Citation Nr: 1754987 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 14-12 616 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and her son ATTORNEY FOR THE BOARD M. Galante, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1970 to July 1990. He died in March 2001, and the Appellant is his widow. This appeal to the Board of Veterans' Appeals (Board) arises from an October 2011 rating decision from the United States Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California, which denied service connection for the cause of the Veteran's death. The RO in Seattle, Washington is currently the Agency of Original Jurisdiction (AOJ). In September 2015, the Appellant and her son appeared and provided testimony before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. In January 2016, the Board remanded this matter to the Under Secretary of Benefits for the issuance of a medical nexus opinion. Having reviewed the claims file, the Board finds there been substantial compliance with its past remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). After the March 2017 Supplemental Statement of the Case (SSOC), the Appellant submitted several statements in support of her claim, as well as her subsequently granted motion for advancement on the docket. The Board finds that her statements were essentially further arguments in support of her appeal and duplicate statements the RO had previously considered. Therefore, there is no need for waiver of AOJ review or issuance of another SSOC. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The Veteran died in March 2001. The immediate causes of death were recorded as respiratory failure; pulmonary edema, congestion (ARDS [acute respiratory distress syndrome] clinically); immunosuppression, aspergillus & pseudomonas infection; acute myocardial infarction clinically; and acute myelogenous leukemia. 2. The Veteran's cumulative in-service exposure to ionizing radiation measured to 0.242 rem. 3. Although it is a radiogenic disease, the competent and credible evidence fails to establish that the Veteran's acute myelogenous leukemia was incurred in service or is otherwise causally or etiologically related to his active service, to include any in-service exposure to ionizing radiation or asbestos. 4. The Veteran has not been shown to have served within the land borders or inland waterways of the Republic of Vietnam and is not presumed to have been exposed to herbicidal agents. Also, the evidence fails to demonstrate the Veteran was actually exposed to herbicidal agents during service. 5. The competent and credible evidence fails to establish that the Veteran's acute myocardial infarction was incurred in service or is otherwise causally or etiologically related to his active service, to include in-service exposure to herbicidal agents. 6. There is no competent and credible evidence establishing that any of the other causes of the Veteran's death (respiratory failure; pulmonary edema, congestion (ARDS [acute respiratory distress syndrome] clinically); and immunosuppression, aspergillus & pseudomonas infection) were incurred in service or is otherwise causally or etiologically related to his active service. CONCLUSION OF LAW The criteria for entitlement to service connection for the Veteran's cause of death have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1154; 1310, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.311, 3.312, 3.313 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable the Appellant to understand the precise basis for the Board's decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1) (2012); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act (VCAA) mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the Appellant. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, infra. Neither the Appellant nor her representative has explicitly raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Reviewing the file, the Appellant has not alleged any deficiency with her Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens, 814 F.3d at 1361, that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott, 789 F.3d at 1378. Thus, the Board need not discuss any potential Bryant problem because the Appellant has not raised that issue before the Board. The regulations pertinent to this decision were most recently provided in the February 2014 Statement of the Case and March 2017 Supplemental Statement of the Case and will not be repeated here, unless deemed appropriate to do so by the Board. The Appellant alleges that her husband's death due primarily to acute myelogenous leukemia and acute myocardial infarction were the direct result of ionizing radiation and herbicide agent exposure he experienced during active military service. See e.g., December 2014 Statement of Accredited Representative in Appealed Case. The Veteran's death certificate lists his cause of death as respiratory failure; pulmonary edema, congestion (ARDS clinically); immunosuppression, aspergillus & pseudomonas infection; acute myocardial infarction clinically; and acute myelogenous leukemia. Based on the following analysis, the Board concludes that the weight of the evidence is against a finding of service connection for the Veteran's death. A. Acute Myelogenous Leukemia In the present matter, service connection for cause of death due to acute myelogenous leukemia can be achieved in four ways. First, service connection for a disability based upon exposure to ionizing radiation can be awarded on a presumptive basis for diseases specific to veterans exposed to radiation under 38 C.F.R. § 3.309(d) (2017). Presumptive service connection may also be established under 38 C.F.R. § 3.303(b) (2017) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a) (2017). Service connection may also be established under 38 C.F.R. § 3.303(d) (2017) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311 (2017), if the condition at issue is a radiogenic disease. Lastly, direct service connection may be granted under 38 C.F.R. § 3.303(d) (2017) when it is established that the disease diagnosed after discharge was otherwise incurred during active service, including as a result of exposure to radiation, without regard to the statutory presumptions. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). i. Presumptive Service Connection under 38 C.F.R. § 3.309(d). Although acute myelogenous leukemia is a medical condition for which the ionizing radiation presumption under 38 C.F.R. § 3.309(d) may be considered, the Veteran was not a "radiation-exposed veteran" as described in 38 C.F.R. § 3.309(d)(3). The Veteran did not participate in nuclear weapons testing, was not involved in the occupation of Hiroshima or Nagasaki, Japan, was not a prisoner of war in Japan exposed to radiation from the atomic bombing, did not serve at any of the applicable gaseous diffusion plants, and did not serve in any capacity explicitly listed in 38 C.F.R. § 3.309(d)(3)(ii)(E) (2017). Accordingly, this presumptive regulation has no application. ii. Presumptive Service Connection under 38 C.F.R. §§ 3.303(b) and 3.309(a). Where the Appellant asserts entitlement to service-connected cause of death due to the Veteran's chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013); 38 C.F.R. § 3.307 (2017) (service connection authorized for chronic diseases diagnosed within the presumptive period). Leukemia is listed as a chronic disease under 38 C.F.R. § 3.309(a), so the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology and of 38 C.F.R. § 3.307 pertaining to presumptive service connection for a chronic disease do apply in the instant case. However, the record establishes that the Veteran's acute myelogenous leukemia was first diagnosed in 1999, nearly 10 years after his active service had ended. The Veteran's service treatment records reflect no complaints of, treatment for, or a diagnosis related to leukemia. Nonetheless, the Appellant maintains that in-service paint and radiation exposure, as well as several health complaints documented in service treatment records, contributed to his eventual diagnosis of leukemia. In particular, she cites low red blood and platelet counts obtained during the Veteran's service on the U.S.S. Permit as proof that the Veteran was experiencing the dormant early stages of his leukemia. See March 2014 lay statement. The Board notes that the Appellant is not competent to opine on complex medical matters such as the etiology or causation of cancer. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Appellant lacks the medical expertise necessary to render a competent medical opinion in this matter. Id. Moreover, in August 2004, a competent medical opinion was obtained to address the Appellant's contentions. Following a review of the claims file, Dr. M.O. issued a negative nexus opinion. Specifically, Dr. M.O. opined: Review of the Service Medical Records and other medical records after military service showed no evidence of [acute myelogenous leukemia] while on active duty or within one year of release from active duty. The isolated values of the white blood cells (WBC) being elevated on one occasion and then returning to normal and the low platelet count (PLT) on one occasion and then returning to the normal range does not indicate a diagnosis of [acute myelogenous leukemia] during military service. The CBC values throughout the 1990s were not indicative of [acute myelogenous leukemia] until 9/1999 when they were diagnostic for this condition. There were no symptoms or signs during active duty showing a service connected disability which contributed to his cause of death. Finally, Dr. M.O. indicated he could find no scientific literature tying the Veteran's in-service exposure to ionizing radiation and organotin compounds (in paint) to the Veteran's eventual diagnosis with acute myelogenous leukemia. Respectively, he stated: The medical online database, Entrez PubMed was reviewed at length to look for any references indicating