident from the text of the relevant federal statutes and
regulations themselves that the state-law judgment below is not pre
empted, it is not necessary to decide whether, or to what extent, the
presumption should apply in a case such as this one, where Congress
has not enacted an express-pre-emption clause. Cf. Altria Group, Inc.
v. Good, 555 U. S. ___, ___ (2008) (THOMAS, J., dissenting) (rejecting the
use of a presumption against pre-emption in express pre-emption
cases).
 Cite as: 555 U. S. ____ (2009) 9

THOMAS, J., concurring in judgment

eral and state regulations is a physical impossibility”). The
Court has generally articulated a very narrow “impossibil
ity standard,” see Crosby, 530 U. S., at 372–373 (citing
Florida Lime & Avocado Growers, supra, at 142–143); see
also Sprietsma v. Mercury Marine, 537 U. S. 51, 64–65
(2002); United States v. Locke, 529 U. S. 89, 109 (2000)—in
part because the overly broad sweep of the Court’s “pur
poses and objectives” approach, see infra, at 13–23, has
rendered it unnecessary for the Court to rely on “impossi
bility” pre-emption.
The Court, in fact, has not explained why a narrow
“physical impossibility” standard is the best proxy for
determining when state and federal laws “directly conflict”
for purposes of the Supremacy Clause. There could be
instances where it is not “physically impossible” to comply
with both state and federal law, even when the state and
federal laws give directly conflicting commands. See
Nelson, Preemption, 86 Va. L. Rev. 225, 260–261 (2000).
For example, if federal law gives an individual the right to
engage in certain behavior that state law prohibits, the
laws would give contradictory commands notwithstanding
the fact that an individual could comply with both by
electing to refrain from the covered behavior. Ibid. There
fore, “physical impossibility” may not be the most appro
priate standard for determining whether the text of state
and federal laws directly conflict. See ibid. (concluding
that the Supremacy Clause does not limit direct conflicts
to cases with “physically impossible” conflicts and arguing
that evidence from the Founding supports a standard of
“logical-contradiction”); see also AT&T, supra, at 227
(requiring that the state-law claims “directly conflict” with
federal law); 3 Story §1836, at 701 (suggesting instead
that a state law is pre-empted by the Supremacy Clause
when it is “repugnant to the constitution of the United
States” (emphasis added)).
Nonetheless, whatever the precise constitutional con
10 WYETH v. LEVINE

THOMAS, J., concurring in judgment

tours of implied pre-emption may be, I am satisfied that it
does not operate against respondent’s judgment below.
The text of the federal laws at issue do not require that
the state-court judgment at issue be pre-empted, under
either the narrow “physical impossibility” standard, Flor
ida Lime & Avocado Growers, supra, at 142–143, or a
more general “direc[t] conflict” standard, AT&T, supra, at
227.
Under the FDA’s “changes being effected” regulation, 21
CFR §314.70(c)(6)(iii), which was promulgated pursuant to
the FDA’s statutory authority, it is physically possible for
Wyeth to market Phenergan in compliance with federal
and Vermont law. As the majority explains, Wyeth could
have changed the warning on its label regarding IV-push
without violating federal law. See ante, at 11–13. The
“changes being effected” regulation allows drug manufac
turers to change their labels without the FDA’s preapproval
if the changes “add or strengthen a contraindication, warn
ing, precaution, or adverse reaction,” §314.70(c)(6)(iii)(A), or
“add or strengthen an instruction about dosage and ad
ministration that is intended to increase the safe use of the
drug product,” §314.70(c)(6)(iii)(C), in order to “reflect
newly acquired information,” including “new analyses of
previously submitted data,” 73 Fed. Reg. 49603, 49609.
Under the terms of these regulations, after learning of
new incidences of gangrene-induced amputation resulting
from the IV-push administration of Phenergan, see ante,
at 12–13, federal law gave Wyeth the authority to change
Phenergan’s label to “strengthen a . . . warning,”
“strengthen a . . . precaution,” §314.70(c)(6)(iii)(A), or to
“strengthen an instruction about . . . administration [of
the IV-push method] . . . to increase the safe use of the
drug product,” §314.70(c)(6)(iii)(C). Thus, it was physi
cally possible for Wyeth to comply with a state-law re
quirement to provide stronger warnings on Phenergan
about the risks of the IV-push administration method
 Cite as: 555 U. S. ____ (2009) 11

THOMAS, J., concurring in judgment

while continuing to market Phenergan in compliance with
federal law.
In addition, the text of the statutory provisions govern
ing FDA drug labeling, and the regulations promulgated
thereunder, do not give drug manufacturers an uncondi
tional right to market their federally approved drug at all
times with the precise label initially approved by the FDA.
Thus, there is no “direct conflict” between the federal
labeling law and the state-court judgment. The statute
prohibits the interstate marketing of any drug, except for
those that are federally approved. See 21 U. S. C. §355(a)
(“No person shall introduce or deliver for introduction into
interstate commerce any new drug, unless an approval of
an application filed pursuant to subsection (b) or (j) of this
section is effective with respect to such drug” (emphasis
added)). To say, as the statute does, that Wyeth may not
market a drug without federal approval (i.e., without an
FDA-approved label) is not to say that federal approval
gives Wyeth the unfettered right, for all time, to market
its drug with the specific label that was federally ap
proved. Initial approval of a label amounts to a finding by
the FDA that the label is safe for purposes of gaining
federal approval to market the drug. It does not represent
a finding that the drug, as labeled, can never be deemed
unsafe by later federal action, or as in this case, the appli
cation of state law.
Instead, FDA regulations require a drug manufac
turer—after initial federal approval of a drug’s label—to
revise the federally approved label “to include a warning
as soon as there is reasonable evidence of an association of
a serious hazard with a drug.” 21 CFR §201.80(e). Drug
manufacturers are also required to “establish and main
tain records and make reports” to the FDA about “[a]ny
adverse event associated with the use of a drug in hu
mans, whether or not considered drug related,” after it has
received federal approval. §§314.80(a), (c), (j). In addition,
12 WYETH v. LEVINE

THOMAS, J., concurring in judgment

the manufacturer must make periodic reports about “ad
verse drug experience[s]” associated with its drug and
include “a history of actions taken since the last report
because of adverse drug experiences (for example, labeling
changes or studies initiated).” §§314.80(c)(2)(i)–(ii). When
such records and reports are not made, the FDA can with
draw its approval of the drug. §314.80(j); see also 21
U. S. C. §355(e) (“The Secretary may . . . withdraw the
approval of an application . . . if the Secretary finds . . . that
the applicant has failed to establish a system for maintain
ing required records, or has repeatedly or deliberately failed
to maintain such records or to make required reports”).
The FDA may also determine that a drug is no longer safe
for use based on “clinical or other experience, tests, or
other scientific data.” Ibid. (approval may be withdrawn if
“the Secretary finds . . . that clinical or other experience,
tests, or other scientific data show that such drug is un
safe for use under the conditions of use upon the basis of
which the application was approved”).
The text of the statutory provisions and the accompany
ing regulatory scheme governing the FDA drug approval
process, therefore, establish that the FDA’s initial ap
proval of a drug is not a guarantee that the drug’s label
will never need to be changed. And nothing in the text of
the statutory or regulatory scheme necessarily insulates
Wyeth from liability under state law simply because the
FDA has approved a particular label.
In sum, the relevant federal law did not give Wyeth a
right that the state-law judgment took away, and it was
possible for Wyeth to comply with both federal law and the
Vermont-law judgment at issue here. The federal statute
and regulations neither prohibited the stronger warning
label required by the state judgment, nor insulated Wyeth
from the risk of state-law liability. With no “direct con
flict” between the federal and state law, then, the state
law judgment is not pre-empted. Cf. AT&T, 524 U. S., at
 Cite as: 555 U. S. ____ (2009) 13

THOMAS, J., concurring in judgment

221–226 (finding pre-emption where federal law forbade
common carriers from extending communications privi
leges requested by state-law claims); Foster, 522 U. S., at
68–69 (finding pre-emption where the federal statute
required congressional elections on a particular date
different from that provided by state statute).
B
Wyeth also contends that state and federal law conflict
because “recognition of [this] state tort action creates an
unacceptable ‘obstacle to the accomplishment and execu
tion of the full purposes and objectives of Congress,’ Hines
v. Davidowitz, 312 U. S. 52, 67 (1941), because it substi
tutes a lay jury’s decision about drug labeling for the
expert judgment of the FDA.” Ante, at 6–7. This Court’s
entire body of “purposes and objectives” pre-emption juris
prudence is inherently flawed. The cases improperly rely
on legislative history, broad atextual notions of congres
sional purpose, and even congressional inaction in order to
pre-empt state law. See supra, at 5–7. I, therefore, cannot
join the majority’s analysis of this claim, see ante, at 17–
25, or its reaffirmation of the Court’s “purposes and objec
tives” jurisprudence, ante, at 17–18 (analyzing congres
sional purposes); ante, at 20 (quoting the “ ‘purposes and
objectives’ ” pre-emption standard from Hines v.
Davidowitz, 312 U. S. 52, 67 (1941), and Geier, 529 U. S.,
at 883); ante, at 23–24, and nn. 13–14 (analyzing this case
in light of Geier, 529 U. S. 861).
1
The Court first formulated its current “purposes and
objectives” pre-emption standard in Hines when it consid
ered whether the federal Alien Registration Act pre
empted an Alien Registration Act adopted by the Com
monwealth of Pennsylvania. The Court did not find that
the two statutes, by their terms, directly conflicted. See
14 WYETH v. LEVINE

