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Improving the Presumptive Disability Decision-Making Process for Veterans

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The United States has long recognized and honored the service and sacrifices of its military and veterans. Veterans who have been injured by their service (whether their injury appears during service or afterwards) are owed appropriate health care and disability compensation. For some medical conditions that develop after military service, the scientific information needed to connect the health conditions to the circumstances of service may be incomplete. When information is incomplete, Congress or the Department of Veterans Affairs (VA) may need to make a "presumption" of service connection so that a group of veterans can be appropriately compensated.

The missing information may be about the specific exposures of the veterans, or there may be incomplete scientific evidence as to whether an exposure during service causes the health condition of concern. For example, when the exposures of military personnel in Vietnam to Agent Orange could not be clearly documented, a presumption was established that all those who set foot on Vietnam soil were exposed to Agent Orange. The Institute of Medicine (IOM) Committee was charged with reviewing and describing how presumptions have been made in the past and, if needed, to make recommendations for an improved scientific framework that could be used in the future for determining if a presumption should be made. The Committee was asked to consider and describe the processes of all participants in the current presumptive disability decision-making process for veterans. The Committee was not asked to offer an opinion about past presumptive decisions or to suggest specific future presumptions.

The Committee heard from a range of groups that figure into this decision-making process, including past and present staffers from Congress, the VA, the IOM, veterans service organizations, and individual veterans. The Department of Defense (DoD) briefed the Committee about its current activities and plans to better track the exposures and health conditions of military personnel. The Committee further documented the current process by developing case studies around exposures and health conditions for which presumptions had been made. Improving the Presumptive Disability Decision-Making Process for Veterans explains recommendations made by the committee general methods by which scientists, as well as government and other organizations, evaluate scientific evidence in order to determine if a specific exposure causes a health condition.


Suggested Citation

Institute of Medicine. 2008. Improving the Presumptive Disability Decision-Making Process for Veterans. Washington, DC: The National Academies Press.

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Publication Info

813 pages |6 x 9
  • Paperback: 978-0-309-10730-3
  • Ebook: 978-0-309-16439-9

Table of Contents

skim chapter
Front Matter i-xxxii
General Summary 1-6
Summary 7-26
1 Introduction 27-35
2 A Brief History of Presumptive Disability Decisions for Veterans 36-51
3 The Presumptive Disability Decision-Making Process 52-69
4 Legislative Background on Presumptions 70-82
5 Case Studies Summary Chapter 83-135
6 Establishing an Evidence-Based Framework 136-149
7 Scientific Evidence for Causation in the Population 150-174
8 Synthesizing the Evidence for Causation 175-197
9 Applying Population-Based Results to Individuals: From Observational Studies to Personal Compensation 198-236
10 Health and Exposure Data Infrastructure to Improve the Scientific Basis of Presumptions 237-297
11 Governmental Classification and Secrecy 298-308
12 The Way Forward 309-328
13 Recommendations 329-338
Appendix A: Statement of the Veterans' Disability Benefits Commission to the Institute of Medicine's Committee on the Presumptive Disability Decision-Making Process, May 31, 2006 339-343
Appendix B: Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans Open Session Meeting Agendas 344-348
Appendix C: Glossary 349-408
Title Page 409-409
Appendix D: Historical Background 410-423
Appendix E: Arguments Favoring and Opposing Presumptions 424-433
Appendix F: Tables: Summary of Presumptive Disability Decision-Making Legislative History 434-565
Appendix G: VA's White Paper on the Presumptive Disability Decision-Making Process 566-569
Appendix H: IOM's Statements of Task and Conclusions for Agent Orange and Gulf War Reports 570-591
Appendix I: Case Studies 592-709
Appendix J: Causation and Statistical Causal Methods 710-719
Appendix K: Sources of Health and Exposure Data for Veterans 720-763
Appendix L: Additional Classification and Secrecy Information 764-773
Appendix M: Biographical Sketches of Committee Members, Consultants, and Staff 774-781

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