High-frequency death certifiers in Taiwan: a sociocultural product.

Accurate death certification is essential to high-quality mortality statistics. Physicians who certify disproportionately large numbers of deaths can significantly affect the validity of the resultant mortality data. In Taiwan in 1994, 110 death certifiers issued more than 100 death certificates each; and nine of these high-frequency certifiers issued more than 500 death certificates. We explore the cultural, political, economic, historical, and social contexts of high-frequency death certification in Taiwan. Because of the traditional belief in Taiwan that one must die at home for the soul to be incorporated into the collective ancestral tablet of the household, many families bring their loved ones home from the hospital just before death. Hospital physicians cannot legally issue a death certificate in these cases because they did not witness the dying process. Although the government introduced an administrative certification system to handle these outside-hospital deaths, the great demands of this system have attracted many 'special exam' doctors (doctors with no formal medical degree) to adopt death certification as a full-time business. In this context, it is not surprising that 'routinization' of death certification (J. Health Soc. Behav. 32 (1991) 273) has led to low-quality reporting among these certifiers. We argue that attempts to improve the quality of mortality statistics should take into account the unique sociocultural contexts of different countries.