We Should Be Skeptical of Death Certificates and Cause-of-Death Data

Historically, the overwhelming majority of Americans have ignored death certificates and the topic of how they are processed, produced, and compiled for purposes of government statistics.

During 2020, however, death certificates rose to a level of unprecedented prominence in the United States. This was due to the fact that both state and federal government agencies began using covid death counts as a means to justify a wide variety of radical new government decrees designed to combat disease.

Given that governments were leaning so heavily on death counts as an excuse for unprecedented expansions of state power, many observers quite understandably began to question how these deaths were being counted.

It turns out that the administration of death certificates is something ripe for some serious skepticism. Even before the panic that ensued over rising reports of covid-19 deaths, the accuracy of death certificates was an ongoing concern.

In recent decades, the number of autopsies had declined, meaning that fewer and fewer death certificates are backed up by more thorough investigation. Moreover, studies have shown that nearly half of physicians in some cases “knowingly reported an inaccurate cause of death” on death certificates. Other studies have suggested that a majority of death certificates contained “multiple errors.”

The implications of this for government policy are significant, to say the least, and it calls into question the accuracy of one of the most basic building blocks underlying today’s public health technocracy. Statistics on causes of death rely heavily on aggregate death-certificate data. But if physicians admit to poor training, and to even providing misleading info on causes of death, then attempts to justify government policy with data from death certificates becomes increasingly suspect.

Yet, the media and government agencies tend to present this data as if it were unimpeachable and an ever-reliable source of health data. Just as with other types of government data, however, death certificates ought to be viewed with far more skepticism than is presently the case.

Problems with Collecting the Data

Back in April of 2020, as state and local governments were using official numbers on covid deaths to justify policy changes, public curiosity over death certificates began to rise. The importance of reporting accurate cause-of-death information was highlighted on April 7, 2020 when the Trump administration’s infectious disease advisor Deborah Birx discussed CDC recommendations on reporting deaths. Birx noted:

We’ve taken a very liberal approach to mortality …. if someone dies with COVID-19 we are counting that as a COVID-19 death.

Moreover, federal policy provided a monetary inventive to report more deaths as covid-19 deaths. According to Factcheck.org:

It is true … that the government will pay more to hospitals for COVID-19 cases in two senses: By paying an additional 20% on top of traditional Medicare rates for COVID-19 patients during the public health emergency, and by reimbursing hospitals for treating the uninsured patients with the disease (at that enhanced Medicare rate).

Both of those provisions stem from the Coronavirus Aid, Relief, and Economic Security Act, or CARES Act.

This doesn’t mean that doctors are putting “covid-19″ as the cause of death in many cases when they know something else to be true—all while laughing an evil laugh. Rather, the effect is likely more subtle. In cases where there is ambiguity as to the cause of death, these policies provide a nudge in the direction of including covid-19 as a cause of death because it unlikely to be questioned, and it ensures health care providers receive higher levels of reimbursement. 

Many different factors can go into choosing a cause of death. After all, causes of death don’t just miraculously appear on paperwork. The cause of death must be reported in the paperwork by a human being who uses his or her own judgment as to what the cause of death is. Although the cause of death often seems obvious in the popular culture—such as a bullet wound in the head in a crime drama—the cause of death is often anything by self-evident in real life.

But, federal policy has made it it very easy for medical personnel to just put “covid” on the death certificate and be done with it. Indeed, it’s unlikely that medical professionals needed more urging than this. As it turns out, the medical profession has been moving away from insisting on thorough investigations in cause-of-death information. In this 2017 article on geriatric medicine and “death certificate accuracy,” the authors report:

Death certificate inaccuracy is a well-recognized problem at both the national and international levels. Infractions range from major, such as errors in identifying cause and manner of death, to minor, such as illegibility and incompleteness. Despite such known shortcomings, we continue to use these data at a state, national, and international level to inform research projects, direct funding streams, and determine health care goals.1

As one Washington Post headline put it in 2013: “nearly one-third of all death certificates are wrong.”

This is partly due to a paucity of training. In a 2005 article for American Family Physician, Dr. Geoffrey Swain, et al, write that “physicians receive inadequate training in this important area, and their performance on this task remains less than ideal. …While the cause of death may be difficult to agree on sometimes, most problems with death certificates stem from failure to complete them correctly.”

Another reason for death certificate errors and inaccuracies is the fact that relatively few autopsies are performed anymore, and few resources are apparently dedicated to auditing cause-of-death reporting or confirming the reported causes of death. For example,

The average autopsy rate in US hospitals was ≈50% in the 1940s and 41% in 1970, just before the Joint Commission on the Accreditation of Hospitals eliminated the requirement for a 20% autopsy rate. Since that time, autopsy rates have been in free fall, with estimated rates currently ≈8% overall, including forensic cases, but only 4% among in-hospital deaths.2

Some doctors, researchers and bureaucrats claim that autopsies are no longer necessary except in a few cases because medical personnel are supposedly so much better at identifying cause of death today. Many others disagree, however, and “In medicine, autopsies remain a critical weapon” in the fight to expand medical knowledge.

For example, a meta-analysis comparing clinical diagnoses against autopsy findings states: “At least a third of death certificates are likely to be incorrect and 50% of autopsies produce findings unsuspected before death.” And, an Ohio study of infant death certificates found 56.5% of death certificates were discordant with autopsy findings.

Moreover, it appears the field of forensic pathology has become rather unpopular. According to Judy Melink, MD, forensic pathologists are getting older on average, and their total numbers are down. This has been encouraged by federal policy, and “Hospitals are no longer required to have autopsy programs to qualify for Medicare reimbursement.”

Thorough investigation of the cause of death also tends to uncover more evidence of medical errors. Thus, As Lee Goldman, MD has noted, a lack of autopsy information “represents a huge missed opportunity for understanding how to reduce deaths attributable to medical errors.” In some cases, medical personnel might even avoid autopsies for nefarious reasons. As Melink concludes, the decline in requirements for autopsies can mean that if hospital staff “find themselves motivated to bury their mistakes, they are now free to do so.”

In a field where more than 100,000 deaths per year may be due to medical errors, this is no small issue.

In some cases, there have been bureaucratic obstacles to reporting what doctors believed to be the correct conclusion. The Washington Post reports: 

As to why doctors were reporting inaccurate causes of death, it actually appears to be a weirdly bureaucratic reason: Three-quarters said the system they use in New York City would not accept what they thought to be the real cause of death. So they put in something else instead.

The Politicization of Death Certificates

Prior to 2020, the issue of interpreting death certificates usually garnered attention from the general public in cases of criminal justice. As in the George Floyd case, the official cause of death became a matter of legal debate.

This might occur in some cases at the macro level as well. Police in Japan, for instance, have long been suspected of declaring suspicious deaths to be suicides, and then discouraging autopsies which might uncover homicide. As The Los Angeles Times reported in 2007:

Police discourage autopsies that might reveal a higher homicide rate in their jurisdiction, and pressure doctors to attribute unnatural deaths to health reasons, usually heart failure, the group alleges. Odds are, it says, that people are getting away with murder in Japan, a country that officially claims one of the lowest per capita homicide rates in the world.

In any case, a situation in which there is motivation to conduct a lackluster investigation into the cause of death can be problematic, and potential problems don’t end with the stage at which death certificates are filled out. Further problems can arise when “public health” officials make decisions about how this data will be compiled, labeled, and used.

As all government data, such as employment data, crime data, or data on homeownership, this data can be used in a variety of ways to justify and craft additional government interventions in the private sector. It’s important to keep in mind that death certificate data, like any other bureaucratic metric, is subject to human errors and human choices, and ought always be regarded as just one fallible factor in political decision-making.

• 1. Emily Carter, MD; Christina Holt, MD, MSc; and Amy Haskins, PhD, “Research Review: Death Certificate Accuracy — Why It Matters and How to Achieve It” in
  Today’s Geriatric Medicine, Vol. 10 No. 5 P. 26
• 2. Lee Goldman, “Autopsy 2018:Still Necessary, Even if Occasionally Not Sufficient” in Circulation, June 19/26, 2018;137:2686–2688.