The accounting of deaths and the social organization of death in Brazil

Abstract

The article aims to understand the development of the way deaths are accounted for in Brazil and its influence on how we perceive death. The rationality of registration systems is analyzed, considering their role in population control. The way successive governments have created and developed these monitoring mechanisms is then investigated, considering the modernizing process through which the country has passed since the end of the nineteenth century. Finally, the arrangement of the categories on the death certificate is described, along with how, through this document, an inquisitive technology that distributes rights and duties between actors and establishes the preliminary elements for a given social organization of death works, focusing on the city of Belo Horizonte.

death; mortality; registration; biopolitics

Resumo

O artigo visa compreender a formação da contabilidade dos óbitos no Brasil e sua influência no modo como percebemos a morte. Para tanto, analisamos a racionalidade dos sistemas de registro, considerando o seu papel de controle populacional. Em seguida, investigamos como os sucessivos governos criaram e desenvolveram esses mecanismos de monitoramento, considerando o processo modernizador pelo qual o país passa desde finais do século XIX. Por fim, delineamos a disposição das categorias da declaração de óbito e como, por meio desse documento, funciona uma tecnologia inquisitiva que distribui direitos e deveres entre atores e estabelece os elementos preliminares de uma organização social da morte, tendo como campo a cidade de Belo Horizonte.

morte; mortalidade; registro; biopolítica

One of the explanations for the existence of funeral rites concerns man’s need to exert control over his own death. For us, death is unfathomable: we do not know if there is life after death, nor can we even predict accurately when, where, or how it will occur. The fact that life can be wiped out at any moment makes people seek out different ways of exerting some control over the random nature of death. Examples of this include rites of passage, the worship of the dead, and the archetypal construction of the world of the gods, which social anthropology has studied so long. Today, however, our encounter with death is divided: on the one hand are specialized medical discourse and related bureaucratic procedures; on the other, an intensely personal sense of loss (Walter, 2002). We therefore propose to analyze the first part of this divide, considering the development of mortality systems in Brazil. The methodology involves a mixture of literature review, documental analysis, and field study (Goldenberg, 1997).

This paper is divided into six parts. After this introduction, the second part investigates how bureaucratic regimens seek to control and reduce the unpredictability of death by developing registration systems and systems with increasingly refined medical categories. Foucault’s concepts of biopolitics, mechanisms of security, and governmentality are used for this analysis. Next, we briefly review the history of systems for the control of mortality that exist in the country, taking the Foucauldian concepts as a basis. In the fourth part, the logic of the death certificate is analyzed from the perspective of its purpose as a sophisticated instrument of surveillance. In the fifth part, the daily routine of the registration of deaths, one of many other bureaucratic routines, is explored. Finally, we conclude that the mortality surveillance system distributes rights and duties to public and private institutions and individuals, establishing the baseline parameters for the social organization of death in cities like Belo Horizonte, in Brazil.

The control of death: from rites to numbers and categories

In his classic text, Blauner (1966) argues that bureaucratization has become a way of controlling death in secularized societies (Weber, 1979). He believes that the decline of religious authority and changes in family functions also underlie the transfer of death-related matters to representatives of the technological rationality in specialized institutions, free from the bonds of kinship, who can impose order on the unpredictability of events in standardized processes. If previously it was more common to see families taking care of terminally ill relatives and preparing their body for burial, today we tend to associate such activities with hospitals and funeral homes, each with their own set of specific routines (Sudnow, 1967; Glaser, Strauss, 1965, 1968).

This means that to counter the disruptive and disturbing potential of death, whose effects may “spill over onto the larger social territory and affect large numbers of people” (Blauner, 1966, p.23), we have established an increasing number of specialized institutions – hospitals, mortality statistics, institutions to prepare the body etc. This specialization can be seen as our response to the danger death continuously poses to the collective, for greater social cohesion is counterbalanced against the disintegrating potential it represents. Consequently, the image of death as an entity that takes away individuals is replaced by life expectancy tables, which give actuaries the data to calculate pensions and healthcare planners the means to compare mortality with environmental conditions, nutrition, income etc. (Walter, 2002). Thus, to understand what death represents socially, we have to deal with the “question of how modern societies hold together” (Walter, 1999, p.22).

Howarth (2016) also subscribes to the idea that “sin” and “fate” as causes of death have gradually given way to statistical probability – a change of mindset that has enabled the advent of mortality censuses based on death registration figures. Created for States to manage the risks inherent to rapid urbanization (machinery, occupational illnesses and accidents), these “registration systems” have produced enormous quantities of numbers on the nature and frequency of deaths to map out their occurrence and find ways to avoid them. Furthermore, the way death is understood and investigated – i.e., medicalized, like a disease, a risk, or a danger to be avoided or delayed – has led to even more innovations, including the development of public health policies and labor legislation.