THOMAS, J., concurring in judgment

Hines, supra, at 59–60, and n. 1 (citing Pa. Stat. Ann., Tit.
35, §§1801–1806 (Purdon Supp. 1940)); 312 U. S., at 60,
and n. 5 (citing Act of June 28, 1940, 54 Stat. 670); 312
U. S., at 69–74 (analyzing numerous extratextual sources
and finding pre-emption without concluding that the
terms of the federal and state laws directly conflict); see
also id., at 78 (noting that “[i]t is conceded that the federal
act in operation does not at any point conflict with the
state statute” (Stone, J., dissenting)).3 Nonetheless, the
Court determined that it was not confined to considering
merely the terms of the relevant federal law in conducting
its pre-emption analysis. Rather, it went on to ask
whether the state law “stands as an obstacle to the accom
plishment and execution of the full purposes and objec
tives of Congress.” Id., at 67.
In so doing, the Court looked far beyond the relevant
federal statutory text and instead embarked on its own
——————
3 According to the Court, the Pennsylvania Act required:
“every alien 18 years or over, with certain exceptions, to register once
each year; provide such information as is required by the statute, plus
any ‘other information and details’ that the Department of Labor and
Industry may direct; pay $1 as an annual registration fee; receive an
alien identification card and carry it at all times; show the card when
ever it may be demanded by any police officer or any agent of the
Department of Labor and Industry; and exhibit the card as a condition
precedent to registering a motor vehicle in his name or obtaining a
license to operate one. . . . Nonexempt aliens who fail to register are
subject to a fine . . . or imprisonment . . . . For failure to carry an
identification card or for failure to show it upon proper demand, the
punishment is a fine . . . or imprisonment . . . .” Hines, 312 U. S., at 59–
60 (footnote omitted).
The Court explained that the federal Alien Registration Act required:
“a single registration of aliens 14 years of age and over; detailed
information specified by the Act, plus ‘such additional matters as may
be prescribed by the Commissioner, with the approval of the Attorney
General’; finger-printing of all registrants; and secrecy of the federal
files . . . . No requirement that aliens carry a registration card to be
exhibited to police or others is embodied in the law, and only the wilful
failure to register is made a criminal offense . . . .” Id., at 60–61.
 Cite as: 555 U. S. ____ (2009) 15

THOMAS, J., concurring in judgment

freeranging speculation about what the purposes of the
federal law must have been. See id., at 69–74. In addition
to the meaning of the relevant federal text, the Court
attempted to discern “[t]he nature of the power exerted by
Congress, the object sought to be attained, and the charac
ter of the obligations imposed by the law.” Id., at 70. To
do so, the Court looked in part to public sentiment, noting
that “[o]pposition to laws . . . singling out aliens as par
ticularly dangerous and undesirable groups, is deep-seated
in this country.” Ibid. The Court also relied on state
ments by particular Members of Congress and on congres
sional inaction, finding it pertinent that numerous bills
with requirements similar to Pennsylvania’s law had
failed to garner enough votes in Congress to become law.
Id., at 71–73, and nn. 32–34. Concluding that these
sources revealed a federal purpose to “protect the personal
liberties of law-abiding aliens through one uniform na
tional registration system,” the Court held that the Penn
sylvania law was pre-empted. Id., at 74.
Justice Stone, in dissent, questioned the majority’s
decision to read an exclusive registration system for aliens
into a statute that did not specifically provide such exclu
sivity. See id., at 75. He noted his concern that state
power would be improperly diminished through a pre
emption doctrine driven by the Court’s “own conceptions of
a policy which Congress ha[d] not expressed and which is
not plainly to be inferred from the legislation which it
ha[d] enacted.” Ibid. In his view, nothing that Congress
enacted had “denie[d] the states the practicable means of
identifying their alien residents and of recording their
whereabouts.” Id., at 78. Yet, the Hines majority em
ployed pre-emption to override numerous state alien
registration laws even though enacted federal law “at no
point conflict[ed] with the state legislation and [was]
16 WYETH v. LEVINE

THOMAS, J., concurring in judgment

harmonious with it.” Id., at 79.4
2
The consequences of this Court’s broad approach to
“purposes and objectives” pre-emption are exemplified in
this Court’s decision in Geier, which both the majority and
the dissent incorporate into their analysis today. See ante,
at 23–24, and nn. 13–14; post, at 6–9 (opinion of ALITO, J.).
In Geier, pursuant to the National Traffic and Motor
Vehicle Safety Act of 1966 (Safety Act), 80 Stat. 718, 15
U. S. C. §1381 et seq. (1988 ed.), the Department of Trans
portation (DOT) had promulgated a Federal Motor Vehicle
Safety Standard that “required auto manufacturers to
equip some but not all of their 1987 vehicles with passive
restraints.” 529 U. S., at 864–865. The case required this
Court to decide whether the Safety Act pre-empted a state
common-law tort action in which the plaintiff claimed that
an auto manufacturer, though in compliance with the
federal standard, should nonetheless have equipped a
1987 automobile with airbags. Id., at 865. The Court first
concluded that the Safety Act’s express pre-emption provi
sion and its saving clause, read together, did not expressly
pre-empt state common-law claims. See id., at 867–868.5
——————
4 According to Justice Stone, the Hines majority’s analysis resembled

an inquiry into whether the federal act “ ‘occupied the field,’ ” rather
than an application of simple conflict pre-emption principles. Id., at 78
(dissenting opinion). Regardless of whether Hines involved field or
conflict pre-emption, the dissent accurately observed that in assessing
the boundaries of the federal law—i.e., the scope of its pre-emptive
effect—the Court should look to the federal statute itself, rather than
speculate about Congress’ unstated intentions. Id., at 78–79. See also
Camps Newfound/Owatonna, Inc. v. Town of Harrison, 520 U. S. 564,
616–617 (1997) (THOMAS, J., dissenting) (noting that “field pre-emption
is itself suspect, at least as applied in the absence of a congressional
command that a particular field be pre-empted”).
5 The Safety Act’s express pre-emption provision stated in part:

“Whenever a Federal motor vehicle safety standard established
under this subchapter is in effect, no State . . . shall have any authority
 Cite as: 555 U. S. ____ (2009) 17

THOMAS, J., concurring in judgment

The Court then proceeded to consider whether the state
action was nonetheless pre-empted as an “obstacle” to the
purposes of the federal law. The Court held that the state
tort claim was pre-empted, relying in large part on com
ments that DOT made when promulgating its regulation,
statements that the Government made in its brief to the
Court, and regulatory history that related to the federal
regulation of passive restraints. See id., at 874–886.
In particular, the majority found that DOT intended to
“deliberately provid[e] the manufacturer[s] with a range of
choices among different passive restraint devices” and to
“bring about a mix of different devices introduced gradu
ally over time,” based on comments that DOT made when
promulgating its regulation, rather than the Safety Act’s
text. Id., at 875. The majority also embarked on a judicial
inquiry into “why and how DOT sought these objectives,”
ibid., by considering regulatory history and the Govern
ment’s brief, which described DOT’s safety standard as
“ ‘embod[ying] the Secretary’s policy judgment that safety
would best be promoted if manufacturers installed alter
native protection systems in their fleets rather than one
particular system in every car,’ ” id., at 881 (quoting Brief
for United States as Amicus Curiae in Geier v. American
Honda Motor Co., O. T. 1999, No. 98–1811, p. 25); see also
——————
either to establish, or to continue in effect, with respect to any motor
vehicle or item of motor vehicle equipment[,] any safety standard
applicable to the same aspect of performance of such vehicle or item of
equipment which is not identical to the Federal standard.” 15 U. S. C.
§1392(d) (1988 ed.).
The Safety Act also included a saving clause, which stated: “Compli
ance with any Federal motor vehicle safety standard issued under this
subchapter does not exempt any person from any liability under com
mon law.” §1397(k). The majority and dissent in Geier agreed that the
import of the express pre-emption provision and the saving clause, read
together, was that by its terms, the Safety Act did not expressly pre
empt state common-law actions. See Geier, 529 U. S., at 867–868; id.,
at 895–898 (STEVENS, J., dissenting).
18 WYETH v. LEVINE

THOMAS, J., concurring in judgment

529 U. S., at 883–884. Based on this “ex post administra
tive litigating position and inferences from regulatory
history and final commentary,” id., at 910–911 (STEVENS.,
J., dissenting), the Court found that the state action was
pre-empted because it would have required manufacturers
of all cars similar to that in which the plaintiff was injured
to “install airbags rather than other passive restraint
systems” and would have, therefore, “presented an obsta
cle to the variety and mix of devices that the federal regu
lation sought” to phase in gradually, id., at 881.
The Court’s decision in Geier to apply “purposes and
objectives” pre-emption based on agency comments, regu
latory history, and agency litigating positions was espe
cially flawed, given that it conflicted with the plain statu
tory text of the saving clause within the Safety Act, which
explicitly preserved state common-law actions by provid
ing that “[c]ompliance with any Federal motor vehicle
safety standard issued under this subchapter does not
exempt any person from any liability under common law,”
15 U. S. C. §1397(k) (1988 ed.).6 See Engine Mfrs. Assn. v.
——————
6 In addition to the impropriety of looking beyond the plain text of the
saving clause to regulatory history, DOT comments, and an administra
tive litigating position to evaluate the Safety Act’s pre-emptive effect, it
is unclear that the Court in Geier accurately assessed the federal
objectives of the relevant federal law. As the dissent in Geier pointed
out, the purpose of the Safety Act, as stated by Congress, was generally
“ ‘to reduce traffic accidents and deaths and injuries to persons result
ing from traffic accidents.’ ” Id., at 888–889 (opinion of STEVENS, J.)
(quoting 15 U. S. C. §1381 (1988 ed.)). On its face, that goal is of course
consistent with a state-law judgment that a particular vehicle needed a
passive restraint system that would better protect persons from death
and injury during traffic accidents. Furthermore, the dissent observed
that “by definition all of the standards established under the Safety Act
. . . impose minimum, rather than fixed or maximum, requirements.”
529 U. S., at 903 (citing 15 U. S. C. §1391(2) (1988 ed.)). Thus, in the
dissent’s view, the requirements of the DOT regulation were not
ceilings, and it was “obvious that the Secretary favored a more rapid
increase” than required by the regulations. 529 U. S., at 903. That
 Cite as: 555 U. S. ____ (2009) 19

