Michael A Grodin, Erin L Miller, Johnathan I Kelly. American Journal of Public Health. Volume 108, Issue 1. January 2018.
Medicine and Public Health in Nazi Genocide
This article, in commemoration of the 70th anniversary of the Doctors’ Trial at Nuremberg, reflects on the Nazi eugenics and “euthanasia” programs and their relevance for today. The Nazi doctors used eugenic ideals to justify sterilizations, child and adult “euthanasia,” and, ultimately, genocide. Contemporary euthanasia has experienced a progression from voluntary to nonvoluntary and from passive to active killing. Modern eugenics has included both positive and negative selective activities. The 70th anniversary of the Doctors’ Trial at Nuremberg provides an important opportunity to reflect on the implications of the Nazi eugenics and “euthanasia” programs for contemporary health law, bioethics, and human rights. In this article, we will examine the role that health practitioners played in the promotion and implementation of State-sponsored eugenics and “euthanasia” in Nazi Germany, followed by an exploration of contemporary parallels and debates in modern bioethics.
The involvement of health practitioners in conceptualizing, initiating, and implementing Nazi mass murder remains an unparalleled case of medicine and public health’s participation in genocide. By January 1933, more than half of the German medical profession had joined the Nazi Party and many participated in the murder of Jews, Sinti, and Roma; the disabled; the mentally ill; and other “unfit” persons under the guise of improving public health and Rassenhygiene (racial hygiene, the German version of eugenics).
Doctors in Germany became tightly integrated into the Nazi Party and supportive of its ideals. During the Weimar period, a large number of German doctors were unemployed or under-employed and witnessed a decline in their honor and prestige. The Nazi Party seemed like an organization that could reestablish physicians with the power and status they had lost. In 1929, physicians within Germany formed Nationalsozialistischer Deutscher Ärtzebund (The National Socialist German Physicians’ League) and unified the goals of physicians and the State. Physicians joined the Nazi Party both earlier and in larger numbers than any other group of professionals. As the historian Michael Kater writes, “Physicians became Nazified more thoroughly and much sooner than any other profession, and as Nazis they did more in service of the nefarious regime than any of their extraprofessional peers.” By 1942, 38 000 physicians had joined the Nazi Party. In addition, the Nazi Physicians League began a process of removing Jewish physicians from the medical profession in March 1933, and in April 1933 a law was passed forbidding Jewish physician civil servants from practicing medicine at universities and hospitals throughout Germany.
Physicians further medicalized Nazi ideology by propagating the “science” that formed the foundation of a supposed truth. By portraying or certifying Jews and other peoples as racially, physically, or mentally unfit, physicians and government officials claimed to be cleansing Germany of the hereditarily imperfect and the weak. Nazi physicians rose to power and prestige as they used their skills to treat a supposed “racial” sickness that threatened to contaminate the Volkskörper (body of the German people). Cooperation between the Nazis and health practitioners added powerful justification and facilitated a State-run program of forced sterilization and murder that would have been much harder to accomplish without the willing participation of physicians. What began as purification would ultimately lead to genocide.
A series of recurrent themes arose in Nazi medicine as physicians undertook the mission of cleansing the State: the devaluation and dehumanization of segments of the community, medicalization of social and political problems, training of physicians to identify with the political goals of the government, fear of consequences of refusing to cooperate with civil authority, bureaucratization of the medical role, and the lack of concern for medical ethics and human rights. Nazi physicians viewed the State as their primary “patient”; some came to see quarantine (ghettoization), exclusion (emigration), then extermination of an entire people as “treatment” required for the State’s health. These physicians thought of themselves as “biological soldiers” instead of healers and caretakers.
Eugenics and Racial Hygiene
Eugenics arose in the late 19th century as a science that dealt with the improvement of hereditary qualities. Indeed, it was considered to be the leading, cutting-edge science of the time, as it was developed and practiced in several countries. This included the United States, where scientists and politicians worked together to research and implement ways of decreasing the number of people considered to be hereditarily weak (negative eugenics) and increasing the number of people thought to be hereditarily strong (positive eugenics).
