  United States Court of Appeals
      for the Federal Circuit
                ______________________

 CHASE BOATMON, MAURINA CUPID, PARENTS
           OF J.B., DECEASED,
            Petitioners-Appellants

                           v.

      SECRETARY OF HEALTH AND HUMAN
                  SERVICES,
              Respondent-Appellee
             ______________________

                      2018-2333
                ______________________

    Appeal from the United States Court of Federal Claims
in No. 1:13-vv-00611-TCW, Judge Thomas C. Wheeler.
                 ______________________

              Decided: November 7, 2019
               ______________________

   JOSEPH PEPPER, Conway Homer, PC, Boston, MA, ar-
gued for petitioners-appellants. Also represented by
RONALD C. HOMER.

    THOMAS G. WARD, Torts Branch, Civil Division, United
States Department of Justice, Washington, DC, argued for
respondent-appellee. Also represented by ROBERT PAUL
COLEMAN, III, JOSEPH H. HUNT, C. SALVATORE D'ALESSIO,
CATHARINE E. REEVES.
                ______________________
2                                          BOATMON v. HHS




    Before PROST, Chief Judge, NEWMAN and WALLACH,
                     Circuit Judges.
     Opinion for the court filed by Chief Judge PROST.
    Concurring opinion filed by Circuit Judge WALLACH.
    Dissenting opinion filed by Circuit Judge NEWMAN.
PROST, Chief Judge.
     This case, brought under the National Childhood Vac-
cine Injury Act of 1986, 42 U.S.C. §§ 300aa-1 to -34, as
amended (the “Vaccine Act”), presents the question of
whether Petitioners Chase Boatmon and Maurina Cupid
have proven by a preponderance of the evidence that the
vaccinations their son, J.B., received caused or substan-
tially contributed to his death from sudden infant death
syndrome (“SIDS”). The Special Master found that Peti-
tioners had met their burden and were entitled to compen-
sation. Boatmon v. Sec’y of Health & Human Servs.,
No. 13-611V, 2017 WL 3432329 (Fed. Cl. Spec. Mstr. July
10, 2017) (“Special Master Decision”). The United States
Court of Federal Claims reversed the Special Master’s find-
ing. Boatmon v. Sec’y of Health & Human Servs., 138 Fed.
Cl. 566 (2018). While we disagree with most of the Court
of Federal Claims’ rationale, for the reasons explained be-
low, we affirm its judgment.
                             I
                            A
    J.B. was born four weeks prematurely on April 7, 2011.
Special Master Decision, at *4. Despite being born prema-
turely, J.B. was progressing with normal growth and de-
velopment.     At his four-month well baby visit on
September 2, 2011, J.B. was healthy, with normal chest
and lungs and no fever, nasal congestion, or cough. At that
appointment, J.B. received vaccinations for diphtheria-tet-
anus-acellular pertussis (DTaP), inactivated polio (IPV),
BOATMON v. HHS                                             3



pneumococcal conjugate (PCV), rotavirus, and Hepatitis B
(Hep B). Id.
    Later that evening, J.B. reportedly had a fever and did
not sleep well. See id. at *5. At 4:00 AM on September 3,
2011, J.B.’s parents gave him Advil for his fever, and he
went back to sleep. By approximately 8:00 AM, J.B. was
again running a fever and was given another dose of Advil.
     In the early afternoon, J.B.’s father put him down for a
nap on his back in his crib. J.B.’s mother checked on him
and replaced his pacifier. She returned to check on him a
second time and found him unresponsive on his right side.
At 2:39 PM, J.B.’s mother called 911 and attempted CPR.
Responders arrived at the house within minutes and trans-
ported J.B. to the hospital. Efforts to resuscitate J.B. were
unsuccessful and he was pronounced dead at 4:01 PM. See
id. at *6.
    A death investigation and scene reenactment indicated
that J.B. was placed to sleep on his back and was found on
his right side. Photographs of the scene showed that his
crib contained soft blankets and a flat soft pillow but no
clutter or toys.
    The medical examiner performed an autopsy and con-
cluded that the cause of death was SIDS. 1 Id.
                             B
    The Vaccine Act, enacted in 1986, created the National
Vaccine Injury Compensation Program, through which
claimants can petition to receive compensation for vaccine-
related injuries or death. See 42 U.S.C. § 300aa-10(a).



    1   The dissent’s assertions that “no cause of death
was established” and that “SIDS is not a cause of death”
are incorrect. Dissent Op. 9, 7. The autopsy report listed
“the cause of death” as “SIDS.” J.A. 519.
4                                            BOATMON v. HHS




     There are two ways a petitioner can qualify for com-
pensation under the program. First, if the petitioner can
establish an injury listed on the Vaccine Act Injury Table
that occurred after the administration of a designated vac-
cine within a designated period of time (“Table cases”),
then causation is presumed. See id. §§ 300aa-11(c), 300aa-
14(a). Second, if the petitioner claims an injury not listed
in the Vaccine Act Injury Table (“off-Table cases”), the pe-
titioner must prove, by a preponderance of the evidence,
that the vaccine was the cause-in-fact of the claimed injury.
Id. §§ 300aa–11(c)(1)(C)(ii)(I), 300aa-13(a)(1). “[A] proxi-
mate temporal association alone does not suffice to show a
causal link between the vaccination and the injury.” Grant
v. Sec’y of Dep’t of Health & Human Servs., 956 F.2d 1144,
1148 (Fed. Cir. 1992); see also LaLonde v. Sec’y of Health &
Human Servs., 746 F.3d 1334, 1341 (Fed. Cir. 2014) (“As
we have stated before, a temporal correlation alone is not
enough to demonstrate causation.”). The dissent’s sugges-
tion that temporal proximity of the vaccination to the in-
jury creates a prima facie case of connection or causation is
contrary to our precedent. Dissent Op. 7–10.
    Rather, to prove causation in fact in an off-Table case,
the petitioner must
    show by preponderant evidence that the vaccina-
    tion brought about [the] injury by providing: (1) a
    medical theory causally connecting the vaccination
    and the injury; (2) a logical sequence of cause and
    effect showing that the vaccination was the reason
    for the injury; and (3) a showing of a proximate
    temporal relationship between vaccination and in-
    jury.
Moberly v. Sec’y of Health & Human Servs., 592 F.3d 1315,
1321–22 (Fed. Cir. 2010) (quoting Althen v. Sec’y of Health
& Human Servs., 418 F.3d 1274, 1278 (Fed. Cir. 2005)).
These requirements are known as the three Althen prongs.
If a petitioner proves all three Althen prongs by a
BOATMON v. HHS                                             5



