Johnny C. McClain v. Metabolife International, Inc

[PUBLISH]

IN THE UNITED STATES COURT OF APPEALS

FOR THE ELEVENTH CIRCUIT FILED
________________________
U.S. COURT OF APPEALS
ELEVENTH CIRCUIT
No. 03-12776 March 2, 2005
________________________ THOMAS K. KAHN
D. C. Docket No. 01-01801-CV-AR-S CLERK

JOHNNY C. MCCLAIN,
ANNIE MCCLAIN,
Plaintiffs-Appellees,

SHIRLEY FRANKS,
WILMER HUDSON, et al.,
Plaintiffs-Appellees,
Cross-Appellants,
versus

METABOLIFE INTERNATIONAL, INC.,
a corporation,
Defendant-Appellant,
Cross-Appellee.
________________________

Appeals from the United States District Court
for the Northern District of Alabama
_________________________
(March 2, 2005)

Before ANDERSON and BIRCH, Circuit Judges, and ROYAL*, District Judge.

ROYAL, District Judge:
_______________________
*Honorable C. Ashley Royal, United States District Judge for the Middle District of Georgia,
sitting by designation.
 This is an appeal of a jury verdict in a products liability action against

Metabolife International, Inc. At trial Plaintiffs claimed that they suffered serious

medical problems after taking Metabolife 356, an herbal weight-loss supplement,

manufactured, marketed, and sold by Metabolife. After hearing the evidence, a

jury returned a verdict in Plaintiffs' favor. Metabolife now appeals that verdict on

the ground that the trial court erred in admitting the testimony of Plaintiffs' experts

on the issue of causation. For the reasons discussed below, we find that the trial

court erroneously admitted Plaintiffs' experts' testimony. Accordingly, we

REVERSE and REMAND for proceedings below consistent with these rulings.

I. Background Information

Annie McClain, Shirley Franks, Connie Thornburg and Wilmer Hudson

contend that they suffered serious injuries after taking Metabolife 356, an herbal

appetite suppressant containing ephedrine and caffeine. Ephedrine occurs

naturally in a plant called ma huang and has been used for decades for treating

adults and children, especially in over-the-counter medicines.

Plaintiffs brought this action against Defendant Metabolife International,

Inc., charging that Metabolife manufactured, marketed, and sold an unreasonably

dangerous diet drug. Plaintiffs further contend that Metabolife knew that its

product could cause heart attacks and strokes, but nonetheless, continued to sell

2
the drug without adequate warning. All four Plaintiffs took the dietary aid.

Plaintiffs Thornburg, Franks, and McCain suffered ischemic cerebral events

(strokes), and Plaintiff Hudson suffered an acute myocardial infarction (heart

attack).

Before trial Metabolife moved to exclude Plaintiffs' experts' testimony on

medical causation asserting that Plaintiffs' experts' opinions lacked a reliable

foundation for admission under the standards of Daubert v. Merrell Dow

Pharmaceuticals, Inc., 509 U.S. 579 (1993). The trial court held a Daubert

hearing, and Plaintiffs offered two expert witnesses to prove causation: James

O'Donnell, Pharm. D., and Hashim Hakim, M.D., a neurologist. Dr. O'Donnell

primarily offered opinions on general causation. Dr. Hakim offered testimony on

both general and individual causation.

In its brief written order on the motion, the district court acknowledged its

role as a gatekeeper under FED. R. EVID. 702, but concluded that it lacked

sufficient knowledge on the scientific subject matter to exclude the testimony

presented and that Defendant had not produced competing testimony for it to

determine that, as a matter of law, testimony from Plaintiffs' experts was

inadmissible. Metabolife later filed a motion for reconsideration on the issue, and

it was denied. The two experts testified at trial on the issues covered by

3
Defendant's motion, and the jury returned a verdict for Plaintiffs. Defendant

appealed contending that the district court abused it discretion in admitting

Plaintiffs' experts' testimony on medical causation.

II. Legal Standard

This is a toxic tort case. Plaintiffs contend that the toxic combination of

ephedrine and caffeine in the Metabolife 356 that they ingested harmed them. To

prove their toxic tort claims, Plaintiffs must prove the toxicity of the ephedrine/

caffeine combination and that it had a toxic effect on them causing the injuries that

they suffered — ischemic strokes in three Plaintiffs and a heart attack in the other.

This type of proof requires expert testimony, and when a party offers expert

testimony and the opposing party raises a Daubert challenge, the trial court must

"make certain that an expert, whether basing testimony upon professional studies

or personal experience, employs in the courtroom the same level of intellectual

rigor that characterizes the practice of an expert in the relevant field." Kumho Tire

Co. v. Carmichael, 526 U.S. 137, 152 (1999). This requirement for proof of the

reliability of the expert's method comes from FED. R. EVID. 702, which authorizes

the admission of expert opinion testimony "if (1) the testimony is based upon

sufficient facts or data, (2) the testimony is the product of reliable principles and

4
methods, and (3) the witness has applied the principles and methods reliably to the

facts of

the case." Rule 702 lays the foundation for the trial court's Daubert analysis. 509

U.S. at 590.

Daubert requires the trial court to act as a gatekeeper to insure that

speculative and unreliable opinions do not reach the jury. Id. at 589 n. 7, 597. As a

gatekeeper the court must do "a preliminary assessment of whether the reasoning or

methodology underlying the testimony is scientifically valid and of whether that

reasoning or methodology properly can be applied to the facts in issue." Id. at 593-

94. The proposed testimony must derive from the scientific method; good grounds

and appropriate validation must support it.1 Id. at 590. "In short, the requirement

that an expert's testimony pertain to 'scientific knowledge' establishes a standard of

evidentiary reliability." Id. The court must consider the testimony with the

understanding that "[t]he burden of establishing qualification, reliability, and

1
While this opinion focuses upon the scientific methodology of an expert, it should be
remembered that "experience in a field may offer another path to expert status." United States v.
Frazier, 387 F.3d 1244, 1260 (11th Cir. 2004). "In fact, the plain language of Rule 702 makes
this clear: expert status may be based on 'knowledge, skill, experience, training, or education.'"
Id. (emphasis omitted).

5
helpfulness rests on the proponent of the expert opinion. . . ." United States v.

Frazier, 387 F.3d 1244, 1260 (11th Cir. 2004).2

The court of appeals reviews a trial court's Daubert rulings under an abuse of

discretion standard. Gen. Elec. Co. v. Joiner, 522 U.S. 136, 140 (1999). A "district

court enjoys 'considerable leeway' in making [reliability] determinations" under

Daubert. Kumho, 526 U.S. at 152. Thus, "[w]hen applying [the] abuse of

discretion standard, we must affirm unless we at least determine that the district

court has made a 'clear error of judgment,' or has applied an incorrect legal

standard." See Piamba Cortes v. Am. Airlines, Inc., 177 F.3d 1272, 1306 (11th Cir.

1999) (quoting SunAmerica Corp. v. Sun Life Assurance Co. of Canada, 77 F.3d

1325, 1333 (11th Cir. 1996)).

A trial court, however, abuses its discretion by failing to act as a gatekeeper.

In this case the trial court essentially abdicated its gatekeeping role. Although the

trial court conducted a Daubert hearing, and both witnesses were subject to a

2
In its order following the Daubert hearing, the court below indicated that it was unclear
who bore the burden of proof as to the reliability of a proffered expert's opinions. That burden
clearly rests with the proponent of that expert, see Frazier at 1260, and thus in this case Plaintiffs
bore the burden of establishing the reliability of their experts' opinions.

