The purpose of this article is to increase the awareness of the nurses’

involvement in these crimes against humanity and, in so doing, present vari-

ous factors that could have affected the individual nurses’ decisions to com-

mit these actions against patients in their care.

BACKGROUND

Before the time of the genocide of millions (known as the Holocaust), the

German government established euthanasia programs for handicapped Ger-

man children and adults. Nurses were participants in both. In reality, these

programs had little to do with the contemporary understanding of the word

euthanasia

. In actuality, the programs were involuntary killings of handi-

capped children and adults that were sanctioned by the government and

society.

In the early part of the 20

th

century, a eugenics movement arose in Europe

and in the United States. This movement sought to apply the scientific prin-

ciples of natural biology to human society with the stated goal of improving

and strengthening the human race. Involuntary sterilization of the “feeble-

minded and hereditarily unfit” (Gallagher, 1995, p. 51.) was practiced in the

United States and Europe. In the United States, 30 states enacted legislation

to allow involuntary sterilization. In fact, the United States led the western

world in involuntary sterilization with the enactment of sterilization laws 20

years before the Germans (Gallagher, 1995). Involuntary sterilization in

Germany was activated and provided a first step in the “Healing of the

Volk.” The killing of the handicapped was the next step.

The origins of planned euthanasia were in place earlier than the Nazi era.

“The idea of ending ‘lives not worth living’ did not begin with the Nazis but

had been discussed in the legal and medical literatures since the end of the

First World War,” with supportive articles appearing in both European and

American literature (Proctor, 1992, p. 24). In 1920, Dr. Alfred Hoche, a phy-

sician, and Karl Binding published a pamphlet titled “The Sanctioning of the

Destruction of Life Unworthy of Living.” The emphasis of the book was on

the reduction of suffering of the acutely ill and their families (Nadav, 1994,

p. 45). Later, in 1935, Hitler told the Reich physician leader, Dr. Gerhard

Wagner, that he would implement euthanasia once war began (U.S. Military

Tribunal, Transcripts of the Proceedings in Case 1, p. 2,482, Testimony of

Karl Brandt).

The German people were exposed to the idea of euthanasia through post-

ers, movies, and books supporting the destruction of lives not worth living.

April 1999, Vol. 21, No. 2

247

In 1936, a book titled Sendung und Gewissen (Mission and Conscience) was

published in Germany by an ophthalmologist, and it was widely read. This

novel told the story of a young wife with multiple sclerosis who was eutha-

nized by her physician husband. This novel was important in preparing the

ground for the euthanasia programs (Proctor, 1988, p. 183). It was made into

a movie, Ich Klage an! (I Accuse), and it was widely shown during these

years. Two other popular movies of the time also dealt with euthanasia, Life

Unworth Life

(1934-1935) and Presence Without Life (1940-1941) (Amir,

1977, p. 97). “Opfer der Vergangenheit (Victims of the Past, 1937) was pro-

duced under Hitler’s direct order and shown by law in all 5,300 German

theaters” (Michalczyk, 1994, p. 65). These films argued that keeping seri-

ously ill people alive was against the basic principles of nature (Michalczyk,

1994, p. 65).

Posters were displayed throughout Germany showing a healthy German

supporting on his shoulders the weight of handicapped individuals with the

saying “You are sharing the load! A genetically ill individual costs approxi-

mately 50,000 reichsmarks by the age of sixty” (Gross, 1935/1988, p. 335).

Even high school textbooks contained mathematical problems using the cost

of caring for the mentally ill as examples (Donner, 1935/1988). The elderly

and the ill, too, were considered by some to be burdens: “It must be made

clear to anyone suffering from an incurable disease that the useless dissipa-

tion of costly medications drawn from the public store cannot be justified”

and “It made no sense for persons ‘on the threshold of old age’ to receive ser-

vices such as orthopedic therapy or dental bridgework; such services were to

be reserved for healthier elements of the population” (Proctor, 1988, p. 183).

It is important to see these attitudes as the context for nursing at that time.

The Children’s Euthanasia Program

Because of the prevalence of the negative attitude of the public toward the

handicapped, “Parents were made to feel shame and embarrassment at hav-

ing to raise an abnormal or malformed child” (Proctor, 1992, p. 25). The chil-

dren’s euthanasia program in Germany during the Nazi era is reported to have

had its origin in the request to Hitler by a father of a deformed and retarded

child to have this child killed. Hitler asked his personal physician to investi-

gate the situation, and the child was eventually killed. In 1936 to 1937, a

secret Reich committee for the scientific registering of serious hereditary and

congenital illnesses was established in Hitler’s chancellory. This committee

of three with medical and psychiatric expertise discussed euthanasia and, in

1939, drafted a prospective law calling for the “destruction of life unworthy

248

Western Journal of Nursing Research

of life.” This prospective law would have provided legal sanction for “kill-

ing people suffering from serious congenital mental or physical ‘malform-

ation,’ because they required long-term care, aroused ‘horror’ in other people,

and were situated on ‘the lowest animal level’.” (Burleigh, 1994, p. 98)

In 1939, a Ministry of Justice commission proposed the following:

Clause 1: Whoever is suffering from an incurable or terminal illness which is a ma-

jor burden to himself or others can request mercy killing by a doctor, provided
it is his express wish and has the approval of a specially empowered doctor.