preponderance of the evidence, he or she is entitled to re-
cover unless the government shows “by a preponderance of
evidence[] that the injury was in fact caused by factors un-
related to the vaccine.” Althen, 418 F.3d at 1278 (quoting
Knudsen v. Sec’y of the Dep’t of Health & Human Servs., 35
F.3d 543, 547 (Fed. Cir. 1994)).
                             C
    J.B.’s parents filed a petition for compensation under
the Vaccine Act, alleging that the vaccinations their son re-
ceived contributed to his death from SIDS. Because this
was an off-Table case, the Petitioners were required to
prove causation in fact by establishing each of the three Al-
then prongs by a preponderance of the evidence.
   The case was assigned to a Special Master, who held
an evidentiary hearing. The Special Master considered
medical and scientific literature as well as expert testi-
mony from Dr. Douglas Miller for the Petitioners and Dr.
Christine McCusker and Dr. Brent Harris for the govern-
ment.
    The parties do not dispute that J.B.’s cause of death
was SIDS. See Special Master Decision, at *6. “SIDS is
defined as ‘the sudden death of an infant under one year of
age which remains unexplained after a thorough case in-
vestigation, including performance of a complete autopsy,
death scene investigation, and review of the clinical his-
tory.’” Id. at *7 (quoting James J. Filiano & Hannah C.
Kinney, Arcuate Nucleus Hypoplasia in the Sudden Infant
Death Syndrome, 51 J. Neuropathology & Experimental
Neurology 394 (1992)). Studies indicate that SIDS occurs
during sleep or transitions between sleep and waking. Id.
Dr. Hannah C. Kinney, a neuropathologist at Harvard, is
an undisputed leader in SIDS research and understanding.
In 1994, Dr. Kinney and her colleagues “synthesized many
neuropathological studies into their proposed ‘Triple Risk
Model.’”     Id.   This model posits that SIDS is
6                                            BOATMON v. HHS




“multifactorial,” occurring “when: (1) an infant in a critical
development period; (2) possessing an underlying vulnera-
bility; (3) encounters an exogenous stressor.” Id. at *7–8,
*33. The following Venn diagram has been used to illus-
trate the Triple Risk Model:




Id. at *7.
      The first factor, the critical development period, was
initially defined as the first year of life, but has more re-
cently been understood to be the first six months of life. Id.
at *8. The second factor, an underlying intrinsic vulnera-
bility in the infant, includes prematurity, “‘male gender,
African-American race, poverty, adverse prenatal factors
such as maternal smoking or alcohol use during pregnancy,
. . . genetic polymorphisms,’” and “brainstem abnormality
in the neuroregulation of cardiorespiratory control.” Id.
(quoting Hannah C. Kinney et al., The Brainstem and Ser-
otonin in the Sudden Infant Death Syndrome, 4 Annu. Rev.
Pathol. Mech. Dis. 517, 519, 521 (2009) (J.A. 553–88) (“Kin-
ney 2009”)). The third factor, exogenous stressors, has
been identified in the literature to include “prone sleep po-
sition, face-down position, covered face in the supine posi-
tion, soft bedding, bed sharing, over-bundling, elevated
room temperature, and minor infection at the time of
death.” Id. at *10 (citing Kinney 2009, at 519 (J.A. 555)).
BOATMON v. HHS                                             7



    Dr. Miller, the Petitioners’ expert, theorized that re-
ceiving a vaccine can be an exogenous stressor for SIDS be-
cause its prompts the upregulation of cytokines. Id. at *21
(“Dr. Miller stated that vaccinations can be an extrinsic
risk factor in SIDS, as they prompt the upregulation of cy-
tokines that, among other things, produce fever.”). Accord-
ing to Dr. Miller, the upregulation of cytokines following
vaccinations can be similar to the upregulation of cytokines
associated with a mild infection, a known extrinsic risk fac-
tor for SIDS. Id. at *20–21. Dr. Miller theorized that the
cytokines can inhibit the activity of 5–hydroxytryptamine
(“5–HT” or serotonin) neurons in the medulla causing pro-
longed apneas and interference with autoresuscitation. Id.
Approximately 50–70% of infants who die of SIDS appear
to have abnormalities in the medullary 5–HT system. Id.
at *8. According to Dr. Miller’s theory, “[w]hen the vac-
cines are administered in the presence of the defects in the
medulla, during the critical developmental period, they are
likely to have a similar effect as mild infection that may
cause a failure of the medullary response system and ulti-
mately a death.” Id. at *21. But by Dr. Miller’s own ad-
mission, no other medical professionals or researchers have
adopted his theory. See J.A. 161–62; see also Special Mas-
ter Decision, at *21.
     Dr. McCusker disagreed with Dr. Miller’s theory. Spe-
cifically, she disagreed that upper respiratory infections—
and by Dr. Miller’s extension, vaccinations—act as neuro-
chemical exogenous stressors. Special Master Decision, at
*23. Instead, Dr. McCusker testified that upper respira-
tory infections, like the other identified exogenous stress-
ors, are mechanical, meaning that they interfere with an
infant’s ability to exhale carbon dioxide and inhale fresh
oxygen. Id. at *23, *25.
    The Special Master found that the Petitioners had es-
tablished all three Althen prongs by a preponderance of the
evidence. On Althen prong one, the Special Master adopted
Dr. Miller’s extension of the Triple Risk Model, concluding
8                                               BOATMON v. HHS




that “vaccines can . . . play a critical role . . . by stimulating
the production of inflammatory cytokines.” Id. at *39. We
note for clarity that the Special Master also stated that “I
have not concluded that vaccines present a substantial risk
of SIDS. In fact, the evidence is to the contrary.” Id. at
*42.
    On the second Althen prong, the Special Master found
that “the cytokines triggered by the vaccines” in combina-
tion with “other intrinsic and/or extrinsic risk factors in the
presence of a defective or underdeveloped brainstem seems
likely to have produced the perfect storm that resulted in
J.B.’s death.” Id. at *41 (emphasis added). The Special
Master’s analysis of the second Althen prong therefore de-
pends on J.B. having a defective or underdeveloped brain-
stem. But notably, the autopsy did not examine or section
J.B.’s arcuate nucleus or other medullary areas to deter-
mine whether J.B. had any such brainstem abnormality.
Id. at *7, *30–31. The Special Master found that the Peti-
tioners had proven by a preponderance of the evidence that
J.B. had a brainstem abnormality based, in part, on statis-
tical evidence that a brainstem defect is found in 50–70%
of SIDS cases and Dr. Miller’s testimony that, based on this
statistical evidence, J.B. likely had the defect. See id. at
*32.
    The Special Master also found that Petitioners had es-
tablished the temporal requirement of the third Althen
prong. See id. at *42. The Special Master therefore found
in favor of the Petitioners. Id. at *42–43.
                                D
    The government sought review of the Special Master’s
decision in the Court of Federal Claims. The Court of Fed-
eral Claims reversed the Special Master, finding “as a mat-
ter of law that the Special Master erred in ruling for
Petitioners, and in finding that Petitioners had met their
burden of proof as established by applicable statutes and
case law.” Boatmon, 138 Fed. Cl. at 567; see also id. at 571
BOATMON v. HHS                                              9



(faulting the Special Master’s “improper application of the
standard of proof required in vaccine cases”).
    The Court of Federal Claims reviewed four decisions by
three other Special Masters that considered Dr. Miller’s
theory of vaccination causation in other SIDS cases and
“uniformly found that the evidence presented by Dr. Miller
to prove his theory of vaccine causation was not persua-
sive.” Id. at 571. 2 Despite acknowledging that “[a] Special
Master is not bound to follow the opinions of other Special
Masters,” the Court of Federal Claims criticized the Special
Master for “ma[king] no acknowledgement of the other
cases reaching opposite conclusions and ma[king] no at-
tempt to distinguish the instant case from any of the oth-
ers.” Id.




