THIS VERSION ICLUDES THE ERRATAS DATED 15SEP00 AND 17OCT00-e

           UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS


                                             No. 99-347

                                  MERLE D. STONE , APPELLANT ,

                                                 V.


                                    HERSHEL W. GOBER,
                      ACTING SECRETARY OF VETERANS AFFAIRS, APPELLEE.


                         On Appeal from the Board of Veterans' Appeals


                                      (Decided Sep 11, 2000)



       James J. Wall, of Wilmington, N.C., was on the pleadings for the appellant.

       Robert E. Coy, Acting General Counsel; Ron Garvin, Assistant General Counsel; Carolyn
F. Washington, Deputy Assistant General Counsel; and Michael R. Smalls, all of Washington, D.C.,
were on the pleadings for the appellee.

       Before FARLEY, IVERS, and GREENE, Judges.

       IVERS, Judge: The appellant, Merle D. Stone, widow of veteran Percy V. Stone, appeals a
February 4, 1999, decision of the Board of Veterans' Appeals (BVA or Board) that denied service
connection for the cause of the veteran's death. Record (R.) at 10. Both the Secretary and the
veteran have filed briefs. This appeal is timely, and the Court has jurisdiction pursuant to 38 U.S.C.
§ 7252(a) and 7266(a). For the reasons set forth below, the Court will vacate the Board's February 4,
1999, decision and remand the matter.


                                             I. FACTS
       The veteran, Percy V. Stone, served on active duty in the U.S. Army from October 1943 to
January 1946. R. at 14. The record reflects that the veteran served with the 62nd Signal Battalion
in the Hiroshima area from October 22, 1945, to December 27, 1945. R. at 3, 14, 97. The veteran
was first diagnosed with carcinoma at a private hospital in September 1978. R. at 18-24. The
veteran was hospitalized at the local VA medical center several times, including December 1978 to
January 1979 (R. at 83-90) and in February, May, June, and July 1979 (R. at 61-70, 75-82, 85). There
is no mention in any of the veteran's service medical records (SMRs) of exposure to radiation
during service. R. at 61-70, 75-82, 83-90. The veteran's SMRs are available (R. at 46-59), but may
be incomplete because a report from the National Personnel Records Center (NPRC) indicates that
the fire at the NPRC building in St. Louis, Missouri in 1973 caused some of the veteran's records to
be destroyed or lost. R. at 92. The veteran's available SMRs reflect that he did not have any diseases
of the liver, colon, or rectum and no carcinoma on any part of his body during service. R. at 46-59.
The veteran died on September 11, 1979, with the immediate cause of death listed as
cardiorespiratory arrest. R. 101. Carcinoma of the rectum with metastasis to liver was listed under
"other significant conditions contributing to death but not related to cause." Id. The veteran was
not service connected for any disability at the time of his death.
        In October 1986, the appellant filed a claim for service connection for the cause of the
veteran's death. R. at 37-40. The claim was denied in an unappealed September 1987 rating
decision. R. at 111-12. After the decision, the regional office (RO) notified the appellant that
substantive changes had been made to the laws and regulations governing radiation claims. R. at
114-16. In June 1993, in response to the RO's notice, the appellant filed a new claim for service
connection for the cause of the veteran's death. R. at 118, 120. The RO requested an estimate from
the Defense Nuclear Agency (DNA) of the possible radiation dose that the veteran might have
received from his service in the vicinity of Hiroshima. R. at 30. DNA determined that the veteran
was exposed to a maximum of .03 rem gamma radiation and no neutron radiation, resulting in a total
possible exposure of less than 1 rem. R. at 140.
        In June 1996, VA Chief Public Health and Environmental Hazards Officer, Susan H. Mather,
M.D., M.P.H., on behalf of the Under Secretary for Health, determined that "it is unlikely that the
[veteran's] carcinoma of the rectum and anal area can be attributed to exposure to ionizing radiation
in service." R. at 153. In July 1996, the Under Secretary for Benefits, after reviewing Dr. Mather's
opinion, determined, "As a result of this opinion, and following review of the evidence in its entirety,
it is our opinion that there is no reasonable possibility that the veteran's disability was the result of
such exposure." R. at 155. The RO, relying upon Dr. Mather's opinion, denied the claim in July
1996. R. at 157-59. The appellant appealed the denial. R. at 183-85. The appellant noted in her
VA Form 9:
       While the theory of a threshold dose of ionizing radiation, below which there was no
       carcinogenic effect, was generally accepted in the past, the consensus today is that
       any level of radiation today is probably harmful, in the sense that exposed individuals
       run increased risks of developing malignant disease. . . . Furthermore after recent
       readjustment of the radiation doses received by atomic bomb survivors in Japan, a
       growing debate about permissible exposure levels has recently led to call [sic] many
       scientists for the standard setting agencies to lower the permissible levels.

