Citation Nr: 1334418 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 06-33 684 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Appellant ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty from March 1951 to March 1953. He died on November [redacted], 2003. The appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. On August 5, 2010, the appellant testified at a Board hearing before the undersigned Veterans Law Judge, sitting at the RO. A transcript of that hearing has been associated with the record. The instant matter was previously before the Board in January 2011, at which time it was remanded for further development. Upon completion of the requested development, the agency of original jurisdiction (AOJ) issued an April 2013 supplemental statement of the case (SSOC) wherein in denied service connection for the cause of the Veteran's death. FINDINGS OF FACT 1. The Veteran served on active duty from March 1951 to March 1953. He died on November [redacted], 2003. The appellant is his surviving spouse. 2. The cause of the Veteran's death in November 2003 was listed on his certificate of death as multi-organ failure and acute myelogenous leukemia (AML). 3. At the time of the Veteran's death, service connection was in effect for hyperthyroidism with recurrent major depression, which disability is not a principle or contributory causes of his death. 4. The causes of the Veteran's death were not manifested during active service or for many years thereafter, nor were they otherwise causally related to active service, to include any exposure to chemical, biological, and radiological warfare agents, nor was AML manifested to a compensable degree within one year of discharge from service. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1310 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. It also requires VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the context of a claim for dependency and indemnity compensation (DIC) benefits, VCAA notice must also include: (1) a statement of the conditions, if any, for which the Veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). In the instant case, the Board finds that the appellant was fully apprised of the evidence required to substantiate her claim of service connection for the cause of the Veteran's death through letters dated in November 2004, April 2008, and September 2011. Specifically, those letters advised the appellant of the information already in VA's possession and the evidence that VA would obtain on her behalf, as well as of the evidence that she was responsible for providing to VA, to include any records not in the possession of a Federal agency. The April 2008 letter also provided the appellant with the notice elements required by Dingess for how VA determines disability ratings and effective dates, and in September 2011, the appellant was advised with respect to the three required notice elements as mandated by Hupp, supra. The appellant has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the above-mentioned notice letters comply with the requirements of 38 U.S.C.A. § 5103(a) and Hupp, supra, and afforded the appellant a meaningful opportunity to participate in the development of her claim. As to any error with respect to the timing of notice in this case, any such error was effectively cured by the readjudication of the appellant's claim in April 2013 after notice was provided. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (holding that timing error can be effectively "cured" by providing any necessary VCAA notice followed by a readjudication of the claim). Thus, the Board is satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. Regarding the duty to assist, the Board also finds that VA has fulfilled its obligation to assist the appellant. All available evidence pertaining to the appellant's claim has been obtained. The evidence includes the Veteran's STRs, VA and private medical records, to include several medical opinions, lay statements, the Veteran's death certificate, records from the Defense Technical Information Center (DTIC) and Dugway Proving Ground, and information regarding testing done at Dugway Proving Ground. The Veteran has not identified any outstanding relevant evidence and the Board is aware of none. The Board also finds that the medical evidence of record is adequate for the Board to rely upon in this case. Multiple opinions were obtained on remand from the Board in January 2011, to include opinions by the Director for Environmental Agents Service on behalf of the Under Secretary for Health, the Director of VA's Compensation and Pension Service, and a VA oncologist with expertise in hematology and medical oncology. The medical opinions take into consideration the appellant's specific arguments, to include consideration of whether it is at least as likely as not that the Veteran's AML was the result of any possible exposure to radiation and/or chemical or biological warfare agents during military service. The Board finds that the opinion reports contain sufficient evidence by which to evaluate the appellant's claim of service connection for the cause of the Veteran's death and that the Board has properly assisted the appellant in this regard. The Board also finds that the actions taken by the AOJ comply with the development procedures required by 38 C.F.R § 3.311 for claims pertaining to radiogenic diseases. II. Analysis Pursuant to 38 U.S.C.A § 1310, DIC is paid to a surviving spouse of a qualifying veteran who died from a service-connected disability. See 38 U.S.C.A § 1310 (West 2002); Dyment v. West, 13 Vet. App. 141 (1999), aff'd sub nom. Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). A veteran's death will be considered service connected where a service-connected disability was either the principal or a contributory cause of death. 38 C.F.R. § 3.312(a) (2013). The disability is the principal cause of death if it was "the immediate or underlying cause of death or was etiologically related thereto." 38 C.F.R. § 3.312(b). It is a contributory cause if it "contributed substantially or materially" to the cause of death, "combined to cause death," or "aided or lent assistance to the production of death." 38 C.F.R. § 3.312(c)(1). It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. Id. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In determining whether a veteran's death was service connected, the first element is always satisfied in that the current disability is the condition that resulted in the veteran's death. See Carbino v. Gober, 10 Vet. App. 507, 509 (1997), aff'd sub nom. Carbino v. West, 168 F.3d 32 (Fed.Cir.1999). In addition, certain chronic diseases, including leukemia, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2013). The Veteran died in November 2003. His cause of death was listed as multi-organ failure and AML. The record reflects that service connection was in effect for hyperthyroidism with recurrent major depression. The appellant does not assert, nor does the evidence of record suggest, that a service-connected disability contributed to the Veteran's death. Rather, it is the appellant's contention that the Veteran's AML was the result of his exposure to chemical, biological, and radiological warfare agents while he was stationed at Dugway Proving Ground, Utah, from 1951 to 1953. In support of her claim, the appellant has asserted her belief that the Veteran was exposed to toxic agents transported in the air by the wind. She submitted a newspaper article that noted the release of 388.5 curies (units of radioactivity) into the air in May 1952 and a statement from a fellow serviceman who indicated that he had worked with the Veteran at Dugway Proving Ground and who stated that he and the Veteran were charged with collecting caged pigeons that had been exposed to nerve gas. The fellow serviceman reported finding dead pigeons that he and the Veteran transported back to the laboratory and stated that they wore full rubber suits, rubber boots and gloves, parkas, and gas masks and reported that they "did everything in a safe way." During her August 2010 hearing, the appellant also read a statement from a fellow serviceman who purportedly performed mustard gas garment testing with the Veteran. The fellow serviceman reportedly stated that they would crawl over a six to eight-foot mat with mustard gas, wearing no gas mask and normal clothing. (The Board notes that this statement was not made part of the record, despite the appellant being requested to submit it on remand in January 2011.) The appellant also submitted numerous articles detailing the types of radiological, chemical, and biological testing that was conducted at Dugway in the 1950s and copies of records that set forth the names and report numbers for a variety of tests conducted at Dugway during the relevant time period. The appellant also submitted records from J.O., M.D., dated in 1987 that showed that he had evaluated the Veteran related to complaints of fatigue. It was indicated that during the summer of 1985, the Veteran had developed flu-like symptoms that never resolved and was determined to have Epstein Barr virus syndrome. Prior to that time, the Veteran was reportedly in good health. Dr. J.O. noted an abnormally low immune globulin level and recommended a course of intravenous gamma globulin in an attempt to reverse the Veteran's symptomatology. In a May 2004 letter, Dr. J.O. indicated that he had evaluated the Veteran in 1987, at which time he believed the Veteran had Common Variable Immunodeficiency (CVID) possibly secondary to Epstein Barr virus infection. Dr. J.O. then stated, however, that upon consideration of the information provided to him regarding the Veteran's exposure at Dugway Proving Ground, the Veteran's subsequent development of leukemia, and the persistence of CVID, it was now his opinion that the symptoms suffered in 1987 were more likely due to toxic exposure at Dugway Proving Ground rather than related to the Veteran's Epstein-Barr virus infection. A review of the record shows that the Veteran had service from March 1951 to March 1953 and that his most significant duty station was Dugway Proving Ground, Utah. The Veteran's STRs are unremarkable for signs or symptoms related to leukemia or exposure to chemical, biological, and radiological warfare agents. They do show that the Veteran was variously treated in service for a cold, tonsillitis, and chest pain, but no abnormalities were noted on his separation examination report and a chest x-ray was negative. Shortly after service, the Veteran was treated for anxiety reaction and toxic diffuse goiter. Service connection was later established for hyperthyroidism with chronic anxiety. According to the autopsy report, in mid-October 2003, the Veteran presented to