Cremation and the medical practitioner

To the Editor: A recent survey found that 65% of Australians choose cremation over burial, and that, in the context of the coronavirus disease 2019 (COVID‐19) pandemic, cremations could be increased fourfold.1 It seems appropriate to look at the various roles of the medical practitioner in approving cremations.

The first crematorium was built in England in 1878.2 Medical practitioners were at the forefront of the movement in Australia, and argued that cemeteries were already overcrowded and in disrepair, that a fear of being buried alive was common, and that cremation was a hygienic way to dispose of the dead when it was still believed that cemeteries were a source of disease in the living.2 The first Australian crematorium was established in Adelaide in 1903, after which progress halted due to ongoing debate;3 however, objections were overcome and many were constructed in the interwar years (Box 1).

The most cogent reason for rejecting cremation was that it could be employed to hide homicides. The contrary argument was that having a medical practitioner verify the cause of death would both prevent undetected crime and advance medical knowledge.4

To provide for this verification step, each Australian state and territory introduced legislation setting out a process for the approval of cremations. Where the cause of death is suspicious or unclear, permission is withheld and referral made to a coroner.

In Queensland, Tasmania and Victoria, any medical practitioner who did not complete the death certificate may issue a cremation permit (Box 2). In the Australian Capital Territory, New South Wales and Western Australia, only government‐appointed medical referees may issue a permit. Some states and territories also require assessment of cremation safety, verifying that there is no implanted battery‐operated device, which may explode and damage the cremator, and that the deceased has not received radioisotopes, which may create a public health risk during cremation.

At the Public Health Unit, we manage the appointment of medical referees for the NSW Ministry of Health. As part of the review of the effectiveness of our procedures, in 2020 we developed a short questionnaire to identify reasons why medical referees may refuse permission to cremate and to seek suggestions for improvement to this administrative process. We emailed it to a 10% random sample of NSW medical referees (n = 77) and received 46 responses (60%). Of these, 29 respondents (63%) had served in the role for more than 15 years, nine (20%) for five to 15 years, and five (11%) for less than five years. The number of permits issued in the previous 12 months ranged widely: 25 had signed zero to ten, and at the other extreme, two provided estimates of 780 and 1200 permits. This large variation is most likely related to varying demands on medical referees by local funeral directors. The reasons for rejecting applications included inconsistencies in the forms (ten), incorrect or unclear cause of death (seven), a reportable death (four), uncertain identity of the deceased (one), and a retained battery‐powered device (one). No suggestions for improvement were made, but three respondents suggested we provide some medical referee training — we have undertaken to develop an online education module.

Although roles differ between Australian jurisdictions, medical practitioners have an important responsibility for verifying that a body is suitable for cremation, a decision that they must make independently of the practitioner who certifies the cause of death.

Box 1 – Woronora Crematorium, Sydney, constructed in 1934*

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* Courtesy of Woronora Memorial Park.