THOMAS, J., concurring in judgment

South Coast Air Quality Management Dist., 541 U. S. 246,
252 (2004) (“Statutory construction must begin with the
language employed by Congress and the assumption that
the ordinary meaning of that language accurately ex
presses the legislative purpose” (internal quotation marks
omitted)); West Virginia Univ. Hospitals, Inc. v. Casey, 499
U. S. 83, 98 (1991) (“The best evidence of th[e] purpose [of
a statute] is the statutory text adopted by both Houses of
Congress and submitted to the President”). In addition,
the Court’s reliance on its divined purpose of the federal
law—to gradually phase in a mix of passive restraint
systems—in order to invalidate a State’s imposition of a
greater safety standard was contrary to the more general
express statutory goal of the Safety Act “to reduce traffic
accidents and deaths and injuries to persons resulting
from traffic accidents,” 15 U. S. C. §1381 (1988 ed.). This
Court has repeatedly stated that when statutory language
is plain, it must be enforced according to its terms. See
Jimenez v. Quarterman, 555 U. S. ___ (2009); see also, e.g.,
Dodd v. United States, 545 U. S. 353, 359 (2005); Lamie v.
United States Trustee, 540 U. S. 526, 534 (2004); Hartford
Underwriters Ins. Co. v. Union Planters Bank, N. A., 530
U. S. 1, 6 (2000). The text in Geier “directly addressed the
precise question at issue” before the Court, so that should
have been “the end of the matter; for the court, as well as
the agency, must give effect to the unambiguously ex
pressed intent of Congress.” National Assn. of Home Build
ers v. Defenders of Wildlife, 551 U. S. 644, ___ (2007) (slip
op., at 18) (2007) (internal quotation marks omitted). With
text that allowed state actions like the one at issue in Geier,
the Court had no authority to comb through agency com
mentaries to find a basis for an alternative conclusion.
——————

goal also would be consistent with a state-law judgment finding that a

manufacturer acted negligently when it failed to include an airbag in a

particular car. See id., at 903–904.

20 WYETH v. LEVINE

THOMAS, J., concurring in judgment

Applying “purposes and objectives” pre-emption in
Geier, as in any case, allowed this Court to vacate a judg
ment issued by another sovereign based on nothing more
than assumptions and goals that were untethered from
the constitutionally enacted federal law authorizing the
federal regulatory standard that was before the Court.
See Watters v. Wachovia Bank, N. A., 550 U. S. 1, 44
(2007) (STEVENS, J., dissenting) (noting that pre-emption
“affects the allocation of powers among sovereigns”).
“ ‘[A]n agency literally has no power to act, let alone pre
empt the [law] of a sovereign State, unless and until Con
gress confers power upon it.’ ” New York v. FERC, 535
U. S., at 18 (quoting Louisiana Pub. Serv. Comm’n v. FCC,
476 U. S. 355, 374 (1986)). Thus, no agency or individual
Member of Congress can pre-empt a State’s judgment by
merely musing about goals or intentions not found within
or authorized by the statutory text. See supra, at 5–7.
The Court’s “purposes and objectives” pre-emption
jurisprudence is also problematic because it encourages an
overly expansive reading of statutory text. The Court’s
desire to divine the broader purposes of the statute before
it inevitably leads it to assume that Congress wanted to
pursue those policies “at all costs”—even when the text
reflects a different balance. See Geier, supra, at 904
(STEVENS, J., dissenting) (finding no evidence to support
the notion that the DOT Secretary intended to advance
the purposes of the safety standard “at all costs”); Nelson,
86 Va. L. Rev., at 279–280. As this Court has repeatedly
noted, “ ‘it frustrates rather than effectuates legislative
intent simplistically to assume that whatever furthers the
statute’s primary objective must be the law.’ ” E.g., Nor
folk Southern R. Co. v. Sorrell, 549 U. S. 158, 171 (2007)
(quoting Rodriguez v. United States, 480 U. S. 522, 526
(1987) (per curiam)). Federal legislation is often the result
of compromise between legislators and “groups with
marked but divergent interests.” See Ragsdale v. Wolver
 Cite as: 555 U. S. ____ (2009) 21

THOMAS, J., concurring in judgment

ine World Wide, Inc., 535 U. S. 81, 93–94 (2002). Thus, a
statute’s text might reflect a compromise between parties
who wanted to pursue a particular goal to different ex
tents. See, e.g., ibid. (noting that the Family and Medical
Leave Act’s provision of only 12 workweeks of yearly leave
“was the result of compromise” that must be given effect
by courts); Silkwood v. Kerr-McGee Corp., 464 U. S. 238,
257 (1984) (finding that a state law was not pre-empted
though it allegedly frustrated a primary purpose of the
Atomic Energy Act because the Act provided that its pur
pose was to be furthered only “to the extent it is consistent
‘with the health and safety of the public’ ” (quoting 42
U. S. C. §2013(d) (1982 ed.))); see also Manning, What
Divides Textualists from Purposivists? 106 Colum. L. Rev.
70, 104 (2006) (“Legislators may compromise on a statute
that does not fully address a perceived mischief, accepting
half a loaf to facilitate a law’s enactment”). Therefore,
there is no factual basis for the assumption underlying the
Court’s “purposes and objectives” pre-emption jurispru
dence that every policy seemingly consistent with federal
statutory text has necessarily been authorized by Con
gress and warrants pre-emptive effect. Instead, our fed
eral system in general, and the Supremacy Clause in
particular, accords pre-emptive effect to only those policies
that are actually authorized by and effectuated through
the statutory text.
3
The majority, while reaching the right conclusion in this
case, demonstrates once again how application of “pur
poses and objectives” pre-emption requires inquiry into
matters beyond the scope of proper judicial review. For
example, the majority relies heavily on Congress’ failure
“during the . . . 70-year history” of the federal Food, Drug,
and Cosmetic Act to enact an express pre-emption provi
sion that addresses approval of a drug label by the FDA.
22 WYETH v. LEVINE

THOMAS, J., concurring in judgment

Ante, at 18. That “silence on the issue, coupled with [Con
gress’] certain awareness of the prevalence of state tort
litigation,” the majority reasons, is evidence that Congress
did not intend for federal approval of drug labels to pre
empt state tort judgments. Ibid.; see also ante, at 17–18
(construing from inaction that Congress “[e]vidently [had]
determined that widely available state rights of action
provided appropriate relief”). Certainly, the absence of a
statutory provision pre-empting all state tort suits related
to approved federal drug labels is pertinent to a finding
that such lawsuits are not pre-empted. But the relevance
is in the fact that no statute explicitly pre-empts the law
suits, and not in any inferences that the Court may draw
from congressional silence about the motivations or poli
cies underlying Congress’ failure to act. See Brown v.
Gardner, 513 U. S. 115, 121 (1994) (“[C]ongressional
silence lacks persuasive significance” (internal quotation
marks omitted)); O’Melveny & Myers v. FDIC, 512 U. S.
79, 85 (1994) (“[M]atters left unaddressed in [a compre
hensive and detailed federal] scheme are presumably left
subject to the disposition provided by state law”); Camps
Newfound, 520 U. S., at 616 (“[O]ur pre-emption jurispru
dence explicitly rejects the notion that mere congressional
silence on a particular issue may be read as pre-empting
state law”).
In this case, the majority has concluded from silence
that Congress believed state lawsuits pose no obstacle to
federal drug-approval objectives. See ante, at 18. That is
the required conclusion, but only because it is compelled
by the text of the relevant statutory and regulatory provi
sions, not judicial suppositions about Congress’ unstated
goals. The fact that the Court reaches the proper conclu
sion does not justify its speculation about the reasons for
congressional inaction. In this case, the Court has relied
on the perceived congressional policies underlying inaction
to find that state law is not pre-empted. But once the
 Cite as: 555 U. S. ____ (2009) 23

THOMAS, J., concurring in judgment

Court shows a willingness to guess at the intent underly
ing congressional inaction, the Court could just as easily
rely on its own perceptions regarding congressional inac
tion to give unduly broad pre-emptive effect to federal law.
See, e.g., American Ins. Assn. v. Garamendi, 539 U. S. 396,
401, 405–408, 429 (2003) (finding that Congress’ failure to
pass legislation indicating that it disagreed with the
President’s executive agreement supported, at least in
part, the Court’s determination that the agreement pre
empted state law). Either approach is illegitimate. Under
the Supremacy Clause, state law is pre-empted only by
federal law “made in Pursuance” of the Constitution,
Art. VI, cl. 2—not by extratextual considerations of the
purposes underlying congressional inaction. See Hoffman
v. Connecticut Dept. of Income Maintenance, 492 U. S. 96,
104 (1989) (plurality opinion) (finding that policy argu
ments that “are not based in the text of the statute . . . are
not helpful”); TVA v. Hill, 437 U. S. 153, 194 (1978) (“Our
individual appraisal of the wisdom or unwisdom of a
particular course consciously selected by the Congress is to
be put aside in the process of interpreting a statute”). Our
role, then, is merely “to interpret the language of the
statute[s] enacted by Congress.” Barnhart v. Sigmon Coal
Co., 534 U. S. 438, 461 (2002).
III
The origins of this Court’s “purposes and objectives” pre
emption jurisprudence in Hines, and its broad application
in cases like Geier, illustrate that this brand of the Court’s
pre-emption jurisprudence facilitates freewheeling, ex
tratextual, and broad evaluations of the “purposes and
objectives” embodied within federal law. This, in turn,
leads to decisions giving improperly broad pre-emptive
effect to judicially manufactured policies, rather than to
the statutory text enacted by Congress pursuant to the
Constitution and the agency actions authorized thereby.
24 WYETH v. LEVINE

THOMAS, J., concurring in judgment

Because such a sweeping approach to pre-emption leads to
the illegitimate—and thus, unconstitutional—invalidation
of state laws, I can no longer assent to a doctrine that pre
empts state laws merely because they “stan[d] as an ob
stacle to the accomplishment and execution of the full
purposes and objectives” of federal law, Hines, 312 U. S.,
at 67, as perceived by this Court. I therefore respectfully
concur only in the judgment.
 Cite as: 555 U. S. ____ (2009) 1

ALITO, J., dissenting

SUPREME COURT OF THE UNITED STATES
_________________

No. 06–1249
_________________

WYETH, PETITIONER v. DIANA LEVINE
ON WRIT OF CERTIORARI TO THE SUPREME COURT OF

VERMONT

[March 4, 2009]