    2    See Jewell v. Sec’y of Health & Human Servs.,
No. 11-138V, 2016 WL 5404165, at *13 (Fed. Cl. Spec.
Mstr. Aug. 29, 2016) (“[T]here is insufficient evidence in
the record to support Petitioner’s argument that vaccines
should be included among Dr. Kinney’s ‘exogenous stress-
ors’ as a potential causal factor in the pathogenesis of
SIDS.”); Copenhaver v. Sec’y of Health & Human Servs.,
No. 13-1002V, 2016 WL 3456436, at *18 (Fed. Cl. Spec.
Mstr. May 31, 2016) (“[T]he Copenhavers have not pre-
sented a persuasive basis for finding that vaccinations can
cause SIDS.”); Lord v. Sec’y of Health & Human Servs., No.
12-255V, 2016 WL 806818, at *14 (Fed. Cl. Spec. Mstr. Feb.
9, 2016) (“Petitioners have failed to show that their inter-
pretation of the Triple Risk Model, as it relates to vaccines,
is a sound and reliable medical theory.”); Cozart v. Sec’y of
Health & Human Servs., No. 00-590V, 2015 WL 6746616,
at *13 (Fed. Cl. Spec. Mstr. Oct. 15, 2015) (“[T]hey failed to
show that their interpretation of the Triple Risk Model, as
it relates to vaccines, is a sound and reliable medical the-
ory.”).
10                                           BOATMON v. HHS




     The Court of Federal Claims determined that the Spe-
cial Master erred by accepting Dr. Miller’s theory because
it was not “supported by a ‘sound and reliable’ medical or
scientific explanation” because it has “not been accepted by
any other experts in the field of SIDS research.” Id. at 571–
72 (quoting Knudsen, 35 F.3d at 548). In doing so, the
Court of Federal Claims invoked Daubert and criticized Dr.
Miller’s theory for not having “been subjected to peer re-
view and publication.” Id. at 572 (citing Daubert v. Merrell
Dow Pharm., Inc., 509 U.S. 579, 593 (1993)). According to
the Court of Federal Claims, by accepting Dr. Miller’s un-
supported theory, the Special Master “applied a standard
so low as to constitute clear error.” Id.
     The Court of Federal Claims reversed the Special Mas-
ter, concluding that “having found that Petitioners failed
to satisfy Althen Prong One, the Court also finds that they
have not presented a persuasive basis for finding that the
vaccinations caused J.B.’s death, as required under Althen
Prong Two.” Id.
    The Petitioners appealed the Court of Federal Claims’
decision.    We have jurisdiction pursuant to 42
U.S.C. § 300aa-12(f).
                             II
                             A
    In Vaccine Act cases, we review the Court of Federal
Claims’ decision de novo. LaLonde, 746 F.3d at 1338. In
so doing, we apply the same standard that the Court of Fed-
eral Claims applies in reviewing the special master’s deci-
sion. Id. We review factual findings under the arbitrary
and capricious standard, and we review legal rulings to de-
termine whether they are not in accordance with law. Id.
at 1339. “In effect, this court performs the same task as
the Court of Federal Claims and determines anew whether
the special master’s findings were arbitrary or capricious.”
Lampe v. Sec’y of Health & Human Servs., 219 F.3d 1357,
BOATMON v. HHS                                           11



1360 (Fed. Cir. 2000). And “[b]ecause we review the trial
court’s legal determination that the special master acted in
a manner not in accordance with law de novo, we effectively
review the special master’s decision under the same stand-
ard.” Althen, 418 F.3d at 1277–78.
                             B
    We first address the flaws in the Court of Federal
Claims’ analysis. We then turn to the reasons we affirm its
ultimate conclusion and judgment.
                             1
    Much of the Court of Federal Claims’ analysis focused
on the fact that the Special Master’s decision in this case
was contrary to other Special Masters’ decisions in other
cases addressing the issue of vaccination causation in SIDS
deaths. The Court of Federal Claims faulted the Special
Master for “ma[king] no acknowledgement of the other
cases reaching opposite conclusions and ma[king] no at-
tempt to distinguish the instant case from any of the oth-
ers.” Boatmon, 138 Fed. Cl. at 571. It concluded that the
Special Master’s “departure from the conclusions of other
Special Masters can only be explained by improper appli-
cation of the standard of proof required in vaccine cases.”
Id.
     To the extent the Court of Federal Claims required that
special masters cite and distinguish the decisions of other
special masters, it was incorrect. As the Court of Federal
Claims itself acknowledged, “[a] Special Master is not
bound to follow the opinions of other Special Masters.” Id.;
see also Hanlon v. Sec’y of Health & Human Servs., 40 Fed.
Cl. 625, 630 (1998) (“Special masters are neither bound by
their own decisions nor by cases from the Court of Federal
Claims, except, of course, in the same case on remand.”),
aff’d, 191 F.3d 1344 (Fed. Cir. 1999). The government also
acknowledges this on appeal. Appellee’s Br. 18 n.1 (“The
decisions of other special masters . . . are not binding
12                                              BOATMON v. HHS




precedent.”); id. at 22 (“[S]pecial masters’ decisions are
non-binding.”). By extension, special masters are not re-
quired to distinguish non-binding decisions of other special
masters. That is, in part, because “[c]ausation in fact un-
der the Vaccine Act is . . . based on the circumstances of the
particular case.” Knudsen, 35 F.3d at 548.
     The Petitioners also argue that the Court of Federal
Claims improperly invoked Daubert in rejecting Dr. Mil-
ler’s theory of causation. Appellants’ Br. 25; Reply Br. 8–
9. To the extent the Court of Federal Claims’ opinion sug-
gests that that Moberly’s requirement for a “reputable
medical or scientific explanation” requires that the special
master apply Daubert and that Daubert requires “peer re-
view and publication,” Boatmon, 138 Fed. Cl. at 572, that
was incorrect. Special masters may, but are not required
to, analyze expert testimony according to Daubert. See Ce-
dillo v. Sec’y of Health & Human Servs., 617 F.3d 1328,
1338–39 (Fed. Cir. 2010) (“We have previously held that
Special Masters may look to the Daubert standards in eval-
uating expert testimony.”); Terran v. Sec’y of Health & Hu-
man Servs., 195 F.3d 1302, 1316 (Fed. Cir. 1999) (“Thus,
the Special Master did not err in analyzing the proffered
testimony according to Daubert.”).
    The Petitioners also contend that the Court of Federal
Claims erred in “wield[ing] one Daubert factor”—whether
the theory at issue has been subjected to peer review and
publication—“as dispositive of the reliability of [the] evi-
dence.” Appellants’ Br. 26. The Daubert factors are “meant
to be helpful, not definitive,” and all factors “do not . . . nec-
essarily apply even in every instance in which the reliabil-
ity of scientific testimony is challenged.” Kumho Tire Co.
v. Carmichael, 526 U.S. 137, 151 (1999); see also Daubert,
509 U.S. at 594–95 (“The inquiry envisioned . . . is, we em-
phasize, a flexible one.”). While special masters may use
the Daubert framework to evaluate the reliability of expert
testimony, we reject any suggestion from the Court of
BOATMON v. HHS                                                13



