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 Contents Front Matter General Summary Summary 1 Introduction 2 A Brief History of Presumptive Disability Decisions for Veterans 3 The Presumptive Disability Decision-Making Process 4 Legislative Background on Presumptions 5 Case Studies Summary Chapter 6 Establishing an Evidence-Based Framework 7 Scientific Evidence for Causation in the Population 8 Synthesizing the Evidence for Causation 9 Applying Population-Based Results to Individuals: From Observational Studies to Personal Compensation 10 Health and Exposure Data Infrastructure to Improve the Scientific Basis of Presumptions 11 Governmental Classification and Secrecy 12 The Way Forward 13 Recommendations 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 Appendix B: Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans Open Session Meeting Agendas Appendix C: Glossary Title Page Appendix D: Historical Background Appendix E: Arguments Favoring and Opposing Presumptions Appendix F: Tables: Summary of Presumptive Disability Decision-Making Legislative History Appendix G: VA's White Paper on the Presumptive Disability Decision-Making Process Appendix H: IOM's Statements of Task and Conclusions for Agent Orange and Gulf War Reports Appendix I: Case Studies Appendix J: Causation and Statistical Causal Methods Appendix K: Sources of Health and Exposure Data for Veterans Appendix L: Additional Classification and Secrecy Information Appendix M: Biographical Sketches of Committee Members, Consultants, and Staff