JUSTICE ALITO, with whom THE CHIEF JUSTICE and
JUSTICE SCALIA join, dissenting.
This case illustrates that tragic facts make bad law.
The Court holds that a state tort jury, rather than the
Food and Drug Administration (FDA), is ultimately re­
sponsible for regulating warning labels for prescription
drugs. That result cannot be reconciled with Geier v.
American Honda Motor Co., 529 U. S. 861 (2000), or gen­
eral principles of conflict pre-emption. I respectfully
dissent.
I
The Court frames the question presented as a “narro[w]”
one—namely, whether Wyeth has a duty to provide “an
adequate warning about using the IV-push method” to
administer Phenergan. Ante, at 8. But that ignores the
antecedent question of who—the FDA or a jury in Ver­
mont—has the authority and responsibility for determin­
ing the “adequacy” of Phenergan’s warnings. Moreover, it
is unclear how a “stronger” warning could have helped
respondent, see ante, at 16; after all, the physician’s assis­
tant who treated her disregarded at least six separate
warnings that are already on Phenergan’s labeling, so
respondent would be hard pressed to prove that a seventh
2 WYETH v. LEVINE

ALITO, J., dissenting

would have made a difference.1
More to the point, the question presented by this case is
not a “narrow” one, and it does not concern whether Phen­
ergan’s label should bear a “stronger” warning. Rather,
the real issue is whether a state tort jury can counter­
mand the FDA’s considered judgment that Phenergan’s
FDA-mandated warning label renders its intravenous (IV)
use “safe.” Indeed, respondent’s amended complaint
alleged that Phenergan is “not reasonably safe for intra­
venous administration,” App. 15, ¶6; respondent’s attorney
told the jury that Phenergan’s label should say, “ ‘Do not
use this drug intravenously,’ ” id., at 32; respondent’s
expert told the jury, “I think the drug should be labeled
‘Not for IV use,’ ” id., at 59; and during his closing argu­
ment, respondent’s attorney told the jury, “Thank God we
don’t rely on the FDA to . . . make the safe[ty] decision.
You will make the decision. . . . The FDA doesn’t make the
decision, you do,” id., at 211–212.2
Federal law, however, does rely on the FDA to make
——————
1 Indeed, respondent conceded below that Wyeth did propose an ade­

quate warning of Phenergan’s risks. See Plaintiff Diana Levine’s
Memorandum in Opposition to Wyeth’s Motion for Summary Judgment
in Levine v. American Home Products Corp. (now Wyeth), No. 670–12–
01 Wncv (Super. Ct. Washington Cty., Vt.), ¶7, p. 26. Specifically,
respondent noted: “In 1988, Wyeth proposed language that would have
prevented this accident by requiring a running IV and explaining why a
running IV will address and reduce the risk [of intra-arterial injec­
tion].” Ibid. See also id., at 24 (“Although not strong enough, this
improved the labeling instruction, if followed, would have prevented the
inadvertent administration of Phenergan into an artery . . .”). The FDA
rejected Wyeth’s proposal. See App. 359.
2 Moreover, in the trial judge’s final charge, he told the jury that “the

critical factual issue which you must decide” is whether Phenergan’s
FDA-mandated label reflects a proper balance between “the risks and
benefits of intravenous administration and the potential for injury to
patients.” Id., at 220. See also ___ Vt. ___, ___, 944 A. 2d 179, 182
(2006) (recognizing that respondent’s argument is that Phenergan’s
“label should not have allowed IV push as a means of administration”).
 Cite as: 555 U. S. ____ (2009) 3

ALITO, J., dissenting

safety determinations like the one it made here. The FDA
has long known about the risks associated with IV push in
general and its use to administer Phenergan in particular.
Whether wisely or not, the FDA has concluded—over the
course of extensive, 54-year-long regulatory proceedings—
that the drug is “safe” and “effective” when used in accor­
dance with its FDA-mandated labeling. The unfortunate
fact that respondent’s healthcare providers ignored Phen­
ergan’s labeling may make this an ideal medical­
malpractice case.3 But turning a common-law tort suit
into a “frontal assault” on the FDA’s regulatory regime for
drug labeling upsets the well-settled meaning of the Su­
premacy Clause and our conflict pre-emption jurispru­
dence. Brief for United States as Amicus Curiae 21.
II

A

To the extent that “[t]he purpose of Congress is the
ultimate touchstone in every pre-emption case,” Med
tronic, Inc. v. Lohr, 518 U. S. 470, 485 (1996) (internal
quotation marks omitted), Congress made its “purpose”
plain in authorizing the FDA—not state tort juries—to
determine when and under what circumstances a drug is
“safe.” “[T]he process for approving new drugs is at least
as rigorous as the premarket approval process for medical
devices,” Riegel v. Medtronic, Inc., 552 U. S. ___, ___
(2008) (slip op., at 11) (GINSBURG, J., dissenting), and we
——————
3 Respondent sued her physician, physician’s assistant, and hospital

for malpractice. After the parties settled that suit for an undisclosed
sum, respondent’s physician sent her a letter in which he admitted
“responsibility” for her injury and expressed his “profoun[d] regre[t]”
and “remors[e]” for his actions. 1 Tr. 178–179 (Mar. 8, 2004) (testimony
of Dr. John Matthew); see also App. 102–103 (testimony of physician’s
assistant Jessica Fisch) (noting that her “sense of grief” was so “great”
that she “would have gladly cut off [her own] arm” and given it to
respondent). Thereafter, both the physician and the physician’s assis­
tant agreed to testify on respondent’s behalf in her suit against Wyeth.
4 WYETH v. LEVINE

ALITO, J., dissenting

held that the latter pre-empted a state-law tort suit that
conflicted with the FDA’s determination that a medical
device was “safe,” id., at ___ (slip op., at 11) (opinion of the
Court).
Under the Federal Food, Drug, and Cosmetic Act
(FDCA), a drug manufacturer may not market a new drug
before first submitting a new drug application (NDA) to
the FDA and receiving the agency’s approval. See 21
U. S. C. §355(a). An NDA must contain, among other
things, “the labeling proposed to be used for such drug,”
§355(b)(1)(F), “full reports of investigations which have
been made to show whether or not such drug is safe for
use and whether such drug is effective in use,”
§355(b)(1)(A), and “a discussion of why the benefits exceed
the risks [of the drug] under the conditions stated in the
labeling,” 21 CFR §314.50(d)(5)(viii) (2008). The FDA will
approve an NDA only if the agency finds, among other
things, that the drug is “safe for use under the conditions
prescribed, recommended, or suggested in the proposed
labeling thereof,” there is “substantial evidence that the
drug will have the effect it purports or is represented to
have under the conditions of use prescribed, recom­
mended, or suggested in the proposed labeling thereof,”
and the proposed labeling is not “false or misleading in
any particular.” 21 U. S. C. §355(d).
After the FDA approves a drug, the manufacturer re­
mains under an obligation to investigate and report any
adverse events associated with the drug, see 21 CFR
§314.80, and must periodically submit any new informa­
tion that may affect the FDA’s previous conclusions about
the safety, effectiveness, or labeling of the drug, 21
U. S. C. §355(k). If the FDA finds that the drug is not
“safe” when used in accordance with its labeling, the
agency “shall” withdraw its approval of the drug. §355(e).
The FDA also “shall” deem a drug “misbranded” if “it is
dangerous to health when used in the dosage or manner,
 Cite as: 555 U. S. ____ (2009) 5

ALITO, J., dissenting

or with the frequency or duration prescribed, recom­
mended, or suggested in the labeling thereof.” §352(j).
Thus, a drug’s warning label “serves as the standard
under which the FDA determines whether a product is
safe and effective.” 50 Fed. Reg. 7470 (1985). Labeling is
“[t]he centerpiece of risk management,” as it “communi­
cates to health care practitioners the agency’s formal,
authoritative conclusions regarding the conditions under
which the product can be used safely and effectively.” 71
Fed. Reg. 3934 (2006). The FDA has underscored the
importance it places on drug labels by promulgating com­
prehensive regulations—spanning an entire part of the
Code of Federal Regulations, see 21 CFR pt. 201, with
seven subparts and 70 separate sections—that set forth
drug manufacturers’ labeling obligations. Under those
regulations, the FDA must be satisfied that a drug’s warn­
ing label contains, among other things, “a summary of the
essential scientific information needed for the safe and
effective use of the drug,” §201.56(1), including a descrip­
tion of “clinically significant adverse reactions,” “other
potential safety hazards,” “limitations in use imposed by
them, . . . and steps that should be taken if they occur,”
§201.57(c)(6)(i). Neither the FDCA nor its implementing
regulations suggest that juries may second-guess the
FDA’s labeling decisions.
B
1
Where the FDA determines, in accordance with its
statutory mandate, that a drug is on balance “safe,” our
conflict pre-emption cases prohibit any State from coun­
termanding that determination. See, e.g., Buckman Co. v.
Plaintiffs’ Legal Comm., 531 U. S. 341, 348 (2001) (after
the FDA has struck “a somewhat delicate balance of statu­
tory objectives” and determined that petitioner submitted
a valid application to manufacture a medical device, a
6 WYETH v. LEVINE

ALITO, J., dissenting

State may not use common law to negate it); International
Paper Co. v. Ouellette, 479 U. S. 481, 494 (1987) (after the
EPA has struck “the balance of public and private inter­
ests so carefully addressed by” the federal permitting
regime for water pollution, a State may not use nuisance
law to “upse[t]” it); Chicago & North Western Transp. Co.
v. Kalo Brick & Tile Co., 450 U. S. 311, 321 (1981) (after
the Interstate Commerce Commission has struck a “bal­
ance” between competing interests in permitting the
abandonment of a railroad line, a State may not use statu­
tory or common law to negate it).
Thus, as the Court itself recognizes, it is irrelevant in
conflict pre-emption cases whether Congress “enacted an
express pre-emption provision at some point during the
FDCA’s 70-year history.” Ante, at 18; see also Geier, 529
U. S., at 869 (holding the absence of an express pre­
emption clause “does not bar the ordinary working of
conflict pre-emption principles”). Rather, the ordinary
principles of conflict pre-emption turn solely on whether a
State has upset the regulatory balance struck by the
federal agency. Id., at 884–885; see also Chicago & North
Western Transp. Co., supra, at 317 (describing conflict pre­
emption as “a two-step process of first ascertaining the
construction of the [federal and state laws] and then de­
termining the constitutional question whether they are
actually in conflict” (internal quotation marks omitted)).
2
A faithful application of this Court’s conflict pre-emption
cases compels the conclusion that the FDA’s 40-year-long
effort to regulate the safety and efficacy of Phenergan pre­
empts respondent’s tort suit. Indeed, that result follows
directly from our conclusion in Geier.
Geier arose under the National Traffic and Motor Safety
Vehicle Act of 1966, which directs the Secretary of the
Department of Transportation (DOT) to “establish by
 Cite as: 555 U. S. ____ (2009) 7