an association between [acute myelogenous leukemia] and any of the occupational exposures that this veteran faced (submarine duty, sonar radiation exposure, organotin compounds). Unfortunately, specific references relating this veteran's potential exposures in the Navy and his later diagnosis of [acute myelogenous leukemia] could not be found. As the only competent medical evidence of record addressing the Appellant's contentions regarding continuity of symptomatology, the Board finds Dr. M.O. to be highly probative and dispositive of the claim on appeal. There is simply no competent evidence establishing that the Veteran's acute myelogenous leukemia manifested during active duty or within one year of discharge from active duty. 38 C.F.R. § 3.307(a)(3) (2017). Presumptive service connection for a chronic disease is not warranted. iii. Service connection under 38 C.F.R. § 3.311. Next, the Board turns to the applicability of 38 C.F.R. § 3.303(d) in conjunction with § 3.311. The Veteran was diagnosed with "acute myelogenous leukemia" in September 1999. All forms of leukemia (except chronic lymphatic (lymphocytic) leukemia) are radiogenic diseases under 38 C.F.R. § 3.311(b)(2). Since the Veteran's acute myelogenous leukemia became manifest nearly ten years after his July 1990 discharge from military service, and given the Appellant's contentions concerning in-service exposure to ionizing radiation, a dose estimate was requested. 38 C.F.R. § 3.311(a) (2017). By all accounts of record, the Veteran was exposed to 0.242 rem of radiation. See e.g., November 1999 Naval Radiation Exposure History. The Veteran's radiation detection film badge was damaged from the period of January 31, 1975 to March 3, 1975; however, the radiation health officer considered the actual exposure of co-workers who performed the same general duties, during the same issue period, and in the same general area to fill in this data gap. See July 1990 Report of Exposure to Ionizing Radiation. Pursuant to 38 C.F.R. § 3.311(b)(1)(iii) and (c), the Appellant's allegations were sent to the Under Secretary of Benefits for referral to the Under Secretary for Health for an advisory medical opinion. In a December 1999 letter, Under Secretary for Health, Dr. S.M., noted the Veteran was exposed to a total lifetime whole body dose of 0.242 rem. Dr. S.M. cited studies indicating that exposure to 1.16 rads or less at age 21 provided a 99 percent credibility that there is no reasonable possibility that it is as least as likely as not that leukemia developing within 20 years of exposure is related to ionizing radiation. Dr. S.M. concluded it was unlikely that the Veteran's acute myelogenous leukemia could be attributed to exposure to ionizing radiation in service. The Appellant's representative raised concerns regarding Dr. S.M.'s opinion, arguing that the exposure calculation was based on the Veteran's exposure at age 21, without regard to the fact that he was exposed to radiation for nearly twenty years and did not leave service until age 39. See December 2015 Statement of Accredited Representative in Appealed Case. The Board acknowledged the representative's contention in its January 2016 opinion and remanded the matter for a new nexus opinion which contemplated the Veteran's continued radiation exposure through the age of 39, as required by 38 C.F.R. § 3.311(e)(4) (2017). In an August 2016 memorandum, the Office of the Director of the Post 9/11 Era Environmental Health Program (10P4Q) rendered a nexus opinion regarding the Appellant's claim. In issuing a negative opinion, the reviewer cited the Health Physics Society position statement PS010-2, Radiation Risk in Perspective, revised in July of 2010, which states that: [I]n accordance with current knowledge of radiation health risks, the Health Physics Society recommends against quantitative estimation of health risks below an individual dose of 5 rem in one year or a lifetime dose of 10 rem above that received from natural sources...there is substantial and convincing scientific evidence for risks following high-dose exposures. However, below 5-10 rem (which includes occupational and environmental exposures), risks of health effects are either too small to be observed or are nonexistent. Consequently, the reviewer concluded, that "[s]ince the Veteran's radiation does did not exceed 5 rem in one year, or 10 rem in a lifetime, it is our opinion that it is unlikely that [acute myelogenous leukemia] was caused by exposure to ionizing radiation while in military service." In August 2016, after reviewing the memorandum issued by the 10P4Q office, the Director of Compensation Service found that there was "no reasonable possibility that the Veteran's acute myelogenous leukemia was the result of exposure to ionizing radiation." Having reviewed the record, the Board finds that the August 2016 nexus opinion, in compliance with 38 C.F.R. § 3.311(c), is highly probative as it is supported by a sufficient rationale based on extensive scientific