Clause 2: The life of a person who, because of incurable mental illness, requires

permanent institutionalization and is not able to sustain an independent exis-
tence may be prematurely terminated by medical measures in a painless and
covert manner. (Burleigh, 1994, p. 99)

It became compulsory to register all malformed newborn children with

the Reich Committee. The Reich Committee for the Scientific Registration

of Severe Hereditary Ailments “was an organization for the killing of chil-

dren who were born mentally deficient or bodily deformed. All physicians

attending at births, midwives, and maternity hospitals were ordered by the

Ministry of Interior to report such cases” (Office of U.S. Chief of Council for

the Prosecution of Axis Criminality, 1945). Three referees—two pediatri-

cians and one physician director of a psychiatric institution—wereto decide

which of the reported children were to be killed. These physicians made the

decisions without seeing the children; these decisions were based solely on

the diagnoses of the midwives and reporting physicians. When the public

health offices were notified of a decision, they were to arrange for the child’s

admission to one of approximately 30 inpatient pediatric clinics. The Reich

committee promised the parents that the child would be treated by specialists

in the clinic, and this promise often allowed the parents to believe they were

acting in the child’s best interest. “Other parents were talked into parting with

their child by their family doctor, or by public health or National Socialist

People’s Welfare nurses doing the round of family home visits or servicing

mothers’ advisory centers” (Burleigh, 1994, p. 102).

The Killings

At the specialized centers, children who were designated by the Reich

committee for euthanasia were killed with medication shortly after arrival.

Other children died of deliberate starvation or by an overdose of Luminal

(phenobarbital).This drug was mixed into the children’s food every morning

and night until they became unconscious and developed pneumonia. Some

April 1999, Vol. 21, No. 2

249

were also given injections of morphine and scopolamine (Burleigh, 1994,

p. 102).

The nursing staff of the pediatric unit of Haar was led by a senior nurse, Emma

D., and two younger colleagues, Emma L. and Maria S. They were forced to

swear an oath of loyalty, pledgingeternalsilenceregardingwhat went on in the

clinic under pain of death. Initially, however, they swallowedthe line that what

they were doing was scientificallyimportant, rationalizingthe high number of

deathsas beingmerelywhat one mightcall collateralcasualties.Althoughthey

sometimes requested transfers, and undoubtedly found the work disturbing,

nonetheless they also regarded it as necessary to release the regrettable crea-

tures in their care from their suffering. Like many nurses who worked in these

clinics, they received a 25RM-per-month (approximately $80 U.S.) supple-

mentarypayment,knownpejorativelyas Schmutzgeld(dirty money).The doc-

tors sometimes received a 250RM (approximately $800 U.S.) Christmas

bonus. In some clinics (notoriously the Kalmenhof at Idstein), the tensions of

the job were soothed by a visit to the wine cellars to mark every 50th killing

with copious amounts of wine and cider. (Burleigh, 1994, p. 104-105)

An estimated 5,000 children were killed during the so-called children’s

euthanasia program (U.S. Military Tribunal, Transcripts of the Proceedings

in Case 1, p. 177, Testimony of Karl Brandt).

The T-4 Adult Euthanasia Program

In 1939, Hitler issued an order to expand the euthanasia program to “the

worthless lives of seriously ill mental patients” which would “result in cer-

tain savings in terms of hospitals, doctors, and nursing staff” (Friedlander,

1995, p. 63). To do this, the Reich committee was expanded from the original

three members to include a number of academics and asylum directors. The

organization went by the name Aktion T-4, named after the location of the

offices, Tiergartenstrasse 4, in Charlottenburg (a district of Berlin). In July

1939, these men were told that a number of psychiatric patients had to be

killed to make hospital space for war casualties and to free up nursing staff

(Burleigh, 1994, p. 119). Six killing centers were set up in existing psychiat-

ric hospitals: Grafeneck, Brandenburg, Hartheim, Sonnenstein, Bernburg,

and Hadamar (Office of U.S. Chief of Council for the Prosecution of Axis

Criminality, 1945).

In 1941, Hadamar ‘celebratedthe cremation of its 10,000th patient in a special

ceremony, where everyone in attendance—secretaries, nurses, and psychia-

trists—received a bottle of beer for the occasion.’ (Proctor, 1992, p. 25).

250

Western Journal of Nursing Research

Although the children were killed with injections or starvation, these

methods were not efficient for the large number of adults at the killing cen-

ters. In these locations, gas was used. Patients were transported by bus from

local and regional hospitals to the killing centers. “At the killing center, the

arriving patients were met by the staff and led to the reception room by a male

or female nurse, who might have accompanied them on their trip” (Fried-

lander, 1995, p. 94). Patients were examined individually by a physician,

photographed, and measured. They were then taken to gas chambers that

were disguised as shower rooms. “The patients were already prepared for the

showers because, while they were undressing, the nurses had told them that

they wouldbe bathed”(Friedlander, 1995, p. 95). “Mostpatientsacceptedthe

nurses’ explanation that they were going to the showers” (Friedlander, 1995,

p. 96). “On rare occasions, nurses might even have to remove bodies from

the gas chamber, a job usually reserved for unskilled laborers” (Friedlander,

1995, p. 101). By 1941, more than 70,000 patients from German mental hos-

pitals had been killed (U.S. National Archives and Records, Record Group

338, Microfilm Publication T-1021, Roll 18, Frame 98). Later, the killing

centers were used for the killing of selected concentration camp prisoners in

the “Special Treatment 14f13” program (Office of Chief Counsel for War

Crimes, Document Number 3354).

The Wild Euthanasia Programs

Hitler ordered the organized euthanasia program for the adults to end in

August 1941. The killings had become public knowledge and opposition to

the programs came from individuals and churches; however, the children’s

euthanasia program continued without interruption, and the stop order

applied only to the killings in the gas chambers of the killing centers. “As

with the children, after the stop order, physicians and nurses killed handi-

capped adults with tablets, injections, and starvation. In fact, more victims of

euthanasia perished after the stop order was issued than before” (Fried-

lander, 1995, p. 151). Just as the children had never been killed in gas cham-

bers, but by medication or starvation, the selected adults were killed by phy-

sicians and nurses in designated institutions. This decentralized euthanasia

program was called “wild” euthanasia by the killers (United States National

Archives and Records, Record Group 238, Microfilm Publication M-1019,

Roll 46). Killing hospitals were set up at Hadamar, Meseritz-Obrawalde,

and Tiegenhof (Dziekanka), but killings were not limited to these

April 1999, Vol. 21, No. 2

251

institutions. Many handicapped patients were killed at other hospitals

throughout the region (Friedlander, 1995, p. 152).

The Role of Nurses in the Killings

During the wild euthanasia phase, handicapped patients that were to be

killed at the killing centers arrived by transport often in the middle of the

night. The staff selected for killing patients who were unable to work as well

as “patientswho causedextra work for the nurses,those who were deaf-mute,

ill, obstructive, or undisciplined,and anyone else who was simply annoying”

(Friedlander, 1995, p. 160). Those selected to be killed were “taken to so-

called killing rooms where physicians and nurses killed them using orally

administered drug overdoses or lethal injections. After they had been killed

by the male and female nurses” (Friedlander, 1995, p. 161), fraudulent death

certificates were prepared and the bodies were cremated. Families were noti-

fied of the deaths of these relatives and could receive an urn of ashes pur-

ported to be those of their loved one. In reality, the urns contained combined

ashes of many people from the crematorium.

At the beginning of 1942, the first trains with about 700 patients arrived at

Obrawalde. At the end of the year and especially in 1943, these trains arrived

more and more frequently. From all parts of Germany, patients were abducted

to be killed in Obrawalde. All the nurses and orderlies—according to their

statements—hadto “unload”the patients.The ill persons were in horrible con-

dition: Many were emaciated and they were very dirty. This condition contrib-

uted to the fact that the nursing personnel were able to distance themselves

emotionally from those people who had been brought into such a condition

beneath human dignity and that the personnel, without considerable pressure,

could be convinced to kill thousands of people. (Ebbinghaus, 1987, p. 224)

When questioned,the senior nurse Ratajczakestimatedthat 18,000 people had

been killed at Obrawalde. Her estimate corresponds to other statements. In

later legal proceedings, mostly a number of 10,000 patients killed by nursing

personnel at Meseritz-Obrawalde is stated. (Ebbinghaus, 1987, p. 219)

Anna G. had been a nurse at the Heil- und Pflegeanstalt Treptow (Healing

and nursing institution—a state hospital and nursing home) for more than 10

years. When it closed, she and other nurses were transferred to Obrawalde.

She was accused of participating in the killing of 150 patients.

When the round was finished, the patients selected by Dr. Mootz had to be

takento the extra room.Generally, the nurseon duty had to undressthe patients

and take them to the extra room. Depending on the circumstances, there were

252

Western Journal of Nursing Research

different methods. If the patient was very confused or ill to such an extent that

she didn’t think about it, after having her undress, I just took her to the extra

room. If the patients were in their right minds and could see through every-

thing, we told them that their health condition had improved in a manner that

they only would have to take a cure in order to get discharged. The patients

believed us in most cases and undressed themselves voluntarily, so we didn’t

have any difficulties with them. We really wanted to make the last way as easy

as possible for the selected patients. In this connection, I remember that one

patientwas a strict Catholic,and the last day she asked for a priest to get the last

sacraments. I remember very clearly and can say with absolute certainty that

the priest was informed before the killing and that the patient, who at least that

daywascompletelyin her rightmind,got the last sacramentsfromthe priest.

I can’t remember that I ever appointed a younger nurse to help me. Young

nurses deliberately weren’t appointed to participate in the killings because we

feared they couldn’t be able to keep their mouths shut.

If my memory serves me right, the patients supposed to be killed weren’t

takento the extraroomtogether. I thinkthe secondpatientwas onlytakento the

extra room when the first one was starting to fall asleep. We then covered her

with a towel.

The killing of patients was never done by only one nurse. Practical experi-

ence had shown that it was absolutelynecessary for the killing to be done by at

least two nurses. I will give the reasons for this necessity. Nurses are also only

humans,and the strengthof their nerves is limited.I think the two nurses had to

supportand help each other when doing the killings.The killingof a personis a

hard strain on the nerves of the person doing it. After all, it could have been

possible that the strong nerves of one nurse wouldn’t have been enough. I will

express by this that one nurse could have fainted, or she could have shrunk

back. But when two or more worked together, the other would have helped to

surmount the weak moment. But the cooperation was not only absolutely nec-

essary for psychological, but also for practical, reasons. I didn’t experience it

one single time that a patient would take such a large quantity of dissolved

medicinevoluntarily. It’s a fact of experiencethat medicinedoesn’t taste good,

and people generally are not readily prepared to take medicine. The same can

be said with regard to injections. Almost all of our patients were scared of in-

jections.In orderto give the dissolvedmedicine,particularlythe injections,the

cooperation of at least two nurses was necessary.

When giving the dissolvedmedicine,I proceededwith a lot of compassion.

I had told patients that they would have to take a cure. Of course, I could tell

these fairy tales only to those patients who were still in their right minds to the

extent that they could understand it. I took them lovingly and stroked them

whenI gavethe medicine.If, for example,a patientdid not emptythe entirecup

because it was too bitter, I talked to her nicely, telling her that she had already

drunk so much that she woulddrink the rest, otherwiseher cure couldn’t be fin-

ished. Some could be convinced to empty the cup completely. In other cases, I

gave the medicine by the spoonful. Like I already told you, our procedure de-

pended on the condition of the patients. Old women, for example, who had to

be fed couldn’t drink on their own, so it wasn’t possible to give them the medi-

cine by the spoonful. They were not to be tortured more than necessary, and I

thoughtit would be better to give them an injection.In this connection,I would

April 1999, Vol. 21, No. 2

253

like to say that, like me, Luise E. (Erdmann),MargareteRatajczak,and Erna E.

thought that the patients were not to be tortured more than necessary. (Ebbing-

haus, 1987, p. 239)

The accused nurse was asked if patients knew what was going to happen to

them. She responded,

The patients didn’t notice it for a long period. Later, there were a few of them

who did notice it. Possiblythey realizedthat the physicianpointed his finger to

individualpatients and talked about them to the senior nurse and those patients

were taken to the so-called small room. It is also possible that the patients, or a

few of them, observed that the patients didn’t come back alive from that room.

When I gave the above-mentionedpatientthe injection,I didn’t talk to her any-

more. The patient also didn’t talk anymore. It was a patient in a condition that

had to be describedas bad. I thinkthe patientdidn’t noticeanything.In general,

some patients anxiously already had lifted themselves in the bed. Some drank

the medicine on their own. Also, the dose varied from one patient to the other.

In one case, on request of the patient, I called a priest. It was the same priest I

already mentionedbefore and who is living now in East Germany. A colleague

told me that this patient would ask for me so I went to see her. The patient told

me that it was her turn the next day. I didn’t know that. She asked me to get a

priestbecauseshe wantedto confess.The patientknewexactlywhat was going

on. She asked me to tell her relatives as soon as she was dead that she had

passed away peacefully. She also asked me to give her the rosary after her

death. (Ebbinghaus, 1987, p. 241)

Why the Nurses Participated

After almost 50 years of postwar proceedings,proof has not been providedin a

single case that someone who refused to participate in killing operations was

shot, incarcerated, or penalized in any way, except perhaps through transfer to the

front, which was, after all, the destiny of most German soldiers. But it is possi-

ble that putative duress did apply, that is, these young, impressionable nurses

might have believed that the intimidating Christian Wirth [the supervisor at

Hartheim hospital] would place them in a concentration camp. (Friedlander,

1995, p. 235-236)

The following reasons for not refusing to participate were provided by the

nurses of Meseritz-Obrawalde hospital:

Helene Wieczorek [accused of killing several hundred patients]: Director

Grabowskitold us we had to help the senior nurses—itwas too much for them.

We also would have to give the injections.First, I refused and he said that there

was no point in it because, being a civil servant of many years’ standing, I

would performmy duty, especiallyin times of war. He added, it would be a law

that the incurable mentally ill persons were to be released from their suffering.

254

Western Journal of Nursing Research

I only did my duty, and I did everythingon order of my superiors.The Director

Grabowski always warned us of the Gestapo. He said he would inform the

Gestapo if we didn’t do what he ordered. (Ebbinghaus, 1987, p. 219)

Luise Erdmann [the main defendant of the trial, accused of participatingin the

killing of 210 patients]: Through the behavior of Dr. Wernicke, I realized that

incurable patients were to be released by giving them Veronal [barbituricacid]

or anothermedicine.I also declarethat I, neitherby Dr. Wernickenor any other

personat the home,havebeeninformedaboutthe euthanasia.I wasn’t swornto

secrecy in this respect. . . . I was of the opinion that one took it for granted or

believed that I would approve of euthanasia. My attitude to euthanasia was,

should I become incurably ill—I don’t make a difference between mental or

physical illness—I would consider it as a release if a physician or, on direction

of a physician, another person would give me a dose releasing me from every-

thing. Despite my attitude to euthanasia, I have—when confronted with the

problem—foughtout serious inner conflicts. Euthanasia, in the form I experi-

enced it at that time, after all was a killingof people,and I asked myselfif a leg-

islator had the right at all to order or permit the killing of people. Never, how-

ever, did I hear about a corresponding law on the use of euthanasia but, on the

other hand, Dr. Mootz explainedto me once that there was no need for reserva-

tion as, should the situation arise, he would cover up for me. From this state-

ment, I concluded that there had to be a legality for euthanasia. (Ebbinghaus,

1987, p. 232)

In my first questioning,I expressedthat, for me, there were justifiedand unjus-

tified cases of euthanasia. In my opinion, I described so clearly what I under-

stand by justified and unjustifiedcases during my first questioning,that I don’t

need to give an additional explanation in this matter. A refusal in those cases

which I regarded as justified would have been illogical, so I don’t have to give

further explanation of this.