In some ways, US eugenics programs served as models for the early eugenic initiatives promulgated in Germany. Though the Nazi regime later made eugenics infamous through mass genocide, Britain and the United States also promoted policies to apply eugenics to social problems. The United States was at the forefront of the eugenics movement and initiated involuntary sterilization through laws often drafted by physicians. In 1907, Indiana became the first state to enact a law sanctioning the sterilization of “social misfits.” By 1926, 23 states had involuntary sterilization laws motivated primarily by eugenic ideas. In 1927, Virginia’s law was found constitutional by the US Supreme Court in an opinion by Oliver Wendell Holmes Jr, which used an analogy to the wartime draft.
Hitler’s enthusiasm for eugenic theory is well-known. He read Menschliche Erblichkeitslehre und Rassenhygiene (Principles of Human Heredity and Racial Hygiene), the standard eugenics textbook during the Weimar years, and incorporated its ideas into Mein Kampf (My Struggle). Though Mein Kampf is known for its promotion of eugenic ideas, it was preceded by a number of other formative texts and acts that developed the scope of eugenics to include eradicating diseases, disabilities, mental illnesses, and, finally, whole races.
Following World War I, German health practitioners openly discussed sterilization of the “unfit,” labeling the care of certain populations a financial burden on the State. In Germany, State-sponsored sterilization began in the early 1930s, in the waning days of the Weimar Republic, after legislation was approved to encourage, but not require, the sterilization of patients deemed “unfit.” Compulsory sterilization of the “unfit,” promoted for decades by prominent figures in German medicine, quickly became official policy soon after Hitler took power in 1933.
On July 14, 1933, the “Law for the Prevention of Genetically Diseased Offspring” required the compulsory sterilization of people with any of the following categories of disease: hereditary or congenital feeble-mindedness, schizophrenia, bipolar disease, hereditary epilepsy, Huntington’s disease, chorea, hereditary blindness, hereditary deafness, malformation, and severe alcoholism. Patients were sent to eugenic health courts by their primary care doctors—further integrating the State and doctors into Germany’s eugenic mission. Decisions regarding sterilization were then made by “Hereditary Health Courts,” which consisted of a 3-person panel. Two panel members were physicians, one a health official likely tied to the Nazi Party and the other an expert in eugenics and hereditary diseases. A district judge, usually a Nazi Party member, served as the third, coordinating member of the panel. German physicians forcibly sterilized 360 000 to 375 000 persons between 1933 and 1939.
“Euthanasia,” which literally means a “good death,” is most commonly understood today as the bringing about of a merciful death for the terminally, irreversibly ill who are in pain and are suffering. Many patients also fear a loss of autonomy and wish not to be a burden. In a medical context, voluntary euthanasia is understood as the patient’s decision to end his or her life. But in the Third Reich, “euthanasia” was a program of State-sponsored medicalized mass murder. The Nazi “euthanasia” program was part of negative eugenics and Nazi racial hygiene’s claim that the only way to purify the Volk was by eliminating the “unfit.” To purify the Aryan German population, 200 000 to 300 000 people were murdered under the guise of “mercy killing,” including many of the mentally ill, disabled, asocials, and others deemed “unfit.”
Like the eugenics movement, advocacy for a large-scale program of State-sponsored euthanasia preceded the Third Reich. The prominent German jurist Karl Binding and German psychiatrist Alfred Hoche published a widely discussed book, Die Freigabe der Vernichtung Lebensunwertes Lebens (Permitting the Destruction of Life Unworthy of Living), in 1920. In their text, written as a standard academic treatise, Binding and Hoche introduced the idea of lebensunwertes leben (“life unworthy of living”) and the legalization of the “mercy killing” of such populations. Drawing on eugenics and Social Darwinism, they argued that the burden on society by having to care for these individuals was too high and their human status too low, that the appropriate solution was the killing of these populations. Although not accepted by the majority of German physicians at the time, many of the procedures put forward by Binding and Hoche, including the 3-person panel deciding whether a patient should be killed, were adopted into the Nazi “euthanasia” program.
A pivotal case of State-sponsored “euthanasia” occurred in fall 1938 and was granted personally by Hitler. The father of an infant born blind, with a malformed brain, and with 1 arm and part of 1 leg missing, petitioned Hitler for the right to a “mercy death” for his son. Karl Brandt, Hitler’s personal physician at the time, was sent to Leipzig by Hitler, where the baby was hospitalized, to consult with the doctors in charge. At the Doctors’ Trial, Brandt described the orders Hitler gave him: “If the facts given by the father were correct, I was to inform the physicians in Hitler’s name that they could carry out euthanasia,” an order that Brandt followed.
