The “Inability to Treat” Pathway: How Spicer v. McDonough Opened a New Way to Connect Conditions

After Spicer v. McDonough, your service-connected condition does not have to cause another condition for you to connect it. If your service-connected condition, or the medicine that treats it, blocked or delayed the treatment of another condition, that may be enough. This is one of the most useful changes in VA law in years, and almost no one explains it in plain English. Here is what it means and how it works.

What Changed

For a long time, connecting a second condition to your service usually meant proving one thing: your service-connected condition caused the new one, or made it worse. In 2023, a federal court widened the door. In Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023), the Court of Appeals for the Federal Circuit ruled that the law uses a broader test called “but for” causation. Under that test, a condition can be connected if it would be less severe today but for your service-connected disability, including when your service-connected condition got in the way of treating it.

That last part is the new opening. It is often called the inability to treat pathway.

What Spicer Actually Decided

The story behind the case makes it clear. Luther Spicer served in the Air Force and was exposed to hazardous chemicals in aircraft fuel. He later developed chronic myeloid leukemia, a blood cancer, which the VA connected to his service and rated at 100%.

Separately, he developed bad arthritis in both knees and needed a wheelchair. He was scheduled for knee replacement surgery, which would have helped. But the surgery had to be canceled, because the medicine that controlled his leukemia lowered his red blood cell count so much that surgery was not safe. His blood counts would never recover enough to allow it. So his knees stayed worse than they would have been after surgery.

He argued that his service-connected leukemia was the reason his knees could not be fixed, so his knees were worse but for his service-connected condition. The VA, the Board, and the Veterans Court all said no. The Federal Circuit disagreed and sent the case back, holding that the law’s causation test is broad enough to cover exactly this kind of situation.

The Three Ways to Connect a Condition Now

After Spicer, there are three ways your service-connected condition can connect a new condition. You only need one of them.

How a service-connected condition can connect another condition

What the Inability to Treat Pathway Means

The third pathway is the one most veterans have never heard of. The idea is simple. Sometimes a service-connected condition does not cause another problem directly, but it stands in the way of fixing it. When that happens, and the other condition ends up worse because of it, you may be able to connect the two.

This can happen in several real ways:

• Your service-connected condition makes a needed surgery unsafe, so a fixable condition cannot be fixed.

• The medicine you must take for a service-connected condition cannot be combined with the medicine that would treat another condition.

• Your service-connected condition delayed or interfered with care, so another condition got worse while it went untreated.

What “But For” Means in Plain English

The whole pathway turns on one question. Ask yourself:

If the honest answer is yes, you may have a claim, even if your service-connected condition did not cause the other one from scratch. The court was clear that this test is broad. It covers both action (something the service-connected condition did) and inaction (something it prevented), as long as the other condition is worse because of it.

A Real VA Decision That Used It

This is not just theory. The Board of Veterans’ Appeals has already granted claims on this pathway. The decision below is real and public. It is not a binding rule for other cases, but it shows how the pathway works.

Notice the shape of it. The heart disease did not cause the erectile dysfunction. But the treatment for the heart disease closed off the treatment for the erectile dysfunction, and that was enough. The reason the two cannot be combined is well established in cardiology: nitrates and erectile dysfunction drugs taken together can cause a dangerous drop in blood pressure, so they should not be used at the same time (ACC/AHA expert consensus, Circulation, 1999).

Who This Helps Most

The inability to treat pathway is worth a close look if any of these sound familiar:

• You take a medication for a service-connected condition that rules out another medication you need.

• A service-connected condition (for example, a blood, heart, or lung condition) makes a surgery or procedure too risky.

• Your service-connected condition forced you to stop or change a treatment that was helping another condition.

• Care for another condition was delayed because of your service-connected disability, and the condition got worse in the meantime.

These cases were often dead ends before 2023. Now they have a clear legal footing.

The Catch: The May 2026 Rule Update

Here is the part most websites skip. On May 1, 2026, the VA updated its internal rulebook, the M21-1 adjudication manual, to apply Spicer. That is good news, because it tells VA reviewers to consider whether a service-connected condition caused, worsened, delayed, prevented, or interfered with treatment of another condition.

But there is a flip side. Spicer also struck down one VA aggravation regulation, 38 C.F.R. 3.310(b), for conflicting with the law, and the new manual guidance asks for clearer proof of the but-for link. In plain terms: the door is wider, but a vague claim is still easy to deny. The veterans who win these claims are the ones who bring specific medical evidence, not just a theory.

What Your Nexus Letter Needs to Show

An inability to treat claim lives or dies on the medical detail. A strong nexus letter should:

• Name the service-connected condition and the treatment it requires.

• Name the other condition and the treatment that would have helped it.

• Explain exactly how the first blocked the second: the surgery that became unsafe, the medicines that cannot be combined, or the care that was delayed.

• Explain that the other condition is worse today as a result, and would be less severe but for the service-connected condition.

• State the opinion at the “at least as likely as not” standard, and tie it to the but-for test from Spicer.

This is the level of detail VA reviewers are now told to look for. A short, general letter will not carry it. A clear, clinician-written opinion that walks through each link can.

Frequently Asked Questions

References

1. Spicer v. McDonough, 61 F.4th 1360, 1364–66 (Fed. Cir. 2023) (secondary service connection under a but-for standard, including where a service-connected disability results in the inability to treat another condition; 38 C.F.R. 3.310(b), the aggravation regulation, held unlawful as inconsistent with 38 U.S.C. 1110).

2. 38 U.S.C. 1110 (compensation for disability resulting from service); 38 C.F.R. 3.310 (secondary service connection).

3. VA M21-1 Adjudication Procedures Manual, update implementing Spicer (effective May 1, 2026).

4. Citation Nr. 23066058 (BVA Dec. 13, 2023) (erectile dysfunction granted secondary to coronary artery disease where heart medication blocked ED treatment).

5. Citation Nr. 25001352 (BVA Jan. 29, 2025) (obesity intermediate step analysis reframed under Spicer). Non-precedential, illustrative.

6. Cheitlin MD, Hutter AM Jr, Brindis RG, et al. ACC/AHA Expert Consensus Document: Use of Sildenafil (Viagra) in Patients With Cardiovascular Disease. Circulation. 1999;99(1):168–177 (nitrate and PDE5-inhibitor combination contraindicated due to risk of severe hypotension).