ALITO, J., dissenting

order . . . motor vehicle safety standards,” 15 U. S. C.
§1392(a) (1988 ed.), which are defined as “minimum stan­
dard[s] for motor vehicle performance, or motor vehicle
equipment performance,” §1391(2). Acting pursuant to
that statutory mandate, the Secretary of Transportation
promulgated Federal Motor Vehicle Safety Standard 208,
which required car manufacturers to include passive
restraint systems (i.e., devices that work automatically to
protect occupants from injury during a collision) in a
certain percentage of their cars built in or after 1987. See
49 CFR §571.208 (1999). Standard 208 did not require
installation of any particular type of passive restraint;
instead, it gave manufacturers the option to install auto­
matic seatbelts, airbags, or any other suitable technology
that they might develop, provided the restraint(s) met the
performance requirements specified in the rule. Ibid.
Alexis Geier drove her 1987 Honda Accord into a tree,
and although she was wearing her seatbelt, she nonethe­
less suffered serious injuries. She then sued Honda under
state tort law, alleging that her car was negligently and
defectively designed because it lacked a driver’s-side
airbag. She argued that Congress had empowered the
Secretary to set only “minimum standard[s]” for vehicle
safety. 15 U. S. C. §1391(2). She also emphasized that the
National Traffic and Motor Safety Vehicle Act contains a
saving clause, which provides that “[c]ompliance with any
Federal motor vehicle safety standard issued under this
subchapter does not exempt any person from any liability
under common law.” §1397(k).
Notwithstanding the statute’s saving clause, and not­
withstanding the fact that Congress gave the Secretary
authority to set only “minimum” safety standards, we held
Geier’s state tort suit pre-empted. In reaching that result,
we relied heavily on the view of the Secretary of Transpor­
tation—expressed in an amicus brief—that Standard 208
“ ‘embodies the Secretary’s policy judgment that safety
8 WYETH v. LEVINE

ALITO, J., dissenting

would best be promoted if manufacturers installed alter
native protection systems in their fleets rather than one
particular system in every car.’ ” 529 U. S., at 881 (quot­
ing Brief for United States as Amicus Curiae, O. T. 1999,
No. 98–1811, p. 25). Because the Secretary determined
that a menu of alternative technologies was “safe,” the
doctrine of conflict pre-emption barred Geier’s efforts to
deem some of those federally approved alternatives “un­
safe” under state tort law.
The same rationale applies here. Through Phenergan’s
label, the FDA offered medical professionals a menu of
federally approved, “safe” and “effective” alternatives—
including IV push—for administering the drug. Through a
state tort suit, respondent attempted to deem IV push
“unsafe” and “ineffective.” To be sure, federal law does not
prohibit Wyeth from contraindicating IV push, just as
federal law did not prohibit Honda from installing airbags
in all its cars. But just as we held that States may not
compel the latter, so, too, are States precluded from com­
pelling the former. See also Fidelity Fed. Sav. & Loan
Assn. v. De la Cuesta, 458 U. S. 141, 155 (1982) (“The
conflict does not evaporate because the [agency’s] regula­
tion simply permits, but does not compel,” the action
forbidden by state law). If anything, a finding of pre­
emption is even more appropriate here because the
FDCA—unlike the National Traffic and Motor Safety
Vehicle Act—contains no evidence that Congress intended
the FDA to set only “minimum standards,” and the FDCA
does not contain a saving clause.4 See also ante, at 18
——————
4 To be sure, Congress recognized the principles of conflict pre­

emption in the FDCA. See Drug Amendments of 1962, §202, 76 Stat.
793 (“Nothing in the amendments made by this Act to the Federal
Food, Drug, and Cosmetic Act shall be construed as invalidating any
provision of State law . . . unless there is a direct and positive conflict
between such amendments and such provision of State law”). But a
provision that simply recognizes the background principles of conflict
 Cite as: 555 U. S. ____ (2009) 9

ALITO, J., dissenting

(conceding Congress’ “silence” on the issue).
III
In its attempt to evade Geier’s applicability to this case,
the Court commits both factual and legal errors. First, as
a factual matter, it is demonstrably untrue that the FDA
failed to consider (and strike a “balance” between) the
specific costs and benefits associated with IV push. Sec­
ond, as a legal matter, Geier does not stand for the legal
propositions espoused by the dissenters (and specifically
rejected by the majority) in that case. Third, drug labeling
by jury verdict undermines both our broader pre-emption
jurisprudence and the broader workability of the federal
drug-labeling regime.
A
Phenergan’s warning label has been subject to the
FDA’s strict regulatory oversight since the 1950’s. For at
least the last 34 years, the FDA has focused specifically on
whether IV-push administration of Phenergan is “safe”
and “effective” when performed in accordance with Phen­
ergan’s label. The agency’s ultimate decision—to retain IV
push as one means for administering Phenergan, albeit
subject to stringent warnings—is reflected in the plain
text of Phenergan’s label (sometimes in boldfaced font and
all-capital letters). And the record contains ample evi­
dence that the FDA specifically considered and reconsid­
ered the strength of Phenergan’s IV-push-related warn­
ings in light of new scientific and medical data. The
——————
pre-emption is not a traditional “saving clause,” and even if it were, it
would not displace our conflict-pre-emption analysis. See Geier v.
American Honda Motor Co., 529 U. S. 861, 869 (2000) (“[T]he saving
clause . . . does not bar the ordinary working of conflict pre-emption
principles”); id., at 873–874 (“The Court has . . . refused to read general
‘saving’ provisions to tolerate actual conflict both in cases involving
impossibility and in ‘frustration-of-purpose’ cases” (emphasis deleted
and citation omitted)).
10 WYETH v. LEVINE

ALITO, J., dissenting

majority’s factual assertions to the contrary are mistaken.
1
The FDA’s focus on IV push as a means of administering
Phenergan dates back at least to 1975. In August of that
year, several representatives from both the FDA and
Wyeth met to discuss Phenergan’s warning label. At that
meeting, the FDA specifically proposed “that Phenergan
Injection should not be used in Tubex®.” 2 Record 583,
586 (Plaintiff’s Trial Exh. 17, Internal Correspondence
from W. E. Langeland to File (Sept. 5, 1975) (hereinafter
1975 Memo)). “Tubex” is a syringe system used exclu­
sively for IV push. See App. 43. An FDA official explained
that the agency’s concerns arose from medical-malpractice
lawsuits involving IV push of the drug, see 1975 Memo
586, and that the FDA was aware of “5 cases involving
amputation where the drug had been administered by
Tubex together with several additional cases involving
necrosis,” id., at 586–587. Rather than contraindicating
Phenergan for IV push, however, the agency and Wyeth
agreed “that there was a need for better instruction re­
garding the problems of intraarterial injection.” Id., at
587.
The next year, the FDA convened an advisory committee
to study, among other things, the risks associated with the
Tubex system and IV push. App. 294. At the conclusion of
its study, the committee recommended an additional IV­
push-specific warning for Phenergan’s label, see ibid., but
did not recommend eliminating IV push from the drug
label altogether. In response to the committee’s recom­
mendations, the FDA instructed Wyeth to make several
changes to strengthen Phenergan’s label, including the
addition of upper case warnings related to IV push. See
id., at 279–280, 282–283.
In 1987, the FDA directed Wyeth to amend its label to
include the following text:
 Cite as: 555 U. S. ____ (2009) 11

ALITO, J., dissenting

“ ‘[1] When used intravenously, [Phenergan] should be
given in a concentration no greater than 25 mg/ml and
at a rate not to exceed 25 mg/minute. [2] Injection
through a properly running intravenous infusion may
enhance the possibility of detecting arterial place­
ment.’ ” Id., at 311–312.
The first of the two quoted sentences refers specifically to
IV push; as respondent’s medical expert testified at trial,
the label’s recommended rate of administration (not to
exceed 25 mg per minute) refers to “IV push, as opposed to
say being in a bag and dripped over a couple of hours.”
Id., at 52. The second of the two quoted sentences refers
to IV drip. See id., at 15–16 (emphasizing that a “running
IV” is the same thing as “IV drip”).
In its 1987 labeling order, the FDA cited voluminous
materials to “suppor[t]” its new and stronger warnings
related to IV push and the preferability of IV drip.5 Id., at
313. One of those articles specifically discussed the rela­
tive advantages and disadvantages of IV drip compared to
IV push, as well as the costs and benefits of administering
Phenergan via IV push.6 The FDA also cited published
case reports from the 1960’s of gangrene caused by the
——————
5 The FDA cited numerous articles that generally discuss the costs

and benefits associated with IV push. See, e.g., Nahrwold & Phelps,
Inadvertent Intra-Arterial Injection of Mephenteramine, 70 Rocky
Mountain Medical J. 38 (Sept. 1973) (cited in App. 314, no. 14); Albo,
Cheung, Ruth, Snyder, & Beemtsma, Effect of Intra-Arterial Injections
of Barbituates, 120 Am. J. of Surgery 676 (1970) (cited in App. 314,
no. 12); Corser, Masey, Jacob, Kernoff, & Browne, Ischaemia Following
Self-administered Intra-arterial Injection of Methylphenidate and
Diamorphine, 40 Anesthesiology 51 (1985) (cited in App. 314, no. 9);
Correspondence Regarding Thiopental and Thiamylal (3 letters), 59
Anesthesiology 153 (1983) (cited in App. 314, no. 11); Miller, Arthur, &
Stratigos, Intra-arterial Injection of a Barbituate, 23 Anesthesia
Progress 25 (1976) (cited in App. 315, no. 19).
6 See Webb & Lampert, Accidental Arterial Injections, 101 Am. J.