R. at 185. (Citing Gordy-Gray, Attorney's Textbook of Medicine.)
       In February 1998, the Board remanded the claim, with the instruction, among others, that the
claim was to be returned to Dr. Mather so that she could consider the appellant's contention that
recent scientific developments were pertinent to the question, and address whether there had been
any intervening scientific developments that would alter her findings or conclusion. R. at 190.
Dr. Mather, in a September 4, 1998 memorandum, responded, "We are not aware of any significant
scientific developments regarding the relationship between ionizing radiation and the development
of rectal or anal carcinomas since our previous opinion dated June 13, 1996." R. at 205. Dr.
Mather's original opinion, that it was unlikely that the veteran's carcinoma could be attributed to
exposure to ionizing radiation in service, remained unchanged. Id.
       The RO, in compliance with remand instructions from the Board (R. at 188-91), requested
that the appellant submit the autopsy report and the veteran's medical treatment records from his final
hospitalization. R. at 193. The RO informed the appellant that because the requested documents
were held by a private hospital, she would have to acquire the records and submit them. Id. The
record does not indicate that the appellant has submitted the requested records.
       The Board, in the decision here on appeal, denied service connection for the veteran's cause
of death. R. at 3.




                                          II. ANALYSIS
                                   A. Adequate Reasons or Bases
         Service connection may be granted for a veteran's cause of death if a disability causing death
occurred during service or if a service-connected disability either caused death or contributed
substantially and materially to the cause of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312 (1999).
Service connection for cancer which is claimed to be attributable to ionizing radiation exposure
during service can be established in three different ways. Ramey v. Brown, 11 Vet.App. 40, 44
(1996). First, under 38 U.S.C. § 1112(c) there are 15 types of cancer which can be presumptively
service connected. Second, 38 C.F.R. § 3.311(b) (1999) provides a list of "radiogenic diseases"
which will be service connected if certain conditions specified in the regulation have been met.
Third, direct service connection can be established by "show[ing] that the disease or malady was
incurred during or aggravated by service," a task that "includes the difficult burden of tracing
causation to a condition or event during service." Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir.
1994).
         The Board denied direct service connection for the veteran's cause of death, cancer of the
rectum. R. at 6-7, 10. Rectal cancer is not one of the 15 diseases subject to presumptive service
connection under 38 U.S.C. § 1112(c) and its implementing regulation 38 C.F.R. § 3.309(d). Rectal
cancer, is however, a "radiogenic disease" listed in 38 C.F.R. § 3.311(b)(2). Section 3.311(b)(1)
concerning initial review of claims provides:
         (b)(1) When it is determined:

                (i) A veteran was exposed to ionizing radiation as a result of participation in
                the atmospheric testing of nuclear weapons, the occupation of Hiroshima or
                Nagasaki, Japan, from September 1945 until July 1946, or other activities as
                claimed;
                (ii) The veteran subsequently develops a radiogenic disease; and
                (iii) Such disease first became manifest within the period specified in
                paragraph (b)(5) of this section; before its adjudication the claim will be
                referred to the Under Secretary for Benefits for further consideration in
                accordance with paragraph (c) of this section. If any of the foregoing 3
                requirements has not been met, it shall not be determined that a disease has
                resulted from exposure to ionizing radiation under such circumstances.