Federal Claims that such testimony must meet each Daub-
ert factor to be reliable. See Terran, 195 F.3d at 1316.
    In sum, we reject any implication from the Court of
Federal Claims’ decision that special masters must cite and
distinguish the decisions of other special masters, that they
must apply Daubert in assessing expert testimony, or that
each Daubert factor must be satisfied.
                               2
    The Court of Federal Claims was correct, however, in
determining that the Special Master erred by lowering the
standard of proof for causation. Under the proper stand-
ard, Petitioners failed to meet their burden to prove by a
preponderance of evidence that vaccinations can and did
cause or contribute to J.B.’s death from SIDS.
                               a
    In off-Table cases like this one, it is the petitioners’ bur-
den to prove actual causation by a preponderance of the ev-
idence. Moberly, 592 F.3d at 1322. The Vaccine Act
“relaxes proof of causation for injuries satisfying the Ta-
ble[,] . . . but does not relax proof of causation in fact for
non-Table Injuries.” Id. (quoting Grant, 956 F.2d at 1148).
A petitioner must provide a “reputable medical or scientific
explanation” for its theory. Id. While it does not require
medical or scientific certainty, it must still be “sound and
reliable.” Knudsen, 35 F.3d at 548–49.
    The Special Master deviated from the correct “reputa-
ble,” “sound and reliable” standard and articulated a lower
“reasonable” standard. See Special Master Decision, at *30
(“[P]etitioners must show by a preponderance of the evi-
dence a reasonable theory as to how the vaccine could cause
the harm at issue.” (emphasis added)); id. at *39 (“Accord-
ingly, [P]etitioners have satisfied the requirement of Al-
then Prong One by presenting a reasonable explanation of
how the vaccine could cause or substantially contribute to
the child’s death.” (emphasis added)); id. at *40 (“Dr.
14                                            BOATMON v. HHS




Miller has presented a reasonable and persuasive theory.”
(emphasis added)); J.A. 674 (Dr. Miller explaining a “plau-
sible mechanism whereby such infants, presumptively in-
cluding [J.B.], can die from the indirect effects of the
vaccine” (emphasis added)). These articulations of the
standard are incorrect as a matter of law.
    We have consistently rejected theories that the vaccine
only “likely caused” the injury and reiterated that a “plau-
sible” or “possible” causal theory does not satisfy the stand-
ard. Moberly, 592 F.3d at 1322 (rejecting a “more relaxed
standard” of whether the condition was “likely caused” by
the vaccine and reiterating that “proof of a ‘plausible’ or
‘possible’ causal link between the vaccine and the in-
jury . . . is not the statutory standard”); see also LaLonde,
746 F.3d at 1339 (“However, in the past we have made clear
that simply identifying a ‘plausible’ theory of causation is
insufficient for a petitioner to meet her burden of proof.”
(quoting Moberly, 592 F.3d at 1322)).
     By the Special Master’s and Dr. Miller’s own assess-
ment, Dr. Miller’s theory is only “plausible.” See, e.g., Spe-
cial Master Decision, at *21 (“[Dr. Miller] testified that,
based on the literature, there is a scientifically-plausible
mechanism for vaccinations acting as the extrinsic risk fac-
tor in SIDS in much the same way as a mild infection.”
(emphasis added)); id. (“[Dr. Miller] concluded that the
mechanism [underlying his theory] is plausible.” (empha-
sis added)); J.A. 670 (Dr. Miller stating in his report that
“it is medically plausible that this case of SIDS was related
to these vaccinations” (emphasis added)). The Special Mas-
ter erred in allowing a theory that was at best “plausible”
to satisfy the Petitioners’ burden of proof.
                              b
     The Special Master also erred in determining that Pe-
titioners’ theory that vaccinations can be an exogenous risk
factor under the Triple Risk Model is a sound and reliable
medical theory as required by Althen prong one.
BOATMON v. HHS                                            15



     First, Petitioners have not shown that their theory that
vaccinations can be an exogenous stressor under the Triple
Risk Model of SIDS is a sound and reliable medical theory.
It would be an extension of the Triple Risk Model to include
vaccination-induced cytokine activity in the list of exoge-
nous stressors as Dr. Miller proposes. Dr. Miller himself
concedes that, outside of Vaccine Act litigation, vaccina-
tions have not been identified as an exogenous stressor for
SIDS. See Special Master Decision, at *21 (Special Master
noting that Dr. Miller “acknowledged that there is not wide
recognition, or a generally accepted theory, that vaccina-
tions are an exogenous stressor [for SIDS]”). Dr. Miller was
unable to identify any other medical professional who iden-
tified vaccinations as exogenous stressors under the Triple
Risk Model. See J.A. 161–62 (Dr. Miller testifying that,
other than experts in Vaccine Act cases, no one in the med-
ical community has asserted that vaccines are more likely
than not an external risk factor for SIDS). “Although a
Vaccine Act claimant is not required to present proof of
causation to the level of scientific certainty, the special
master is entitled to require some indicia of reliability to
support the assertion of the expert witness.” Moberly, 592
F.3d at 1324. Daubert is not required, see Terran, 195 F.3d
at 1316, but reliability and reputability are, Moberly, 592
F.3d at 1324; Knudsen, 35 F.3d at 549. Here there is noth-
ing more than the assertion of Dr. Miller. The Special Mas-
ter erred in adopting an unsound and unreliable theory
that constitutes a significant extension of the Triple Risk
Model in the absence of any indicia of reliability.
    Second, the Petitioners failed to show by a preponder-
ance of the evidence that vaccinations cause cytokines to
provoke an abnormal brainstem serotonin response or oth-
erwise cause or contribute to a SIDS death. When asked
at oral argument to identify what material in the record
shows how the function of cytokines, not just the presence
or expression of cytokines, affects the brain and supports
Dr. Miller’s theory, the Petitioners replied that there are
16                                           BOATMON v. HHS




