Dear editor,
The recently published study by COVID-19 Excess Mortality Collaborators1 confirms that the COVID-19 pandemic has been devastating for humanity and resulted in high mortality.
We want to draw attention to a medico-legal aspect that, in this pandemic, has been the subject of fervent debate. Often, when analyzing the mortality of COVID-19, there are disputes about the concepts of death “with” COVID-19 and death “due to” COVID-19.2,3 This distinction was also exploited by COVID-19 skeptics to claim that SARS-CoV-2 was not a dangerous virus. According to those denying COVID-19 associated mortality, subjects with COVID-19 did not die from the virus but from pre-existing co-morbidities and/or disease conditions.3 This theory, despite having a tangible basis (e.g. subjects suffering from conditions such as diabetes or hypertension are at a higher risk of dying for COVID-19), is characterized by a medico-legal error. It is fundamental to emphasize that a factor defined as the “cause of an event” does not necessarily have to be the only causal element. All concauses are fundamental in the cause of an event.
In the case of COVID-19, although other factors (such as co-morbidities) occurred in the determinism of death, the SARS-CoV-2 infection cannot be excluded from the causal chain. Indeed, the correct reasoning foresees primarily the following question: would the person in the absence of COVID-19 still have died at that time? If the answer to this question is no, it can be stated that the subject died because of COVID-19.
In conclusion, from a medico-legal perspective, the debate on death with COVID-19 or due to COVID-19 is irrelevant. Identifying if a subject has died because of COVID-19 is also crucial to delineate any professional responsibilities. Especially in the early stages of the pandemic, many issues relating to medical professional liability have arisen.4,5 Therefore, before proceeding with any medico-legal assessment on the conduct of doctors and the responsibility of health facilities, it will be essential to clearly identify the cause of death of a subject. In particular, it will be crucial to understand if COVID-19 contributed to a patient’s death, even if it was only a contributing factor.
This operating methodology must not include the unnecessary distinction, without any medical or legal basis, between death “with” COVID-19 and death “due to” COVID-19.
Footnotes
Declaration of conflicting interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Andrea Cioffi https://orcid.org/0000-0001-5163-9558
References
- 1.COVID-19 Excess Mortality Collaborators. Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020-21. Lancet 2022; S0140-6736(21)02796-3. Online ahead of print. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Slater TA, Straw S, Drozd Met al. et al. Dying ‘due to’ or ‘with’ COVID-19: a cause of death analysis in hospitalised patients. Clin Med (Lond) 2020; 20: e189–e190. Epub 2020 Aug 3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mannix L. Dying of COVID or with it? Pathologists take on conspiracy theorists. The Sydney Morning Herald 2021, https://www.smh.com.au/national/dying-of-covid-or-with-it-pathologists-take-on-conspiracy-theorists-20211111-p5982e.html.
- 4.Cioffi A, Rinaldi R. COVID-19 and medical liability: a delicate balance. Med Leg J 2020; 88: 187–188. Epub 2020 Jul 3. [DOI] [PubMed] [Google Scholar]
- 5.Parisi SG, Viel G, Cecchi Ret al. et al. COVID-19: the wrong target for healthcare liability claims. Leg Med (Tokyo) 2020; 46: 101718. Epub 2020 May 16. [DOI] [PMC free article] [PubMed] [Google Scholar]