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International Journal of Mental Health, vol. 36, no. 1, Spring 2007, pp. 4–16.
© 2007 M.E. Sharpe, Inc. All rights reserved.
ISSN 0020–7411/2007 $9.50 + 0.00.
DOI 10.2753/IMH0020-7411360101

K

ARL

K

ESSLER

Physicians and the Nazi Euthanasia
Program

ABSTRACT: This article is a discussion of the Nazi euthanasia program, with
special reference to the origins of the program in the eugenics movement, the
relation between Nazi racial policy and medicine, and the role and motivation
of physicians who participated in the euthanasia program.

One of the enduring questions regarding the Nazi period is how a barbaric ideol-
ogy came to rule in a country that had the history of cultural and scientific achieve-
ment of Germany. A derivative of this question is what led to the participation of
so many German physicians in carrying out some of the worst barbarities of the
Nazi regime.

“Physicians became Nazified more thoroughly and much sooner than any other

profession, and as Nazis they did more in the service of the nefarious regime than any
of their professional peers” [1, p. 4]. Physician membership in the Nazi Party was
higher than for any other profession. The 45 percent membership in the party for
physicians compares with 25 percent for lawyers, 24 percent for teachers, 22 percent
for musicians, and the average of 9 percent for the general population [2, p. 79].

The Schutzstaffel (SS) also attracted many physicians. Their skills were useful

to the SS, and the SS wanted to attract established professional elites, which in-
cluded physicians. In turn, the SS provided physicians opportunities for power
and advancement. Eventually, 7 percent of all physicians in Germany became
members of the SS. Only lawyers had a higher representation [2, p. 81].

What led to this enthusiastic embrace of Nazi ideology and practice by such an

educated and intelligent group? Part of the explanation is that Nazi ideology was
fundamentally a racial ideology, rather than a political or nationalistic ideology.
Its nationalism was racial. The benefits of the state were available only to the

Karl Kessler, M.D., is Chief of the Child and Adolescent Unit at Hall-Brooke Hospital,

47 Long Lots Road, Westport, CT 06880; e-mail: [e-mail].

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5

racially select, rather than to anyone who spoke the language or embraced German
culture. The answer to “Who is an Aryan?” was not simply one who embraced
Germany, but one whose “racial” background was Aryan. One could not join the
race. This racial ideology was at its core a faith, a belief in us versus them. But, it
was also partly developed from medicine and science, although the science was
often nascent knowledge or pseudoscience. Nonetheless, prevalent theories of ge-
netics and anthropology formed the “scientific” basis of the racial state.

The study of race and racial hygiene was flourishing long before the Nazis came

to power. It had its basis in anthropology, the selective breeding of plants and ani-
mals, genetic theories, and the laws of inheritance. Darwin’s theory of evolution
pointed the way toward a scientifically based science of humankind. One possibil-
ity for the future of humankind was that evolution, through the mechanism of natu-
ral selection, would lead to gradual improvement in the human race. An opposing
theory was that the advances of civilization would result in an “unnatural” over
breeding of inferior types, which would eventually lead to a gradual deterioration
of humankind. The latter theory was based on the idea that whereas nature had
previously tended to eliminate the disabled and infirm, the advances of science and
medicine and the humanitarian impulse of society to care for them would result in
the increased breeding of inferior types, with the resultant decline of the racial
stock. Francis Galton, Darwin’s cousin, believed in helping mankind along the
road of improvement through selective breeding. For this, he coined the term eu-
genics, which he derived from the Greek words meaning “of good birth.” Eugenics
could encourage desirable births (positive eugenics) or discourage undesirable ones
(negative eugenics). When applied to nations and races, eugenics claimed that the
well-being and vitality of a nation depended on the genetic fitness of its members.
Such thinking could also explain the differences between nations and races, be-
cause some of these differences could be explained in biological or genetic terms.

Many eugenicists were social reformers who were interested in a general im-

provement in the living conditions of peoples. If disability, poverty, and illness
could be prevented through birth control and genetics, then humankind in general
would benefit. On the other hand, eugenics categorized individuals according to
their genetic value and eroded the belief that all life was of equal value. It was a
small step to go from asking whether an inferior birth should be prevented to
asking whether an inferior life should be eliminated.