animal studies and in vitro studies that show that cyto-
kines cross the blood brain barrier and interfere with the
central nervous system. See Oral Arg. at 37:12–39:28,
No. 2018-2333,      http://www.cafc.uscourts.gov/oral-argu-
ment-recordings. The Petitioners stated that “it is almost
ubiquitous in the literature that cytokines from a periph-
eral insult, including infection, vaccination, can and do
cross the blood brain barrier.” Id. at 37:29–37:39 (empha-
sis added). The Petitioners specifically identified Frøen3
(J.A. 736–40), Brambilla 4 (J.A. 600–07), and Stoltenberg 5
(not included in the Joint Appendix but referred to in the
record) for support. None support Dr. Miller’s proposed
theory.
    In the Frøen study, a first group of piglets was given
IL–1β (a pro-inflammatory cytokine that is released during
infection), a second group was given nicotine, a third group
was given nicotine and the cytokine, and a fourth control
group was given a placebo. J.A. 736. Apnea, defined as a
deprivation of airflow for greater than five seconds, was in-
duced by artificial means on each group of piglets. J.A. 737.
The study found that nicotine worsened autoresuscitation
after apnea and that it was further aggravated when com-
bined with cytokines. J.A. 737–38. The study did not show



     3   J. Frederik Frøen et al., Adverse Effects of Nicotine
and Interleukin–1β on Autoresuscitation After Apnea in
Piglets: Implications for Sudden Infant Death Syndrome,
105 Pediatrics (April 2000).
    4    D. Brambilla et al., Interleukin–1 Inhibits Firing of
Serotonergic Neurons in the Dorsal Raphe Nucleus and En-
hances GABAergic Inhibitory Post-Synaptic Potentials, 26
Eur. J. Neuroscience 1862 (2007).
    5    Lauritz Stoltenberg et al., Changes in Apnea and
Autoresuscitation in Piglets After Intravenous and In-
trathecal Interleukin–1β Injection, 22 J. Perinatal Med. 421
(1994).
BOATMON v. HHS                                            17



that cytokines alone caused any spontaneous apneas before
the first induced apnea. J.A. 738.
     The Stoltenberg study is not included in the Joint Ap-
pendix but was considered by the Special Master. Stolten-
berg, also conducted on piglets, was similar to Frøen and
showed that exposure to cytokines may prolong artificially
induced apnea. See Special Master Decision, at *16. Dr.
McCusker opined that the Frøen and Stoltenberg studies,
performed on very young piglets, have limited relevance to
what happens in living human infant brains. See id. at *26.
Fundamentally, neither the Frøen nor the Stoltenberg
study examined the effects of vaccinations and neither
show that vaccinations can produce the kind of cytokine ac-
tivity in the brain that Dr. Miller theorizes.
     Brambilla, a study conducted on rat brains in vitro,
looked at the effect of exposure to IL–1β on the firing of
serotonin neurons and GABAergic neurons in the dorsal
raphe nucleus in the medulla. J.A. 600–01. The research-
ers euthanized the rats, removed and sectioned the brains,
bathed them with IL–1β, stimulated them, then observed
the firing of the neurons. J.A. 601. The study found that
IL–1β suppressed the firing of the serotonin neurons and
increased the firing of the GABA neurons. J.A. 604. Dr.
McCusker opined that the Brambilla study, performed on
rat brains in petri dishes, does not reflect what happens in
a living vulnerable infant in a crisis situation. See Special
Master Decision, at *26.
    In our view, these studies do not provide support for
Dr. Miller’s proposed theory because they do not show that
that cytokine activity is capable of impacting the brain’s 5–
HT system in the manner Dr. Miller claims or that vaccina-
tions are capable of producing such cytokine activity in the
brain.
    For these reasons, the Petitioners have failed to show
by a preponderance of the evidence that Dr. Miller’s theory
18                                           BOATMON v. HHS




that vaccinations can be exogenous stressors for SIDS is a
sound and reliable medical theory of causation.
                              c
    The second prong of Althen requires that the petitioner
show by a preponderance of the evidence “a logical se-
quence of cause and effect showing that the vaccination
was the reason for the injury.” Althen, 418 F.3d at 1278.
Here, because the Petitioners failed to present a sound and
reliable theory of how vaccinations can cause SIDS, they
have also failed to show that vaccinations caused or con-
tributed to J.B.’s death from SIDS.
     Additionally, on the second Althen prong, the govern-
ment argues that the Special Master erred by “conclud[ing]
based on statistical evidence alone that J.B. did in fact have
a brainstem vulnerability.” Appellee’s Br. 24–28. The Spe-
cial Master’s determination that the Petitioners satisfied
the second Althen prong depended on his conclusion that
J.B. had a brainstem abnormality. See Special Master De-
cision, at *32. In reaching this conclusion, the Special Mas-
ter relied, in part, on what he regarded as a concession by
Dr. McCusker that J.B. must have had a brainstem abnor-
mality. See id. The testimony in question was Dr.
McCusker’s statement that “the brain problem that -- ac-
cording to the triple-risk theory, the brain problem must
exist.” J.A. 272 ll. 21–22. The Special Master took this to
be an admission by Dr. McCusker that the brain problem
must have existed in J.B.’s case. Special Master Decision,
at *22 (“Dr. McCusker agreed that ‘according to the Triple
Risk theory, the brain problem must exist [in J.B.’s case].’”
(alteration in original) (quoting J.A. 272)). Notably, the
“[in J.B.’s case]” was the Special Master’s addition and was
not part of Dr. McCusker’s testimony. The Special Master
relied on this “admission” in adopting Dr. Miller’s theory.
    The government strongly contests that Dr. McCusker’s
testimony was a concession that J.B. had the brainstem ab-
normality. In fact, the government has contested whether
BOATMON v. HHS                                                19



J.B. had a brainstem abnormality throughout this case.
See Boatmon, 138 Fed. Cl. at 571 (“Respondent maintains
that the Special Master impermissibly found, based on sta-
tistical evidence alone, that J.B. had a defective brainstem
making him vulnerable to vaccines under the Special Mas-
ter’s extension of the Triple Risk Theory.”); Appellee’s
Br. 24–28; Oral Arg. at 26:21–27:29.
     Aside from this contested testimony, the Special Mas-
ter’s determination that J.B. had a brainstem abnormality
rested in part on an assumption based on statistics. J.B.’s
autopsy did not examine or section the area required to de-
termine whether he had the brainstem abnormality. See
Special Master Decision, at *7, *30–31. In the absence of
actual evidence, Dr. Miller relied on statistics that a brain-
stem defect is found in 50–70% of SIDS cases and that,
given these statistics, J.B. likely had a defect. Id. at *22,
*32; see also J.A. 107 ll. 6–12 (Dr. Miller testifying that “we
make the assumption . . . that based on the statistics . . . it’s
most likely the physiological abnormality in the 5–HT sys-
tem, but we don’t have proof of that in individual cases”);
J.A. 128 ll. 17–23 (Dr. Miller testifying that “it’s statisti-
cally likely that [J.B.] was one of those [infants with a de-
fective 5–HT system]. I don’t have proof of that, but we can
assume that”). Notably, we have previously rejected sta-
tistical likelihood alone as proof of actual causation. See,
e.g., Knudsen, 35 F.3d at 550 (rejecting alternative cause
theory based on “[t]he bare statistical fact that there are
more reported cases of viral encephalopathies than there
are reported cases of DTP encephalopathies”).
    We conclude that the Petitioners have failed to demon-
strate by a preponderance of the evidence a logical se-
quence of cause and effect showing that the vaccinations
J.B. received caused or contributed to his death.
                               III
   We have considered the Petitioners’ remaining argu-
ments and find them unpersuasive. The circumstances of
20                                             BOATMON v. HHS