It was different with the cases where I didn’t regard the killing as necessary

or appropriate. When I did participate in those killings and thus acted against

my inner attitude and conviction, this happened because I was used to obey

strictly the orders of the physicians. I was brought up and instructed to do so.

As a nurse or orderly, you don’t have the level of education of a physician, and

thus, one can’t evaluate if the order of the physician is right. The permanent

processof obeyingthe orderof a physicianbecomessecondnatureto the extent

that one’s own thinking is switched off. (Ebbinghaus, 1987, p. 234)

I was and still am without interruption of the Protestant faith. I must say that

basically I describe the whole Protestant faith also as my faith. I would like to

express by this that the commandment “Du sollst nicht toten” (thou shall not

kill) is truth for me. When I did the killings, I must admit that I offended this

commandment.But as I expressed in my questioning,I didn’t do it with a light

heart but only after serious inner fights I obeyed the orders.

I had to consider that one physician who, after all, also is only a human be-

ing, could make mistakes in diagnosis or prognosis. I realized that I offended

seriouslythe divine and moral law by participatingin the killings.I would only

moderatemy guilt by trusting strictly that the physiciandidn’t make a mistake.

April 1999, Vol. 21, No. 2

255

But as I couldn’t completely exclude a mistake, I prayed to my God to forgive

me in such a case.In addition,I have to supposethat the ill peopleselectedto be

killed by the physicians were such seriously ill people that even in case of a

mistake, I had to see it as a release for them.
I estimate it important to say that the attitude of people to life and death de-
pends on the situation. I spent my whole life in nursing and experienced more
than usual the living and dying of people. I’ll not express by this that by experi-
encing it I became harder, but only that my attitude and position to these human
problems was a different one. I was aware of the fact that a person was killed,
but I didn’t see it as a murder, but as a release. (Ebbinghaus, 1987, p. 236)
Anna G. [accused of participatingin the killing of 150 patients]: It is true that I

was brought up as a Christianand that for my whole life I was convincedof the

Christian faith. On the other hand, during my work, especially on the ward for

the insane, I have seen such horrible misery and have seen all of the different

sicknesses until the terminal stage. In view of these experiences, I have seen it

as an act of mercy and a release when the killings were done. . . . I herewith

declare that I have never been forced by anybody to participate. . . . I would

never have committed a bank robbery or other theft because that is just not

done. In addition, theft wouldn’t have belonged to my tasks. I would never

have committeda theft becauseI know one isn’t allowedto do it. (Ebbinghaus,

1987, p. 236)

Martha W. [accused of participatingin the killing of 150 patients]: I’ve always

disapprovedof euthanasia.In the course of my work as a nurse, I could see that

a lot of patients were sent to the mental institution who before had been very

estimable people. It was a big injustice for me to kill those people because of

their illness.WhenI’m reproachedfor the fact that I was broughtup as a Catho-

lic and the commandmentsalso represent my convictions,this is correct. Until

today, it is my convictionthat peopleare not allowedto interfere.Nevertheless,

I participatedin the killings, and I recognize that I acted against the command-

ments and my conviction and have burdened my conscience seriously. The

only explanationI can give is that I didn’t have enough time to think about it at

that time because the nurses were put under a lot of stress. (Ebbinghaus,1987,

p. 240)

Erna D.: Please believe me, that I didn’t do it readily because I really detested

it. I repeat,I didn’t do it readily. In fact, I can’t say why I didn’t refuse.(Ebbing-

haus, 1987, p. 243)

Margarete T. [accused of killing 150 patients]: I was brought up as a Christian

and still today I’m a very religious person and, as far as possible, I attend the

service regularly. For this reason, when the killings began at Ward U1, I felt

deeply guilty and still do today. Due to the many years of working as a nurse,

practicallyfrom since I was young, I was educated to strict obedience,and dis-

ciplineand obediencewerethe supremerulesamongthe nurses.We all, includ-

ing me, took the orders of the physicians, head nurses, and ward nurses as

orders to be strictly obeyed to and didn’t or couldn’t form our own opinion

about the legality of these orders. I was a civil servant at that time and, on one

256

Western Journal of Nursing Research

hand, I was sworn to secrecy and, on the other hand, I was obliged to obey

given orders. I think at that time, I’ve always lived in conflict with my own

opinionand the fact that I was a civil servant.On the one hand, I saw the killing

of people, even though it was incurable mentally handicapped people who

exclusively were accommodated on Ward U1, as a big injustice and often

asked myself why it was done. On the other hand, I was a civil servant and

obliged to do my work and didn’t see a possibilityof getting around the orders.