6
thorough and extensive examination, the court ultimately disavowed its ability to

handle the Daubert issues.3 This abdication was in itself an abuse of discretion.4

Yet, even had the trial court fully accepted its role, it would have abused its

discretion by admitting the experts' testimony. The record of their testimony in the

pretrial hearing demonstrates that their testimony failed to satisfy the standards of

reliability required under Daubert and its progeny. The admission of their

testimony on medical causation in this toxic tort case substantially prejudiced

Metabolife and authorizes reversal of the judgment. See Piamba Cortes, 177 F.3d

at 1305.

3
In ruling on the Daubert motion, the trial court stated:
Trying to cope in this case without a pharmacological, or a medical, or a chemical,
or a scientific background, the court cannot fully and fairly appreciate and
evaluate the methodology employed by either of these witnesses as they reached
the conclusions they reached, conclusions that a jury could not reach without
some expert opinion testimony. Neither can the court fully appreciate or evaluate
the criticisms made by defendant of the proposed testimony of these witnesses,
especially when the criticisms do not come from competing proposed experts.
This court does not pretend to know enough to formulate a logical basis for a
preclusionary order that would necessarily find, as a matter of law, that these
witnesses cannot express to a jury the opinions they articulated to the court.
4
See Kumho, 526 U.S. at 158-59 (Scalia, J. concurring) ("[T]rial-court discretion in
choosing the manner of testing expert reliability — is not discretion to abandon the gatekeeping
function. I think it worth adding that it is not discretion to perform the function inadequately.
Rather, it is discretion to choose among reasonable means of excluding expertise that is fausse
and science that is junky."); Joiner, 522 U.S. at 148. (Breyer J. concurring) ("Of course, neither
the difficulty of the task nor any comparative lack of expertise can excuse the judge from
exercising the 'gatekeeper' duties that the Federal Rules of Evidence impose . . . .").

7
 In analyzing the experts' testimony, we note that toxic tort cases usually

come in two broad categories: first, those cases in which the medical community

generally recognizes the toxicity of the drug or chemical at issue, and second, those

cases in which the medical community does not generally recognize the agent as

both toxic and causing the injury plaintiff alleges. Examples of the first type

include toxins like asbestos, which causes asbestosis and mesothelioma; silica,

which causes silicosis; and cigarette smoke, which causes cancer. This case,

involving Metabolife's combination of ephedrine and caffeine, falls into the second

category. The medical community does not generally recognize the toxicity of this

drug combination or ephedrine alone as causing the injuries Plaintiffs allege.

The court need not undertake an extensive Daubert analysis on the general

toxicity question when the medical community recognizes that the agent causes the

type of harm a plaintiff alleges. The battleground in this first category of cases

focuses on plaintiff-specific questions: was plaintiff exposed to the toxin, was

plaintiff exposed to enough of the toxin to cause the alleged injury, and did the

toxin in fact cause the injury? A Daubert analysis in the first type of case deals

with questions of individual causation to plaintiff.

In the second category of toxic tort cases, the Daubert analysis covers not

only the expert's methodology for the plaintiff-specific questions about individual

8
causation but also the general question of whether the drug or chemical can cause

the harm plaintiff alleges.5 This is called general causation. "General causation is

concerned with whether an agent increases the incidence of disease in a group and

not whether the agent caused any given individual's disease." Michael D. Green et

al., Reference Guide on Epidemiology, in REFERENCE MANUAL ON SCIENTIFIC

EVIDENCE 392 (Federal Judicial Center, 2d ed. 2000). Thus, in this case, Plaintiffs'

experts must offer reliable opinions about Metabolife's general toxicity for the

harm Plaintiffs allege and that it in fact harmed them. The court will consider,

therefore, the reliability of Plaintiffs' experts' opinions on the question of general

causation and also the question of individual causation.

III. James O'Donnell, Pharm. D.

Dr. O'Donnell, Pharm. D., testified as an expert in pharmacy, pharmacology

and nutrition; he is not a toxicologist or a medical doctor. He based his opinions

5
This is not an effort to resurrect the test first announced in Frye v. United States, 293 F.
1013, 1014 (D.C. Cir. 1923), and later applied by the Ninth Circuit Court of Appeals in its ruling
on Daubert stating that "expert opinion based on a scientific technique is inadmissible unless the
technique is 'generally accepted' as reliable in the relevant scientific community." Daubert, 951
F. 2d 1128, 1129-1130, vacated, 509 U.S. 579 (1993) (overruling Frye). This two-part
designation for toxic tort cases is devised to further the interests of judicial economy. There is
rarely a reason for a court to consider opinions that medical doctors routinely and widely
recognize as true, like cigarette smoking causes lung cancer and heart disease, too much alcohol
causes cirrhosis of the liver, and that the ingestion of sufficient amounts of arsenic causes death.
This two-part division follows a point made in Kumho that the trial court does not need to waste
time with a Daubert hearing "where the reliability of an expert's methods is properly taken for
granted, and to require appropriate proceedings in the less usual or more complex cases where
cause for questioning the expert's reliability arises." Kumho, 526 U.S. at 152.

9
about Metabolife's toxicity and its ability to cause heart attacks and strokes in

substantial part on ephedrine's classification as a sympathomimetic drug. He

testified that drugs in the sympathomimetic family, including ephedrine, cause

constriction of blood vessels that leads to increased pulse rate and increased blood

pressure. The long-term use of ephedrine can cause narrowing of blood vessels,

called vasospasm, a transitory constriction of a blood vessel, and also vasculitis, an

inflamation or irritation of blood vessels. Vasospasm and vasculitis caused by

extended use of ephedrine can lead to heart attacks and strokes. That Metabolife

causes vasospasm and vasculitis, which in turn causes strokes and heart attacks, is

O'Donnell's ultimate opinion that the court must analyze under Daubert.

O'Donnell also testified that adding caffeine to ephedrine in Metabolife 356

makes ephedrine more toxic, so any amount of caffeine added to ephedrine is too

much. This combination of drugs poses an "imminent risk of death."

O'Donnell's opinions lack the indicia of reliability necessary to survive a

Daubert inquiry and challenge under Rule 702. He draws speculative conclusions

about Metabolife's toxicity from questionable principles of pharmacology, while at

the same time, neglecting the hallmark of the science of toxic torts — the dose-

response relationship. He also draws unsubstantiated analogies between ephedrine

and phenylpropanolamine, infers conclusions from studies and reports that the

10
papers do not authorize, and unjustifiably relies on government public health

reports and consumer complaints to establish medical causation. In short,

O'Donnell does not support his opinions with sufficient data or reliable principles,

as identified by the Daubert rubric, and fails to follow the basic methodology that

experts should follow in toxic tort cases.

A. Application of Broad Scientific Principles

O'Donnell testified that ephedrine belongs to a family of drugs called the

sympathomimetics. These drugs stimulate the cardiovascular system by raising

heart rate and blood pressure. He drew key conclusions about ephedrine's toxicity

from its classification as a sympathomimetic. A close examination of his

testimony, however, shows that he dramatically dilutes the value of these

conclusions, which in turn, impugns his methodology. About ephedrine's family or

drug class connection and effects, he left a trail of equivocation by making the

following statements at various points in his testimony: Sympathomimetics can

constrict blood vessels. And when you constrict blood vessels, you may raise

blood pressure. Sympathomimetics stimulate the heart and increase the pulse,

increase the heart rate. If you stimulate the heart, you may cause an abnormal heart

rate or an abnormal heart rhythm. If you constrict blood vessels, if it happens in a

11
cerebral vessel in the brain, it may cause vasospasm which may lead to a stroke. If

you stimulate or cause a constriction in the coronary blood vessel that can cause

vasospasm and it may lead to chest pain, angina, arrhythmia, or myocardial

infarction. He also testified that "aggravation of blood pressure is something that

the ephedrine and caffeine in Metabolife or any product containing those drugs can

do." He further explained that the ephedrine/caffeine combination "can elevate

blood pressure and stimulate the heart, and it has been reported to be associated

with strokes and heart attacks." Or as O'Donnell stated: "this may be dangerous

for some patients." O'Donnell's equivocation about the effects of

sympathomimetics exposes a tenuous basis for his opinions about Metabolife's

profound toxicity — that any level of caffeine combined with ephedrine poses "an

unreasonable risk of harm."