As for these registration systems (demographics etc.), it is quite clear that despite their primary concern with death, they do not speak of death per se.¹ Rather, they talk of “mortality” and mortality rates. This is a significant point in the modern world, for attention is no longer paid to the fate of individual bodies, let alone the understanding of death by the subjects involved, but rather to the “fate of the species” (Prior, 1989). Indeed, the attempts of secularized societies to record and measure patterns of mortality have much in common with what Foucault (2008a) calls the “biopolitics” of populations. Appearing when the population becomes the prime object of government techniques, biopolitics is a way to “rationalize the problems posed for governmental practice by phenomena characteristic of a group of living beings constituted as a population: health, hygiene, natality, longevity, race” (Foucault, 2008a, p.431). A technique of power applied to the human species, biopolitics operates as a normalizing power integrated into the technology of the body and targeted towards the population (Calvet, 2008). In other words, it:

focused on the species-body, the body imbued with the mechanics of life and serving as the basis of the biological processes: propagation, births and mortality, the level of health, life expectancy and longevity, with all the conditions that can cause these to vary. Their supervision was effected through an entire series of interventions and ‘regulatory controls: a biopolitics of the population’ (Foucault, 2003, p.131; emphasis added).²

Biopolitics is a fundamental dimension of governmentality. Indeed, we are currently living in the “era of governmentality” (Foucault, 2008b, p.145),³ which began in the late eighteenth century, since which time government technology has not ceased being dogged by the question of liberalism, understood as the question of “overgoverning” (Foucault, 2008a, p.436). It is therefore unfeasible to understand the modern state without referring to the “general tactics of governmentality,” without referring to the “tactics of government that allow the continual definition of what should and what should not fall within the State’s domain, what is public and what is private, what is and is not within the State’s competence” (Foucault, 2008b, p.145) – so as not to fall into the excesses of governmentality.

For the purposes of this article, we can basically understand governmentality as the “the ensemble formed by institutions, procedures, analyses and reflections, calculations, and tactics” that enable a power relation to be exerted that targets the population, has the political economy as its primary form of knowledge, and apparatuses of security as its essential technical instrument (Foucault, 2008b, p.143). Governmentality, in this context, becomes a relational approach on occurrences that link “men” and “things,” and which may include “accidents, misfortunes, famine, epidemics, and death” (Foucault, 2008b, p.129; see Lemke, 2016).⁴ It is also important to stress that the emergence of governmentality coincides with the “discovery of the population” and the systematic use of numbers, which turns opaque population-related phenomena into an intelligible object:

In fact, statistics, which had hitherto functioned within administrative frameworks, and so in terms of the functioning of sovereignty, now discovers and gradually reveals that the population possesses its own regularities: its death rate, its incidence of disease, its regularities of accidents (Foucault, 2008b, p.138).

It is at this point of discovery that statistical measurement comes in, with the first demographics. It could therefore be argued that the emergence of the population both lacked and depended on the emergence of “mechanisms of security” that would allow calculations about the variables of a population to be made.⁵ Mechanisms of security are dispositifs of governmentality that, rather than monolithic, should be understood as a “thoroughly heterogeneous,” if stable, ensemble of “discourses, institutions, architectural forms, regulatory decisions, laws, administrative measures, scientific statements, philosophical, moral and philanthropic propositions” (Foucault, 2000, p.244).⁶

Ian Hacking (1991, p.185-189) also agrees that the use of numbers to acquire systematic and rationalized knowledge about a population is a fundamental prerequisite for the emergence of the modern state and the exercise of the governmentality that constitutes it. He identifies three interrelated historical events from the late eighteenth century and into the nineteenth century that make use of numbers, a phenomenon of modern politics. Firstly, the “erosion of determinism” by the positivist epistemology that accompanied the Enlightenment, leading to increasing attention being paid to indeterminism to explain the occurrence of social events. The second development, in response to this newly discovered insecurity, were the attempts to “tame” chance by finding out “probabilities,” in view of our ignorance as to the true causes of the real facts of nature. Finally came an “avalanche of numbers”: an exponential increase in the publication of figures between 1820 and 1840 in Western Europe alongside the expansion and centralization of statistics bureaus. Viewed together, these were the signs of the “birth of modern statistics.”

Analyzing the emergence of population statistics in Palestine as a biopolitical technology, Jan Busse (2015) suggests there are three interrelated processes at play in the non-governmental use of numbers – processes that extrapolate the reality of that country; namely, “problematization”, “normalization,” and “objectification.” First, security mechanisms enable the identification of the risks populations run, turning them into “problems.” Problematization is intrinsically political, since it is based on the general tactics of governmentality employed by the State (Foucault, 2008b). Continuing with Busse’s analysis, an event has to first be identified as a “problem” to then become an object of statistical inquiry. This is a precondition for a modern “governmental” State: the numbers it produces interconnect those that govern with the people, processes, and problems to be governed, since these very numbers are “‘integral to the problematizations’ that shape what is to be governed, ‘to the programmes’ that seek to give effect to government and ‘to the ... evaluation’ of the performance of government” (Rose, 1999, p.199; emphasis added).