You ask me if I had also committed a theft on order, I say that I wouldn’t have

done it. I saw, however, the act of giving medicine, even in order to kill men-

tally handicapped persons, as an obligation I wasn’t allowed to refuse. In case

of refusal, I always imagined my dismissal from the job of nurse and civil ser-

vant, which is why I didn’t refuse. (Ebbinghaus, 1987, p. 244)

Meta P. [when asked why she became implicated in the killing of patients]:

Among the nurses, there was strict discipline and every subordinate nurse was

obliged to strictly execute the orders of the superior. (Ebbinghaus, 1987,

p. 244)

Berta H. [accused of participatingin the killing of 35 patients]: In other words,

at that time I thought, I wouldn’t be guilty if I didn’t do the actual killings. To

my own conscience,I always felt a little bit guilty, and I tried to cope with it as

far as possible to forget everything. (Ebbinghaus, 1987, p. 244)

Martha Elisabeth G. [accused of killing 28 patients]: Certainly, I felt guilty

about it at that time and, although I didn’t do any killings by myself, I did help

and I had a certainfellingof guilt.I’m onlyan ordinarynurse. . . and neverreal-

ized that, legally speaking,I had becomeimplicatedin the killings.When I had

to assistin the killings,I actedunderduressand neverwiththe intentionto kill a

person. At that time, nobody would have helped us at Obrawalde if we had

refused to do the work, and there wasn’t anybody to pour out one’s heart to and

who we could trust. As a sort of slaves, we were completelyat the mercy of the

rulers and their political line. (Ebbinghaus, 1987, p. 245)

Edith B.: Although I knew, respectively assumed from hearsay, that at Ward

U2 . . . killings were done and the patients I moved to that ward possibly were

condemned women, I didn’t see anything wrong with it. (Ebbinghaus, 1987,

p. 245)

Margarete Maria M. [accused of killing three patients]: If I had refused to exe-

cute her [another nurse’s] orders, I would have been dismissed. I could have

quit the job, but at that time I was obliged to support my grandparents in

Meseritz. (Ebbinghaus, 1987, p. 245)

Gertrude F. [accused of killing five patients]: When I did it by preparing the

medicine, I did it without any knowledge of legal consequences.The prepara-

tion of medicine in order to give it to the patient actually was one of my duties

which was one of the reasons why I didn’t realize that I did somethingwrong. I

wasn’t able to see a direct connection between my work and the killings. In

addition, you have to consider that I had worked in a mental institution for

April 1999, Vol. 21, No. 2

257

yearsand thatthe nurseswereobligedto strictlyobeytheirsuperiors,the senior

nurses, the physicians and, last but not least, the director of the institution. In

addition,I was the youngestnurse at our ward. Still today, I haven’t completely

become aware of my wrongdoing. (Ebbinghaus, 1987, p. 245)

Erna Elfriede E. [accused of participating in the killing of 200 patients]: They

didn’t make me swear on a secret matter of the Reich, and I wasn’t sworn to

silence. . . . I considered the killings as injustice. Something like that was not

supposed to happen, because nobody was allowed to order it. I was brought up

quite as a Christian.I already learned as a child what one may and mustn’t do. I

learned that one mustn’t steal and mustn’t kill. [When asked why she didn’t

refuse to participate in the killings] Because I was ordered to do it. When I am

asked again, why I didn’t refuse, although I realized that it was an injustice, I

can’t give an answer to this question.I do and did in the past have a strong feel-

ing of guilt, but it is impossible for me to give a reason for the fact that I didn’t

refuse. It simply was ordered, and I had to execute the orders. (Ebbinghaus,

1987, p. 246)

Analytic Framework for Understanding the Nurses’ Participation

Ideological Commitment

It is essential to understand the societal values of the Nazi era. The con-

cept of the life not worthy of life was a widely held value. The severe men-

tally and physically ill were considered to be living less than a human exis-

tence. This devaluation of the handicapped had its origins in the eugenics

movement that was widely embraced in Europe as well as the United States.

The Third Reich’s quest for the development of a superior race called for the

elimination of those judged to be inferior, whether because of handicap,

race, or ethnicity. Humans with physical or mental imperfections were to be

prevented from reproducing through involuntary sterilization, and others

were to be eliminated. The term useless eaters was often applied to the

severely handicapped and others regarded as nonproductive (Friedlander,

1995, p. 61). Added to this were the economic needs of the time. Valuable

resources were to go to the war effort and to those who could work and be

productive. Perhaps these nurses saw their actions as being congruent with

these values. This is similar to the view of the ethicist Dr. Arthur Caplan who

stated that, in his belief, physicians did not set aside their ethics during the

Holocaust, but rather, they saw their actions as congruent with their ethical

commitment to heal the people (Healing the Volk) through the elimination

of undesirable elements (Michalczyk, 1992). Furthermore, many people

believed that euthanasia was not illegal, although a law permitting euthana-

sia had, in fact, never been passed in Germany (Proctor, 1988, p. 183).

258

Western Journal of Nursing Research

The belief that they were doing nothing wrong or even doing something

of benefit was apparent in the statements of several of the nurses who

seemed surprised that there were legal consequences to their actions. Two

(Edith B. and Gertrude F.) stated that they did not see anything wrong with

it, and three others saw the killings as “releasing people from their suffer-

ing.” Only 7 of these 14 nurses of Obrawalde indicated feelings of some de-

gree of guilt over their participation in the killings.