Obstetrics & Gynecology 365 (1968) (cited in App. 313, no. 5).
12 WYETH v. LEVINE

ALITO, J., dissenting

intra-arterial injection of Phenergan,7 and the FDA in­
structed Wyeth to amend Phenergan’s label in accordance
with the latest medical research.8 The FDA also studied
drugs similar to Phenergan and cited numerous caution­
ary articles—one of which urged the agency to consider
contraindicating such drugs for IV use altogether.9
——————
7 See Hager & Wilson, Gangrene of the Hand Following Intra-arterial
Injection, 94 Archives of Surgery 86 (1967) (cited in App. 313, no. 7);
Enloe, Sylvester, & Morris, Hazards of Intra-Arterial Injection of
Hydroxyzine, 16 Canadian Anaesthetists’ Society J. 425 (1969) (herein­
after Enloe) (noting “recent reports” of “the occurrence of severe necro­
sis and gangrene following [administration of] promethazine (Phener­
gan®)” (cited in App. 314, no. 15)). See also Mostafavi & Samimi,
Accidental Intra-arterial Injection of Promethazine HCl During Gen­
eral Anesthesia, 35 Anesthesiology 645 (1971) (reporting a case of
gangrene, which required partial amputation of three fingers, after
Phenergan was inadvertently pushed into an artery in the “antecubital”
area); Promethazine, p. 7, in Clinical Pharmacology (Gold Standard
Multimedia Inc. CD–ROM, version 1.16 (1998) (noting that “[i]nad­
vertent intra-arterial injection [of Phenergan] can result in arterio­
spasm . . . and development of gangrene”)).
8 Hager and Wilson noted that the most common reactions to intra­

arterial injections of drugs like Phenergan include “[i]mmediate, severe,
burning pain,” as well as “blanching.” 94 Archives of Surgery, at 87–88.
The FDA required Wyeth to include Hager and Wilson’s observations
on Phenergan’s label. See App. 311 (requiring the label to warn that
“ ‘[t]he first sign [of an intra-arterial injection] may be the patient’s
reaction to a sensation of fiery burning’ ” pain and “ ‘[b]lanching’ ”).
9 See Enloe 427 (discussing hydroxyzine—an antihistamine with

chemical properties similar to those of Phenergan—and suggesting its
“temporary” benefits can never outweigh the risks of intra-arterial
injection); see also Goldsmith & Trieger, Accidental Intra-Arterial
Injection: A Medical Emergency, 22 Anesthesia Progress 180 (1975)
(noting the risks of intra-arterial administration of hydroxyzine) (cited
in App. 315, no. 18); Klatte, Brooks, & Rhamy, Toxicity of Intra-Arterial
Barbituates and Tranquilizing Drugs, 92 Radiology 700 (1969) (same)
(cited in App. 314, no. 13). With full knowledge of those risks, FDA
retained IV push for Phenergan, although the agency required Wyeth
to incorporate observations from the Enloe article into Phenergan’s
label. Compare Enloe 427 (arguing that “every precaution should be
taken to avoid inadvertent intra-arterial injection,” including the use of
 Cite as: 555 U. S. ____ (2009) 13

ALITO, J., dissenting

In “support” of its labeling order, the FDA also cited
numerous articles that singled out the inner crook of the
elbow—known as the “antecubital fossa” in the medical
community—which is both a commonly used injection site,
see id., at 70 (noting that respondent’s injection was
pushed into “the antecubital space”), and a universally
recognized high-risk area for inadvertent intra-arterial
injections. One of the articles explained:
“Because of the numerous superficial positions the
ulnar artery might occupy, it has often been entered
during attempted venipuncture [of the antecubital
fossa]. . . . However, the brachial and the radial arter­
ies might also be quite superficial in the elbow re­
gion. . . . The arterial variations of the arm, especially
in and about the cubital fossa, are common and nu­
merous. If venipuncture must be performed in this
area, a higher index of suspicion must be maintained
to forestall misdirected injections.” Stone & Donnelly,
The Accidental Intra-arterial Injection of Thiopental,
22 Anesthesiology 995, 996 (1961) (footnote omitted;
cited in App. 315, no. 20).10

——————
“an obviously well-functioning venoclysis”), with App. 312 (FDA’s 1987
changes to Phenergan’s label). In contrast, at some time around 1970,
the FDA prohibited all intravenous use of hydroxyzine. See id., at 79
(testimony of Dr. Harold Green). The FDA’s decision to regulate the
two drugs differently—notwithstanding (1) the agency’s knowledge of
the risks associated with both drugs and (2) the agency’s recognition of
the relevance of hydroxyzine-related articles and case reports in its
regulation of Phenergan—further demonstrates that the FDA inten­
tionally preserved IV-push administration for Phenergan. See also
Haas, Correspondence, 33 Anesthesia Progress 281 (1986) (“[Hydroxyz­
ine’s] restriction does not lie with the medicine itself, but in the practice
and malpractice of intravenous techniques. Unfortunately, the practi­
tioner who knows how to treat injection technique problems is usually
not the practitioner with the intravenous technique problems”).
10 See also Engler, Freeman, Kanavage, Ogden, & Moretz, Production

of Gangrenous Extremities by Intra-Arterial Injections, 30 Am. Sur­
14 WYETH v. LEVINE

ALITO, J., dissenting

Based on this and other research, the FDA ordered Wyeth
to include a specific warning related to the use of the
antecubital space for IV push.11
2
When respondent was injured in 2000, Phenergan’s
label specifically addressed IV push in several passages
(sometimes in lieu of and sometimes in addition to those
discussed above). For example, the label warned of the
risks of intra-arterial injection associated with “aspira­
tion,” which is a technique used only in conjunction with
IV push.12 The label also cautioned against the use of
——————
geon 602 (1964) (“Accidental arterial injection most often occurs in the
antecubital region because this is a favorite site for venopuncture and
in this area the ulnar and brachial arteries are superficial and easily
entered” (cited in App. 313, no. 6)); Engler, Gangrenous Extremities
Resulting from Intra-arterial Injections, 94 Archives of Surgery 644
(1966) (similar) (cited in App. 314, no. 16); Lynas & Bisset, Intra­
arterial Thiopentone, 24 Anaesthesia 257 (1969) (“Most [anesthesiolo­
gists] agree that injections on the medial aspect of the antecubital fossa
are best avoided” (cited in App. 314, no. 8)); Waters, Intra-arterial
Thiopentone, 21 Anesthesia 346 (1966) (“The risk of producing gan­
grene of the forearm by accidental injection of sodium thiopentone into
an artery at the elbow has been recognised for many years” (cited in
App. 314, no. 10)); see also Hager & Wilson, 94 Archives of Surgery, at
88 (emphasizing that one of the best ways to prevent inadvertent intra­
arterial injections is to be aware of “aberrant or superficial arteries at
the antecubital, forearm, wrist, and hand level”); Mostafavi & Samimi,
supra (warning against antecubital injections).
11 See App. 311 (requiring Phenergan’s label to warn that practitio­

ners should “ ‘[b]eware of the close proximity of arteries and veins at
commonly used injection sites and consider the possibility of aberrant
arteries’ ”).
12 “Aspiration” refers to drawing a small amount of blood back into

the needle to determine whether the needle is in an artery or a vein.
Ordinarily, arterial blood is brighter than venous blood—but contact
with Phenergan causes discoloration, which makes aspiration an
unreliable method of protecting against intra-arterial injection. See id.,
at 282. Therefore, the label warned that when using IV push, a medi­
cal professional should beware that “[a]spiration of dark blood does not
 Cite as: 555 U. S. ____ (2009) 15

ALITO, J., dissenting

“syringes with rigid plungers,” App. 390, which are used
only to administer the drug via IV push. As respondent’s
medical expert testified at trial, “by talking plungers and
rigid needles, that’s the way you do it, to push it with the
plunger.” Id., at 53 (testimony of Dr. John Matthew).
Moreover, Phenergan’s 2000 label devoted almost a full
page to discussing the “Tubex system,” see id., at 391,
which, as noted above, is used only to administer the drug
via IV push.
While Phenergan’s label very clearly authorized the use
of IV push, it also made clear that IV push is the delivery
method of last resort. The label specified that “[t]he pre­
ferred parenteral route of administration is by deep in­
tramuscular injection.” Id., at 390. If an intramuscular
injection is ineffective, then “it is usually preferable to
inject [Phenergan] through the tubing of an intravenous
infusion set that is known to be functioning satisfactorily.”
Ibid. See also id., at 50–51 (testimony of respondent’s
medical expert, Dr. John Matthew) (conceding that the
best way to determine that an IV set is functioning satis­
factorily is to use IV drip). Finally, if for whatever reason
a medical professional chooses to use IV push, he or she is
on notice that “INADVERTENT INTRA-ARTERIAL
INJECTION CAN RESULT IN GANGRENE OF THE
AFFECTED EXTREMITY.” Id., at 391; see also id., at
390 (“Under no circumstances should Phenergan Injection
be given by intra-arterial injection due to the likelihood of
severe arteriospasm and the possibility of resultant gan­
grene”).
Phenergan’s label also directs medical practitioners to
choose veins wisely when using IV push:
“Due to the close proximity of arteries and veins in the
areas most commonly used for intravenous injection,
——————
preclude intra-arterial needle placement, because blood is discolored
upon contact with Phenergan Injection.” Id., at 390.
16 WYETH v. LEVINE