O'Donnell likewise offered nothing specific about how Metabolife affects

individuals. When asked how one tablet of Metabolife might increase heart rate, he

could not give an answer and explained that it would vary from patient to patient.

He also could not say how much it might elevate a patient's blood pressure. He

agreed that effect would vary from patient to patient and admitted that it might not

raise a person's blood pressure at all. He further said that aerobic exercise impacts

12
blood pressure and heart rate more than the maximum recommended dosage of

Metabolife.

Although he agreed that a drug's effect is dose-driven, he offered no

testimony about the dose of Metabolife required to injure Plaintiffs or anyone else.

He could not say how much is too much. In explaining his opinion about the

extreme danger of Metabolife, while at the same time offering no opinions about

dose, he said: "[t]hat's why I always answer with potential, may, or could." On the

other hand, he admitted that the amount of ephedrine in Metabolife 356 does not

exceed the amount of ephedrine in the hundreds of over-the-counter products

available to the public. Likewise, he conceded that many people take drugs

containing ephedrine at the same time they ingest large amounts of caffeine from

coffee, and that the recommended dose of Metabolife 356 contains 72 milligrams

of ephedrine, roughly half the FDA allowable limits on ephedrine. His lack of

testimony about the dose-response relationship combined with his vague testimony

about significant individual variations leaves a muddle of ambiguity that

undermines his opinions.

Because of this ambiguity, O'Donnell laid no reliable groundwork for

determining the dose-response relationship for either ephedrine or ephedrine and

caffeine. This signals a methodology problem. In toxic tort cases, "[s]cientific

13
knowledge of the harmful level of exposure to a chemical plus knowledge that

plaintiff was exposed to such quantities are minimal facts necessary to sustain the

plaintiff's burden . . . ." Allen v. Pennsylvania Eng'g Corp., 102 F.3d 194, 199 (5th

Cir. 1996). Or, as the Court of Appeals for the Tenth Circuit explained in Mitchell

v. Gencorp, 165 F.3d 778, 781 (10th Cir. 1999), to carry the burden in a toxic tort

case, "a plaintiff must demonstrate 'the levels of exposure that are hazardous to

human beings generally as well as the plaintiff's actual level of exposure to the

defendant's toxic substance before he or she may recover,'" (quoting Wright v.

Willamette Indus., Inc., 91 F.3d 1105, 1106 (8th Cir. 1996)); see also Moore v.

Ashland Chem. Inc., 151 F.3d 269, 278 (5th Cir. 1998) (excluding expert testimony

which "offered no scientific support for his general theory that exposure to toluene

solution at any level would cause RADS.").6

Although Plaintiffs can testify about how much Metabolife 356 they took,

O'Donnell could not provide any opinions about the general dose-response levels

for Metabolife's toxicity, i.e., the dose or level of exposure at which it causes harm.

O'Donnell opined that any level is too much, but this statement conflicts with the

importance of individual responses to toxins — "[b]ecause of individual variation,

6
One should not conclude from this analysis that to pass Daubert muster an expert must
give precise numbers about a dose-response relationship. Some ambiguity about individual
responses is expected. However, the link between an expert's opinions and the dose-response
relationship is a key element of reliability in toxic tort cases.

14
a toxic agent generally will not cause disease in every person exposed." Green,

supra, at 392.

When analyzing an expert's methodology in toxic tort cases, the court should

pay careful attention to the expert's testimony about the dose-response relationship.

The dose-response relationship is "[a] relationship in which a change in amount,

intensity, or duration of exposure to an agent is associated with a change — either

an increase or decrease — in risk of disease." Id. at 390. The expert who avoids or

neglects this principle of toxic torts without justification casts suspicion on the

reliability of his methodology.

To help federal judges deal with Daubert issues in toxic tort cases, the

Federal Judicial Center published several articles in the Journal of Law and Policy

under the title "Science for Judges I: Papers on Toxicology and Epidemiology."

12 J.L. & POL'Y 1 (2003).7 The article entitled "Scientific Judgment and Toxic

Torts — A Primer in Toxicology for Judges and Lawyers" by Dr. David Eaton

provides valuable insight for understanding how to assess Daubert issues in these

cases. Id. at 5. Dr. Eaton, Ph.D., is a toxicologist and Professor of Environmental

and Occupational Health Sciences at the University of Washington. Id. He also

7
The FJC collaborated on this work with the Brooklyn Law School's Center for Health
Law and Policy and the Panel on Science, Law and Technology of the National Academy of
Sciences. 12 J.L. & POL'Y 1 (2003).

15
serves as Associate Dean for Research, School of Public Health and Community

Medicine at the University. Id.

In his article Eaton describes some key principles of toxicology that a court

should consider in "any attempt to establish whether a chemical exposure was

causally related to a specific adverse effect or disease in an individual." Id. at 9.

Foremost among these principles is the dose-response relationship.

Dr. Eaton explains that "the relationship between dose and effect (dose-

response relationship) is the hallmark of basic toxicology." Id. at 15. "Dose is the

single most important factor to consider in evaluating whether an alleged exposure

caused a specific adverse effect." Id. at 11. Often "low dose exposures — even for

many years — will have no consequence at all, since the body is often able to

completely detoxify low doses before they do any damage." Id. at 13.

Furthermore, "for most types of dose-response relationships following chronic

(repeated) exposure, thresholds exist, such that there is some dose below which

even repeated, long-term exposure would not cause an effect in any individual."

Id. at 16.

These essential principles of toxicology directly contradict several of what

O'Donnell calls "the broad principles of pharmacology" upon which he bases his

opinions. But more importantly, it shows something about O'Donnell's

16
methodology: he does not follow the basic methodology that scientists use to

determine causation — the dose-response relationship.

Beyond explaining the importance of the dose-response relationship, Dr.

Eaton offers four scientific criteria for proving causation between a chemical

exposure and a particular illness in an individual. First, "the toxic substance in

question must have been demonstrated to cause the type of illness or disease in

question." Id. at 38. This focuses on the issue of general causation. O'Donnell has

failed to show that Metabolife 356 causes either strokes or heart attacks.

Furthermore, the medical literature does not support this opinion. O'Donnell has

simply substituted his own ipse dixit for scientific proof on this essential issue.

Second, "the individual must have been exposed to a sufficient amount of the

substance in question to elicit the health effect in question." Id. at 39. This

requires not simply proof of exposure to the substance, but proof of enough

exposure to cause the plaintiff's specific illness. This focuses on the issue of

individual causation.

As already shown, O'Donnell offers no opinion about the dose of Metabolife

that caused ischemic strokes in three Plaintiffs and a heart attack in the other. He

17
only said that any amount of Metabolife is too much, which clearly contradicts the

principles of reliable methodology delineated by Eaton.8

Third, "the chronological relationship between exposure and effect must be

biologically plausible." Id. On this point Eaton explains that "if a disease or

illness in an individual preceded the established period of exposure, then it cannot

be concluded that the chemical caused the disease, although it may be possible to

establish that the chemical aggravated a pre-existing condition or disease." Id. at

39-40. This also focuses on individual causation.

The issue of the chronological relationship leads to another important point

— proving a temporal relationship between taking Metabolife and the onset of

symptoms does not establish a causal relationship. In other words, simply because

a person takes drugs and then suffers an injury does not show causation. Drawing

such a conclusion from temporal relationships leads to the blunder of the post hoc

ergo propter hoc fallacy.

