Medicalized Killing from an Historical Viewpoint

The concept that the Holocaust in Nazi Germany during World War II started with medicalized killing by German psychiatrists is not new, nor is it unsubstantiated. But until relatively recently it has remained a little-know fact. In A Sign for Cain, Dr. Fredric Wertham acknowledges the positive role Germany played in the development of modern psychiatry:

It is a great achievement of psychiatry to have brought about the scientific and humane treatment of mental patients after centuries of struggles against great obstacles. In this progress, as is universally acknowledged, German psychiatrists played a prominent part. And German public psychiatric hospitals had been among the best and most humane in the world.¹

Yet it was in the psychiatric area that the medicalized killing began. The process was planned and precise, and it was implemented on a vast scale.

Starting in 1939, psychiatric patients were systematically killed, until by 1945 the total number of patients left in the psychiatric hospitals of Berlin alone had dropped by three-fourths. “Useless eaters” such as retarded children, the old, and even World War I veterans who had lost a limb were included in the killing process.

Ironically, at the outset “Jewish mental patients, old and young, were strictly spared and excluded. The reason given was that they did not deserve the ‘benefit’ of psychiatric euthanasia. This lasted up to the second half of 1940.”² After that they were almost all killed very rapidly as part of Hitler’s program of genocide.

The seed for the concept of life unworthy of life was taking root in German culture even before Hitler made it infamous. It was in 1920 that jurist Karl Binding and neurologist Alfred Hoche published The Permission to Destroy Life Unworthy of Life, in which they advocated euthanasia for those suffering from incurable physical and mental illness as well as for the severely retarded.

In the Journal of the American Medical Association, in a 1920 review written by the Berlin Correspondent, the book is said to advocate the destruction of all those who are incurably insane, “irrespective as to whether the mental disease is of congenital origin or otherwise.” Cost and burden of care are sufficient reasons to kill such people. According to the review, the book also advocates the killing of mentally sound people who are incurably ill and wish to end their life, as well as those in a coma who “would only awaken to indescribable pain and misery.” The decision for the life or death of the terminally ill was to be left to the discretion of the state or the attending physician.³

Thus the concept of life unworthy of life was presented to the public and specifically to physicians before Hitler rose to power. The book, endorsed by Hitler, was well received by the German people.

The human tendency to take the easy way out helped inspire public approval of Hitler’s euthanasia policies. Before Hitler authorized euthanasia in the 1920s, many parents already wanted to be able to seek mercy killing for their disabled children. The nation was ready.

It is important to keep in mind that Hitler’s authorization for euthanasia was just that: permission to kill, not an order to kill. Comments Dr. D. Alan Shewmon:

Significantly, Hitler’s authorization was not so much a command but an extension of the “authority of physicians . . . so that a mercy death may be granted to patients who according to human judgment are incurably ill according to the most critical evaluation of the state of their disease.”⁴

The machinery for medicalized killing was, however, set in precise motion:

All state institutions were required to report on patients who had been ill five years or more and who were unable to work, by filling out questionnaires giving name, race, marital status, nationality, next of kin, whether regularly visited and by whom, who bore financial responsibility and so forth. The decision regarding which patients should be killed was made entirely on the basis of this brief information by expert consultants, most of whom were professors of psychiatry in the key universities. The consultants never saw the patients themselves.⁵

The more direct political orders came later - for the Jews! Euthanasia of mental patients and those continued defective continued until the end of the war, paralleling the process of genocide.

Dr. Wertham states:

The tragedy is that the psychiatrist did not have to have an order. They acted on their own. They were not carrying out a death sentence pronounced by somebody else. They were the legislators who laid down the rules for deciding who was to die; they were the administrators who worked out the procedures, provided the patients and places, and decided the methods of killing; they pronounced a sentence of life or death in every individual case; they were the executioners who carried the sentences out or – without being coerced to do so – surrendered their patients to be killed in other institutions; they supervised and often watched the slow deaths.⁶

These physicians of the Third Reich were not underlings. They were men of prominence. They were leaders of their day. They were heads of medical schools and hospitals. They personified the truth of the statement made two centuries earlier by Dr. Christopher Hupeland: “If the doctor presumes to take into consideration in his work whether a life has value or not, the consequences are boundless and the physician becomes the most dangerous man in the state.”

Yet the psychiatrists of the Third Reich were not inherently more evil than other physicians of their day. Nor, as some might like to assume from this discussion, is psychiatry necessarily evil today. But loose diagnoses of nonspecific illnesses, combined with the current fad then (as now) of genetic engineering, provided a tool by which evil could prosper. For while genetic engineering can be used to avoid certain hereditary diseases, it can also be used to attempt to develop a “super race” and to weed out those characteristics and those people who are not wanted by a given society at a given time.

Like nuclear fission, genetic engineering and psychiatry are neutral tools that can be used for good or evil:

The euthanasia propaganda then was essentially no different from what it is now. . . . There was continuing reference to the costs of caring for the handicapped, retarded, and insane. The purpose behind such propaganda was to facilitate the ongoing program of involuntary “euthanasia.” But the point here is that-whether voluntary or involuntary-the indications for legalized killing naturally expand. Eventually patients with minor deformities, the mildly senile, amputee war victims, “problem children,” bed-wetters, and the like were being selected by physicians on their own initiative for “mercy deaths.”⁷

In Germany the process quickly escalated from so-called mercy killing to killing those who were just not wanted and eventually to Hitler's long-term goal: annihilating European Jews. In the Third Reich, decisions about euthanasia always remained in the hands of the medical profession; it remained medicalized killing.

Footnotes

Fredric Wertham, M.D., A Sign for Cain: An Exploration of Human Violence (New York: Macmillan, 1966), 153.
Ibid. 157, 159.
Berlin Correspondent, “The Right of Putting Incurable Patients Out of the Way,” Journal of the American Medical Association 75 (October 2, 1920) 1283.
D. Alan Shewmon, “Active Voluntary Euthanasia: A Needless Pandora’s Box,” Issues in Law and Medicine 3 (1987) 228. See also F. Wertham, A Sign for Cain, 162.
Leo Alexander, M.D., “Medical Science Under Dictatorship,” New England Journal of Medicine 241 (July 14, 1949) 39.
Wertham, A Sign for Cain, 165.
Shewmon, “Active Voluntary Euthanasia”228.

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