ALITO, J., dissenting

extreme care should be exercised to avoid perivascular
extravasation or inadvertent intra-arterial injection.
Reports compatible with inadvertent intra-arterial in­
jection of Phenergan Injection, usually in conjunction
with other drugs intended for intravenous use, sug­
gest that pain, severe chemical irritation, severe
spasm of distal vessels, and resultant gangrene re­
quiring amputation are likely under such circum­
stances.” Ibid.
Thus, it is demonstrably untrue that, as of 2000, Phen­
ergan’s “labeling did not contain a specific warning about
the risks of IV-push administration.” Ante, at 4. And
whatever else might be said about the extensive medical
authorities and case reports that the FDA cited in “sup­
port” of its approval of IV-push administration of Phener­
gan, it cannot be said that the FDA “paid no more than
passing attention to” IV push, ante, at 6; nor can it be said
that the FDA failed to weigh its costs and benefits, Brief
for Respondent 50.
3
For her part, respondent does not dispute the FDA’s
conclusion that IV push has certain benefits. At trial, her
medical practitioners testified that they used IV push in
order to help her “in a swift and timely way” when she
showed up at the hospital for the second time in one day
complaining of “intractable” migraines, “terrible pain,”
inability to “bear light or sound,” sleeplessness, hours-long
spasms of “retching” and “vomiting,” and when “every
possible” alternative treatment had “failed.” App. 40
(testimony of Dr. John Matthew); id., at 103, 106, 109
(testimony of physician’s assistant Jessica Fisch).
Rather than disputing the benefits of IV push, respon­
dent complains that the FDA and Wyeth underestimated
its costs (and hence did not provide sufficient warnings
regarding its risks). But when the FDA mandated that
 Cite as: 555 U. S. ____ (2009) 17

ALITO, J., dissenting

Phenergan’s label read, “INADVERTENT INTRA-
ARTERIAL INJECTION CAN RESULT IN
GANGRENE OF THE AFFECTED EXTREMITY,” id.,
at 391, and when the FDA required Wyeth to warn that
“[u]nder no circumstances should Phenergan Injection be
given by intra-arterial injection,” id., at 390, the agency
could reasonably assume that medical professionals would
take care not to inject Phenergan intra-arterially. See also
71 Fed. Reg. 3934 (noting that a drug’s warning label
“communicates to health care practitioners the agency’s
formal, authoritative conclusions regarding the conditions
under which the product can be used safely and effec­
tively”). Unfortunately, the physician’s assistant who
treated respondent in this case disregarded Phenergan’s
label and pushed the drug into the single spot on her arm
that is most likely to cause an inadvertent intra-arterial
injection.
As noted above, when the FDA approved Phenergan’s
label, it was textbook medical knowledge that the “antecu­
bital fossa” creates a high risk of inadvertent intra-arterial
injection, given the close proximity of veins and arteries.
See supra, at 13–14; see also The Lippincott Manual of
Nursing Practice 99 (7th ed. 2001) (noting, in a red-text
“NURSING ALERT,” that the antecubital fossa is “not
recommended” for administering dangerous drugs, “due to
the potential for extravasation”).13 According to the physi­
cian’s assistant who injured respondent, however, “[i]t
never crossed my mind” that an antecubital injection of
Phenergan could hit an artery. App. 110; see also ibid.
(“[It] just wasn’t something that I was aware of at the
time”). Oblivious to the risks emphasized in Phenergan’s
——————
13 In addition, respondent’s own medical expert testified at trial that

it is a principle of “basic anatomy” that the antecubital fossa contains
aberrant arteries. See 2 Tr. 34–35 (Mar. 9, 2004) (testimony of Dr.
Daniel O’Brien); see also ibid. (noting that Gray’s Anatomy, which is
“the Bible of anatomy,” also warns of arteries in the antecubital space).
18 WYETH v. LEVINE

ALITO, J., dissenting

warnings, the physician’s assistant pushed a double dose
of the drug into an antecubital artery over the course of
“[p]robably about three to four minutes,” id., at 111; id., at
105, notwithstanding respondent’s complaints of a
“ ‘burn[ing]’ ” sensation that she subsequently described as
“ ‘one of the most extreme pains that I’ve ever felt,’ ” id., at
110, 180–181. And when asked why she ignored Phener­
gan’s label and failed to stop pushing the drug after re­
spondent complained of burning pains, the physician’s
assistant explained that it would have been “just crazy” to
“worr[y] about an [intra-arterial] injection” under the
circumstances, id., at 111.
The FDA, however, did not think that the risks associ­
ated with IV push—especially in the antecubital space—
were “just crazy.” That is why Phenergan’s label so clearly
warns against them.
B
Given the “balance” that the FDA struck between the
costs and benefits of administering Phenergan via IV
push, Geier compels the pre-emption of tort suits (like this
one) that would upset that balance. The contrary conclu­
sion requires turning yesterday’s dissent into today’s
majority opinion.
First, the Court denies the existence of a federal-state
conflict in this case because Vermont merely counter­
manded the FDA’s determination that IV push is “safe”
when performed in accordance with Phenergan’s warning
label; the Court concludes that there is no conflict because
Vermont did not “mandate a particular” label as a “re­
placement” for the one that the jury nullified, and because
the State stopped short of altogether “contraindicating IV­
push administration.” Ante, at 8. But as we emphasized
in Geier (over the dissent’s assertions to the contrary), the
degree of a State’s intrusion upon federal law is irrele­
vant—the Supremacy Clause applies with equal force to a
 Cite as: 555 U. S. ____ (2009) 19

ALITO, J., dissenting

state tort law that merely countermands a federal safety
determination and to a state law that altogether prohibits
car manufacturers from selling cars without airbags.
Compare 529 U. S., at 881–882, with id., at 902 (STEVENS,
J., dissenting). Indeed, as recently as last Term, we held
that the Supremacy Clause pre-empts a “[s]tate tort law
that requires a manufacturer’s catheters to be safer, but
hence less effective, than the model the FDA has ap­
proved . . . .” Riegel, 552 U. S., at ___ (slip op., at 11). It
did not matter there that the State stopped short of alto­
gether prohibiting the use of FDA-approved catheters—
just as it does not matter here that Vermont stopped short
of altogether prohibiting an FDA-approved method for
administering Phenergan. See also Lohr, 518 U. S., at 504
(BREYER, J., concurring in part and concurring in judg­
ment) (noting it would be an “anomalous result” if pre­
emption applied differently to a state tort suit premised on
the inadequacy of the FDA’s safety regulations and a state
law that specifically prohibited an FDA-approved design).
Second, the Court today distinguishes Geier because the
FDA articulated its pre-emptive intent “without offering
States or other interested parties notice or opportunity for
comment.” Ante, at 21; see also ante, at 24. But the Geier
Court specifically rejected the argument (again made by
the dissenters in that case) that conflict pre-emption is
appropriate only where the agency expresses its pre­
emptive intent through notice-and-comment rulemaking.
Compare 529 U. S., at 885 (“To insist on a specific expres­
sion of agency intent to pre-empt, made after notice-and­
comment rulemaking, would be in certain cases to tolerate
conflicts that an agency, and therefore Congress, is most
unlikely to have intended. The dissent, as we have said,
apparently welcomes that result . . . . We do not”), with
id., at 908–910 (STEVENS, J., dissenting) (emphasizing
that “we generally expect an administrative regulation to
declare any intention to pre-empt state law with some
20 WYETH v. LEVINE

ALITO, J., dissenting

specificity,” and that “[t]his expectation . . . serves to
ensure that States will be able to have a dialog with agen­
cies regarding pre-emption decisions ex ante through the
normal notice-and-comment procedures of the Administra­
tive Procedure Act” (internal quotation marks omitted)).
Indeed, pre-emption is arguably more appropriate here
than in Geier because the FDA (unlike the DOT) declared
its pre-emptive intent in the Federal Register. See 71 Fed.
Reg. 3933–3936. Yet the majority dismisses the FDA’s
published preamble as “inherently suspect,” ante, at 21,
and an afterthought that is entitled to “no weight,” ante,
at 25. Compare Lohr, supra, at 506 (opinion of BREYER,
J.) (emphasizing that the FDA has a “special understand­
ing of the likely impact of both state and federal require­
ments, as well as an understanding of whether (or the
extent to which) state requirements may interfere with
federal objectives,” and that “[t]he FDA can translate
these understandings into particularized pre-emptive
intentions . . . through statements in ‘regulations, pre-
ambles, interpretive statements, and responses to
comments’ ”).
Third, the Court distinguishes Geier because the DOT’s
regulation “bear[s] the force of law,” whereas the FDA’s
preamble does not. Ante, at 24; see also ante, at 19. But it
is irrelevant that the FDA’s preamble does not “bear the
force of law” because the FDA’s labeling decisions surely
do. See 21 U. S. C. §355. It is well within the FDA’s
discretion to make its labeling decisions through adminis­
trative adjudications rather than through less-formal and
less-flexible rulemaking proceedings, see SEC v. Chenery
Corp., 332 U. S. 194 (1947), and we have never previously
held that our pre-emption analysis turns on the agency’s
choice of the latter over the former. Moreover, it cannot be
said that Geier’s outcome hinged on the agency’s choice to
promulgate a rule. See ante, at 19, 24. The Geier Court
relied—again over the dissenters’ protestations—on mate­
 Cite as: 555 U. S. ____ (2009) 21

ALITO, J., dissenting

rials other than the Secretary’s regulation to explain the
conflict between state and federal law. Compare 529
U. S., at 881, with id., at 899–900 (STEVENS, J., dissent­
ing), and ante, at 1–2 (BREYER, J., concurring).
Fourth, the Court sandwiches its discussion of Geier
between the “presumption against pre-emption,” ante, at
18, and heavy emphasis on “the longstanding coexistence
of state and federal law and the FDA’s traditional recogni­
tion of state-law remedies,” ante, at 24. But the Geier
Court specifically rejected the argument (again made by
the dissenters in that case) that the “presumption against
pre-emption” is relevant to the conflict pre-emption analy­
sis. See 529 U. S., at 906–907 (STEVENS, J., dissenting)
(“[T]he Court simply ignores the presumption [against pre­
emption]”). Rather than invoking such a “presumption,”
the Court emphasized that it was applying “ordinary,”
“longstanding,” and “experience-proved principles of con­
flict pre-emption.” Id., at 874. Under these principles, the
sole question is whether there is an “actual conflict” be­
tween state and federal law; if so, then pre-emption fol­
lows automatically by operation of the Supremacy Clause.
Id., at 871–872. See also Buckman, 531 U. S., at 347–348
(“[P]etitioner’s dealings with the FDA were prompted by
[federal law], and the very subject matter of petitioner’s
statements [to the FDA] were dictated by [federal law].
Accordingly—and in contrast to situations implicating
‘federalism concerns and the historic primacy of state
regulation of matters of health and safety’—no presump­
tion against pre-emption obtains in this case” (citation
omitted)).14
——————
14 Thus, it is not true that “this Court has long” applied a presump­

tion against pre-emption in conflict pre-emption cases. Ante, at 9, n. 3
(majority opinion). As long ago as Gibbons v. Ogden, 9 Wheat. 1, 210
(1824), the Court inquired whether a state law “interfer[ed] with,” was
“contrary to,” or “c[a]me into collision with” federal law—and it did so
without ever invoking a “presumption.” See also Davis, Unmasking the
22 WYETH v. LEVINE