The post hoc ergo propter hoc fallacy assumes causality from temporal

sequence. It literally means "after this, because of this." BLACK'S LAW

8
Although the court understands that Daubert focuses on the methodology used to derive
opinions rather than on the accuracy of the opinion, when the opinions clearly demonstrate
something about the expert's methodology, as in this case, the court can draw inferences about
the methodology from the opinions. As the Supreme Court said in Joiner: "Conclusions and
methodology are not entirely distinct from one another." 522 U.S. at 147.

18
DICTIONARY 1186 (7th ed. 1999). It is called a fallacy because it makes an

assumption based on the false inference that a temporal relationship proves a causal

relationship. As the Court of Appeals for the District of Columbia explained in a

similar context: "[i]n essence, the requirement of 'adequate documentation in

scientific literature' ensures that decision makers will not be misled by the post hoc

ergo propter hoc fallacy — the fallacy of assuming that because a biological injury

occurred after a spill, it must have been caused by the spill." Ohio v. U.S. Dept. of

the Interior, 880 F.2d 432, 473 (D.C. Cir. 1989).

Fourth, and finally, "the likelihood that the chemical caused the disease or

illness in an individual should be considered in the context of other known causes."

Eaton, supra, at 40. This refers to the background risk of a specific disease — the

risk that everyone faces of suffering the same malady that a plaintiff claims without

having exposure to the same toxin.

A reliable methodology should take into account the background risk. The

background risk is not the risk posed by the chemical or drug at issue in the

case. It is the risk a plaintiff and other members of the general public have of

suffering the disease or injury that plaintiff alleges without exposure to the drug or

chemical in question. The background risks include all those causes of a disease,

whether known or unknown, excluding the drug or chemical in question. So, the

19
background risk for heart attack is very high because heart disease is the leading

cause of morbidity and mortality in America. See Heart Attacks, Nat'l Heart,

Lung, & Blood Inst., at http://www.nhlbi.nih.gov (last visited Dec. 27, 2004).

Likewise, stroke is the third leading cause of death in America and the leading

cause of disability. See Jeffrey L. Arnold, Ischemic Stroke, emedicine, at

http://www.emedicine.com (last visited Dec. 27, 2004). Ischemic strokes, like

three Plaintiffs suffered in this case, account for 80% of all stroke cases. Id.

Thus, in evaluating the reliability of the experts' opinions on general

causation, it would help to know how much additional risk for heart attack or

ischemic stroke Metabolife consumers have over the risks the general population

faces. If ephedrine or an ephedrine/caffeine combination do not increase the

incidence of heart attack and ischemic stroke in persons who ingest it, as opposed

to all those who do not and still have heart attacks and strokes, that fact would

reduce the likelihood that Metabolife harmed Plaintiffs. Likewise, if Plaintiffs

could show that taking Metabolife increases the risk of heart attack and ischemic

stroke beyond the usual incidence of these common diseases, that would support

their methodology in this case. O'Donnell offered no evidence of additional risk.

The court must assume that it does not exist. (Indeed, O'Donnell testified that he

did not know the background risk for stroke and heart attack.)

20
 Toxicologists and medical doctors doing research commonly assess risks

posed by drugs, chemicals and other agents. A quick internet search of TOXNET

for "risk assessment" or "background risks" will show thousands of articles about

risks for various drugs and chemicals — Plaintiffs' experts offered no such

evidence. See generally, Thomas v. Hoffman-LaRoche, Inc., 949 F.2d 806, 816

(5th Cir. 1992); Norfolk v. W. Ry. Co. v. Ayers, 538 U.S. 135, 156 (2003).

Now as to these four criteria for proving causation, O'Donnell failed to

demonstrate a link between Metabolife and the types of injuries Plaintiffs suffered

as required by the first criteria. He also failed to show that Plaintiffs had sufficient

individual exposure to Metabolife to cause the medical problems as required by the

second criteria, and he further failed to show evidence of an increased incidence of

strokes and heart attacks from Metabolife 356 over the background risk as required

by the fourth criteria. There is evidence in the case supporting the third criteria, the

chronological relationship between exposure and effect, but this does not overcome

the failure of proof on the other three propositions.

Finally, on the speculative nature of his testimony, O'Donnell attempts to

anoint his opinions by claiming that he based them on the "broad principles of

pharmacology." In the Daubert context, such phrases have little value. They are

not shibboleths that distinguish those experts that offer reliable science from those

21
who foist junk science on the court. "The expert's assurances that he has utilized

generally accepted scientific methodology [are] insufficient." See Moore, 151 F.3d

at 276. Such statements can spring just as quickly from the ipse dixit of the expert

as some ultimate opinion about causation or toxicity. As the Supreme Court

explained in Joiner: "nothing in either Daubert or the Federal Rules of Evidence

requires a district court to admit opinion evidence that is connected to existing data

only by the ipse dixit of the expert." 522 U.S. at 147. Moreover, "[t]he trial court's

gatekeeping function requires more than simply 'taking the expert's word for it.'"

FED. R. EVID. 702 advisory committee's note (2000).

B. The PPA Analogy

In reaching his opinions about general causation, O'Donnell relies heavily on

an analogy between ephedrine and phenylpropanolamine (PPA). PPA is a

sympathomimetic drug that has been used widely in over-the-counter cough and

cold medications and weight loss products. RALPH I. HOROWITZ ET AL.,

PHENYLPROPANOLAMINE & RISK OF HEMORRHAGIC STROKE: FINAL REPORT OF THE

HEMORRHAGIC STROKE PROJECT (2000). The conclusions that O'Donnell draws

about ephedrine by analogy from PPA are very important to his opinions, but he

did not show the reliability of each of his steps in deducing Metabolife's toxicity

from this analogy. This is a fatal defect under Daubert. "The Daubert 'requirement

22
that the expert testify to scientific knowledge — conclusions supported by good

grounds for each step in the analysis — means that any step that renders the

analysis unreliable under the Daubert factors renders the expert's testimony

inadmissible.'" Amorgianos v. Nat'l R.R. Passenger Corp., 303 F.3d 256, 267

(2002) (quoting In re Paoli R.R. Yard PCB Litig., 35 F.3d 717, 745 (3rd Cir.

1994)).

When O'Donnell described how ephedrine damages blood vessels based on

the PPA analogy, he stated that the longer one has exposure to a chemical, the more

rigid a blood vessel becomes, and it takes time for the body to release a chemical

even after the person stops taking the medicine. Thus, the drug can cause

vasospasm or vasculitis and continue to cause these problems even after someone

stops taking the drug. These steps are essential to his analysis of Metabolife's

toxicity in general and for Plaintiffs' specific injuries. But he admitted that this

theory has only been proven with PPA, not ephedrine.

O'Donnell cannot show that Metabolife causes vasospasm and vasculitis,

which in turn causes ischemic strokes and heart attacks, except by a leap of faith.

He also cannot show that Metabolife stays in the body for prolonged periods after

someone stops taking it or that its effects linger. The medical articles do not

support these conclusions. Speculation replaces science in this unreliable analogy

23
between ephedrine and phenylpropanolamine. "Subjective speculation that

masquerades as scientific knowledge" does not provide good grounds for the

admissibility of expert opinions. Glastetter v. Novartis Pharm. Corp., 252 F.3d

986, 989 (8th Cir. 2001).

