Why do we die? The question is existential, scientific, and spiritual at the very least. It's also bureaucratic. Like voter registration cards and driver's licenses, death certificates relegate the cause of our physical demise to a discrete category that becomes a single data point in a sea of statistical information. And they are vitally important to the public's health.
In "Final Forms," an excellent article in the April 7 issue of The New Yorker, Kathryn Schulz tells the story of the death certificate: its history, its public health significance, its shortcomings.
Schulz traces the origins of the modern death certificate back to 1512. In London, Bills of Mortality were first issued to track the number of people who died from the plague, in addition to the number succumbing to non-plague causes. The Bills included no information about individual decedents, such as their name or what exactly killed them (other than the plague), and were only issued sporadically after the terror of the Black Death subsided. Things changed, however, in 1629 when King James I mandated that the Bills be issued on a regular basis, capture every death, and its cause. Years later, an actuarially-oriented haberdasher named John Gaunt reviewed 20 years worth of Bills and teased out 81 distinct causes of death across the four categories: chronic diseases, epidemic disease, conditions that killed children, and injuries.
Gaunt may have developed death's first classification system, but it wasn't until 1837 -- when William Farr, who is considered a forefather of epidemiology, became Compiler of Abstracts at England's General Register Office -- that the death certificate became a document of public health significance. Farr saw death data as holding answers to questions about how people could live longer, healthier lives. Farr's philosophy was that we could prevent death, disease, and disability by taking action on the basis of knowledge about what kills who in a population.
In 1853, Farr worked with the International Statistical Congress to develop a more refined taxonomy of death, this one containing 139 causes across seven categories. The work provided the foundation for the first International List on the Causes of Death, containing 161 causes, published in 1893. Today, the International Statistical Classification of Diseases and Related Health Problems (the "ICD" as it's known in the health professions) is on its 10th edition and contains over 8,000 reasons for why we expire.
Today, death certificates serve the same public health function as they did centuries ago: they provide guidance about how to allocate scarce resources for public health research, education, medical care, and preventive intervention. The Philadelphia Medical Examiner's Office, for example, uses patterns from death certificates as the beginning of in-depth reviews of health and safety issues for specific groups, such as children and homeless people, that end with policy recommendations intended to reduce deaths. We need to know what's killing us in order to make us stronger.
Despite the essential public health function they serve, death certificates are not without their faults. As Schulz describes, a survey of over 500 medical residents in New York City found that 48.6% had knowingly reported the cause of death inaccurately on a death certificate, for reasons such as the computerized system not accepting the "correct" cause of death and office personnel instructing them to list a different cause. Family pressure and reputation of the deceased can play a role as well; AIDS used to be left off death certificates; suicide may still be.
Death certificates have also been found to over-report leading causes of death, such as heart disease (the #1 cause of death in the U.S.), and under-report less common ones. A study found that deaths "caused" by heart disease decreased by a whopping 54% after hospital staff participated in intervention aimed at reducing heart disease over-reporting, compared to a reduction of 6% at hospitals that did not receive the intervention.
Given these issues, might the death certificate as we know it be nearing the end of its life? Could physician judgment be replaced by an automated algorithm that determines cause of death on the basis of social risk factors and biometrics? While only time will tell,
makes clear that, in one form or another, death certificates are here to stay.