Obedience

A second aspect to consider is that of obedience. Obedience was greatly

valued in Germany, and nurses were to be obedient to their senior ranking

nurses as well as to physicians.In the hospitals,nurses collaboratedwith phy-

sicians in the killings.

This collaboration was usually voluntary. The physicians were given the

choice of accepting or declining, and they in turn gave that choice to their

nurses. In the hierarchical German hospital system, as in that of most other

counties, nurses were trained to obey physicians and often had a dependent

relationship with the physicians they assisted. Although this was hardly an

excuse for following orders to kill, as the refusal of some to do so proves, it

does help explain the motives of some nurses. (Friedlander, 1995, p. 231)

Perceptions of powerlessness were evident in the statements of several of

the nurseswho “didn’t see a way aroundthe orders,didn’t have anyoneto talk

to, had no one trust if they told” and “[were] the youngest nurses on the

ward.” Others, however, did not remain powerless. They relocated, changed

jobs, asked for transfers,and/orbecamepregnant(Friedlander, 1995, p. 236).

Role of Religion

Religion had an effect on the nurses’ participation in three ways: as an

effect on the individual, as an element of nursing education, and by its

effects on society. Individual religious commitment and its congruence or

conflict with participation in the euthanasia program has been established in

the testimony of several nurses at their trials. Some of the nurses did see

themselves as religious persons and some, although not all, did admit to hav-

ing guilty consciences over their killings. During this era, nursing education

was based on religion (Steppe, 1989). There were Catholic and Deaconess

nursing programs—both of which incorporated religion into their nursing

curricula. It was religion—in the person of Bishop Galen—that is thought to

have contributed to a cessation of the organized euthanasia programs (but

April 1999, Vol. 21, No. 2

259

not an end to euthanasia). Knowledge of the euthanasia programs had

become widespread among the population, and in August 1941, Bishop

Galen delivered a sermon in which he described the killing of patients,

including their registration and transfer. Copies of the sermon were dropped

by the RAF over Germany. Shortly thereafter, Hitler ordered a stop to the

gassing of patients. This order did not apply to the children’s euthanasia

program.

Role of Nursing Education and the Nursing Professional Organizations

The role that nursing education played in the nurses’ participation in

euthanasia overlaps both gender and religion. Nursing education was differ-

ent for males and females. Most female nurses were educated in religion-

based programs. The professional nursing organizations that were estab-

lished during the Nazi era were separate for male and female nurses. The

female nurses organizations included the (a) Protestant Nursing Orders,

(b) Catholic Sisterhoods, (c) Red Cross Sisterhoods, (d) Federation of Pro-

fessional Nurses, and (e) the Sisterhood of the National Socialists. In 1939,

only 9% of the nurses were members of the Nazi sisterhood. Therefore, it

was not only the nurses who were members of the Nazi organization that

were involved in the euthanasia programs.

Putative Duress

Fear of the consequences of refusing to participate in the killings—would

be reported to the Gestapo if refused and afraid of losing job—was not fre-

quently cited by these nurses, but it has been given by other nurses as the rea-

son for not refusing to help with the killings (Friedlander, 1995, p. 236). Cer-

tainly, the Gestapo were greatly feared during this era. In at least one

institution, the nurses were made to sign pledges of silence under threat of

death if they discussed the euthanasia program at their institution (Richarz,

1987). For the male nurses, there was always the threat of being sent to the

Eastern front.

Economic Factors

Economic factors were an influence for some nurses. Nurses working on

the euthanasia units received additional pay and/or bonus payments. For

example, the nurses in the children’s euthanasia wards at Eglfing-Haar

received about $80 extra per month (Burleigh, 1994, pp. 104-105). Other

nurses later testified that they continued to work in the euthanasia programs

260

Western Journal of Nursing Research

because they were afraid of losing their jobs (Ebbinghaus, 1987). As civil

servants, the nurses had benefits not available with all other jobs.

CONCLUSION

Following the end of World War II, some nurses were tried with the phy-

sicians they had assisted (United States National Archives and Records,

Record Group 338, Case File 12-449, US v. Alfons Klein; Testimony of

Pauline Kneissler, Document No. 470, U.S. Military Tribunal Case Number

1, Tribunal 1, U.S. v. Karl Brandt et al.). When the Russians invaded and

found the conditions at Obrawalde, they made the senior nurse, Ratajczak,

reenact the killings. She, along with an orderly, was shot a few days later

(Ebbinghaus, 1987, p. 218). The other nurses of Obrawalde were later tried

for the killings. On March 12, 1965, “all fourteen women accused in the

Munchner Schwesternprozess (Nurses’ trial at Munich) were acquitted on

the charge of complicity in murder” (Ebbinghaus, 1987, p. 246).