According to O'Donnell, studies have shown that PPA causes vasospasm and

vasculitis that lead to stroke and heart attack, and the studies also show that long-

term use of the drug can cause a continuation of symptoms even after a person

stops taking it. For these conclusions he relied primarily on the Hemorrhagic

Stroke Project (HSP) that showed a 15-fold increase in the risk of hemorrhagic

strokes in patients who took PPA as a diet supplement rather than as a cough and

cold remedy. Horowitz, supra, at 2. These results, he said, should be reasonably

analogized to ephedrine and especially ephedrine with caffeine. This analogy

authorizes him to conclude that not only will ephedrine cause the hemorrhagic

strokes demonstrated in the HSP from taking PPA, but also ischemic strokes and

heart attacks. (None of the Plaintiffs in this case had hemorrhagic strokes.) Yet, he

admitted that while the FDA banned PPA because of the risk of strokes, it

authorized ephedrine to replace PPA in over-the-counter medications. But more

importantly, the plain reading of the HSP article does not authorize O'Donnell's

conclusions.

24
 In 2000, the New England Journal of Medicine published the report on the

Hemorrhagic Stroke Project. The report shows that the investigators devised and

implemented a scientific approach to evaluate the toxicity of PPA. Id. The authors

concluded that "the results of the HSP suggest that PPA increases the risk for

hemorrhagic strokes. For both individuals considering use of PPA and for policy-

makers, the HSP provides important data for a contemporary assessment of risks

associated with the use of PPA." Id. at 3. The authors draw no conclusions about

ephedrine and nowhere say that ephedrine is analogous to PPA in any respect.

The authors likewise do not say that PPA is associated with ischemic stroke

or heart attack or that one can analogize that because PPA may cause hemorrhagic

strokes, it also causes ischemic strokes and heart attacks. Furthermore, the authors

do not attempt to explain the physiological mechanism by which PPA causes

strokes. Although O'Donnell contends that the PPA analogy supports his opinions

that ephedrine causes vasospasm or vasculitis, nowhere in the HSP study do the

authors assert this about PPA, much less about the ephedrine/caffeine combination.

This study offers no support for O'Donnell's opinions.

But another methodological problem undermines O'Donnell's analogical

approach. As Dr. Eaton explains: "even small differences in chemical structure can

25
sometimes make very large differences in the type of toxic response that is

produced." See Eaton, supra, at 10-11. Likewise, as this court noted in Rider v.

Sandoz Pharm. Corp., 295 F.3d 1194 (11th Cir. 2002), "[e]ven minor deviations in

chemical structure can radically change a particular substance's properties and

propensities." Id. at 1201 (citing Glastetter v. Novartis Pharm. Corp., 252 F.3d

986, 990 (8th Cir. 2001)). O'Donnell failed to show that the PPA analogy is valid

or that the differences in chemical structure between PPA and ephedrine make no

difference. He simply assumes its validity without offering any scientific evidence.

As he said, one presumes the same effect by drugs in the same class until proven

otherwise. Such presumptions do not make for reliable opinions in toxic tort cases.

(As Dr. Hakim admitted, if one product had the same effect as another product, it

would be the same product.)

The court addressed drug analogies in detail in Rider where plaintiffs sued

Sandoz claiming that they suffered postpartum hemorrhagic strokes from ingesting

Parlodel to suppress lactation after childbirth. Id. at 1196. Plaintiffs' experts in

that case followed an analogical approach similar to O'Donnell's. They testified

that Parlodel (bromocriptine) is a member of a class of drugs known as ergot

alkaloids, and that ergot alkaloids can cause vasoconstriction, which suggests that

Parlodel causes vasoconstriction. Id. at 1198. Animal studies also suggest that

26
Parlodel causes vasoconstriction. Id. Vasoconstriction can cause high blood

pressure and ischemic stroke. Id. Because Parlodel can cause vasoconstriction,

which causes high blood pressure resulting in ischemic stroke, it can also cause

hemorrhagic stroke. Id. Thus, Parlodel caused plaintiffs' hemorrhagic strokes,

according to Plaintiffs' experts. Id.

This drug analogy is stronger than O'Donnell's because in Rider the experts

analogized from the same drug and also had some partial support for their theory

from animal studies. 295 F.3d at 1200-02. O'Donnell, on the other hand, compares

one drug, PPA, to a different drug, ephedrine, to reach his opinions that not only

does ephedrine cause hemorrhagic stroke, as reported about PPA, it also causes

ischemic stroke and heart attack. (Hemorrhagic stroke occurs when a blood vessel

ruptures. Ischemic stroke occurs because of decreased blood flow to the brain.)

The court in Rider properly rejected the testimony because of the unreliable

analogy. Id. As the court stated, "[e]vidence suggest[ing] that [a chemical] may

cause ischemic stroke does not apply to situations involving hemorrhagic stroke.

This is 'a leap of faith' supported by little more than the fact that both conditions

are commonly called strokes." Id. at 1202.

Finally, on O'Donnell's analogy methodology, he agreed that: "[t]here is a

tendency in the literature, particularly in government monographs, to lump together

27
all ephedrine alkaloids. Doing so is both foolish and misleading as it implies that

the toxicity of all enantiomers is equivalent, which is clearly not the case." After

agreeing with this statement, he went on to say that "it's not predictable."

This lack of predictability, O'Donnell's use of an unreliable analogy and his

inclination to draw overreaching conclusions from self-limiting medical articles,

show the speculative nature of his opinions. As Judge Posner explained: "the

courtroom is not the place for scientific guesswork, even of the inspired sort. Law

lags science; it does not lead it." Rosen v. Ciba-Geigy Corp., 78 F.3d 316, 319 (7th

Cir. 1996).

C. Reliance on Other Studies and Reports

O'Donnell also relied on several other studies to support his opinions about

the toxicity of ephedrine and caffeine. A close analysis of the studies, however,

shows that they do not authorize his opinions. The authors of the articles limit the

application of their studies consistent with the principles of good science;

O'Donnell expands the application beyond good science.

O'Donnell relied heavily on a report by Haller and Benowitz published in

the New England Journal of Medicine that concluded that the ephedrine/caffeine

combination "in some patients may cause toxicity." Christine A. Haller & Neal

Benowitz, "Adverse Cardiovascular and Central Nervous System Events

28
Associated with Dietary Supplements Containing Ephedra Alkaloids," 343 NEW

ENG. J. MED. 1933-38 (2000) (emphasis supplied). The authors studied 140

adverse incident reports from persons who took dietary supplements containing

ephedra alkaloids. Id. The authors said that "these interactions between

phenylpropanolamine and caffeine support the idea that the combination of

ephedrine and caffeine could increase the risk of adverse effects." Id. (emphasis

supplied). The authors, however, admit that their study does not offer a basis to

determine the incidence of serious adverse effects of ephedrine alkaloids, and they

recognize the necessity for study of "the determinants of individual susceptibility

to serious adverse effects of dietary supplements containing ephedra alkaloids so

that the appropriate guidelines and warnings can be devised." Id. Moreover,

O'Donnell agreed that Haller and Benowitz concluded from this study that "the use

of dietary supplements that contained ephedra alkaloids may pose health risks to

some persons." Id. (emphasis supplied). He further conceded that the authors sent

a letter to the editor explaining that the study did not prove causation.

In the same volume of the New England Journal of Medicine, Dr. G.

Alexander Fleming published an editorial entitled "The FDA, Regulation, and the

Risk of Stroke," in which he discusses the Haller and Benowitz study that

O'Donnell considers so important. 343 NEW ENG. J. MED. 1886-87 (2000). About

29
that study Fleming stated: "the study by Haller and Benowitz represents only an

early step in the process of pharmacologic vigilance. Data from spontaneous

reports usually provide only preliminary evidence of risk and not proof of risk."