this case are, of course, heartbreaking. However, we can-
not allow unsupported, unreliable theories of causation to
provide a basis for recovery in off-Table cases under the
Vaccine Act. In this case, the Petitioners failed to prove by
a preponderance of the evidence that the vaccinations J.B.
received can and did cause or contribute to his death. We
therefore affirm the judgment of the Court of Federal
Claims.
                        AFFIRMED
                           COSTS
     The parties shall bear their own costs.
  United States Court of Appeals
      for the Federal Circuit
                 ______________________

 CHASE BOATMON, MAURINA CUPID, PARENTS
           OF J.B., DECEASED,
            Petitioners-Appellants

                            v.

      SECRETARY OF HEALTH AND HUMAN
                  SERVICES,
              Respondent-Appellee
             ______________________

                       2018-2333
                 ______________________

    Appeal from the United States Court of Federal Claims
in No. 1:13-vv-00611-TCW, Judge Thomas C. Wheeler.
                 ______________________

WALLACH, Circuit Judge, joining and concurring.
    I join with the majority opinion. I write in concurrence
to respond to Judge Newman’s dissent.
    The Dissent asserts that “the standard of common
sense and sound reason” compels finding causation when
vaccination is “soon followed by” injury. Dissent Op. 10.
The Dissent would obviate the need for a “medical theory”
based on “proof of a logical sequence of cause and effect,”
supported by a “reputable medical or scientific explana-
tion,” Althen v. Sec’y of Health & Human Servs., 418 F.3d
1274, 1278 (Fed. Cir. 2005); see 42 U.S.C. § 300aa-13(a)(1)
(2012) (requiring proof of causation by a “preponderance of
the evidence” for injuries not in the Vaccine Injury Table).
2                                            BOATMON v. HHS




The Dissent believes that, given the “inadequacy of present
scientific knowledge,” “common sense must suffice.” Dis-
sent Op. 10.
     Respectfully, an unverified assertion of fact is not com-
mon sense; it is a non-cognizable argument. A statement
of law without basis in statute or precedent is not sound
reason. Refusal to abide by governing law because it of-
fends a judge’s sensibilities is not stare decisis. I take the
unusual step of concurring to respond to a dissent because
to leave the Dissent without a response would, in my opin-
ion, be an abrogation of my judicial duty.
  United States Court of Appeals
      for the Federal Circuit
                 ______________________

 CHASE BOATMON, MAURINA CUPID, PARENTS
           OF J.B., DECEASED,
            Petitioners-Appellants

                            v.

      SECRETARY OF HEALTH AND HUMAN
                  SERVICES,
              Respondent-Appellee
             ______________________

                       2018-2333
                 ______________________

    Appeal from the United States Court of Federal Claims
in No. 1:13-vv-00611-TCW, Judge Thomas C. Wheeler.
                 ______________________
Newman, Circuit Judge, dissenting.
    I respectfully dissent, for the court’s ruling conflicts
with the text and the purpose of the National Childhood
Vaccine Injury Act. During a Senate hearing leading to the
National Childhood Vaccine-Injury Compensation Act, the
Assistant Secretary of the Department of Health and Hu-
man Services, testified concerning vaccines:
   Immunization of children is one of the most spec-
   tacularly successful preventive health measures
   available. Through the appropriate use of vaccine,
   smallpox has been eradicated from the earth. In
   this country we have also essentially eliminated
   diphtheria, tetanus, and poliomyelitis as diseases
2                                           BOATMON v. HHS




    of children. We are on the verge of achieving elim-
    ination of measles as a native disease and are be-
    ginning to intensify our efforts in order to hasten
    the ultimate elimination of rubella.
National Childhood Vaccine-Injury Compensation Act:
Hearing on S.2117 Before the S. Comm. on Labor & Human
Res., 98th Cong. 6 (1984) (statement of Edward M. Brandt,
Jr., M.D., Assistant Sec’y of Health, Dep’t of Health & Hu-
man Servs.).
    However, Senator Hatch cautioned, there is “a small
but significant public health problem—the incidence of
harmful and occasionally even fatal reactions to vaccines
administered to children.” Id. at 2 (statement of Sen. Orrin
Hatch, S. Comm. on Labor & Human Res.). Senator Ken-
nedy, a primary sponsor of this legislation, elaborated on
the incidence of vaccine injury:
    Even when vaccines are properly manufactured,
    distributed and administered, there will be a case
    of paralytic polio which will result from the admin-
    istration of each 5 million doses of polio vaccine;
    there will be a serious neurological injury which
    will result from every 300,000 doses of DTP vac-
    cine, and in rare cases there are severe conse-
    quences from the administration of MMR vaccines.
    These few but important injuries create doubts and
    fears in our National Childhood Vaccination Pro-
    grams.
Id. at 3–4 (statement of Sen. Edward Kennedy, S. Comm.
on Labor & Human Res.). Senator Kennedy explained the
need for legislative action:
    We must be able to assure parents that when their
    children are the victims of an appropriate and ra-
    tional national policy, a compassionate Govern-
    ment will assist them in their hour of need.
BOATMON v. HHS                                             3



Id. at 4. Thus, the Vaccine Act provides a system of com-
pensation for children who are injured by vaccine. A legis-
lative Report for an oversight hearing states the guiding
principles, including:
    In proposing this legislation, the Committee reiter-
    ates its intent that the vaccine injury compensation
    system be informal, flexible, and expeditious, and
    that all participants proceed accordingly. The re-
    invention of the adversarial process will serve nei-
    ther to compensate injured children nor maintain
    the stability of the immunization programs of the
    United States.
H.R. Rep. No. 101-247, at 510 (1989), as reprinted in 1989
U.S.C.C.A.N. 1906, 2236.
     As discussed in Knudsen v. Sec’y of Dep’t Health & Hu-
man Servs., 35 F.3d 543 (Fed. Cir. 1994), there has been
inadequate medical understanding of the causes of vaccine
injury. The Knudsen court explained that “to require iden-
tification and proof of specific biological mechanisms would
be inconsistent with the purpose and nature of the vaccine
compensation program. The Vaccine Act does not contem-
plate full blown tort litigation.” Id. at 549. The court held
that compensation is available when vaccine injury is “‘log-
ical’ and legally probable, not medically or scientifically
certain.” Id. at 548–49. Again in Althen v. Sec’y of Health
& Human Servs., 418 F.3d 1274 (Fed. Cir. 2005), the court
recognized the dearth of scientific understanding of vaccine
injury, and explained that Congress encouraged “the use of
circumstantial evidence” and envisioned that “close calls
regarding causation [would be] resolved in favor of injured
claimants.” Id. at 1280.
    This precedent conforms to a goal of the Vaccine Act—
to foster public confidence and participation in childhood
4                                            BOATMON v. HHS