Secondly, security apparatuses do not impose models of behavior on populations in the way that disciplinary power operates on individuals (Foucault, 2008b). Instead, the “normalization” of security mechanisms first plots the different curves of normality and only then establishes “an interplay between these different distributions of normality and in acting to bring the most unfavorable in line with the more favorable” (Foucault, 2008b, p.83). For instance, in the eighteenth century, it was “normal” for there to be one death per eight cases of smallpox and intervention only to be taken if the death rate rose. Population averages and projections are decisive; it is impossible to generate an open series of variables without having first identified the elements and estimated the probability of their occurrence (Foucault, 2008b, p.26-27). In this sense, systematic numerical data on populations enable mechanisms of security.

Finally, numbers contribute to the “objectification” of the population, which becomes “a sort of technical-political object of management and government” (Foucault, 2008b, p.92). This objectification comes about in two ways, argues Jan Busse (2015). On the one hand, numbers give a sense of objectivity that increases the credibility of those who govern. An indispensable part of the politics practiced today, writes Rose (1999, p.198), numbers also depoliticize whole areas of political judgement by “purporting to act as automatic technical mechanisms for making judgements, prioritizing problems and allocating scarce resources.” Meanwhile, on an instrumental level, numbers turn people into “objects,” thereby facilitating the exercise of power over them. “Those who fail to confirm are stigmatized,” while the others will have “‘internalized the values’ of an ever more pervasive bureaucracy;” a bureaucracy whose “power is inseparable from [its] objectivity;” a bureaucracy “through which an oppressive language of normality and abnormality is created,” writes Porter (1995, p.77-78; emphasis added). This state of affairs enables the credibility of numbers to often be accepted unquestioningly, even if these numbers are produced in the context of political relations.

Figure 1
: Death certificate from the nineteenth century (Coleção Brasiliana Itaú)

For Prior (1989), our understanding of death has been subordinated to the mechanisms of population control and anything that will produce or consume its health and vitality. It follows, he goes on, that “mortality” should have been meticulously dismembered into increasingly precise “categories” (sex, age, cause of death etc.). To measure it, increasingly complex instruments have become necessary, namely, the different types of mortality rate (infant, occupational, adult, male, female etc.) and their components (infant: preterm newborn, post-term newborn, post-newborn etc.). Furthermore, alongside this interest in the fate of populations there “arose a whole series of regulations, activities, organisations and occupations to collect, collate and analyse the associated data,” which included civil registration (births, deaths, marriages), official certificates and returns, accounting mechanisms, the admission of registrars, statisticians, and epidemiologists, and rules for the disposal of bodies (Prior, 1989). Prior suggests that it is these instruments, far more than people’s attitudes or feelings towards death, that structure the way death is organized in society. Following his advice, we will now begin our investigations based on them.

Mechanisms for the control of mortality in Brazil

In Brazil, the public entities that handle mortality have been changed and transformed according to the demands of different Brazilian governments and, after the advent of the republic, have been incorporated into the “secular State.” The “secularity” of the State should be understood as something that is more than religious neutrality in government acts; it should be seen as a “precondition for the governmentality of a State” (Diniz, 2013, p.1704). In this process, the Brazilian physician emerges as a “civilizing hero” who stands out in the midst of a meagerly cultivated elite in the nineteenth century. Active in the political scenario, these professionals believed in the “transformational power of reason, and in medicine as the ultimate ally,” for “only the specialized knowledge of the physician would raise Brazil to the height of civilized Europe” (Reis, 2012, p.248). Nonetheless, notwithstanding the earlier efforts to modernize the control of mortality in the country, as changes to civil registration demonstrate (Silva, 2000, v.2, p.657-659), the big change really came in the 1970s, when the two systems for the control of mortality that exist to this day were created: the system run by the Brazilian Institute for Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE), in 1973, and the Mortality Information System (Sistema de Informações sobre Mortalidade, SIM), from 1975. It is as of the constitution of these systems that we can begin to think about how death is organized in Brazil.

For Silveira and Laurenti (1973), “registration” can be understood as the whole data-gathering process, whereby each fact or event is noted down: how, when, and where it came about. In law, the authors continue, the main function of a record is to make a given legal situation that affects the interests of third parties public knowledge. As such, a register has the function of assuring and defending a right. One specific type of record is the “vital record,” which records each person’s status from their birth to their death, passing through all the intervening events – marriage, adoption, divorce, guardianship etc. There are several legal acts and facts that change a person’s life in important ways, which are known as “vital facts.” On a population level, these facts are recorded as “vital statistics.”