Id. Fleming reviewed the eleven cases of sudden catastrophic cardiovascular

and cerebrovascular events that Haller and Benowitz attributed as definitely or

probably caused by ephedra alkaloids. Id. He concluded that only one of the

cases should be attributed to supplements containing ephedra alkaloids. Id. He

reached this conclusion in substantial part because of the background risk of

subarachnoid hemorrhage and myocardial infarction. As he explained,

"subarachnoid hemorrhage and myocardial infarction are too common, even

among young and middle-aged people to be pathognomonic of complications of

the use of products containing ephedra alkaloids." Id. He acknowledges the

importance of background risks in reaching conclusions about toxicity and

individual injury. Id.

Fleming went on to explain that

it is much less clear whether the FDA should take steps to ban or even
restrict the use of products containing ephedra alkaloids. The risks of
such products, when they are used as directed, have not been
adequately established. A large body of data suggests that products
containing ephedra alkaloids and ephedrine as an over-the-counter
drug have a low risk of adverse effects at the recommended levels of
consumption. The report by Haller and Benowitz provides

30
 information that justifies the initiation of the same kind of study that
was conducted by the Hemorrhagic Stroke Project.

Id.
Fleming neither exonerates nor indicts ephedra alkaloids, but he does

explain the limitations of the Haller and Benowitz study which, in turn, shows that

O'Donnell does not follow the conservative approach of scientists in this field. Dr.

Fleming exemplifies this approach by limiting conclusions about causation from

insufficient evidence. Indeed, Haller and Benowitz limit the conclusions

authorized from their study by saying that it does not prove causation. The

comments of Fleming and Haller and Benowitz demonstrate the intellectual rigor

in this field of science, an intellectual rigor that is conservative and does not leap

to specific conclusions about causation or toxicity from incomplete evidence or

broad principles. But the record offers yet more evidence of O'Donnell's

willingness to exceed the limits of the conservative scientific methodology.

He also relies on an article called "Adverse Cardiovascular Events

Temporally Associated with Ma Huang, an Herbal Source of Ephedrine"

published in the Mayo Clinic Proceedings. David Samenuk et al., 77 MAYO CLIN

PROC. 12-16 (2002). The author studied adverse reaction reports filed with the

FDA by consumers of ma huang, a natural source of ephedrine. The study focused

on the safety of ma huang for adverse cardiovascular effects. Id. Of the 926

31
complaints studied, 37 involved serious cardiovascular events. Id. at 15. But the

authors of the study explained that their report "must be interpreted as

demonstrating only a temporal, not a causal, relationship between ma huang

(ephedrine) and the adverse cardiovascular events." Id. at 13. The authors further

explained that "[o]ur report has the limitation of being an observational study and

as such does not definitively establish the relationship between ma huang use and

the risk of adverse cardiovascular events." But this shows again O'Donnell's lack

of scientific rigor in that he draws unauthorized conclusions from limited data —

conclusions the authors of the study do not make.

D. Reliance on FDA Reports and Recommendations

O'Donnell also placed great weight on a Food & Drug Administration

(FDA) proposal to severely restrict the sale and distribution of herbal supplements

containing ephedrine. But the FDA did not publish those rules because the

General Accounting Office (GAO) reviewed the FDA data and found a need for

further study.

The GAO determined that the FDA's methodology relied heavily on adverse

incident reports without sufficient scientific controls. In other words, the FDA

employed a flawed methodology to reach its proposal to restrict ephedrine in

herbal

32
supplements. In response to this criticism, the FDA withdrew the proposed

rules.

But O'Donnell's use of FDA data and recommendations raises a more subtle

methodological issue in a toxic tort case. The issue involves identifying and

contrasting the type of risk assessment that a government agency follows for

establishing public health guidelines versus an expert analysis of toxicity and

causation in a toxic tort case.

The Reference Manual on Scientific Evidence explains that

[p]roof of risk and proof of causation entail somewhat different
questions because risk assessment frequently calls for a cost-benefit
analysis. The agency assessing risk may decide to bar a substance or
product if the potential benefits are outweighed by the possibility of
risks that are largely unquantifiable because of presently unknown
contingencies. Consequently, risk assessors may pay heed to any
evidence that points to a need for caution, rather than assess the
likelihood that a causal relationship in a specific case is more likely
than not.

Margaret A. Berger, The Supreme Court's Trilogy on the Admissibility of Expert

Testimony, in REFERENCE MANUAL ON SCIENTIFIC EVIDENCE, 33 (Federal Judicial

Center, 2d. ed. 2000). Obviously, in a toxic tort case the court must focus on

assessing causation, not on a cost-benefit analysis for restricting the sale and use

of a drug.

33
 As Dr. Eaton explains:

[i]t is important to recognize that the procedures commonly used in
"risk assessment" for the purpose of establishing public health
guidelines that represent "acceptable" exposure levels for large
populations are often, in this author's opinion, of marginal relevance
to estimating "causation" in an individual — e.g., whether a particular
chemical caused or contributed to a particular disease or illness in a
given person. Although toxicological data — and the basic principles
of toxicology outlined above — are useful for both (establishing
guidelines for protection of public health and establishing
"causation"), there are substantial differences in approach.

Eaton, supra, at 34.

He then gives a helpful explanation of this difference. "Public health

guidelines, however, should not be interpreted as predicting exact levels at which

effects would occur in a given individual." Id.

Because a number of protective, often "worst-case" assumptions . . .
are made in estimating allowable exposures for large populations,
these criteria and the resulting regulatory levels . . . generally
overestimate potential toxicity levels for nearly all individuals.
Furthermore, because these guidelines are intended to be protective of
all individuals in a population, including the very young, the very old,
and other potentially "sensitive" individuals, the theoretical risks from
exposure at the guideline range level is likely to be substantially over-
estimated for the large majority of individuals in the population.

Id. at 34-35.

Understanding how government agencies establish rules for public health is

important in this case for two reasons. First, in trying to determine the reliability

34
of an expert's opinions based on agency rules, it is important to know both what

the agency intended by setting the guidelines and how the expert uses the

guidelines to support his opinions. The court is not rejecting public health rules

from consideration in a Daubert analysis. Rather, in ruling on methodology

issues, the trial court should understand what the rule really means about causation

for the specific plaintiff, not simply about protecting the public-at-large from risk

of harm based on a risk-utility analysis of the drug.

As this court explained in Rider:

[the] risk-utility analysis involves a much lower standard than that
which is demanded by a court of law. A regulatory agency such as
the FDA may choose to err on the side of caution. Courts, however,
are required under the Daubert trilogy to engage in objective review
of evidence to determine whether it has sufficient scientific basis to
be considered reliable.

295 F.3d at 1201.

The Court of Appeals for the Eighth Circuit further explained the difference

between a public agency approach and a courtroom causation approach in a case

involving Parlodel.

The FDA's approach differs from ours in another critical aspect. The
FDA will remove drugs from the marketplace upon a lesser showing
of harm to the public than the preponderance-of-the-evidence or the
more-like-than-not standard used to assess tort liability. "The
methodology employed by a government agency 'results from the
preventive perspective that the agencies adopt in order to reduce

35
 public exposure to harmful substances. . . .'" The FDA's 1994
decision that Parlodel can cause strokes is unreliable proof of medical
causation in the present case because the FDA employs a reduced
standard (vis-a-vis tort liability) for gauging causation when it
decides to rescind drug approval.

Glastetter, 252 F.3d at 991 (internal cites omitted).

Consideration of the risk-utility or the cost-benefit approach versus the

expert-causation approach is important in this case for a second reason. O'Donnell

testified at the Daubert hearing in a way more adjusted to agency-risk analysis

than courtroom-causation analysis. For example, he said: "[s]o the issue of risk

benefit is, what is the benefit? If there is no proven benefit, it's all risk. So the

risk benefit analysis is lopsided on the risk side." Also, when asked about how

much Metabolife is too much, he said: "I don't have a number. I've said I think it's

unreasonable to combine caffeine because it adds to the toxicity. I don't see a

beneficial effect in using this in the population." This implies a risk-benefit

analysis, which does not directly focus on the question of causation in these four

Plaintiffs — the heart of this toxic tort case.

