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’!