Brandt attempted to defend his decision at the Trial by testifying that the decision to kill the infant was hardly unique and in line with a procedure already followed in many German hospitals. “In maternity wards in some circumstances it was quite normal for the doctors themselves to perform euthanasia in such a case without anything further being said about it,” Brandt said at the Doctors’ Trial. Upon returning to Berlin, Brandt was told by Hitler to proceed in similar fashion with other incurably ill children, an order that initiated the establishment of a formal structure for the “euthanasia” program.
A systematic program of “euthanasia” of “unfit” children and adults became official policy in Germany in 1939 when Hitler issued a decree commissioning doctors to perform “mercy killings” on those who were judged “incurably sick by medical examination.” It was thought that the killing of the very young, newborns, and children up to age 3 or 4 years, would be considered the most “natural” or acceptable, and so the “euthanasia” program began with the killing of children. These first “mercy death[s]” involved “5,000 children killed by starvation, exposure in unheated wards, or the administration of cyanide, chemical warfare agents, or other poisons.” The program was then expanded to include adults in mental hospitals in accordance with the decree issued by Hitler in October 1939 and backdated to September 1 to coincide with the beginning of the war. The killing of adults was further employed as means of freeing space in hospitals for soldiers who suffered injuries in battle. Hitler chose Brandt and Philipp Bouhler, chief of Hitler’s Chancellery, to lead and administer the program. Brandt assured the doctors operating the program that Hitler’s decree had the force of law and that they would not be prosecuted for their involvement. The overall program for killing adults was given the codename Aktion T4 after Tiergartenstrasse 4, the address that housed the offices for the program in Berlin.
The doctors and administrators responsible for carrying out the program created a medicalized structure for each step of the killing process. Midwives and doctors were ordered to report all cases of children with serious hereditary diseases to the Reich Health Ministry. Similarly, doctors were required to report adult patients with certain diseases, patients deemed mentally ill, or patients who had been institutionalized for at least 5 years. These reports resembled a standard medical questionnaire and led some physicians to believe that these reports were merely being used to further scientific research. Then, solely on the basis of these questionnaires, a panel of 3 “medical experts” was asked to judge whether the patient needed “treatment”—killing—or whether “postponement” or “observation” was appropriate. The 3-member panel consisted of representatives of the T4 leadership, usually Brandt or Herbert Linden of the Interior Ministry, along with “outside consultants” such as Werner Catel or Hans Heinze, who were in charge of the child euthanasia operations at several hospitals. The whole process encouraged the 3 “experts” to issue a decision for killing. The killing was usually ordered by the supervising doctor and often was done by repeated dosages of strong sedatives or morphine. False death certificates were then issued; the cause of death usually listed an ordinary disease.
In the case of the larger killing operation of adults and children, “transport lists” were issued for those ordered to be transferred and murdered at one of the killing centers.12(p70) Buses operated by Schutzstaffel (SS) officers dressed in white medical uniforms took patients to the killing centers. The destination of the buses was kept secret from the staffs of most hospitals and the patients themselves. Thus, from the reporting of hereditarily ill children and adults to the killing operation itself, the whole “euthanasia” program was a medical procedure administered by medical personnel.
Six sites were chosen as “euthanasia centers”—Brandenburg, Bernburg, Hartheim, Grafeneck, Sonnenstein, and Hadamar. The 6 sites were selected for their isolated locations; each had been mental hospitals, nursing homes, or jails before being transformed into killing centers. At first, killing was done by lethal injection, and it was later performed through carbon monoxide in gas chambers disguised as showers. After SS chemists had “perfected” the gassing operation, Brandt insisted that only doctors should carry out the gassings. The bodies were disposed of in crematoria and the ashes sent in urns to the families along with falsified death certificates issued under a false name by the “Condolence Letter Department.”