research. Further, the opinion considered the Veteran's medical history, probable dose of radiation, and time lapse between exposure and onset of disease. Moreover, a review of the evidence of record indicates that the information supplied to the 10P4Q office was accurate, and there is no reason to conclude that the reviewer's conclusions were made based on an incorrect factual basis. See 38 C.F.R. § 3.311(e) (2017). Accordingly, the Board concludes that the Appellant is not entitled to service connection for the Veteran's death under 38 C.F.R. § 3.303(d) in conjunction with § 3.311. In November 2017, the Veteran's representative argued that the opinion offered by the 10P4Q office did not discuss other possible etiologies of the Veteran's acute myelogenous leukemia, implying the opinion was deficient. The Board is not persuaded. Medical review by the Under Secretary of Health or his/her designate is expressly limited under 38 C.F.R. § 3.311(c) to determining the causal connection between the Veteran's radiogenic disease and his military service ionizing radiation exposure. Presumably, the Veteran's representative is requesting a medical nexus opinion under the direct service connection scheme. However, as highlighted below in section A. iv. of this decision, the Veteran experienced no complaint or symptoms of acute myelogenous leukemia while in service and there is no credible, competent indication of record that the Veteran's acute myelogenous leukemia may be associated with his military service. In fact, as the preceding sections establish, such a connection has been explicitly rejected by the most probative medical opinions of record. Thus, additional nexus opinions are not required under McClendon v. Nicholson, 20 Vet App. 79, 81 (2006). The Board finds the evidence of record has sufficiently addressed the etiology of the Veteran's acute myelogenous leukemia in connection with his military service. The record contains a May 2000 statement from the Veteran's treating oncologist, Dr. D.M., which states, "one of the few known causes of leukemia is exposure to radiation. [The Veteran] served on nuclear submarines, and exposure to radiation during that time may have contributed to or caused his leukemia. There is no way to prove whether or not shipboard radiation was a cause, but is certainly possible." The Board finds that Dr. D.M.'s opinion, with its use of the terms "may have" and "possible," is too speculative to establish a causal relationship, and the opinion is of no probative value. See Bostain v. West, 11 Vet. App. 124, 127 (1998) (a physician's opinion that an unspecified preexisting service- related condition "may have" contributed to the Veteran's death was too speculative to be new and material evidence); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (noting that speculative opinion is not legally sufficient to establish service connection). Furthermore, Dr. D.M. did not cite any basis or supporting rationale for his opinion, nor did he cite the Veteran's specific level of radiation exposure or any of the other relevant considerations set forth in 38 C.F.R. § 3.311(e)(2017). Accordingly, Dr. D.M.'s medical opinion has been afforded little to no evidentiary weight in this determination. The Appellant has also submitted a June 1991 report from the John Hopkins University, Department of Epidemiology, entitled Health Effects of Low-Level Radiation in Shipyard Workers to support her claim. This report does not in any way relate the Veteran's acute myelogenous leukemia to his in-service ionizing radiation exposure. See Wallin v. West, 11 Vet. App. 509, 514 (1998) (treatise evidence cannot simply provide speculative generic statements not relevant to the veteran's claim, but, "standing alone," must include "generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion"). As such, this report is of no probative value to the Veteran's specific situation or the Appellant's claims on appeal. iv. Direct Service Connection Although it has been the Appellant's primary assertion that the Veteran's acute myelogenous leukemia was attributable to in-service ionizing radiation exposure on a presumptive basis, she is not precluded from establishing service connection with proof of actual direct causation as due to active duty service. See Combee, 34 F.3d at 1041-42. However, the evidence is against such a finding. As detailed extensively above, the Veteran experienced no complaint or symptoms of acute myelogenous leukemia while in service (per VA medical opinion, see above) and no competent medical opinion of record has definitively linked the Veteran's condition to his active duty service. Although the Veteran was exposed to a minimal level of ionizing radiation during the course of his military duties, the evidence does not show that this radiation played a role in the subsequent development of his acute myelogenous leukemia and death. Consequently, without any in-service incurrence of disease or any competent medical