his primary care physician with a three-day history of fever, increased shortness of breath, chest pain, and swelling in the lips and nose, preceded by a six-month history of increasing fatigue, weakness, and weight loss. A bone marrow biopsy resulted in a diagnosis of AML and the Veteran died the following month. In February 2005, the RO sought to confirm the Veteran's radiation risk. The National Personnel Records Center (NPRC) responded the following month, stating that the Veteran's records were destroyed in a fire at the NPRC and could not be reconstructed. Thereafter, the RO requested from the U.S. Army Aviation and Missile Command any information regarding the Veteran's radiation exposure. A response was received from the U.S. Army Radiation Standards and Dosimetry Laboratory that same month stating that no records for the Veteran were found. However, the response specifically indicated that records at that facility date back only to the middle of 1954. In July 2005, the RO requested from the National Technical Information Service (NTIS) and from the Defense Technical Information Center (DTIC) any available information related to the Veteran concerning any possible in-service exposure to radiation and/or chemical or biological agents. The RO noted that the Veteran's service records had been destroyed and indicated that he had been assigned to Dugway Proving Ground between March 1951 and March 1953. The NTIS responded that same month stating that in order to search for the requested information, the agency would need further information, such as titles, authors, report date, and corporate source. The RO also received a negative response from the DTIC, which response indicated that DTIC did not maintain service or medical records for any current or former military or civilian service members. Notably, in an April 2006 statement of the case (SOC), the RO conceded that the Veteran "was stationed at an area where radiological, biological, and chemical warfare tests were conducted." In a July 2010 statement from G.G., M.D., the Veteran's VA physician, it was opined that "it is more likely than not that [the Veteran's] exposure to radiation and toxins during his military career caused him to develop the acute leukemia that ultimately took his life." The VA physician stated that the record was clear that the Veteran had exposure to dangerous toxins while stationed at Dugway Proving Ground, which agents were well known to be carcinogenic. The VA physician further indicated that radiation was involved in the tests conducted during the Veteran's period of service, the exposure to which more likely than not contributed to the development of the Veteran's AML. In January 2011, the Board remanded the matter for the AOJ to attempt to obtain any available information regarding the radiological, chemical, and biological testing that was conducted during the Veteran's period of service at Dugway Proving Grounds, with instructions to contact Dugway Proving Ground itself and make another inquiry with the DTIC in an attempt to verify the Veteran's alleged involvement in radiological, chemical, and/or biological testing from 1951 to 1953. The Board also instructed the AOJ to obtain a medical opinion regarding the likely etiology of the Veteran's AML, to include the likelihood that the Veteran's AML was the result of any possible exposure to radiation and/or chemical or biological warfare agents during military service. On remand from the Board, the AOJ referred the matter to the Under Secretary for Health to prepare a radiation dose estimate for the Veteran, to the extent feasible, and to provide an opinion as to whether it was at least as likely as not that the Veteran's AML was the result of any possible exposure to radiation and/or chemical or biological warfare agents during military service. In July 2011, T.W., M.D., the Director for the Environmental Agents Service, reviewed the Veteran's claims folder, noting that there was no documented exposure to radiation in the Veteran's record. Regarding the anecdotal evidence of radiation exposure, Dr. T.W. stated that the Veteran's level of exposure would not have reached that which is significant to the causation of leukemia. Dr. T.W. stated that the highest doses seen amongst veterans were that of 18 rem for veterans who were present at nuclear weapons test sites, of which the Veteran was not. Citing to treatise evidence regarding the medical effects of ionizing radiation, Dr. T.W. noted that the "Committee on Biological Effects of Ionizing Radiations . . . has indicated that leukemia mortality is statistically significant above 0.4 Gy [40 rad(rem)] but not at lower doses." Dr. T.W. also pointed out that according to this medical treatise evidence "the increased risk of developing leukemia is markedly reduced or almost gone 30 years following exposure," and noted that the Veteran was not diagnosed as having AML until "some 50 years after any potential radiation exposure." Regarding the likelihood that any exposure to chemical or biological warfare agents led to the development of AML, Dr. T.W. noted that exposure to chemical or biological warfare agents are known to cause acute sickness and death, but that "[a] search of the medical literature had revealed no citations to substantiate the causation of leukemia due to occupational or acute low dose exposure to these agents." Dr. T.W. also