A death certificate confirms the legal status of a deceased person (Silveira, Laurenti, 1973). With death, all the individual’s ties to society are broken and their inherent “personal rights” cease, but not the material rights of their estate, which pass on to their heirs or successors provided everything is duly recorded (Miranda, 1983). In Brazil, during imperial times, there were no civil records of births or deaths of Catholics, as these were recorded on baptism certificates and church records of deaths (Silva, 2000). In the religious context of the day, parish records were legally valid (Silveira, Laurenti, 1973). Despite the links between State and church, there was no shortage of attempts to secularize civil records: the first government act concerning death certification came in 1814. Later, in 1870, the General Directorship of Statistics was created to produce data on births, marriages, and deaths. But it was only in 1888, with decree 9,886, that births, marriages, and deaths had to be recorded in civil registries, upon which ecclesiastical records ceased to have any legal effect. In 1912, a bill was drafted with proposed amendments to this decree. The ensuing law brought in two important changes: it made it legal for pharmacists to pronounce a death in the absence of a physician, and for the first time it presented a standard format for a death certificate (Silva, v.2, 2000). Historically, decree 9,886 ushered in the obligatory presentation of a death certificate stating the (medical) cause of death for the (civil) registration of deaths (Vasconcelos, 1998).

As Vasconcelos (1998) writes, even after death certificates became mandatory, death statistics remained deficient for many years, except in São Paulo state and a few state capitals. The underreporting of births and deaths⁷ and the disorganization of the vital statistics system were the main problems. In order to improve this state of affairs, in 1973 the federal government tasked IBGE with producing Brazilian vital statistics according to United Nations guidelines. IBGE accordingly standardized the collection of these data on a nationwide level, working with civil registries, which resulted in the improved registration of vital events (Jorge, Laurenti, Gotlieb, 2009). Also in 1973, an act was passed (known as the Brazilian law of public records) that linked burial to the registration of a death (Brasil, 31 dez. 1973). Since this time, the medical certification of death has observed this law, while the government has attempted to cut down on the number of clandestine burial grounds in the country – places associated with poverty and more prevalent in rural parts, where burials can be arranged without presenting a certificate (Szwarcwald et al., 2002).

Despite this modernization, the control system still had some flaws, not least because the “maps of deaths” produced by IBGE, despite providing considerable detail on the decedent, did not contain the cause of death, merely its “nature” (violent or natural). In the face of political pressure from international entities for this gap to be rectified, in 1975 the Ministry of Health resolved to introduce a new system for the control of morbidity and mortality (Jorge, Laurenti, Gotlieb, 2009). This was the year when the SIM system was created, with the primary objective of producing mortality statistics broken down by “causes” across the country. With the new control system came a new death certificate format that was standardized across the country and aligned the medical causes of death with the nomenclature of the International Classification Diseases (ICD), as recommended by the World Health Organization.

Any analysis of the emergence of the SIM system would be incomplete without taking into consideration the broader context in which it was developed (Viana, Machado, 2009). The SIM system was launched one year after the second National Development Plan, which was introduced in 1974 (Brasil, 1974). This plan was important, among other things, as the first project by the military regime to recognize that social development should accompany economic development (Escorel, 2012). One of the plan’s targets in the social field was the health sector, whose perceived lack of managerial capacity and technical structure was leading to a “sanitary crisis”⁸ (Escorel, 2012).

For Hésio Cordeiro (1980, p.163; enphasis in the original), the “‘sanitary scenario’ marks the end of the economic miracle and indicates a state of ‘sanitary insolvency’, with increased costs on hospitalizations while spending on public health are reduced.” Faced with this reality, the government’s bureaucrats wondered “why the Revolution, which overcame so many antagonisms to lift the Country out of underdevelopment, is unable to put our chaotic medical and sanitary care system in order.” The solution included ascertaining the “sanitary state” of the Brazilian population through the “elements that compose ‘vital statistics or biostatistics’;” elements that “do not give a measure of health, but rather the ‘effects’ or consequences of diseases that kill” (Bastos, 1977, p.34-35; emphasis added). That government’s response to the public health crisis that proceeded the “economic miracle” was shaped by “rationalizing policies” that “incorporated the ideology of health planning as part of a reform project of a modernizing and authoritarian nature” (Paim, 2008, p.70). As of 1975, and through the second National Development Plan, the Ministry of Health saw its budget expanded, which enabled it to develop networks of projects and people, fund research, hire professionals, foster greater coordination with state health departments, and devise alternative proposals for health services and human resources (Escorel, 2012), all of which was certainly instrumental in the development of the SIM system that year.

The use of SIM introduced two changes (Vasconcelos, 1998). The first was greater control of the sociodemographic features of decedents and the circumstances of their death according to international standards as published in the International Classification of Diseases, whose latest version is ICD-10 (OMS, 1995). The other was the decentralization of SIM, unlike the IBGE system, which is centralized. This decentralization increased in 1991 with the transition to democratic rule and the accompanying move towards greater federalism, with state and municipal health departments themselves collecting data for the SIM system directly from hospitals, cemeteries, and health clinics (Viana, Machado, 2009; Jorge, Laurenti, Gotlieb, 2009).