evidence linking the Veteran's death from acute myelogenous leukemia to military service, the Appellant's claim must be denied. Arguing in support of direct service connection, the Veteran's representative cites a 1984 House of Representatives Report accompanying the Radiation Compensation Act which states, "there is limited scientific understanding of the relationship between exposure to low doses of ionizing radiation and subsequent health problems." Given the age of this report and the Veteran's representative's failure to acknowledge the more recent scientific research, such as the July 2010 Health Physics Society position statement PS010-2 relied upon by the 10P4Q office, the Board does not find this argument/evidence convincing. The July 2010 Health Physics Society position statement PS010-2 clearly establishes that the Veteran's total 0.242 rem of in-service ionizing radiation exposure resulted in health effects that are either too small to be observed or are nonexistent. Finally, when the Veteran submitted his claim for leukemia, he also asserted it was due to asbestos exposure. In 2016, the Appellant's representative submitted a statement generally discussing asbestos exposure in Navy veterans. However, even assuming the Veteran was exposed to asbestos throughout his lengthy naval career, there is no suggestion in the medical evidence that this played any role in his leukemia diagnosis. B. Acute Myocardial Infarction The Appellant contends that the Veteran's heart disability, manifesting itself as a myocardial infarction, resulted in his death and was caused by exposure to herbicidal agents during Vietnam service. See December 2009 and 2010 lay statements; December 2015 Statement of Accredited Representative in Appealed Case. Specifically, the Appellant has asserted the Veteran served in Saigon, Vietnam, while her representative has asserted he served in DaNang, Vietnam. Id. i. Presumptive Service Connection under 38 C.F.R. § 3.309. Service connection may be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, including ischemic heart disease (myocardial infarction), though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 C.F.R. §§ 3.307, 3.309(e), 3.313 (2017). The Board acknowledges that the Veteran's myocardial infarction contributed to his death, and that ischemic heart disease, including myocardial infarction, is one of the conditions subject to presumptive service connection consideration under the regulations for exposure to herbicidal agents in the Republic of Vietnam. However, the weight of the evidence is against a finding that the Veteran ever stepped foot in the Republic of Vietnam. A Personnel Information Exchange System (PIES) response dated in January 2010 was negative for any indication that the Veteran served in the Republic of Vietnam. A review of the Veteran's military personnel and service treatment records also fail to contain any evidence substantiating Republic of Vietnam service. Included in the Veteran's military personnel records is a document listing the Veteran's "history of assignments" for the entire period of his active duty service. Nowhere in this document does it describe any service in the Republic of Vietnam. Furthermore, in a February 1990 "Medical Surveillance Questionnaire," the Veteran listed all of his duty stations [Illinois, Florida, Connecticut, Hawaii, and California], but did not include service in the Republic of Vietnam. On this same document, the Veteran denied in-service exposure to hazardous chemicals. Finally, the Board notes in correspondence dated March 2014, the Appellant stated "I never claimed that [the Veteran] was in Vietnam because I honestly did not know." The uncertainty in this statement certainly cuts against the veracity of Appellant's presumptive service connection claim. With the above considerations in mind, no service within the land borders or inland waterways of the Republic of Vietnam has been shown and the Veteran is not entitled to the presumption of herbicidal agent exposure. Likewise, the record does not contain evidence of actual herbicidal agent exposure. Thus, service connection for the disabilities listed in 38 C.F.R. § 3.309(e), including ischemic heart disease (myocardial infarction), is not presumed. Finally, the Board notes that myocardial infarctions could be considered as a "cardiovascular-renal disease" under 38 C.F.R. § 3.309(a) (2017), subject to presumptive service connection consideration under 38 C.F.R. § 3.303(b) (2017). See also Walker, 708 F.3d at 1338-39. However, because myocardial infarction, or any cardiovascular disease, has not been shown to have manifested in service or within the first year after the Veteran's July 1990 separation from service, entitlement to presumptive service connection for chronic disease must be denied. ii. Direct Service Connection The Appellant argues that the Veteran had a heart murmur during service, as well as a variety of symptoms/complaints, that she believes led to his myocardial infarction. In a November 1990 rating decision, the Veteran was denied service connection for a heart condition. A September 1990 VA examination found no evidence of a chronic heart condition in service. The examiner did note the Veteran's February 1990 episodes of bradycardia, commenting that: Because of some vague cerebral symptoms, [the Veteran] was placed on a holter monitor and a review of his military records shows that there some PVCs [premature ventricular contractions] but there were no symptoms at the time of the PVCs. [The Veteran] does not admit to any symptoms of palpitations or irregular heart rate. An EEG [electroencephalogram] and CAT [computed tomography] scan were done and both were normal. All of his lab studies, also were normal. Since that time, no additional evidence has been submitted showing an in-service occurrence of heart disease. Additionally, no medical professional of record has ever indicated that the Veteran's heart disease and resulting myocardial infarction were incurred during active duty or that the Veteran's cardiac-related death was otherwise etiologically related to his military service. While a myocardial infraction admittedly contributed to the Veteran's death, no competent evidence of record has linked this condition to the Veteran's military service. Having failed to establish the elements for direct service connection, the Appellant's claim must be denied. C. Other Considerations Finally, the immediate causes of death also included respiratory failure; pulmonary edema, congestion (ARDS [acute respiratory distress syndrome] clinically); and immunosuppression, aspergillus & pseudomonas infection. The Appellant does not contend that any of these conditions began during the Veteran's military service, and there is nothing in the record to suggest this is possible. As noted above, the representative submitted general information on asbestos exposure in Navy veterans in 2016. There is no suggestion, though, that the Veteran had asbestosis, or that the respiratory failure/pulmonary edema, congestion that caused his death was in any way due to asbestos exposure. There are also no medical opinions linking these other causes of his death to his service. D. September 2015 Board Hearing testimony The Board has considered the hearing testimony of the Appellant and her son in relation to the claims on appeal. For the purposes of clarity, the Board notes that the testimony of the Appellant and her son at the September 2015 Board hearing focused exclusively on the Appellant's claims that the Veteran's death due to acute myelogenous leukemia was caused by in-service ionizing radiation exposure. Neither witness discussed the claim addressing herbicide agent exposure and heart disease as contributing to the Veteran's death. As laypersons, the Board finds the witnesses to be credible and competent to discuss their personal observations of the Veteran's symptoms and their own in-person experiences. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness). However, to the extent that the witness' testimony attempts to assess the etiology of the Veteran's symptoms or relate such symptoms to the Veteran's active duty, to include radiation exposure, they are not competent evidence. Although lay persons are competent to provide opinions on some medical issues in certain circumstances, the specific disability at issue, acute myelogenous leukemia and its relation to the Veteran's in-service ionizing radiation exposure, is outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Accordingly, the witnesses lack the medical training and expertise to offer an opinion on a complex medical matter, including the diagnosis or etiology of a specific disability. Jandreau, 492 F.3d at 1376-1377. The Board finds that the testimony of the Appellant and her son are of little probative value in establishing service connection for the cause of the Veteran's death. E. Conclusion The Board recognizes the Appellant's sincere belief that the Veteran's death was related in some way to his military service. Unfortunately, the record is devoid of any competent medical opinions linking the Veteran's death to his military service. With the preponderance of the evidence against entitlement to service connection for cause of death, the doctrine of reasonable doubt does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board acknowledges the Veteran's honorable service to our country and is sympathetic to the Appellant's circumstances; however, the Board must apply the law as it exists. See Owings v. Brown, 8 Vet. App. 17, 23 (1995) (providing that the Board must apply the law as it exists and is not permitted to award benefits based on sympathy for a particular appellant). The Board is grateful to the Veteran for his honorable service and regrets that a more favorable outcome could not be reached for the Appellant. ORDER Entitlement to service connection for the Veteran's cause of death is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs