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. Table of ContentsFront MatterGeneral SummarySummary1 Introduction2 A Brief History of Presumptive Disability Decisions for Veterans3 The Presumptive Disability Decision-Making Process4 Legislative Background on Presumptions5 Case Studies Summary Chapter6 Establishing an Evidence-Based Framework7 Scientific Evidence for Causation in the Population8 Synthesizing the Evidence for Causation9 Applying Population-Based Results to Individuals: FromObservational Studies to Personal Compensation10 Health and Exposure Data Infrastructure to Improve theScientific Basis of Presumptions11 Governmental Classification and Secrecy12 The Way Forward13 RecommendationsAppendix A: Statement of the Veterans' Disability BenefitsCommission to the Institute of Medicine's Committee on thePresumptive Disability Decision-Making Process, May 31, 2006Appendix B: Committee on Evaluation of the Presumptive DisabilityDecision-Making Process for Veterans Open Session Meeting AgendasAppendix C: GlossaryTitle PageAppendix D: Historical BackgroundAppendix E: Arguments Favoring and Opposing PresumptionsAppendix F: Tables: Summary of Presumptive DisabilityDecision-Making Legislative HistoryAppendix G: VA's White Paper on the Presumptive DisabilityDecision-Making ProcessAppendix H: IOM's Statements of Task and Conclusions for AgentOrange and Gulf War ReportsAppendix I: Case StudiesAppendix J: Causation and Statistical Causal MethodsAppendix K: Sources of Health and Exposure Data for VeteransAppendix L: Additional Classification and Secrecy InformationAppendix M: Biographical Sketches of Committee Members,Consultants, and Staff