It may never be possible to fully understand the participation of nurses in

crimes that would seem to be unthinkable today, yet their participation must

continue to be studied so that nursing never again finds itself in the role of

killer. Proponents of the slippery slope argument hold that the involvement

of health care professionals in euthanasia could begin the downward decline

from voluntary euthanasia to involuntary euthanasia. Singer and Siegler

(1990) state concern that, even in the presence of safeguards about euthana-

sia, patients could be euthanized without their consent or against their

wishes (p. 1883). Misbin (1991) stated that “it is not unreasonable to be con-

cerned that allowing physicians to kill patients might lead to desensitization

to the value of human life. Especially in a society such as ours, in which so

many people lack basic medical care, there is fear that euthanasia could be

used as an economic expedient” (p. 1309). Beauchamp and Childress (1989)

maintain that it is necessary to have rules against mercy killing in order to

maintain attitudes of respect for life.

The history of the nurses’ participation presents today’s nurses with the

obligations of being sensitive to any indications of discrimination toward

any individuals or groups of people and of never letting professional behav-

ior become secondary to individual morality.

April 1999, Vol. 21, No. 2

261

NOTE

1. This project is the result of a fellowship for Research on Medical Ethics and the Holocaust

granted to Susan Benedict by the Research Institute of the United States Holocaust Memorial
Museum, with funds provided by The Merck Company Foundation.

REFERENCES

Amir, A. (1977). Euthanasia in Nazi Germany. Unpublished doctoral dissertation, State Univer-

sity of New York at Albany. (University Microfilms International No. 77-32, 241)

Beauchamp, T., & Childress, J. (1989). Principles of biomedical ethics (3rd ed.). New York:

Oxford University Press.

Burleigh, M. (1994). Death and Deliverance. Cambridge, UK: Cambridge University Press.

Donner, A. (1988). Mathematik im Dienste der nationalpolitischen Erziehung. In R. Proctor,

The destruction of “lives not worth living.” In Racial hygiene: Medicine under the Nazis.

Cambridge, MA: Harvard University Press. (Original work published in 1935)

Ebbinghaus, A. (1987). Opfer und Taterinnen [Victims and female perpetrators]. Nördlingen,

Germany: Delphi Politik.

Friedlander, H. (1995). The Origins of Nazi Genocide. Chapel Hill: University of North Carolina

Press.

Gallagher, H. (1995). By trust betrayed. Arlington, VA: Vandamere Press.

Gross, W. (1988). Drei jahre rassenpolitische Aufklarungsarbeit, Volk und Rasse, 10(1935). In

R. Proctor, The destruction of “lives not worth living.” In Racial hygiene: Medicine under

the Nazis. Cambridge, MA: Harvard University Press. (Original work published in 1935)

Michalczyk, J. (Producer, Director). (1992). In the shadow of the Third Reich: Nazi medicine

[Film]. (Available from First Run Features, 153 Waverly Place, New York, NY 10014)

Michalczyk, J. (1994). Euthanasia in Nazi propaganda films: Selling murder. In J. J. Michalczyk

(Ed.), Medicine, ethics, and the Third Reich: Historical and contemporary issues. Kansas

City: Sheed & Ward.

Misbin, R. (1991). Sounding board: Physicians’ aid in dying. New England Journal of Medicine,

325(18), 1307-1311.

Nadav, D. (1994). Sterilization, euthanasia, and the Holocaust—the brutal chain. In J. J. Michalczyk

(Ed.), Medicine, ethics, and the Third Reich: Historical and contemporary issues. Kansas

City: Sheed & Ward.

Office of US Chief of Council for the Prosecution of Axis Criminality, Document Number 630-

DPS, 17 September 1945.

Office of Chief Counsel for War Crimes, Document Number 3354.

Proctor, R. (1988). The destruction of “lives not worth living.” In G. Annas & M. Grodin (Eds.),

Racial hygiene: Medicine under the Nazis (pp. 17-52). Cambridge, MA: Harvard University

Press.

Proctor, R. (1992). Nazi doctors, racial medicine, and human experimentation. In G. Annas &

M. Grodin, The Nazi doctors and the Nuremberg code. New York: Oxford University Press.

Richarz, B. (1987). Heilen, Pflegen, Toten [Healing, caregiving, killing]. Gottingen: Verlag fur

Med. Psychologie im Verl. Vandenhoeck u. Ruprecht, 188.

262

Western Journal of Nursing Research

Singer, P., & Siegler, M. (1990). Sounding board—Euthanasia—A critique. New England Jour-

nal of Medicine, 322(26), 1881-1883.

Steppe, H. (1989). Krankenpflege im Nationalsocialismus [Nursing in national socialism].

Frankfurt am Main: Mabuse Verlag.

Steppe, H. (1992). Nursing in Nazi Germany. Western Journal of Nursing Research, 14(6), 744-

753.

United States National Archives and Records, Suitland Maryland Records Branch, Record

Group 338, Records of U.S. Army commands, 1942, Case File 12-449, U.S. v. Alfons Klein

et al., 8-15 October 1945.

U.S. Military Tribunal, Official transcript of the Proceedings in Case 1, U.S. v. Karl Brandt et al.

U.S. National Archives and Records, National Archives Building, Washington, DC, Record

Group 338, Microfilm Publication T-1021, German documents among the war crimes

records of the Judge Advocate Division Headquarters, Europe.

U.S. National Archives and Records, National Archives Building, Record Group 238, Microfilm

Publication M-1019, Records of the U.S. Nuremburg war crimes trials, interrogations, 1946-

1949, Roll 46: Friedrich Mennecke.

April 1999, Vol. 21, No. 2

263