Two Masters

the principle of distrust of government. Not only is power within the federal government checked and balanced. Power is divided between the federal government and the state governments. So what if a state law conflicts with a federal law? The Constitution says that the “Constitution, and the Laws of the United States . . . shall be the supreme Law of the Land; . . . any Thing in the . . . Laws of any State to the Contrary notwithstanding.” Sometimes the conflict between federal and state law is obvious and the Supremacy Clause is easily applied. But sometimes . . . Diana Levine received an intramuscular injection of Demerol for her migraine headache and of Phenergan—an antihistamine made by Wyeth—for her nausea.1 She soon returned “complaining of ‘intractable’ migraines, ‘terrible pain,’ inability to ‘bear light or sound,’ sleeplessness, [and] hours-long spasms of ‘retching’ and ‘vomiting.’” A physician’s assistant gave her both drugs again, this time intravenously. The PA had a choice between “the ‘IV-push’ method, whereby the drug is injected directly into a patient’s vein, or the ‘IVdrip’ 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.” Phenergan is corrosive and causes gangrene if it enters an artery. The danger is greater with IV push because the needle may penetrate an artery or the drug may escape “from the vein into surrounding tissue” (perivascular extravasation) and contact arterial blood. Phenergan’s label had “at least six separate warnings” about this. The label said