immunizations—by compensating the rare vaccine injury. 1
Today’s decision, denying compensation for a highly prob-
able vaccine injury, does not conform to the statutory pur-
pose.
    J.B.’s Immunizations
     At J.B.’s four-month well-baby examination, his pedia-
trician recorded that he was “healthy appearing and coop-
erative . . . well nourished and well developed.” His father
stated that J.B. was “smiling and cooing like normal” dur-
ing the examination. Boatmon v. Sec’y of Health & Human
Servs., No. 13-611V (Special Master), 2017 WL 3432329, at
*5 (Fed. Cl. July 10, 2017) (“Special Master Op.”). The pe-
diatrician administered vaccines for diphtheria-tetanus-
acellular-pertussis (DTaP), inactivated polio virus (IPV),
haemophilus influenzae (Hib), pneumococcal conjugate
(PCV) and rotavirus.
    J.B.’s parents testified that later in the day, J.B. began
acting abnormally, was not moving as usual, seemed quiet
and withdrawn, and had a fever. The next day he was dis-
tant and very quiet, would not eat, and had a fever. He



    1    The Health Resources & Services Administration
reports that for the period from January 1, 2006 through
December 31, 2017, a total of 3,454,269,356 doses of cov-
ered vaccines were distributed in the United States.
Health Res. & Servs. Admin. Data & Statistics, National
Vaccine Injury Compensation Program Monthly Statistics
Report, at 3, https://www.hrsa.gov/sites/default/files/hrsa/
vaccine-compensation/data/data-statistics-october-2019.pdf.
The HRSA reports that “[f]or petitions filed in this time pe-
riod, 6,493 petitions were adjudicated by the Court [of Fed-
eral Claims], and of those 4,470 were compensated. This
means for every 1 million doses of vaccine that were dis-
tributed, approximately 1 individual was compensated.”
Id. at 1.
BOATMON v. HHS                                            5



became unresponsive, and his mother called 911
at 2:39 p.m. The record recites the efforts to revive him.
At the hospital he was pronounced dead at 4:01 p.m.
    A medical examiner conducted an autopsy. The Au-
topsy Report states that J.B. had no known medical prob-
lems and had regular infant care and immunizations. The
Report cites the “absence of findings and the reported
sleeping position in a child with no anatomic or microscopic
significant findings.” Special Master Op. at *6. The medi-
cal examiner classified J.B.’s death as “Sudden Infant
Death Syndrome” (SIDS).
    SIDS is defined as “the sudden, unexplained death of a
baby younger than 1 year of age that doesn’t have a known
cause even after a complete investigation. This investiga-
tion includes performing a complete autopsy, examining
the death scene, and reviewing the clinical history.” Nat’l
Insts. of Health, What Is SIDS?, https://safeto-
sleep.nichd.nih.gov/safesleepbasics/SIDS; see also Special
Master Op. at *7 (quoting James J. Filiano & Hannah C.
Kinney, Arcuate Nucleus Hypoplasia in the Sudden Infant
Death Syndrome, 51 J. Neuropathology & Experimental
Neurology 394 (1992)).
    The government denied Vaccine Act compensation, and
the J.B.’s parents, petitioners, appealed to the U.S. Court
of Federal Claims. The Special Master held a trial. The
experts from both sides referred to inadequacies in the au-
topsy, and both sides referred to the absence of understand-
ing of vaccine injury and the causes of sudden infant death.
The Special Master discussed the evidence and arguments
at length and depth. For example, the Special Master
stated that:
       The parties’ experts in neuropathology—Dr.
   Miller for petitioners and Dr. Harris for respond-
   ent—reviewed 21 slides from J.B.’s autopsy, in-
   cluding two of J.B.’s brain. Exhibit 13 at 4–5;
   Exhibit A at 5. The first brain slide is a cross-
6                                            BOATMON v. HHS




    section of pons at the level of the locus coeruleus
    (the upper pons), and the second slide is of two cin-
    gulate gyri with a portion of the adjacent corpus
    callosum. Exhibit 13 at 5. These brain sections
    demonstrated no abnormalities. Id. However, the
    medical examiner did not make slides from other
    parts of the brain, such as the medulla or hippo-
    campus. Id. Furthermore, he did not take any pho-
    tographs of the internal examination. Id. The
    parties’ experts agreed that the medical examiner
    did not collect all of the data necessary to defini-
    tively analyze whether J.B. fit the Triple Risk
    Model of SIDS, introduced in the following section.
    Tr. 42–43 (testimony of Dr. Miller); Tr. 334 (testi-
    mony of Dr. Harris). The experts agreed that they
    would section considerably more of the brain in a
    possible SIDS autopsy than the two frontal lobes
    and one area of the pons that were sectioned in this
    case. Dr. Harris indicated that usually a SIDS au-
    topsy should include samples of at least ten areas,
    including the medulla and hippocampus, which can
    help to show hypoxic ischemic changes as well as
    epilepsy related changes. Tr. 334. Both experts
    agreed, however, that in many SIDS cases, brains
    are not examined with the precision that they
    would recommend or that Dr. Kinney’s group at
    Harvard did in their studies (introduced in the fol-
    lowing section). Tr. 346.
Special Master Op. at *7. The Special Master provided a
detailed analysis of all the evidence and argument, in light
of the statute and precedent, and stated:
    I have concluded that the petitioners have demon-
    strated by a preponderance of the evidence that the
    vaccines can and likely did play a critical role in
    this child’s death by stimulating the production of
    inflammatory cytokines that suppressed the res-
    piratory response system and caused the
BOATMON v. HHS                                             7