determined that had the Veteran been exposed to such agents he would likely have been ill at the time of exposure, but that a review of his medical records failed to evidence an acute illness or disease related to any such agents. Dr. T.W. thus concluded that it was unlikely that the Veteran's leukemia could be attributed to exposure to ionizing radiation and/or chemical or biological warfare agents during service. The matter was then referred to the Director of VA's Compensation and Pension Service, who reviewed the evidence, to include the opinion by Dr. T.W., and concluded that there was no reasonable possibility, based on the evidence of record, that the Veteran's AML was the result of any exposure to ionizing radiation and/or chemical or biological warfare agents during service. Also on remand, the AOJ contacted Dugway Proving Ground and the DTIC in an effort to obtain information regarding any radiological, chemical, and/or biological testing that the Veteran may have been involved in. A response from Dugway Proving Ground indicated that relevant documents linked the Veteran to Dugway Proving Ground, and relevant comprehensive reports were attached with a note indicating that the actual reports could be provided if deemed necessary. It appears that such a request was made as the record includes the complete report of one specific test. Information was also received from DTIC that included abstracts of reports of tests conducted at Dugway Proving Ground. Email correspondence also indicates that the matter was referred to the Department of Defense (DoD), who indicated that they were unable to ascertain any exposure based on the information provided. It was also noted that the Veteran was not a confirmed participant in Mustard Gas, Project 112 and Shipboard Hazards and Defense (SHAD) testing, or Chem-Bio programs, according to the joint VA/DoD Chemical Biological Warfare System. In April 2013, the matter was referred to G.B., M.D., a VA oncologist trained in hematology and medical oncology. The clinician reviewed the claims folder, acknowledged the appellant's theory of the case, and noted that the Veteran may have been exposed inadvertently to radiation in service. The clinician indicated that the review of the Veteran's autopsy report showed a diagnosis of oxygen dependent chronic obstructive pulmonary disease (COPD), which she stated is a known complication of smoking, which is a risk factor for the development of AML. The clinician then opined that it was more likely that the Veteran's AML was caused by smoking than by his possible, but not documented, exposure to radiation. She further indicated that possible chemical exposure to mustard gas could not with certainty be excluded as a contributory factor, but that it was more likely that smoking was the cause of the Veteran's leukemia as 50 years passed between the time of any possible chemical exposure and diagnosis. The Board notes that, as discussed above, certain chronic diseases, such as leukemia, may be presumed to have been incurred during service if the disease becomes manifest to a compensable degree within one year of separation from qualifying military service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In the instant case, the Veteran's AML was not shown until October 2003, more than 50 years after separation from service. Further, the record is devoid of any evidence to suggest the Veteran's AML was manifest to compensable degree within a year of separation from service. Indeed, Dr. J.O.'s statement indicates that prior to the summer of 1985 the Veteran was reportedly in good health. Accordingly, there is no basis upon which to presume that the Veteran's AML was incurred in service or to grant service connection for the cause of the Veteran's death on a presumptive basis for chronic diseases. See 38 C.F.R. §§ 3.307, 3.309. Turning to the appellant's specific theories of service connection for the cause of the Veteran's death, the Board notes that for claims based on alleged exposure to ionizing radiation, service connection may be awarded on a presumptive basis for diseases specific to radiation exposed veterans under 38 C.F.R. § 3.309(d). The Veteran's leukemia is among the 21 types of cancer potentially entitled to presumptive service connection under 38 C.F.R. §§ 3.309(d)(2). However, as the Veteran was not a radiation-exposed veteran within the definition of the 38 C.F.R. § 3.309(d)(3), the provisions of 38 C.F.R. § 3.309(d) are not for application. Service connection can also be pursued under 38 C.F.R. § 3.311 on the basis of exposure to ionizing radiation and the subsequent development of a radiogenic disease, of which AML is one. 38 C.F.R. § 3.311(b)(2)(i). At the outset, the Board notes that there is some question as to whether the Veteran was in fact exposed to any amount of radiation in service. As noted by the Director for the Environmental Agents Service, there is no documented exposure to radiation in the Veteran's record. However, it seems clear that various radiological, chemical, and biological testing was conducted at Dugway Proving Ground in the 1950s. Indeed, as mentioned above, in an April 2006 SOC, the RO conceded that the Veteran "was stationed at an area where radiological, biological, and chemical warfare tests were conducted." Further, although a response received from the U.S. Army Radiation Standards and Dosimetry Laboratory stated