E. Reliance on Anecdotal Consumer Complaints

The FDA's adverse events reports (AERs) and other consumer complaints

also provided another important source for O'Donnell's opinions. But these FDA

reports reflect complaints called in by product consumers without any medical

36
controls or scientific assessment. Under the adverse events reporting system,

consumers call in to describe medical problems that they think they are

experiencing from taking a product. These complaints provide the basis for the

AERs. O'Donnell also considered the same type of complaints called into the

"Metabolife health-line." Yet, both O'Donnell and Hakim testified that such

anecdotal reports do not prove causation.

Uncontrolled anecdotal information offers one of the least reliable sources

to justify opinions about both general and individual causation. The GAO found

that the FDA's heavy reliance on the AERs without sufficient scientific controls

undermined the FDA's analysis, yet O'Donnell relies on them in a significant way.

This again implies that O'Donnell follows more of a federal agency risk analysis

approach, rather than a courtroom causation analysis. It also shows that he relied

on data that lacks the indicia of scientific reliability.

F. O'Donnell's Methodology Ultimately Fails to Satisfy the
Requirements of the Daubert Rubric or to Otherwise Comport
with the Basic Methodology which should be Utilized by Experts
in Toxic Tort Cases

While we have addressed certain types of unreliable evidence used by

O'Donnell in reaching his opinions in this case, we find it necessary to also note

that O'Donnell's methodology would have failed to survive the Daubert inquiry

37
using those guidelines set forth in Daubert itself. The Supreme Court in Daubert

identified four nonexclusive factors for trial courts to use in determining the

reliability of scientific opinions; i.e: (1) whether the theory can and has been

tested; (2) whether it has been subjected to peer review; (3) the known or expected

rate of error; and (4) whether the theory and methodology employed is generally

accepted in the relevant scientific community. Daubert, 509 U.S. at 593-94.

There is no doubt that O'Donnell's theory of the toxicity of the ephedrine/

caffeine combination can be tested, as can most theories; but, he has offered no

evidence of any testing of his theory, and therefore, he has shown no proof for

support of his opinions by the scientific community. General acceptance of his

theory would offer important support for the reliability of his opinion. As the

United States Supreme Court has explained:

Finally, "general acceptance" can yet have a bearing on the inquiry. A
"reliability assessment does not require, although it does permit, explicit
identification of a relevant scientific community and an express
determination of a particular degree of acceptance within that community
. . . ." Widespread acceptance can be an important factor in ruling
particular evidence admissible, and "a known technique which has been able
to attract only minimal support within the community" . . . may properly be
viewed with skepticism.

Id. at 594 (internal citations omitted).

38
 O'Donnell has also failed to present evidence of any peer review of his

opinions about the extreme toxicity of ephedrine and caffeine or that their use can

cause strokes and heart attacks. He submitted no publication linking ephedrine

and caffeine to strokes and heart attacks beyond the general incident rate or

background risk for these two very common ailments. He likewise failed to offer

any testimony about the known or expected rate of error of his theories, and

although he has provided unsupported testimony about the general acceptance

within the relevant scientific community of his "broad principles of

pharmacology," he has offered no testimony about the acceptance of his specific

opinions. In fact, his own sources say that their studies cannot be used to show

causation.

It is also important to consider what other evidence O'Donnell failed to

present that might have supported the reliability of his opinions in this case. He

offered no epidemiological data. He offered no clinical trials. He offered no

animal studies to support his opinions. O'Donnell also offered no long-term

studies about the toxicity of the ephedrine/caffeine combination on humans. As

even O'Donnell explained: "[l]ong term studies are used for chronic use to

determine safety;" still, he offered opinions about the safety of Metabolife in

absence of such long-term studies.

39
 Ultimately, O'Donnell failed to show the trial court either that his opinions

were based upon reliable sources and data or that his methodology comported with

that criteria listed in Daubert or with those standards otherwise utilized by experts

in the field of toxicology. It was therefore error to admit his testimony to establish

general causation at trial.

IV. Hashim Hakim, M.D.

Dr. Hakim is a medical doctor specializing in the practice of neurology; he

is a clinician and not a medical researcher. He treated Plaintiff Thornburg and

then saw the other three Plaintiffs on referral from Plaintiffs' counsel. He offered

opinions at the Daubert hearing about the general toxicity of Metabolife and about

its effects on the individual Plaintiffs, including that Metabolife caused ischemic

strokes in three Plaintiffs and a heart attack in the other.

Hakim followed a methodology similar to O'Donnell's in determining the

general toxicity of Metabolife. He relied in significant part on ephedrine's

classification as a sympathomimetic, the PPA analogy, the Haller and Benowitz

study, and the Hemorrhagic Stroke Project. To the degree to which Hakim and

O'Donnell shared the same methodology about the general toxicity of Metabolife,

their opinions share the same fate. Their opinions lack sufficient reliability to

satisfy Daubert. Furthermore, like O'Donnell, Hakim failed to offer the type of

40
evidence that could support his methodology, so his opinions are subject to the

same conclusions that the court made about O'Donnell's opinions. The only

question then about Hakim's testimony is whether the additional bases for his

opinions, which O'Donnell's did not have, can overcome the defects in the

methods they shared. The answer is no.

A. The Differential Diagnosis Method

Hakim used the "differential diagnosis" approach to rule out all causes for

Plaintiffs' injuries, except Metabolife 356. Under certain circumstances,

circumstances that ensure reliability, this approach may offer an important

component of a valid methodology. This approach, however, will not usually

overcome the fundamental failure of laying a scientific groundwork for the general

toxicity of the drug and that it can cause the harm a plaintiff suffered.

Differential diagnosis involves "the determination of which one of two or

more diseases or conditions a patient is suffering from, by systematically

comparing and contrasting their clinical findings." DORLAND'S ILLUSTRATED

MEDICAL DICTIONARY 240, (Douglas M. Anderson et al. ed., 29th ed. 2000). This

leads to the diagnosis of the patient's condition, not necessarily the cause of that

condition. The more precise but rarely used term is differential etiology, which is

"a term used on occasion by expert witnesses or courts to describe the

41
investigation and reasoning that leads to the determination of external causation,

sometimes more specifically described by the witness or court as a process of

identifying external causes by a process of elimination." See Mary Sue Henifin et

al., Reference Guide on Medical Testimony, in REFERENCE MANUAL ON SCIENTIFIC

EVIDENCE 439, 481 (Federal Judicial Center, 2d ed. 2000). The etiology of a

disease is the cause or origin of the disease, and in this case Plaintiffs allege that

Metabolife is the etiology of their medical problems.9

To support this theory, Hakim testified that he employed the differential

diagnosis method. He took medical histories from Plaintiffs, examined them, and

did some tests. After taking these steps, he concluded that he could rule out all the

usual causes for Plaintiffs' injuries and therefore inferred that Metabolife caused

the injuries. He assumed that Metabolife could cause these injuries using the same

evidence offered by O'Donnell, the deficiencies of which the court has

demonstrated at length.

A valid differential diagnosis, however, only satisfies a Daubert analysis if the

9
Hakim's differential diagnosis primarily involved determining the etiology of Plaintiffs'
diseases rather than the diagnoses of three ischemic strokes and a heart attack. Although
defendants often dispute the injuries that plaintiffs allege in toxic tort cases, Defendant does not
dispute the nature of Plaintiffs' injuries, only that Metabolife caused the injuries.