Just introducing the new model would not, however, be enough for the government to attain its goals. First of all, legislation had to be produced for the system to work (Jorge, Laurenti, Gotlieb, 2009); legislation that, amongst other measures, made it mandatory for a death certificate to be presented for a death to be registered (Brasil, 31 ago. 2000); punished doctors who refused to supply a death certificate; and provided for the suspension of funding for primary healthcare programs in any municipal health department that failed to input data into the health information systems, including SIM, for two months running (Brasil, 4 set. 2012, art. 6). Secondly, the production of large quantities of didactic material by the Brazilian Center for Disease Classification (Centro Brasileiro de Classificação de Doenças) for the training of physicians, students, and civil servants (Jorge, Laurenti, Gotlieb, 2009). Furthermore, it set aside resources for academics and municipal and state health authorities to conduct studies into the quality of the disease surveillance of this system.

Consequently, in the 1970s, two independent systems for mortality control came into being in Brazil – the IBGE system (providing statistics based on civil registrations) and the Ministry of Health system (with information on mortality) – offering substantial infrastructure for the collection, collation, and publication of national mortality statistics (Vasconcelos, 1998). The two population security mechanisms have different purposes. Today, the IBGE mortality table is used by the Ministry of Social Security to calculate the pension factor used to adjust pensions under the general social security regime (Brasil, 4 set. 2012). Meanwhile, SIM can be used to monitor the population in real time and by location, enabling the identification of points of risk and the management of health programs – healthcare, research, prevention etc. (Lebrão, 1995).

As Vasconcelos (1998) goes on, the two mortality control systems have detailed registration procedures, fees, and penalties and fines for failure to register an event. This raises two important questions, which we can draw on Foucault to discuss. Firstly, a public sector that acts as a “full guardian” that legislates, plans, executes, procures, funds, and oversees health services concerning the mortality of the population. Secondly, these mortality control systems helping to “institutionalize” a “medicalized” understanding of death, which has a considerable impact on our attitudes towards it. For example, as of the moment of death, backstage, the body becomes the object of investigation of multiple professionals who can keep it in their possession for it to be examined, certified, and clothed. After all, as Parsons (1997) indicates, together with the change in attitudes towards death and the moving of the body to the medical, institutionalized sphere, the formalization of all matters associated to death and the elimination of the cadaver has also increased – which implies a greater participation of specialized companies rather than family members and communities.

Detailing a death

The death certificate is the hub of all the rules and practices that link up the medical, legal, and administrative strands of a complex system (that includes the SIM system). The rules, the disease classifications, and the categories for descriptions and explanations can be found in the federal government manuals that explain how to select and classify causes of death; in the laws that govern the registration of the death and disposal of the body; in the discourse of western medicine; and in the human “practices” of selecting, applying, and adapting all these norms to the organization of social reality (Brasil, 2007; Prior, 1989). Viewing the death certificate as the backbone of this whole system, Schneidman (1976, p.246) writes: “In the western world, death is given its administrative dimension by the death certificate. It is the format and content that determine and reflect the categories in terms of which death is conceptualised and death statistics reported.”

The core document for the SIM is the death certificate (Brasil, 11 fev. 2009), on which a doctor certifies a person’s death and thereby the end of the existence of the “natural person.” In theory, eight of the nine parts of the certificate are the “responsibility of the physician,”⁹ since it is this professional who certifies the death and states its cause or causes (Brasil, 11 jan. 1932). In the field, we found that the association between death and the death certificate is so close that the attending physician of a seriously ill patient may confirm they are close to death by stating that they will be available at any time to make the pronouncement. The document is very detailed; after all, it is legal proof that the individual no longer exists, and is necessary for the body to be buried. Albeit in a different context, Foucault also notes the political significance of investigations like this one and the importance of the “case” and the “history of the case” in general:

For a long time ordinary individuality – the everyday individuality of everybody – remained below the threshold of description. To be looked at, observed, described in detail, followed from day to day by an uninterrupted writing was a privilege. ... The disciplinary methods reversed this relation, lowered the threshold of describable individuality and made of this description a means of control and a method of domination. It is no longer a monument for future memory, but a document for possible use. ... This turning of real lives into writing is no longer a procedure of heroization; it functions as a procedure of objectification and subiection. The carefully collated life of mental patients or delinquents belongs ... to a certain political function of writing (Foucault, 2012, p.215-216).¹⁰

But the minute details we find on a death certificate today were not always there. As Camargo (2007) reports, in São Paulo until around 1860, most so-called “statements” or “notes of burial” were not written by medical doctors but by priests, who wrote them on strips of paper they would cut by hand. This was one of the many functions of men of the cloth, which also included, for example, giving the last rites. At that time, it was a deep-rooted custom for people to call a priest and not a doctor to oversee a patient’s final hours. Generally, in order to certify death, the clergymen would rely on information provided by relatives and others close to the decedent; not unlike what some doctors do today, albeit without the scientific status that medical practice has acquired (Silva, 2000). In many cases, these “notes of burial” did not indicate any causa mortis, insofar as for the church and for most people at the time, the explanation that it was “God’s will” was enough.

As of 1858, Camargo continues, legislation pertaining to burial began to require a physician to certify death and include “the disease of which he died” and “its duration.” The requirement for a doctor to ascertain death before a body was buried was not just a matter of sanitation or the gradual acceptance of science vis-à-vis “unenlightened” practices (since it was common to call healers if witchcraft was suspected), but also related to the “political dimension of death,” since the absence of a “competent authority” to check the body would enable deaths by criminal causes (especially domestic crimes) to go unremarked by the authorities (Camargo, 2007). Truth be told, today the public health and law enforcement dimensions continue to be two of the major goals of the death certificate, bringing the science of death close to the science of crime (Silveira, Laurenti, 1973, p.43).

Medical and family control

The logistics of the distribution and filing of these forms is strictly controlled. In theory, this is to prevent the potential trade in death certificates by funeral homes, even ones signed by a doctor (Jorge, Laurenti, Gotlieb, 2009). Although this control does not prevent every illegal act, as is occasionally seen in newspapers, the whole process of producing and filing a death certificate serves as a preamble for the social organization of death in cities like Belo Horizonte, Brazil. Schematically, each of the three copies of the death certificate goes through a series of steps as shown in the flow chart in Figure 2.

Figure 2
: Flow chart of information on deaths in hospitals (adapted from Brasil, 2001, p.32-33)

The flow chart in Figure 2 represents a formal network along which the death certificate progresses. The domains of personal and medical settings, of legal agents, state bureaucrats, and close relatives are clear from the flows. Just as some agents and settings are included, others are excluded. In this scenario dominated by bureaucracy and medical science, we can see that responsibility for the document lies with the family and at least three institutions: the health establishment, the municipal health authority, and the registry office. For example, the flow chart does not mention funeral homes, insurance companies, community leaders, or friends. This does not mean that some of these do not take part in the funeral rites, but it is clear that they are superfluous for this bureaucracy, which discovers, defines, and attributes causes of death. They are very engaged in this process, as a funeral home worker interviewed at their desk inside a big hospital explained:

Normally, the doctor or the nurse in charge already advises that they have to have the identity of the person who died for me to register it and begin certifying the death ... I register it, I collect the data, and this data is taken to the hospital ... At the hospital, there’s an employee responsible for filling out the death certificate and the doctor puts the causes of death and signs it ... the family pick up the death certificate, which is what this document is, and go to the registry office to file it ... the body is only buried when it’s been filed in a registry office ... you can go ahead with lying in repose, but you can only do a burial if you’ve got the registration (E33).¹¹

As the words of this employee, the flow chart, and also the civil registry law (Brasil, 31 dez. 1973) all reveal, one of the most active players in the process of disposing of the remains is the decedent’s family, who, immediately after the death, have to take a quite different route from the body itself (Bradbury, 1999). In Belo Horizonte, for example, after getting the death certificate signed by the attending physician (if the person died in hospital), or by the physician called out (in deaths at home and without any suspicion of a crime), or by the medical examiner from the coroner’s office who did the autopsy (in case of violent death), the bereaved are instructed to take the form to the registry office in the district where the death occurred. Generally, deaths are certified on the same day as they take place. At the registry office, details of the death, data on the decedent,¹² and the name of the cemetery or crematorium where the body will be taken are noted down before a death certificate and burial permit are issued free of charge.

If no documents are missing, it takes around 15 minutes to register a death. The death certificate – original and at least one copy, to be filed at the cemetery or crematorium – and the burial permit are then duly issued. Bodies cannot be disposed of without these papers. With these two documents in their possession, and after checking the personal documents of the person filing the document and charging administrative costs to open and close the burial plot, the cemetery issues authorization for burial. While their members go to the registry office, the funeral director usually arranges the lying in repose and the burial or cremation. The funeral home may only prepare the body once they have been given the death certificate and the burial permit.

What could seem simple on paper is far from simple in fact. Communicating a death at a registry office comes with a host of difficulties, which the family must manage in order to take all the legal measures necessary for the disposal of the body. Everything is done under the impact of a recent loss, which makes it hard to concentrate on the simplest of tasks necessary to register the death (Bradbury, 1999). At times like this, when bureaucratic zeal seems fussy or petty, it is common for the family members to lose their temper with the attendants when they are asked for a missing document, some information about the decedent that has been lost, or to wait longer than expected for the death certificate. If red tape is by nature a bother, at times of grief this is only compounded, whether it is having to go back to the hospital to pick up a form that was forgotten, confirm the information recorded in the computer, or check with a relative by phone to remember the details of a property, a relative’s name, or any other data on the decedent. The risk of the relative giving erroneous information to the assistants is high, which calls for them to demonstrate emotional control that they report they learn on the job. Giving guidance to their clients is part of the funeral home’s services, or for those who have not made funeral arrangements in life, a first sales pitch:

We have to give information on registry offices, we have to give information on the cemetery ... it’s necessary, so that’s what we’re there for ... that’s what the work is ... when someone dies, in some hospitals we will also go to get the family, too (E52).

There are lots of families who turn up in floods of tears, then I have to get someone from the family who’s better, because there’s lots of information to be given and the person isn’t ready to receive any information because of their psychological state. We comfort them, talk to the family, find out how they are ... there are poor families who don’t have the slightest means for funeral services, and we do an interview to see what their means are, how they will take care of the funeral. And then we get it all started (E33).

Also, even if the family do not always have to travel very far, unless they live in the countryside or on the outskirts of big cities, there is an extra difficulty, which is getting the death registered at the registry office in the district where the person died if the death occurred outside office hours (9 a.m. to 5 p.m.)¹³ or on weekends and holidays, when only one of the eight in the city’s metropolitan district is kept open, and still only during office hours.¹⁴ As one interviewee told us:

The areas are divided up into regions. So if one person dies in Venda Nova and they’re brought to the coroner’s office, when the medical examiner certifies the death, they can’t go to the registry office near the coroner’s office, they have to go back to where the person died, which is the regional registry office of Venda Nova. Today, the registry offices don’t have 24-hour shifts. They only work during office hours, even when they’re open on weekends and holidays. ... some days you get to the door of a registry office and there are ten, 15 families there and it takes time to certify a death. ... Every town has their own registry office ... in some, like Santa Luzia, for example, there’s already a registry office for the São Benedito region. Each region that grows, they create a registry office there to cover that huge region (E02).

Another difficulty is how to handle all the registration paperwork, with all the different documents that have to be found and organized so that only one visit is made to the registry office. There is also the annoyance that at registry offices, like most of the institutions involved in managing mortality, the employees receive little or no training in interacting with the bereaved. The feeling of the people on the receiving end of this service brings to mind the deposition of a young nurse who found herself on the brink of death: “For you, death is part of a routine. For me, it’s new and unique” (Ziegler, 1977, p.206). The endurance test that is part and parcel of the post-death routine does not stop there. The paperwork necessary to hire the services of a funeral home also has to be arranged:

There’s so much information: documents, registry office, funeral procedures ... because when a family does the service, they have to sign a lot of forms ... authorization for treating [the body], the form granting authorization for the services with associated fees, the items they’re acquiring, authorization for the service with the agreement that the funeral service doesn’t cover cemetery costs ... signing the wording on the wreath, because the family picks a phrase or a tribute to the deceased ... there are lots of signatures ... because it’s tricky when you’re dealing with the body of a family member ... so you have to get authorization for the treatment, from shaving to selling an urn ... because any mistake could be an infraction, you see? There could be a really big problem because you’re dealing with the body of someone’s loved one (E33).

As we can see, after death has been confirmed, the body becomes an “object” of different instrumental practices, each of which acts on specific organs and parts of it: autopsy, embalming, registration etc. Just as the dead are only seen as “dead” once they have been pronounced so by a physician (Sudnow, 1967; Glaser, Strauss, 1965, 1968), death is not recognized bureaucratically until the death certificate is filed at the registry office. This recognition is what makes the death certificate (and indirectly the medical certificate of death) a prerequisite for reorganizing the family and social status after a death (Silva, 2000). A prerequisite because failure to produce such a document makes a series of benefits concerning the dead person and their kin unviable, which is why there is a whole body of public functionaries to do it (Silva, 2000). It is therefore very unlikely for any funeral rite to go ahead in Belo Horizonte before the death is certified.

This text would not be complete if we did not refer to the great change that is accompanying this aspect of our society, in which everything is regulated, controlled, and certified. This is the change in modern perceptions that accompanies this bureaucracy. Recall that the two different kinds of death certificate (however similar in appearance) are handed in with no kind of seal and may be read at any time. As Prior (1989) notes, their categories are often the object of discussion in the circle of friends and relatives of the deceased. In fact, in our research, we saw that they spark conversations about the final moments before death, because everyone wants to know what the person died of, what disease was in their body, how long they had been suffering, and whether their death hadn’t been a “blessing” for everyone. The preferred answer to the question of how and why a person died will normally be about the disease or the inefficacy of the treatment or medicine – because today people die much more of diseases than old age, sin, or misfortune. This change in the perception of death could be a definitive consequence of the world we live in and could be understood as a crisis in the narrative experience, whose substance is lived experience (Benjamin, 1985). Reviewing the trajectory we have taken in this paper, “mortality statistics [have] acted as a point of articulation for various shifts in perception of the nature of bodies, health and populations” (Armstrong, 1987, p.654). And as is the case elsewhere, this also seems to have occurred here.

Final considerations

This article concentrated on the social construction of death and the role of bureaucracy as an element of cohesion. Integral to this cohesion is the functioning of a “technological panopticon,” for, as families move from one institution to the next, they are induced to partake of different forms of inquiry and confession to provide the necessary information for the systems of control of mortality (Foucault, 2012). Meanwhile, the social (and symbolic) construction has reduced deaths to their physical manifestations because the precedence of “biological bodies” over the “social body” is one of the key features of the (essentially medical) discourses within which death is analyzed, understood, and recounted (Prior, 1989). So if language in general has its own rules and conventions and if there are institutions where this discourse is produced and divulged, this affirmation also applies to medicine, whose discourse produces knowledge and occupies institutions and specific professional spaces (Nead, 1988). This is not to say that these spaces and institutions are exclusively health-oriented. As we have proposed here, if, due to its authority, medical discourse produces the positions of subjects as physicians, nurses, and patients, it is no wonder that it also produces the positions of the moribund, deceased, and kin; or, indeed, that it sets the thresholds, the activities, and the perceptions relating to how we organize our relationship with the end of life.

ACKNOWLEDGEMENT

We wish to thank the Brazilian science and technology funding agency, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), for the financial assistance received.

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NOTES

• 1
  In fact, for Foucault, death – the end of life – is the threshold of any power relation. Death is the “outside” of the dominion of power, and power only has power over it “in general, overall, or statistical terms. Power has no control over death, but it can control mortality” (Foucault, 2012, p.296).
• 2
  T.N.: Citations in English from Foucault (2003) were sourced from Dianna Taylor (Ed.), Michel Foucault: key concepts, London: Routledge, 2011.
• 3
  T.N.: Citations in English from Foucault (2008b) were sourced from Michel Foucault, Security, territory, population: lectures at the Collège de France, 1977-1978, transl. G. Burchell, New York: Palgrave MacMillan, 2007.
• 4
  As Lemke (2016) notes, this connection came about thanks to the fact that Guillaume de La Perrière (1499-1533) considers “governing” as “the right disposition of things arranged so as to lead to a suitable end” (cited in Foucault, 2008b, p.130). According to Foucault, La Perrière’s notion of “government of things” is not about an opposition of things against men, “but a sort of complex of men and things” (Foucault, 2008b, p.128). Even so, from this perspective of junction of “subject-object,” as is the case of the population, an ensemble of material body and intention, governmentality may determine the limits of what is human (thus, endowed with a sociopolitical existence) and what is non-human (and thus “pure matter”) (Lemke, 2016; Foucault, 2008b).
• 5
  According to Jacques Revel (1990, p.159-169), with statistics there emerges a collective body and a continuous and abstract space where any point is, by definition, the same as any other. If before statistics there were merely residents, with this institution there emerges a population. Through demographic maps it is possible to acquire detailed information about the diseases that affect the population, the group worst hit, and the extent of the damage caused. Strategies to combat mortality are developed using these data.
• 6
  T.N.: Citations in English from Foucault (2000) were sourced from Ruth Wodak and Michael Meyer, Methods of critical discourse analysis, London: Sage, 2009.
• 7
  The causes of under-registration include: poverty, the existence of areas that are hard to access or far from registry offices and health services; “clandestine” burials in rural parts; illiteracy; and lack of interest on the part of the population, who see no benefit in civil registry (Vasconcelos, 1998).
• 8
  Until mid-1974, the government prevented news on the meningitis epidemic and the increase in infant mortality from reaching the press (Gaspari, 2004, p.108-109).
• 9
  According to Niobey et al. (1990), what often happens is that some doctors focus on the “medical” part of the document (Block V) and leave administrative workers to fill out the “less important” parts of the death certificate.
• 10
  T.N.: Citations in English from Foucault (2012) were sourced from Michel Foucault, Discipline and punish: the birth of the prison, transl. Alan Sheridan, New York: Vintage Books, 1977.
• 11
  The recorded interviews were based on a semi-structured script and the identity of the respondents was kept confidential. The interviews were held between April and June 2017 during office hours. Alongside the recorded interviews, informal conversations and participant observations were conducted and a field log was kept. Eighty-one individuals (E1 to E81) involved in the death care industry were interviewed in all.
• 12
  There are the documents of the deceased that must be submitted: birth certificate (if single); marriage certificate (if married); marriage certificate and death certificate of the spouse (if widowed); marriage certificate with decree absolute or equivalent (if divorced or legally separated); ID card; tax number (CPF); voter registration or proof of voting or certificate from the regional electoral tribunal; benefit number and code (if retired or on a government pension).
• 13
  In Belo Horizonte there are six registry offices where deaths can be registered, in the following districts: Floresta, Centro (two), Lourdes, Nova Suíça, and Venda Nova. There are two in Contagem (Centro and Eldorado districts) that also serve Greater Belo Horizonte. Every two months, these registry offices take turns to open on weekends and holidays.
• 14
  On details of the provision of services for the registration of deaths on weekend and holiday, see articles 46 to 53 of CGJ pronouncement #260 (Minas Gerais, 30 out. 2013).

Publication Dates

• Publication in this collection
  13 July 2020
• Date of issue
  Apr-Jun 2020

History

• Received
  7 May 2018
• Accepted
  13 Sept 2018