that no records pertaining to the Veteran were found at that facility, their record dated back only to the middle of 1954. The matter was also referred to the DoD, which indicated that it was unable to ascertain any exposure based on the information provided, which response leaves open the possibility that additional information may have yielded different results. Without regard to whether the Veteran was indeed exposed to any amount of radiation in service, the evidence preponderates against finding that the Veteran's AML was a result of any such exposure. As discussed above, regarding the anecdotal evidence of radiation exposure, Dr. T.W. stated that the Veteran's level of exposure would not have reached that which is significant to the causation of leukemia. Dr. T.W. noted the highest dose estimates seen amongst radiation exposed veterans, stating those dose estimates were seen in veterans who were present at nuclear weapons sites, of which the Veteran was not. Dr. T.W. also cited to medical treatise evidence and information provided by the Committee on Biological Effects of Ionizing Radiations in concluding that the Veteran's exposure would not have exceeded the applicable screening dose for the development of leukemia. Dr. T.W. also noted that at the time that the Veteran developed AML, any increased risk due to radiation exposure would have been markedly reduced or almost gone, as his AML was not diagnosed until 50 years after any potential exposure. In light of the information, Dr. T.W. opined that it was unlikely that the Veteran's AML could be attributed to exposure to ionizing radiation in service. In July 2011, the Director for Compensation and Pension Service stated that there was no reasonable possibility that the Veteran's AML was related to exposure to ionizing radiation in service. The Director relied on the opinion obtained on behalf of the Under Secretary of Health. Also sharing in the opinion that the Veteran's AML was not attributable to any potential exposure to radiation is Dr. G.B., the VA oncologist who provided the April 2013 medical expert opinion. Upon review of the claims folder, Dr. G.B. stated his opinion that the Veteran's AML was likely due to his history of smoking, noting that the Veteran had oxygen dependent COPD, which was consistent with a history of smoking. Although it was somewhat unclear what evidence Dr. G.B. relied upon to conclude that the Veteran had a history of smoking, as Dr. T.W. reported no noted smoking history, the fact remains that Dr. G.B. did not relate the Veteran's AML to any radiation exposure. Further, even without taking Dr. G.B.'s opinion into consideration, the evidence still preponderates against the claim. Indeed, although the appellant has submitted two private opinions, which she alleges support a finding that the Veteran's AML was caused by exposure to radiation and/or toxic chemicals, a review of the private opinions reveals that they are insufficient to rely upon in this case. Notably, Dr. J.O. did not specifically relate the Veteran's AML to radiation exposure. Rather, Dr. J.O. indicated that given that Veteran's subsequent development of leukemia, it was now his opinion that the flu-like symptoms for which he had treated the Veteran during the summer of 1985 were more likely due to toxic exposure at Dugway Proving Ground rather than related to the Veteran's Epstein-Barr virus infection. This statement does not relate the Veteran's development of AML to any exposures in service, nor does Dr. J.O. suggest that the Veteran's flu-like symptoms were early manifestations of AML diagnosed nearly 20 years later. Further, Dr. J.O. does not specifically comment on the nature of information provided to him regarding the Veteran's exposures at Dugway Proving Ground, which renders the basis of his opinion questionable, especially in light of the fact that specific exposures have not been proven. Further, although Dr. G.G., the Veteran's VA physician, opined that it was more likely than not that the Veteran's exposure to radiation and toxins during his military career caused him to develop AML, nowhere does Dr. G.G. discuss the level of any potential radiation exposure, the length of time that passed between the alleged exposure and the development of AML, or other factors that may have contributed to the Veteran's AML. Dr. G.G.'s opinion is, therefore, conclusory at best, and apparently based on guesses as to what happened in service. While there are no reasons or bases requirements imposed on a medical examiner, Ardison v. Brown, 6 Vet. App. 405, 407 (1994), to be adequate, any opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Given the contrary opinions of record, the lack of any supporting rationale renders Dr. G.G.'s opinion inadequate for evaluation purposes. Id.; see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding, in the context of weighing one medical opinion with another, that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion"); D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) ("An opinion is adequate where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one.'" (quoting Ardison, supra). In contrast to Dr. G.G.'s opinion, Dr. T.W specifically addressed the relationship between radiation exposure and AML and provided numerous reasons for her opinion that it was unlikely that the Veteran's AML could be attributed to any exposure to