    vulnerable infant to be unable to respond in the
    normal way to the accumulation of carbon dioxide
    in his system. Accordingly, petitioners have satis-
    fied the requirement of Althen Prong One by pre-
    senting a reasonable explanation of how the
    vaccine could cause or substantially contribute to
    the child’s death.
Id. at *39. The Special Master concluded that:
    The close temporal relationship of the child’s death
    to the receipt of seven vaccines is reasonable and
    consistent with the theory of neuro-modulation in
    the arcuate nucleus by the cytokine response to the
    vaccines.
Id. at *42.
    The panel majority, adopting the government’s argu-
ment, holds that Vaccine Act compensation does not apply
because J.B.’s death was not shown to have resulted from
the immunizations. The majority states that the cause of
death was not the vaccine, but was SIDS. The majority
states that “because the Petitioners failed to present a
sound and reliable theory of how vaccinations can cause
SIDS, they have also failed to show that vaccinations
caused or contributed to J.B.’s death from SIDS.” Maj. Op.
at 18.
     However, SIDS is not a cause of death, SIDS is an ad-
mission that the cause of death is unknown. The close
proximity between vaccine administration to a healthy
baby, and fever and death soon thereafter, presents a suf-
ficient relationship among these events to produce a rea-
sonable—likelihood, a prima facie case that the vaccine
caused or contributed to the injury.
    The prima facie case of vaccine injury
   A “prima facie” case is established with “[a] party’s pro-
duction of enough evidence to allow the fact-trier to infer
8                                              BOATMON v. HHS




the fact at issue and rule in the party’s favor.” Prima Facie
Case, Black’s Law Dictionary 1441 (11th ed. 2019). The
prima facie case then shifts the burden of coming forward
to the opposing party. Furnco Const. Corp. v. Waters, 438
U.S. 567, 577 (1978). The prima facie case “only stands
until its weight is met by evidence to the contrary.” 9 John
H. Wigmore, Evidence § 2487, at 297 (Chadbourn rev.
1981). Wigmore summarizes that:
      A ‘prima facie’ case so made out need not be over-
      come by a preponderance of evidence, or by evi-
      dence of greater weight; but the evidence needs
      only be balanced, put in equipoise, by some evi-
      dence worthy of credence; and if this be done, the
      burden of the evidence has been met and the duty
      of producing further evidence shifts back to the
      party having the burden of proof, who, if he would
      win, must not only begin by making out his case,
      but he must also end by keeping it good. . . . The
      burden of the evidence, or the duty of going forward
      with evidence, strictly speaking, means no more
      than the meeting of a ‘prima facie’ case or rebutting
      a presumption, by evidence of equal weight rather
      than by a preponderance of the evidence.
Id.
    Here, a prima facie case was established by J.B.’s phys-
iological response within hours of vaccine administration,
with death within a day. The petitioners’ expert witness
opined that an adverse reaction to a vaccine had a critical
role in J.B.’s death. The government’s expert witness never
opined that there was no relation between the vaccine and
J.B.’s events; he simply stated that he did not know the
cause of J.B.’s death.
    Upon provision of a prima facie case, the duty of coming
forward with evidence befalls the opponent. Here, not even
minimal contrary evidence was offered. The government’s
expert did not opine that the vaccines could not have been
BOATMON v. HHS                                             9



a factor; he offered no theory to counter J.B.’s observed fe-
ver and death. However, the majority holds that since no
cause of death was established, it is irrelevant that a vac-
cine more-likely-than-not caused or contributed to the in-
jury. This reasoning contravenes the legislative purpose to
provide an informal, flexible, and fair system.
    In Knudsen, this court recognized the inadequate med-
ical understanding of vaccine injury, and reasoned that
causation need only be “‘logical’ and legally probable, not
medically or scientifically certain.” 35 F.3d at 548–49. Ad-
ditionally, Knudsen explained that “to require identifica-
tion and proof of specific biological mechanisms would be
inconsistent with the purpose and nature of the vaccine
compensation program. The Vaccine Act does not contem-
plate full blown tort litigation.” Id. at 549.
    Both parties’ experts discussed the absence of under-
standing of infant death that is called SIDS. The parties
referred to ongoing studies, such as by Dr. H.C. Kinney,
who is described as a leading researcher on SIDS. The par-
ties referred to Dr. Kinney’s theory implicating a neuro-
chemical abnormality on the medullary 5-HT system, as
was found in some SIDS cases. See Kinney, H.C., Brain-
stem Mechanisms Underlying the Sudden Infant Death
Syndrome: Evidence from Human Pathologic Studies, 51
Dev. Psychobiol. 223 (2009). Petitioner’s expert, Dr. Miller,
testified that the sheer cost of conducting a receptor auto-
radiography and the expertise required, makes receptor
autoradiography unfeasible for most medical examiners
conducting autopsies. J.A.107.
    The goals of the Vaccine Act are to foster public confi-
dence and participation in childhood immunizations by
compensating the rare, but serious vaccine injuries. The
judicial obligation is to assure administration of the Vac-
cine Act in accordance with its purpose. “The purpose of
the Vaccine Act’s preponderance standard is to allow the
finding of causation in a field bereft of complete and direct
10                                            BOATMON v. HHS




proof of how vaccines affect the human body.” Althen, 418
F.3d at 1280.
     Here, both sides’ experts acknowledged the inadequacy
of present scientific knowledge, even as both criticized the
medical examiner’s autopsy. Meanwhile, common sense
must suffice. On the standard of common sense and sound
reason, vaccination of a well-baby with seven powerful tox-
ins, soon followed by fever and death, provide a prima facie
case of a causal or contributing relationship between the
vaccine and these ensuing events, whereby the duty of com-
ing forward with evidence and argument befalls the oppo-
nent. Here, the government’s expert stated only that he
did not know the cause of J.B.’s death.
    It is hoped that advances in genetic science, neurologi-
cal science, and other sciences, will enhance the under-
standing of vaccine injury, so that even these rare injuries
can be foreseen and avoided. 2 Meanwhile, common sense
and fair implementation of the legislative purpose are the
judicial recourse. Representative Burton remarked on the
government’s adversarial posture in vaccine injury cases:
     If you talk to families who have been tied up in this
     system, it sounds like this program has become
     every bit as adversarial as the tort system it re-
     placed. Cases drag on for 6 or 8 or 10 years. 3
                           ***



     2  In Oliver v. Sec’y of Health & Human Servs., 900
F.3d 1357 (Fed. Cir. 2018), the record discussed the rela-
tion between a newly discovered genetic mutation and vac-
cine injury in infants found to have the mutation, reporting
results suggesting that delay of immunization may avoid
injury for infants having that mutation.
    3   The Petitioners’ claim was first filed on August 27,
2013.
BOATMON v. HHS                                              11



    Close calls are supposed to go to the families. The
    Government is not supposed to fight them tooth
    and nail. Some of these cases don’t even look like
    close calls, and yet the Government fights them for
    years. That has to stop.
The National Vaccine Injury Program: Is it Working as
Congress Intended?: Hearings Before the H. Comm. on Gov’t
Reform, 107th Cong. 3–5 (2001).
    It is the obligation of the courts to assure that the stat-
utory purpose is implemented. Although vaccine injury is
sparse, the purpose of the Vaccine Act is to provide com-
pensation in the event of injury that is reasonably attribut-
able to vaccine. The record shows, on undisputed facts that
J.B.’s injury and death more-likely-than-not were reasona-
bly attributable to vaccine. My colleagues’ ruling ignores
the evidence, negates the statutory purpose, and contra-
venes the policy of supporting public health and well-being.
I respectfully dissent.
