Survivors and world leaders recently commemorated the 60th anniversary of the liberation of Auschwitz by the advancing Soviet army on 27 January 1945. [1] Auschwitz was the largest of the Nazi death camps, where 1.1 million people died during the Nazi holocaust. However, very little, if any, of the media coverage dwelt on the role of the medical profession in these events. The Nazi holocaust actually had humble beginnings; in nursing homes, geriatric hospitals and psychiatric institutions all over Germany. When the Nazis arrived, the medical profession was ready and waiting.

‘Life unworthy of life’

Germany emerged from the First World War defeated, impoverished and demoralised. Into this vacuum in 1920 Karl Binding, a distinguished lawyer, and Alfred Hoche, a psychiatrist, published a book titled The granting of permission for the destruction of worthless life. Its extent and form. In it they coined the term ‘life unworthy of life’ and argued that in certain cases it was legally justified to kill those suffering from incurable and severely crippling handicaps and injuries. Hoche used the term ballastexistenzen (‘human ballast’) to describe people suffering from various forms of psychiatric disturbance, brain damage and retardation.

By the early 1930s a propaganda barrage had been launched against traditional compassionate 19th century attitudes to the terminally ill and when the Nazi Party came to power in 1933, 6% of doctors were already members of the Nazi Physicians League. In June of that year Deutsches Arzteblatt, today still the most respected and widely read platform for medical education and professional politics in Germany, declared on its title page that the medical profession had ‘unselfishly devoted its services and resources to the goal of protecting the German nation from biogenetic degeneration’. [2]

Purifying the gene pool

From this eugenic platform, Professor Dr Ernst Rudin, Director of the Kaiser Wilhelm Institute of Psychiatry of Munich, became the principle architect of enforced sterilisation. The profession embarked on the campaign with such enthusiasm, that within four years almost 300,000 patients had been sterilised, at least 50% for failing scientifically designed ‘intelligence tests’. [3]

By 1939 (the year the war started), the sterilisation programme was halted and the killing of adult and paediatric patients began. The Nazi regime had received requests for ‘mercy killing’ from the relatives of severely handicapped children, and in that year an infant with limb abnormalities and congenital blindness (named Knauer) became the first to be put to death, with Hitler’s personal authorisation and parental consent. [4]

This ‘test-case’ paved the way for the registration of all children under three years of age with ‘serious hereditary diseases’. This information was then used by a panel of ‘experts’, including three medical professors (who never saw the patients), to authorise death by injection or starvation of some 6,000 children by the end of the war. [5]

The slippery slope

Adult euthanasia began in September 1939 when an organisation headed by Dr Karl Brandt and Philip Bouhler was set up at Tiergartenstrasse 4 (T4). The aim was to create 70,000 beds for war casualties and ethnic German repatriates by mid-1941. All state institutions were required to report on patients who had been ill for five years or more and were unable to work, by filling out questionnaires [6] and chosen patients were gassed and incinerated at one of six institutions (Hadamar being the most famous). False death certificates were issued with diagnoses appropriate for age and previous symptoms, and payment for ‘treatment and burial’ was collected from surviving relatives.

The programme was stopped in 1941 when the necessary number of beds had been created. By this time the covert operation had become public knowledge. The staff from T4 and the six killing centres was then redeployed for the killing of Jews, Gypsies, Poles, Russians and disloyal Germans. By 1943 there were 24 main death camps (and 350 smaller ones) in operation.

Medical involvement

Throughout this process doctors were involved from the earliest stage in reporting, selection, authorisation, execution, certification and research. They were not ordered, but rather empowered to participate. Leo Alexander, a psychiatrist with the Office of the Chief of Counsel for War Crimes at Nuremberg, described the process:

‘The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the attitude, basic in the euthanasia movement that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans.’ [7]

The War Crimes Tribunal reported that ‘part of the medical profession co-operated consciously and even willingly’ with the ‘mass killing of sick Germans’. [8] Among their numbers were some of the leading academics and scientists of the day; including professors of the stature of Hallervorden (neuropathology), Pernkopf (anatomy), Rudin (psychiatry/genetics), Schneider (psychiatry), von Verschuer (genetics) and Voss (anatomy). None of these men were ever prosecuted while of the 23 defendants at Nuremberg, only two were internationally recognised academics.[9]

Looking back

It is easy to distance ourselves from the holocaust and those doctors who were involved. However, images of SS butchers engaged in lethal experiments in prison camps don’t fit the historical facts; the whole process was orchestrated through the collaboration of internationally respected doctors and the State. Furthermore the thinking that laid the foundation was well-entrenched throughout the Western world of the time. The International Eugenics Congress which elected Ernst Rudin as its president in 1932, met not in Berlin, but New York. [10] The United States had itself sterilised 30,000 mentally ill and criminally insane before the war and within Europe Denmark had beaten Germany to the operating table by four years. [11] The lessons of history should alert us to similar trends in our own society. What features can we identify?

Deja Vu?

First, propaganda campaigns were prominent. Films such as The Inheritance degraded and stigmatised handicapped patients; disputing their humanity, inflaming resentment against ‘luxury’ asylum conditions and advocating the ‘natural’ elimination of the weak. [12] Others promoted euthanasia as a merciful relase. I accuse depicted a woman with multiple sclerosis being killed on request by her husband while a colleague played soft piano music in the next room.

The use of euphemisms distorted the facts and added a veneer of respectability to the proceedings. The Reich Committee for the scientific approach to severe illness due to heredity and constitution arranged for the killing of handicapped children. The charitable transport company for the sick transported adult patients to the killing centres while The Charitable Foundation for Institutional Care collected the cost of killings from bereaved relatives. The SS Xray Battalion identified TB patients in the general population and then shot them.

An obsession with cost-benefit analyses was a third feature. School children were given mathematics problems balancing the cost of housing units for young couples against the costs of looking after ‘the crippled, the criminal and the insane’. The killing of 70,000 patients in the T4 programme was calculated to save 245,955.50 Reichsmarks per day. [13] The Germans were diligent gatherers of statistical information. Both the child and adult euthanasia programmes relied on extensive form filling; which became the basis of decisions to kill.

The Nazis’ experiments on human subjects are well-documented: Hallervorden’s collection of brains for his neuropathological collection; radiation and castration for sterilisation; intravenous phenol, gasoline and cyanide; hypothermia and haemorrhage studies. These prompted the drafting of the Nuremberg code in 1947, [14] making informed consent an absolute requirement for research. The ideology which drove the holocaust was utilitarian and Hegelian. The status of certain human beings was denigrated while that of animals was elevated. Ironically, laws restricting research on animals in Nazi Germany were particularly stringent. [15]

The final lesson to learn is the danger of too close a relationship between medicine and the State. In June 1933, Deutsches Arzteblatt affirmed the medical profession’s ‘special responsibility to work within the framework of the state on the tasks posed by population politics and racial improvement’.[16]

Conclusion

The Nazi holocaust arose from small beginnings. Such a progression initially required only four factors; favourable public opinion, a handful of willing physicians, economic pressure and no prosecution for those involved. The remaining ingredients were a eugenic social policy and war.

The many similarities between Germany in the 1930s and the direction Western Medicine is moving today should give cause for alarm. The growing acceptance and practice of euthanasia in Australia, the United States and Europe ring familiar bells. All run counter to post-war ethical declarations adopted by the World Medical Association. This coupled with growing health propaganda, specious euphemisms, obsession with cost-benefit analyses, computerised knowledge and a developing intimacy between profession and state leaves Christian doctors no room for complacency.