42
expert can show the general toxicity of the drug by reliable methods. As the Court

of Appeals for the Ninth Circuit explained:

The first step in the diagnostic process is to compile a comprehensive
list of hypotheses that might explain the set of salient clinical findings
under consideration . . . . The issue at this point in the process is
which of the competing causes are generally capable of causing the
patient's symptoms or mortality. Expert testimony that rules in a
potential cause that is not so capable is unreliable . . . ." It is
important to realize that a fundamental assumption underlying
[differential diagnosis] is that the final, suspected 'cause' . . . must
actually be capable of causing the injury.

Clausen v. M/V New Carissa, 339 F.3d 1049, 1057-58 (9th Cir. 2003) (internal

citations omitted). Thus, an expert does not establish the reliability of his

techniques or the validity of his conclusions simply by claiming that he performed

a differential diagnosis on a patient. As the Court of Appeals for the Fifth Circuit

has explained:

No one doubts the utility of medical histories in general or the
process by which doctors rule out some known causes of disease in
order to finalize a diagnosis. But such general rules must . . . be
applied fact-specifically in each case. The underlying predicates of
any cause-and-effect medical testimony are that medical science
understands the physiological process by which a particular disease or
syndrome develops and knows what factors cause the process to
occur. Based on such predicate knowledge, it may then be possible to
fasten legal liability for a person's disease or injury.

Black v. Food Lion, Inc., 171 F.3d 308, 314 (5th Cir. 1999) (emphasis added).

43
 Here, neither O'Donnell nor Hakim have offered a reliable explanation of

the physiological process by which Metabolife causes heart attacks and ischemic

strokes, i.e., establish general causation. Their PPA analogy does not show it.

The medical articles do not explain it. In the absence of such a foundation for a

differential diagnosis analysis, a differential diagnosis generally may not serve as a

reliable basis for an expert opinion on causation in a toxic tort case.

B. Reliance on Anecdotal Case Reports

In defending his methodology, Hakim also testified about case reports that

he found in the medical literature. The case studies involve reports by doctors

about patients whom the doctor suspects suffered a serious adverse reaction to

ephedrine. These reports are anecdotal, meaning that they are "based on

descriptions of unmatched individual cases rather than on controlled studies."

DORLAND'S, supra, at 76. Because they are anecdotal, "case studies lack controls

and thus do not provide as much information as controlled epidemiological studies

do . . . . Causal attribution based on case studies must be regarded with caution."

Henifin, supra, at 475.

We in fact discussed the value of case reports in Rider, explaining that:

Much of the plaintiffs' expert testimony relied on case reports in
which patients suffered injuries subsequent to the ingestion of
Parlodel. Although the court may rely on anecdotal evidence such as

44
 case reports, . . . courts must consider that case reports are merely
accounts of medical events. They reflect only reported data, not
scientific methodology. . . . Some case reports do contain details of
the treatment and differential diagnosis. Even these more detailed
case reports, however, are not reliable enough, by themselves, to
demonstrate the causal link the plaintiffs assert that they do because
they report symptoms observed in a single patient in an uncontrolled
context. They may rule out other potential causes of the effect, but
they do not rule out the possibility that the effect manifested in the
reported patient's case is simply idiosyncratic or the result of
unknown confounding factors. As such, while they may support
other proof of causation, case reports alone ordinarily cannot prove
causation.

295 F.3d at 1199 (internal citations omitted). Simply stated, case reports raise

questions; they do not answer them.

This analysis of the value and limitations of case reports is important in this

case for two reasons. First, it explains something about Hakim's differential

diagnosis method. If he had taken his findings and opinions about these four

Plaintiffs and submitted them to a medical journal for publication, they would

simply be case reports — anecdotal information, nothing more. Second, in light of

all the other failures of proof on the reliability of their methods, Plaintiffs' experts

cannot now redeem their opinions with this type of anecdotal evidence. They do

not offer the underlying toxicological data in a scientifically reliable form to

satisfy Daubert. Anecdotal evidence will not cure that failure.

C. Challenge/De-challenge/Re-challenge Methodology

45
 Finally, in reaching his opinions that Metabolife 356 in fact caused each of

the Plaintiff's injuries, Hakim claims to have used a "challenge/de-challenge/re-

challenge" methodology. To explain this methodology during the Daubert

hearing, Hakim testified that while treating Plaintiff Thornburg he noticed a

pattern. When she took Metabolife 356, she had strokes, but when she did not

take it, she did not have strokes until she started it again. In essence, the stroke

occurred during the challenge stage when she took the drug. The de-challenge

occurred when she came off the drug and did not have a stroke, and the re-

challenge occurred when she started taking the drug again and had another

ischemic event. But this theory has a serious flaw.

In April of 2000, Hakim decided that Metabolife had caused Thornburg's

strokes and told her to stop taking it. In June of 2000, after being off Metabolife

for two months, she had another ischemic event. In other words, according to his

challenge/de-challenge/re-challenge theory, she had another ischemic event during

the de-challenge phase. During the hearing, Hakim attempted to explain away that

inconsistency by saying that the ischemic event during the de-challenge phase

occurred because of the lingering effects of ephedrine. To bolster this opinion he

resorted to another medical analogy — the analogy of alcohol causing liver

46
damage. Nothing in the evidence, however, supports the dubious analogy that the

ephedrine causes strokes and heart attacks like alcohol causes cirrhosis of the

liver.

Furthermore, "[t]he temporal connection between exposure to chemicals and

an onset of symptoms, standing alone, is entitled to little weight in determining

causation." Moore, 151 F.3d at 278. It is also subject to the problem of assuming

what the witness is trying to prove. This pitfall will most likely arise when, as

here, there are not scientific controls in place.

As this court explained in Rider, "de-challenge/re-challenge tests are still

case reports and do not purport to offer definitive conclusions as to causation."

295 F.3d at 1200. Their value is directly related to the degree of scientific control

used in the testing. Because there were insufficient controls employed in Hakim's

crude challenge/de-challenge/re-challenge methodology, and Hakim's own

testimony established that Thornburg suffered ischemic events when she was not

taking Metabolife 356, this methodology does not provide the necessary indicia of

reliability to his final opinions on causation.

D. Hakim's Overall Methodology

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 Again, like O'Donnell, Hakim failed to offer the type of evidence that could

support the methodology he employed in reaching his opinions. Even considering

the three additional methodologies he used, we must conclude that Hakim failed to

rely upon reliable sources and data and that his overall methodology falls short of

those standards otherwise utilized by experts testifying as to causation in a toxic

tort case. It was therefore error to admit his testimony to establish general or

individual causation at trial.

V. Conclusion

At the outset, we noted that the primary purpose of any Daubert inquiry is

for the district court to determine whether that expert, "whether basing testimony

upon professional studies or personal experience, employs in the courtroom the

same level of intellectual rigor that characterizes the practice of an expert in the

relevant field." Kumho, 526 U.S. at 152. As shown in this case, however, neither

O'Donnell nor Hakim utilized a reliable methodology to prove that use of

Metabolife 356 actually causes strokes or heart attacks, either generally or in these

Plaintiffs. The medical literature does not support such opinions. Plaintiffs'

experts took leaps of faith and substituted their own ipse dixit for scientific proof

on essential points. Here, “there is simply too great an analytical gap between the

data and the opinion proffered.” See Joiner, 522 U.S. at 146.

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 Thus, in the end, we must find that there was no basis for the court below to

conclude that Plaintiffs' experts employed the same level of intellectual rigor that

characterizes the practice of an expert testifying about causation in a toxic tort case.

Plaintiffs' expert testimony did not satisfy the foundational requirements of Rule 702,

because their opinions were not based on sufficient data and were not the product of

reliable methods. Because they did not establish the requisite scientific reliability

Daubert demands, the trial court abused its discretion both by abdicating its

gatekeeper responsibilities and by admitting the expert testimony at trial. We reverse.

REVERSED and REMANDED.

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