ionizing radiation in service. The Board finds Dr. T.W.'s analysis to be sound and finds no reason to discount its probative value based on an inaccurate factual premise or her qualifications as a medical professional. Without any evidence to refute the findings/studies relied upon by Dr. T.W., the Board finds that opinion to be the most probative evidence of record with regard to the question of whether the Veteran's AML could have been caused by any exposure to radiation in service. Similarly, the Board finds Dr. T.W.'s opinion regarding the likelihood that any exposure to chemical or biological agents caused or contributed to the Veteran's development of AML to be more probative that the opinion of Dr. G.G., who summarily suggested that the Veteran's exposure to numerous toxic agents, which were well known to be carcinogenic, led to the development of AML. Notably, Dr. G.G. did not discuss the type or nature of any toxic agents to which the Veteran may have been exposed, nor did he cite to any studies or medical literature suggesting a relationship between AML and any chemical or biological warfare agents. On the contrary, Dr. T.W. stated that a search of medical literature failed to reveal any citations to substantiate the causation of leukemia due to occupational or acute low dose exposure to chemical or biological warfare agents. Dr. T.W. further surmised that had the Veteran been exposed to any such chemical or biological warfare agents, he likely would have been ill at the time of exposure, as exposure to such agents is known to cause acute sickness and death, which was not evidenced in the Veteran's case. Furthermore, according to the joint VA/DoD Chemical Biological Warfare System, the Veteran was not a confirmed participant in Mustard Gas, Project 112 and SHAD testing, or Chem-Bio programs. In sum, the Board finds that the probative evidence of record preponderates against a finding that the Veteran's AML was related to any exposure to radiation and/or chemical or biological warfare agents while he was stationed at Dugway Proving Ground in service. In this regard, the Board has considered the lay evidence of record regarding the Veteran's job duties in service, but finds that regardless of the nature of the Veteran's duties or whether he was indeed exposed to any radiation and/or chemical or biological warfare agents, the persuasive medical evidence fails to relate the Veteran's AML to any such exposure. The Board finds Dr. T.W.'s opinion highly persuasive, as it is based on a review of the claims folder and medical literature, discusses why the objective evidence, to include the length of time between any such exposure and diagnosis, weighs against the claim, and is supported by the evidence of record. The Board emphasizes that its denial is not based on a lack of evidence demonstrating exposure to radiation and/or chemical or biological warfare agents. Rather, the Board finds that service connection for the cause of the Veteran's death is denied because the competent and probative evidence of record simply fails to relate the Veteran's AML to any alleged exposure to radiation and/or chemical or biological warfare agents. Although Dr. G.B. stated that one certainly could not exclude any contribution of possible chemical exposure to mustard gas as a possible contributory factor, the Veteran was not a confirmed participant in any Mustard Gas testing. As to the statement from a fellow serviceman who purportedly performed mustard gas garment testing with the Veteran, read by the appellant during her August 2010 hearing, the Board again notes that this statement was not made part of the record, despite the appellant being requested to submit it on remand in January 2011. While service connection for acute nonlymphocytic leukemia may be awarded in instances where there has been full-body exposure to nitrogen mustard during service, see 38 C.F.R. § 3.316 (2013), based on this evidence, the Board cannot conclude that the Veteran had full-body exposure to nitrogen mustard in service. Further, although the appellant believes that the Veteran was exposed to toxic agents in service and that such exposure led to the Veteran's development of AML, the etiology of dysfunctions and disorders is generally a medical determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1374-75 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the appellant, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion, especially in light of the medical professionals' conclusions to the contrary. See Jandreau, supra. Accordingly, given the competent medical opinion evidence obtained by VA indicating that it is unlikely that the Veteran's AML could be attributed to exposure to ionizing radiation and/or any chemical or biological warfare agents in service, the Board finds that the appellant's claim of service connection for the cause of the Veteran's death must be denied. See Davidson, supra (service connection requires evidence of a nexus between the claimed in-service disease or injury and the present disability); 38 C.F.R. §§ 3.303(d), 3.311(c). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the greater weight of the evidence is against the appellant's claim, that doctrine is not helpful to her. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for the cause of the Veteran's death is denied. ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs