Quirky cultural customs: the causes of death

Have you ever reflected on what a strange concept the notion of a ’cause of death’ really is? We use the term so often that it wouldn’t quickly register as a cultural oddity, but it really is a quirky beast and has an odd history.

I have a bit of a professional interest in this because health economists like to use administrative data on causes of death (which go back a long time and cover many countries) and we like to derive all kinds of things from the scribbles that doctors put down on death certificates, usually to argue we should spend more on something that causes lots of death. So the musings below are not entirely geeky: billions depend on how you think about causes of death.

Suppose you view the human body more or less as a machine. A complicated one, admittedly, but a machine nevertheless. Most of us ‘bods’ die quite old, around 90 if you make it to mid-life. By that time, the number of things wrong with us is countless. Our heart is not as strong as it used to be, our arteries are clotted, are cholesterol is the wrong count, the joints creak, the liver is not optimal, the skin has sores, the eyes have cataracts, some cells can no longer divide, the T-count is minimal, etc.

The typical person dying at home or in a hospital bed doesn’t just have one disease or ailment, they have thousands of them, most of them undiagnosed. Just like ‘healthy’ people, one might add, who also at any time have millions of bacteria that are bad for them and thousands of creeping ailments too small for the average GP to diagnose (thank god!). When the body as a whole then stops functioning entirely, the whole notion of a single cause or even a short list of causes is simply odd. Often the patient would have survived the whole list of ailments seen as their supposed cause of death if the rest of their body was like it was when they were 20.

It is this notion of ‘the cause’ that is the odd bit. Suppose for instance that someone dies and their heart stopped beating. Well, literally speaking the ’cause’ for that heart no longer beating is that the energy in the cells didn’t arrive in time, or that the electric pulse to contract the heart muscle didn’t arrive. Is that what we mean by the ’cause’ of death? Never! We normally want something more substantial than that, even though from a moment-to-moment notion of death, that was the direct cause. We want something bigger in the background that we can blame, something that we can say ‘if it was not for that, the person would not be dead’. And therein lies the problem.

With a machine that has a hundred problems and that has slowed down in many ways for many years and is hence hardly functional in any way that counts for many years, one wouldn’t bother with pretending that anything in particular caused its death and that the machine would still work if only for that one thing. We would say the machine slowly declined, had lots of stuff wrong with it, and at some point it stopped moving entirely! We would just call it ‘broken’ or ‘defunct’. A hundred things and a lifetime of use ’caused it’ to die in the sense that ‘it would still work otherwise’. The notion that X ’caused’ it to stop would sound weird because it hadn’t worked properly for ages. To get it to work properly again would need many things to be different and ‘curing’ any one thing would not make much more than a moment’s difference.

It gets weirder. Taken literally, many answers are ‘correct’ as cause of death. The person stopped breathing. The person’s heart no longer beats. The brain stem has stopped firing. The cells no longer process energy. The patient no longer eats or drinks. The blood is no longer circulating. All true and it is the case for each one of them that they are sort-of necessary ingredients in death as death involves all of them and each one is a necessary condition for death. One could hence rightfully say all of them are a ’cause’ of death.

Why do most death certificates then have something definite on them, like ‘cardiac arrest’, ‘lung cancer’, ‘stroke’, ‘malaria’, or any of these other things that blames death on something specific rather than a more accurate ‘old age in general’ or ‘god knows, but X was probably involved so I will put that down’ description? Why don’t we go for something more sensible like a list of ‘levels of functionings’ at different ages?

The reason is sobering: it is the law that there must be a ’cause’ of death. Even if there is no such thing, there simply has to be a certificate that says there is one, specifically naming something and certified by someone who is supposed to know. There is a whole industry of people supplying causes of death for those who did not die in hospitals, a regular money-spinner. I had to wait for 12 months with a relative of mine whilst pathology labs made a mint out of the government coming up with a cause of death!

And there is actually a good reason for some of this pantomime, even though it is irrelevant for the vast majority of deaths: if the causes of death are deemed ‘not natural’ then someone is supposedly to blame for that death, perchance via negligence or murder, which in turn would set off a murder inquiry and potential criminal culpability in someone. So to have a declaration of a ‘natural cause’ of death is rather important for the living! Police investigations, wills, and inheritances depend on them!

The notion of a natural cause of death is even weirder than a cause of death itself though. What the hell is a natural cause? Is a sickness a natural cause even if it was preventable? Is poverty a natural cause of death if it means someone didn’t eat enough or is unnatural because society could have prevented it? Was the neglect 10 years ago that lead to damaged kidneys and hence an inability to process the medicines today a ‘natural cause’? If you truly think of all the elements going into poor health and hence into the functioning of the body (dead or not), then the notion of a natural cause versus an unnatural cause starts to sound truly weird. Pretty much all of our life is involved in our health, so all of our life is involved in why we are at some point dead, so almost anything that ever happened to us that was ‘unnatural’ will have had some hand in our death. It’s a reasonable supposition to say that it is almost impossible to die without some unnatural element.

So we arrive at an old point in philosophy: our culture creates abstractions out of thin air in order to help in the organisation of society and our institutions subsequently muddle on pretending the abstractions are precise and not the dogs breakfast that they in fact are. And us poor researchers then have to plug that dogs breakfast into a model to come up with health policy recommendations, based on ‘accurate administrative data’!

This entry was posted in Death and taxes, Ethics, Geeky Musings, Health, History, Libertarian Musings, Medical, Science, Social Policy. Bookmark the permalink.

9 Responses to Quirky cultural customs: the causes of death

  1. Chris H says:

    I want to know if a communicable disease caused death. I want to know if a chronic disease caused death. I want to know if an accident caused death. I want to know if a deliberate act caused death.

    There’s nothing wrong with requiring a cause of death. And there’s nothing wrong with a complex cause of death, or a multiple causes of death. There’s a lot wrong with ignoring why we need to know, and how much we do know, about cause of death.

    Sure, some situations will get a rubbery answer. But very many won’t. And the answers we get really do inform policy thinking and give us feedback on changes we have made or allowed in society generally.

    • derrida derider says:

      “Sure, some situations will get a rubbery answer. But very many won’t.”
      I think Paul is asserting, IMO correctly, that it’s the other way around – in almost all situations will get a rubbery answer, and in only a minority of cases can we even clearly distinguish one cause from the surrounding rubber.

      But of course it is precisely that minority that the law will be interested in – which does not solve the social scientist’s (or the potential heir’s) problem.

      • Chris H says:

        Yes, I think that is what Paul asserts. But why? It’s not rubbery to say that someone died of malaria – even if debility due to age, to youth, or to something else contributed. It’s not rubbery to say that someone died of heart failure – even if a range of other problems might have taken them off or made the heart failure more dangerous.

        Really, it’s like the asbestosis problem. Where exposure to asbestos and a history of smoking combine, the risks are very greatly magnified, and allocating harm between the smoking and the asbestos is hard. But surely that means no more than that you have to express reality: it was the combination of harms that did the damage. And you would still disregard other risks that weren’t material.

      • paul frijters says:

        I nominate DD to answer further questions! :-)

        But as direct response to Chris. You exemplify the attitude that prevails but that I find very odd. Sure, one can indeed say that this or that caused death, but one could equally rightfully have chosen a thousand other things as the cause of death. To choose this or that is in many ways arbitrary and pretentious, subject to fashion cycles and improper inferences.

        The medical community does know about this, but many authors prefer to think of it as ‘reporting bias’ or a few ‘multiple risk factors’, with terms like competing risks used by the modellers. Even that terminology is still stuck in the machine-is-working-great-or-it-is-dead mentality wherein an identifiable factor caused machine failure.

        There are literatures where they think differently, particularly in cost-benefit-analyses. Some researchers try to speak of ‘preventable lost years due to X’ or other such terms, which is more cognisant of the complexities and more relevant to health policy-setting where you want to know how much more bang you get for getting rid of addressing problem X in a particular way. Burden of disease is a similarly more expansive concept.

        An example of a study that finds an importance for habits in what physicians put down on death certificates regarding the influence of diabetes:

        Lu TH, Walker S, Johansson LA, Huang CN. An international comparison study indicated physicians’ habits in reporting diabetes in part I of death certificate affected reported national diabetes mortality. J Clin Epidemiol. 2005;58:1150–1157. doi: 10.1016/j.jclinepi.2005.03.009.

        • paul frijters says:

          oh, and this page (http://www.dailymail.co.uk/news/article-2070102/Royal-Society-exhibition-John-Graunts-1679-medical-stats-reveal-Londoners-causes-death.html) shows you a copy of the causes of death in 17th century London. It includes 200 cases of ‘grief’, but also a few ‘found on the street’, ‘frighted’, and ‘itch’. Some items on that 17th century list are more informative in terms of the ’causes of death’ than what you see nowadays, also in terms of policy relevance.

          When is for instance the last time any physician dared to put ‘grief’ on the death certificate, even if that indeed was the thing that shortened someone’s life the most and is something more public resources might alleviate? Physicians now simply wouldn’t dare! Recorded causes of death are now following the habits and incentives of the medical industry!

  2. Nicholas Gruen says:

    But there have been times when I’ve simply been dying of ‘itch’.

  3. Nicholas Gruen says:

    Was this thread, the cause of the death of Club Troppo and the birth of Club Pony?

  4. Ken Parish says:

    I had forgotten that I took my bat home 11 years ago. Fortunately self-induced reports of my blogging retirement proved to be premature.

    BTW My current blogging hiatus isn’t a result of either temper tantrum or disinterest, just supervening family business that is absorbing just about all emotion and spare time.

    Good to see that Nicholas is keeping the Troppo Pony trotting briskly, and that Paul F is still contributing. You never know, we might even get other veteran contributors making occasional comebacks, or commenters interested in writing their own posts … I still think blogs are a superior medium for considered, thoughtful discussion than other forms of “social” media, especially the ubiquitous but relentlessly trivial and fragmented Facebook.

    • Nicholas Gruen says:

      Thanks Ken, ever so much, and thanks for making your comments consistent with Pony’s ‘safe space’ policy.

      In fact we want Pony to be more than a safe space. We want Troppo to be a place where everyone feels loved. All the time.

      We want Pony to be the kind of place where if you can’t talk about an issue without being nice, then just forget all about the issue.

      Pony: where too much politeness is barely enough.

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