Hidden from the German public for years, knowledge about the true nature of the “euthanasia” program became increasingly common in Germany in 1940 and 1941. After widespread public opposition in Germany, including by churchmen, such as Münster Bishop Clemens von Galen, the program appeared to end when Hitler ordered its termination in August 1941. But the official ordering of the end of the “euthanasia” program occurred just as killing in concentration camps began, and a decentralized killing campaign continued in the hospitals. Further murder of the “unfit” started in concentration camps in Germany after August 1941, where a new program titled 14F13 continued as a way of killing large numbers of inmates. In total, between 200 000 and 300 000 people were killed under T4, 14F13, and other related “euthanasia” programs.
The atrocities justified and performed by the health practitioners serving the Nazi eugenics and “euthanasia” programs exemplify how small steps along a slippery slope can lead to crimes against humanity. The Nazi doctors gradually progressed from eugenic sterilization to child and adult “euthanasia” and ultimately to murder and genocide. Framed in such medical terms as “healing work” and “death assistance,” German health practitioners carried out the murder of thousands of the “unfit.” Seventy years after Nuremberg, it is important to reflect on lessons we can draw from the history of the Third Reich and to examine the role of contemporary eugenics and euthanasia in medicine today.
Contemporary euthanasia is legally sanctioned in several countries and states. Euthanasia began by facilitating a “good death” in dying patients who were terminal and irreversibly ill and in pain and suffering. Increasingly there has been a move away from these narrow inclusion criteria to euthanasia in the nonterminally ill, those with chronic disease, reversible treatable disease, and broad notions of psychological and existential suffering. In addition, there has been a progression from voluntary euthanasia to reliance on advance directives or previous statements in cases such as dementia and expanding assisted suicide to active killing. Finally, there has been a limited expansion to include euthanasia of infants and children as well as the incompetent.
Several US states have “Death with Dignity Statutes” allowing physician involvement in assisted suicide, including California, Colorado, Oregon, Vermont, Washington, and Washington, DC. Montana allows the end-of-life option through a state Supreme Court ruling. In June 2016, Canada by judicial opinion legalized medically assisted dying to relieve the suffering of terminally ill adults. This legislation specifies that assisted suicide is only permitted if there is voluntary, informed, and understanding consent from the patient. Increasing the slippery slope, however, Canada allows not only assisted suicide but also direct killing for those unable to kill themselves, thus permitting active euthanasia. Assisted suicide for the relief of suffering from a mental illness is permitted by statute in the Netherlands, Belgium, and Switzerland. Using advance directives to provide prior consent for euthanasia is practiced in Belgium. The Netherlands allows an active ending of the life of an infant or child who is “classified” as having no hope of a good quality of life or no hope of improvement. (See the box on this page).
Despite this contemporary progression of acts of euthanasia, the modern protocols are open and transparent, and publically reported and debated. Nonetheless, there is evidence of the slippery slope moving from competent suicide with physician assistance for adults to the incompetent, including euthanizing children and newborns. Current practices raise the question of ensuring the establishment of proper limits, especially in protecting competent individuals through voluntary and informed consent and defining the role of the State in preventing abuses.
A focus primarily on positive eugenics differentiates modern eugenics as it exists today from American and Nazi eugenics of the early to mid-1900s. Contemporary examples of positive eugenics widely discussed among bioethicists include sex selection, genetic screening or testing, and the more recent controversy over “designer babies.” As research on genome editing has developed, some foresee a danger in modifying human DNA and the creation of “genetically modified humans.” A “designer baby” is an embryo whose genetic makeup has been selected or modified to eradicate a particular defect or to ensure a particular gene is present. This can be accomplished by using gene editing tools such as CRISPR-Cas9, which can remove, add, or alter sections of DNA. All of these tools can be used to promote a healthier population, but also contain the potential for abuse. Thus, genetically modified human embryo work that goes beyond disease prevention has become a global concern. Further modifying DNA of living human beings may have evolutionary impacts. The use of embryo selection and genetics blurs the distinction between positive and negative eugenics. In addition, there is a blurring of public and private roles in eugenics. Rather than government mandate, social pressures arguably “encourage” private eugenic practices.
An example of contemporary negative eugenics is the case of the sterilization of female inmates in California prisons, performed without proper legal permission to do so or without appropriate informed consent procedures. According to the California State Auditor, 144 female inmates were sterilized via bilateral tubal ligation during the years from 2005-2006 to 2012-2013. At least 39 of those women, about a quarter of the female inmates sterilized, were sterilized following an improper “informed consent” process, making these 39 sterilizations illegal. The audit also found that medical staff rarely requested approval from prison administrators to sterilize inmates, and when they did so, it was not always clarified that the requests were approved. As a result of this investigation, a law was enacted prohibiting the use of sterilization as birth control for any inmate under the supervision of the Department of Corrections and Rehabilitation or in a county correctional facility in the state of California. Within this law are specified criteria for when sterilization is permissible, as well as criteria for reporting that such a procedure has been performed. The case highlights the continued responsibility to guard and raise concern for vulnerable people and their rights, especially those who are under guardianship of the State. Of particular concern is the role of doctors in carrying out the sterilizations.
Legacy of the Doctors’ Trial
Although the proceedings of the Doctors’ Trial accomplished much in documenting the medical crimes performed under the Third Reich, the Trial did not go as far as it could have done in establishing the crucial role that medicine, in particular the frameworks of eugenics and euthanasia, played in Nazi ideology and mass murder. One of our aims in this review is thus to add to the understanding we now have of the degree of participation of physicians in medical crimes and mass murder during the Third Reich.
In his discussion of the Trial, the historian Michael Marrus has argued that the Trial “offered only the crudest of explanations for what had occurred and made no links with eugenic thought and the medical culture of Germany.” As Marrus points out, because the Nuremberg trials focused on crimes committed against peoples of the nations who triumphed over Germany rather than on the German people, the trial gave little attention to the history of forced sterilization and the “euthanasia” program within Germany, programs that involved the widespread participation of physicians. As Marrus writes,
The Trial’s focus on non-German victims, mainly in the concentration camps, entailed a downplaying of forcible sterilization and “medicalized killing”—the victimization of several hundred thousand people, mainly Germans, in which physicians were so heavily involved…. As a result, the trial suffered grievously as a chronicle of the medical crimes of the Third Reich… and deflected attention from the involvement of the medical profession as a whole in the Nazi enterprise.
Most startling, as Marrus highlights, is the judges’ response to Brandt’s claim, discussed previously, that there was basis in precedent and humanitarian reasons for the “euthanasia” killings. In their verdict the judges stated,
Whether or not a state may validly enact legislation which imposes euthanasia upon certain classes of its citizens is a question which does not enter into the issues. Assuming that it may do so, the Family of Nations is not obligated to give recognition to such legislation when it manifestly gives legality to plain murder and torture of defenseless and powerless human beings of other nations.
These words ought to give us pause as we consider medical and legal defenses of cases of contemporary eugenics and euthanasia.
One of the most troubling unanswered questions about the Third Reich is how it was possible that physicians could have so willingly participated in mass murder. Were physicians true believers in Nazi racial ideology or instead were they willing and enthusiastic opportunists, who, like Germans in many other professions, joined the Nazi Party for the purposes of career advancement? In dealing with this problem, it could be argued that the medical profession itself includes elements of dehumanization and numbing, as means of coping with the suffering of patients. Alternatively, it could be asked whether the modern medical profession encourages group obedience to authority and the diffusion of responsibility. Physicians may be particularly vulnerable to these pressures, as they have a tendency to compartmentalize, justify, and rationalize problems as a way of coping with what the profession requires. Regardless of whether one finds any of these theories of the perpetrator convincing, there is no denying the vast role that physicians played in shaping and implementing the worst genocide the world has ever witnessed.
Seventy years after the Doctors’ Trial, we recognize that it is the duty of those in the medical profession to discuss the implications of the Trial and its lessons for today. We have offered this preliminary discussion of examples of contemporary parallels in pursuit of this goal, but much work remains. As we have made clear, although some aspects of the contemporary cases are troubling, we must be careful not to conflate instances of contemporary eugenics and euthanasia with Nazi eugenics and “euthanasia.” The misuse of the Nazi analogy is not only offensive and irresponsible, but it can also prevent a clear and important understanding of current cases we need to examine.
The 70th anniversary of the Nuremberg Doctors’ Trial reminds us of the great atrocities that physicians can inflict when medical ethics is distorted by the ideology of a totalitarian State. It is our obligation to study how and why physicians dedicated to health and healing can turn to torture and murder in the “service” of their country. Reflection on the Doctors’ Trial reminds us that physicians have a special obligation to use their power to protect human rights and that medical ethics devoid of human rights is no more than hollow words.