ALITO, J., dissenting

Finally, the Geier Court went out of its way to empha­
size (yet again over the dissenters’ objections) that it
placed “some weight” on the DOT’s amicus brief, which
explained the agency’s regulatory objectives and the ef­
fects of state tort suits on the federal regulatory regime.
529 U. S., at 883; compare id., at 910–911 (STEVENS, J.,
dissenting) (criticizing the majority for “uph[olding] a
regulatory claim of frustration-of-purposes implied conflict
pre-emption based on nothing more than an ex post admin­
istrative litigating position and inferences from regulatory
history and final commentary”). See also Lohr, 518 U. S.,
at 496 (recognizing that the FDA is “uniquely qualified” to
explain whether state law conflicts with the FDA’s objec­
tives). Yet today, the FDA’s explanation of the conflict
between state tort suits and the federal labeling regime,
set forth in the agency’s amicus brief, is not even men­
tioned in the Court’s opinion. Instead of relying on the
FDA’s explanation of its own regulatory purposes, the
Court relies on a decade-old and now-repudiated state­
ment, which the majority finds preferable. See ante, at
21–22, 24, n. 13. Cf. Riegel, 552 U. S., at ___ (slip op., at
13) (noting that “the agency’s earlier position (which the
dissent describes at some length and finds preferable) is
——————
Presumption in Favor of Preemption, 53 S. C. L. Rev. 967, 974 (2002)
(noting that many of the Court’s early pre-emption cases “resulted in
almost automatic preemption of concurrent state regulation”). In
subsequent years the Court has sometimes acknowledged a limited
“presumption against pre-emption,” but it nonetheless remained an
open question—before today—whether that presumption applied in
conflict pre-emption cases. See Crosby v. National Foreign Trade
Council, 530 U. S. 363, 374, n. 8 (2000) (“We leave for another day a
consideration in this context of a presumption against preemption”).
Moreover, this Court has never held that the “presumption” applies in
an area—such as drug labeling—that has long been “reserved for
federal regulation.” United States v. Locke, 529 U. S. 89, 111 (2000).
See also Buckman Co. v. Plaintiffs’ Legal Comm., 531 U. S. 341, 347–
348 (2001).
 Cite as: 555 U. S. ____ (2009) 23

ALITO, J., dissenting

. . . compromised, indeed deprived of all claim to deference,
by the fact that it is no longer the agency’s position” (cita­
tion omitted)); Altria Group, Inc. v. Good, 555 U. S. ___,
___ (2008) (slip op., at 16–17) (rejecting petitioners’ reli­
ance on the pre-emptive effect of the agency’s “longstand­
ing policy” because it is inconsistent with the agency’s
current one). And JUSTICE BREYER suggests that state
tort suits may “help the [FDA],” ante, at 1 (concurring
opinion), notwithstanding the FDA’s insistence that state
tort suits will “disrupt the agency’s balancing of health
risks and benefits,” Brief for United States as Amicus
Curiae 9.
Geier does not countenance the use of state tort suits to
second-guess the FDA’s labeling decisions. And the
Court’s contrary conclusion has potentially far-reaching
consequences.
C
By their very nature, juries are ill-equipped to perform
the FDA’s cost-benefit-balancing function. As we ex­
plained in Riegel, juries tend to focus on the risk of a
particular product’s design or warning label that arguably
contributed to a particular plaintiff’s injury, not on the
overall benefits of that design or label; “the patients who
reaped those benefits are not represented in court.” 552
U. S., at ___ (slip op., at 12). Indeed, patients like respon­
dent are the only ones whom tort juries ever see, and for a
patient like respondent—who has already suffered a tragic
accident—Phenergan’s risks are no longer a matter of
probabilities and potentialities.
In contrast, the FDA has the benefit of the long view.
Its drug-approval determinations consider the interests of
all potential users of a drug, including “those who would
suffer without new medical [products]” if juries in all 50
States were free to contradict the FDA’s expert determina­
tions. Id., at ___ (slip op., at 13). And the FDA conveys its
24 WYETH v. LEVINE

ALITO, J., dissenting

warnings with one voice, rather than whipsawing the
medical community with 50 (or more) potentially conflict­
ing ones. After today’s ruling, however, parochialism may
prevail.
The problem is well illustrated by the labels borne by
“vesicant” drugs, many of which are used for chemother­
apy. As a class, vesicants are much more dangerous than
drugs like Phenergan,15 but the vast majority of vesicant
labels—like Phenergan’s—either allow or do not disallow
IV push. See Appendix, infra. Because vesicant extrava­
sation can have devastating consequences, and because
the potentially lifesaving benefits of these drugs offer
hollow solace to the victim of such a tragedy, a jury’s cost­
benefit analysis in a particular case may well differ from
the FDA’s.
For example, consider Mustargen (mechlorethamine
HCl)—the injectable form of mustard gas—which can be
used as an anticancer drug. Mustargen’s FDA-approved
label warns in several places that “This drug is HIGHLY
TOXIC.”16 Indeed, the drug is so highly toxic:
“Should accidental eye contact occur, copious irriga­
tion for at least 15 minutes with water, normal saline
or a balanced salt ophthalmic irrigating solution
should be instituted immediately, followed by prompt
ophthalmologic consultation. Should accidental skin

——————
15 Vesicants may cause “blistering, severe tissue injury, or tissue
necrosis” upon extravasation—even if the drug is not injected into an
artery. See, e.g., Schulmeister, Administering Vesicants, 9 Clinical J.
of Oncology Nursing 469, 469–470 (2005). See also ante, at 4 (majority
opinion) (noting that Phenergan is labeled as an “irritant”); cf. Brief for
Anju Budhwani et al. as Amici Curiae 15 (suggesting Phenergan should
be considered a “vesicant”).
16 FDA, Oncology Tools Product Label Details, online at
http://www.accessdata.fda.gov/scripts/cder/onctools/
labels.cfm?GN=meclorethamine,%20nitrogen%20mustard (as visited Mar. 2,
2009, and available in Clerk of Court’s case file).
 Cite as: 555 U. S. ____ (2009) 25

ALITO, J., dissenting

contact occur, the affected part must be irrigated im­
mediately with copious amounts of water, for at least
15 minutes while removing contaminated clothing and
shoes, followed by 2% sodium thiosulfate solution.
Medical attention should be sought immediately.
Contaminated clothing should be destroyed.”17
Yet when it comes to administering this highly toxic drug,
the label provides that “the drug may be injected directly
into any suitable vein, [but] it is injected preferably into
the rubber or plastic tubing of a flowing intravenous infu­
sion set. This reduces the possibility of severe local reac­
tions due to extravasation or high concentration of the
drug.” (Emphasis added.) Similarly, the FDA-approved
labels for other powerful chemotherapeutic vesicants—
including Dactinomycin, Oxaliplatin, Vinblastine, and
Vincristine—specifically allow IV push, notwithstanding
their devastating effects when extravasated.
The fact that the labels for such drugs allow IV push is
striking—both because vesicants are much more danger­
ous than Phenergan, and also because they are so fre­
quently extravasated, see Boyle & Engelking, Vesicant
Extravasation: Myths and Realities, 22 Oncology Nursing
Forum 57, 58 (1995) (arguing that the rate of extravasa­
tion is “considerably higher” than 6.4% of all vesicant
administrations). Regardless of the FDA’s reasons for not
contraindicating IV push for these drugs, it is odd (to say
the least) that a jury in Vermont can now order for Phen­
ergan what the FDA has chosen not to order for mustard
gas.18

——————
17 Ibid.
18 The same is true of FDA’s regulation of hydroxyzine. See n. 9,
supra.
26 WYETH v. LEVINE

ALITO, J., dissenting

* * *
To be sure, state tort suits can peacefully coexist with
the FDA’s labeling regime, and they have done so for
decades. Ante, at 17–18. But this case is far from peaceful
coexistence. The FDA told Wyeth that Phenergan’s label
renders its use “safe.” But the State of Vermont, through
its tort law, said: “Not so.”
The state-law rule at issue here is squarely pre-empted.
Therefore, I would reverse the judgment of the Supreme
Court of Vermont.
 Cite as: 555 U. S. ____ (2009)
27

Appendix to J., dissenting , J.

ALITO, opinion of ALITO

APPENDIX TO OPINION OF ALITO, J.

Vesicant1 IV Push2
Dactinomycin Specifically allowed
Mechlorethamine Specifically allowed
(Mustargen)
Oxaliplatin Specifically allowed
Vinblastine Specifically allowed
Vincristine Specifically allowed
Bleomycin Neither mentioned nor prohibited
Carboplatin Neither mentioned nor prohibited
Dacarbazine Neither mentioned nor prohibited
Mitomycin Neither mentioned nor prohibited
Carmustine Not prohibited; IV drip recommended
Cisplatin Not prohibited; IV drip recommended
Epirubicin Not prohibited; IV drip recommended
Etoposide Not prohibited; IV drip recommended
Ifosfamide Not prohibited; IV drip recommended
Mitoxantrone Not prohibited; IV drip recommended
Paclitaxel Not prohibited; IV drip recommended
Teniposide Not prohibited; IV drip recommended
Vinorelbine Not prohibited; IV drip recommended
Daunorubicin Prohibited
Doxorubicin Prohibited
1 Wilkes & Barton-Burke, 2008 Oncology Nursing Drug Handbook

27–33 (2008) (Table 1.6).
2 IV-push information is derived from the “dosage and administra­

tion” sections of individual drug labels (available in Clerk of Court’s
case file).