The veteran satisfies all of the requirements of section 3.311(b)(1): the veteran served as part of the
occupation force at Hiroshima during the requisite time period; and he developed a radiogenic
disease, cancer of the rectum, that manifested itself more than 5 years after exposure pursuant to
section 3.311(b)(5)(iv). Section 3.311(c) of title 38, Code of Federal Regulations provides:
           (1) When a claim is forwarded for review pursuant to paragraph (b)(1) of this
           section . . . the Under Secretary for Benefits shall consider the claim with reference
           to the factors specified in paragraph (e) of this section and may request an advisory
           medical opinion from the Under Secretary of Health.

                  (i) If after such consideration the Under Secretary for Benefits is convinced
                  sound scientific and medical evidence supports the conclusion it is at least as
                  likely as not the veteran's disease resulted from exposure to radiation in
                  service, the Under Secretary for benefits shall so inform the regional office
                  in writing . . .
                  (ii) If the Under Secretary for Benefits determines that there is no reasonable
                  possibility that the veteran's disease resulted from radiation exposure in
                  service, the Under Secretary for Benefits shall so inform the regional office
                  in writing, setting forth the rationale for this conclusion.

           (2) If the Under Secretary for Benefits, after considering any opinion of the Under
           Secretary for Health, is unable to conclude whether it is at least as likely or not, or
           that there is no reasonable possibility, the veteran's disease resulted from radiation
           exposure in service, the Under Secretary for Benefits shall refer the matter to an
           outside consultant in accordance with paragraph (d) of this section.

The Board in its decision stated:

           When presented with the facts of this claim, a medical doctor and representatives of
           the VA Under Secretaries for Benefits and Health determined that based on the
           veteran's low level of exposure to ionizing radiation while in service it is "unlikely"
           that his carcinoma of the rectum was the result of such exposure. When presented
           with the appellant's cited scientific evidence, the VA medical doctor again found it
           "unlikely" the veteran's exposure to ionizing radiation during service resulted in his
           carcinoma. Therefore, service connection for the veteran's carcinoma of the rectum
           is not warranted on a presumptive basis as a "radiogenic" disease under 38 C.F.R.
           § 3.311(b)(2).

R. at 9.
           Section 19.9(a) of title 38, Code of Federal Regulations provides, "If further evidence or
clarification of the evidence or correction of a procedural defect is essential for a proper appellate
decision, [the Board] shall remand the case to the agency of original jurisdiction, specifying the
action to be undertaken . . . ." See also Douglas v. Derwinski, 2 Vet.App. 435, 443-44 (1992). On
behalf of the Under Secretary for Health, Dr. Mather opined that it was unlikely that the veteran's
cancer was caused by his in-service exposure. R. at 153. The Under Secretary for Benefits stated,
"We have received a medical opinion from the Under Secretary [for Health], with which we agree,
that advises it is unlikely that the veteran's carcinoma of the rectum and anal area resulted from his
exposure to ionizing radiation in service." R. at 155.
       This Court has held that the Under Secretary for Benefits is not explicitly required to refer
to the factors listed in section 3.311(e), but should, rather, consult those factors as a point of
reference when making recommendations to the VARO. Hilkert v. West, 12 Vet.App. 145, 149-50
(1999). In this case, while the Under Secretary for Benefits was not required to explicitly consider
each of the factors in section 3.311(e), the cursory explanation provided by the Under Secretary for
Benefits did not provide adequate rationale for the conclusion that there was no reasonable
possibility that the veteran's cancer was caused by his in-service exposure as required by 38 C.F.R.
§ 3.311(c)(ii). R. at 155. The Board erred in relying upon that opinion and in failing to remand the
claim to the Under Secretary for Benefits to request an adequate rationale for its decision.
       Pursuant to 38 U.S.C. § 7104(d)(1), a final decision of the Board must include "a written
statement of the Board's findings and conclusions, and the reasons or bases for those findings and
conclusions, on all material issues of fact and law presented on the record. . . ." This Court has
held "that the BVA [must] articulate with reasonable clarity its 'reasons or bases' for decisions, and
in order to facilitate effective judicial review, the Board must identify those findings it deems
crucial to its decision and account for the evidence which it finds to be persuasive or
unpersuasive." Gilbert v. Derwinski, 1 Vet.App. 49, 57 (1990). Where the Board fails to fulfill this
duty, the Court is precluded from effectively reviewing the adjudication.            Meeks v. Brown,
5 Vet.App. 284, 288 (1993); Browder v. Brown, 5 Vet.App. 268, 272 (1993).
       The Board did not adequately discuss its reasoning for considering it unnecessary to return
the case to the Under Secretary of Benefits for a more complete rationale. There is no articulation
of the Board's reasons for finding the Under Secretary of Benefits' opinion convincing, but rather
a mere restatement of Dr. Mather's opinion in conjunction with the denial of presumptive service
connection. Without such an explanation, the Court holds that the BVA did not provide
adequate reasons or bases for denying the veteran's claim, based on all the evidence presented.
                                          B. Duty to Assist
       The Board further noted in its decision that:
       The appellant has also cited to scientific studies which suggest a connection between
       even extremely low levels of radiation and subsequent carcinomas in humans, but as
       a trier of fact, the Board does not find these sufficient to raise a reasonable doubt in
       favor of the appellant. The cited scientific information only indicates such a link is
           possible as a general matter. Such literature does not provide sufficient guidance in
           resolving the specific question presented in this case: What is the likelihood that the
           cancer this veteran incurred in the 1970s is the result of his exposure to radiation in
           the period from October to December 1945 in the Hiroshima area? In contrast, the
           VA medical expert's opinion is specific to this claim and is made after a review of
           the estimate dosage level and other relevant facts.
R. at 9.
           The U.S. Court of Appeals for the Federal Circuit held in Epps that "under [38 U.S.C.]
§ 5107(a), [VA] has a duty to assist only those claimants who have established 'well[-]grounded' (i.e.,
plausible) claims." Epps v. Gober, 126 F.3d 1464, 1469 (Fed. Cir. 1997), cert. denied, 524 U.S. 940
(1998) (emphasis added). The Federal Circuit has recently held:
           that once a veteran has properly made out a well-grounded claim for a current
           disability as a result of a specific in-service occurrence or aggravation of a disease
           or injury, the agency's duty to assist . . . attaches to the investigation of all possible
           in-service causes of that current disability, including those unknown to the veteran.

Schroeder v. West, 212 F.3d 1265, 1271 (Fed. Cir. 2000) (emphasis in original). The Board found
that the appellant's claim for service connection for the cause of the veteran's death was well
grounded. R. at 6. Therefore, under Schroeder, the Secretary was obligated to assist the appellant
in developing her claim.
           In the September 4, 1996 statement by Dr. Mather, on behalf of the Under Secretary of
Health, she said that she was "not aware of any significant scientific developments regarding the
relationship between ionizing radiation and the development of rectal or anal carcinomas since our
previous opinion dated June 13, 1996." R. at 205. That mere cursory dismissal of the possibility of
the existence of evidence beneficial to the appellant's claim did not satisfy the Secretary's duty to
assist. The Secretary had a duty to inform the appellant that she needed to submit the studies she
relied upon in support of her claim, to attempt to obtain the studies for Dr. Mather's consideration
in making her determination, or, at a minimum, provide specific citations to the materials so that VA
could access them in compliance with the Board's remand instructions. In failing to do so, VA
violated its duty to assist. The Secretary also violated his duty to comply with the Board's remand
instruction that Dr. Mather consider whether any recent intervening scientific developments would
alter her findings or conclusions in violation of Stegall v. West, 11 Vet.App. 268, 271 (1998)
(holding "that a remand by this Court or the Board confers on the veteran or other claimant, as a
matter of law, the right to compliance with the remand orders"). Since the Board found the
appellant's claim to be well grounded, Schroeder requires that the claim be remanded for the
Secretary to satisfy the duty to assist as to all theories of the claim.
        The Court has considered the additional arguments raised in the appellant's brief and finds
them to be without merit.


                                         III. CONCLUSION
        After consideration of the appellant's brief, the Secretary's brief, and a review of the record,
the Court holds that the veteran has demonstrated that the Board committed legal error which would
warrant remand. The Court is also not satisfied that the Board's decision fulfills the "reasons or
bases" requirement of 38 U.S.C. § 7104(d)(1). Therefore, the Board's February 4, 1999, decision is
VACATED and the matter is REMANDED for adjudication consistent with this opinion.