Eugenics was debated and studied throughout the developed world. Journals

and organizations were founded to discuss the problems and promote solutions.
Geneticists, biologists, anthropologists, physicians, and social reformers were ac-
tive in the movement. Biological and anthropological arguments formed the basis
of their ideas. In Germany, the study of eugenics was often called racial hygiene.

The discussion of what it meant to be a German—or a member of other ethnic

or national groups—preceded the science of eugenics. Although the discussants
were often outside the scientific community, they frequently used scientific knowl-
edge and theories to support their arguments. Eugenicists came from a variety of

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political and social viewpoints. Some were not inherently racist, whereas others
argued for a hierarchy of races based on cultural achievement and other factors.
German racial hygiene developed a significant number of proponents of the racial
superiority of the Nordic (northern European or Aryan) race, putting the Aryan
race at the top. German racial hygiene attracted a significant number of racists
who used biological and anthropological arguments to support their ideas of Aryan
racial superiority [3, chap. 1].

As a reaction to Germany’s defeat in World War I and its loss of 2 million men,

the need to champion the superiority of the northern European peoples as an ideal
became more important to some Germans [3, p. 142]. They sought an explanation
for why a superior people such as the Germans could have been defeated. One theory
was that they had been “stabbed in the back” by traitors, including Jews. The “Jew-
ish question” and the question of the deleterious influence of other peoples and races
on the German nation came to occupy a significant part of their work. The Nazis
found in these ideas a biological basis for their racial beliefs and embraced them.

Established genetic science and theories were directly related to the practice of

medicine and were a basis of medical knowledge. Many of the researchers in-
volved were physicians. However, because much of eugenics was theoretical and
not scientific fact, German racial ideology allowed itself to be perverted by “filling
in the gaps” in knowledge with pseudo-scientific theories. Nazi ideologues ap-
peared to be especially interested in finding a genetic basis for illnesses and patho-
logical behaviors, which would fit well with their eugenic theories: the greater the
number of illnesses that had a genetic basis, the easier it would be to use eugenics
to improve the race. Those who would apply genetic and eugenic theories to clini-
cal practice were physicians. Racial hygiene came out of research connected to
medicine and was put into practice by physicians.

Sterilization

After the Nazis came to power, racial hygiene became an integral part of Nazi
social, political, and medical policy. An extant pool of Nazis, other racist ideo-
logues, and fellow travelers existed who could be drawn on to support these poli-
cies. Racial hygiene initially manifested itself in a law for involuntary sterilization.
The Law for the Prevention of Genetically Diseased Offspring was passed in July
1933 and went into effect in 1934. Proposals for similar laws had occurred through-
out the 1920s but were never passed. The passage of this law soon after the Nazis
came to power indicates its importance in Nazi ideology. Sterilization of the dis-
abled had a broad appeal not only because it would improve the fitness of the
general population but also because of the cost savings of not needing to provide
care for future generations of disabled by preventing disabled parents from having
children. The Law for the Prevention of Genetically Diseased Offspring listed spe-
cific conditions indicated for involuntary sterilization: congenital retardation, schizo-
phrenia, manic depression, genetic epilepsy, Huntington’s chorea, genetic blindness

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7

or deafness, and severe alcoholism. The extent of the hereditary component of
some of these conditions remains a matter of debate to the present day. Diagnosing
schizophrenia and manic depression also remains a problem, as does the defini-
tion of what constitutes mental retardation. These clinical diagnoses were made
without laboratory tests to confirm them. The inaccuracy of such diagnoses al-
lowed the law to be applied in a broad manner, as broad as diagnostic error and
using a wide definition of the illness allowed.

The law necessitated the establishment of a large bureaucracy to carry it out.

Doctors were required to receive training in genetic pathology, and all physicians
were required to report disabled (i.e., genetically defective) individuals to appro-
priate central authorities. Genetic health courts and appellate genetic health courts
were established with jurisdiction to rule on all the cases of sterilization. Each
genetic health court was composed of two doctors and a lawyer. One of the doctors
was supposed to be “expert” in genetic pathology. The proceedings of these courts
were secret.

Doctors were required to report every case of genetic illness known to them,

with the threat of a fine for failing to do so. The request for sterilization was made
by the individual (voluntary sterilization had not been legal prior to the passage of
this law), the patient’s legal guardian, or the patient’s physician. Because a large
number of people with the selected conditions were residents of asylums, asylum
patients constituted a large percentage of those given involuntary sterilization. These
requests for sterilization were made by asylum directors. “Those who refused to
submit to sterilization were generally sent to concentration camps” [3, p. 107]. An
estimated 400,000 sterilizations were carried out between 1934 and 1939. In 1939,
the need for sterilization became less necessary because murder of the disabled
was initiated.

The Law for the Prevention of Genetically Diseased Offspring was passed and

promulgated in the usual manner of laws at the time. It was publicly printed along
with a commentary clarifying its meaning and how it was to be enacted. This law
and how it was to be enforced were public knowledge. Although Germany became
a one-party state soon after Hitler was appointed chancellor in 1933, an adherence
to the appearance of the rule of law remained. Hitler and the Nazi Party were also
concerned about public sentiment and would not pass a law that could cause wide-
spread resentment and resistance. They wanted the majority of the populace on
their side. As they had done with their condemnation and marginalization of the
Jews, the Nazi government led a campaign to marginalize the disabled as a means
of preparing the general population for their eventual elimination. The background
to euthanasia had already been laid prior to the Nazi rise to power through public
discussion and various writings about ending lives of those who were so disabled
that they were “unworthy of life.” The Nazis undertook a propaganda campaign
against the disabled that included films, books articles, and tours of the institutions
that housed the disabled [4, chap. 6; 5, pp. 46–47].

The Nazis often sought to legitimize their social policies as much as possible by

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INTERNATIONAL JOURNAL OF MENTAL HEALTH

stating them in medical terms, and they were sometimes carried out by medical
people. For example, the Nuremberg racial laws of 1935 were promulgated as
public health laws [3, pp. 131ff]. One of these laws was the 1935 Law for the
Protection of the Genetic Health of the German People.

The law forbade marriage between individuals suffering from venereal disease,
feeble-mindedness, epilepsy, or any of the other “genetic infirmities.” . . . Those
considered genetically ill (Erbkranken) were permitted to marry other geneti-
cally ill, but only after being sterilized to ensure that they would not leave any
offspring. [3, p. 132]

The implementation of this law involved physicians, through the use of medi-

cal examinations as prerequisites to marriage. The genetic health courts were given
jurisdiction to settle disputes regarding this law.

During the 1930s, the Jews and other racial groups were quickly marginalized by

the Nazis and eventually deprived of citizenship. Racial laws were written with the
goal of excluding non-Aryan “inferior peoples” from citizenship and from the gene
pool to “purify” the Volk. However, other laws, such as the Law for the Prevention of
Genetically Diseased Offspring, were directed at Aryans. These latter laws were
written both to improve the genetic characteristics of the Aryan population and to
save money that would otherwise be spent to maintain nonproductive individuals.
Some considered such seriously disabled individuals not worthy of life, whereas
others saw them as living a life of suffering, which could be humanely ended. These
laws were always written to benefit the Volk at the expense of the individual.

The Nazi ideology intended to create a sort of racial utopia for those of the

Aryan race. If one was lucky enough to be Aryan, a good life was promised. This
good life required that the race be improved by preventing the emergence of de-
fective members, which included a genetic evaluation prior to marriage and sup-
porting healthy prenatal and postnatal practices. The Nazis progressed to killing
disabled infants and, soon thereafter, to killing the disabled of whatever age, a
process the Nazis called euthanasia.

Euthanasia

Out of concern for public objection, the Nazis never promulgated a euthanasia
law. The Nazis chose to begin killing the disabled only after World War II had
begun. It is always easier to undertake such extreme measures during wartime.
Government secrecy and power increase during wartime. The exigencies of war
can overcome the objections of many who would not support such extreme mea-
sures in peacetime. Governments and individuals often carry out actions that they
would not or could not carry out in peacetime. The way the euthanasia program
was enacted was fundamentally different from the way in which the sterilization
law was enacted: It functioned secretly and its workings were kept secret, under
threat of punishment. Also, it was enacted as Hitler’s personal edict. The secrecy
was necessary because it was a murder campaign against German citizens.

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9

As Hitler’s power grew, the Nazis felt less need to formalize their wishes into

laws. Edicts could be promulgated on Hitler’s personal command. This increase in
power became especially apparent once war was declared in September 1939.
Planning for the euthanasia program began under Hitler’s initiative in 1938. Con-
siderable preparation for the program had taken place by the time it was officially,
although secretly, authorized in October 1939 by Hitler himself. It was not legal
under the conventional laws of Germany as they were written at that time, but it
was legal in the sense that anything that was personally ordered by Hitler had the
force of law.

Several arguments were used support the action. One was the need to marshal

all resources for the war effort. Supporting chronically disabled individuals was a
drain on resources that could be used for the war. A corollary of this argument was
the comparison of the injured soldier who needed medical care and rehabilitation
with the congenitally and chronically disabled patient who had never sacrificed for
his country. It is unclear whether the Nazis would have undertaken such a systemic
and massive effort to kill the disabled if the war had not begun, but the question is
beside the point, because starting war was always one of Hitler’s primary goals.
Starting war was itself related to racial hygiene, because war was the ultimate test
of a nation’s “fitness.” Even if there were no war, the action of killing the disabled
is consistent with the Nazi ideology of improving the race and improving the lives
of those deemed worthy while being ruthless to those deemed unworthy.

The justification for euthanasia was consistent with the Nazi ideology that the

needs of the Volk were more important than those of individuals and the Nazi
utilitarian philosophy that rejected conventional morality for the sake of a revolu-
tionary ideology that promised a new and better world. The Nazi hierarchy wanted
the populace to agree with and support state policies and Nazi ideology, rather
than simply forcing their policies on an unwilling populace. To this end, they con-
trolled the media and sources of information available to the general public and
also controlled the education system. By indoctrinating children with their ideol-
ogy, by means of massive and expert propaganda campaigns and by viciously
suppressing any opposing views, the Nazis were able to obtain a certain amount of
public support for their actions. Another reason for the support of the populace
was that Hitler’s economic and foreign policies were initially successful in im-
proving the everyday lives of the Aryan citizen as well as achieving power and
glory for Germany. Hitler became very popular and trusted by the populace.

However, in the matter of euthanasia, Nazi ideology came into conflict with

conventional morality. In this case, they were killing German citizens. These vic-
tims were not the subhuman Jews but fellow Aryans. Even the prolonged propa-
ganda campaign of the 1930s against the disabled, depicting them as subhuman,
was inadequate to obtain the approval of most of the general population for outright
killing of fellow Germans. The government came to believe that many people would
not support the involuntary killing of their fellow Germans. For this reason, this
large program was carried out in secret, with the usual severe punishments, includ-

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INTERNATIONAL JOURNAL OF MENTAL HEALTH

ing the death penalty, applicable to those who did not maintain the secrecy required.

It is important to note that in all vital matters of policy, the ideology of the Third

Reich was Hitler’s ideology. If Hitler wanted a policy enacted, it was generally
enacted and if he was strongly against a policy, it would not be enacted. In the case
of euthanasia, Hitler wanted the program and endorsed it. Both the child and adult
euthanasia programs were administered through Hitler’s personal chancellery in
Berlin. Hitler’s chancellery, which was not a government agency, is another ex-
ample of the remarkable multilayered and overlapping system of administration
that occurred under the Nazis. This system diffused responsibility, made secrecy
easier to maintain and allowed Hitler to play one faction against another. The
main reason for having Hitler’s chancellery administer the program was the need
for secrecy [6, p. 40]. The medical branch of the Reich Ministry of Internal Af-
fairs assisted with the program to the extent necessary and in such a way that it
was not directly involved in the killing and did not compromise the secrecy of the
program.

Hitler endorsed the conception of the program as a medical policy for several

reasons. Most important, the people to be eliminated were in the care of physi-
cians, and he needed the cooperation of those physicians to carry out his plans.
Another reason was that the ideology of euthanasia was based on pseudo-scientific
eugenics, which is a derivative of biology and medicine. The result was that the
euthanasia program included physicians in its top administration and was carried
out by physicians.

The euthanasia program began with the killing of disabled children in 1940 [6,

chap. 3]. Although the goals of the program were kept secret, physicians through-
out the country were enlisted in the program unknowingly, fulfilling the request to
complete a questionnaire for each child they were treating if the child had any
significant handicaps. Most of the children killed under this program came from
the community, not institutions. The doctors referring them were pediatricians and
general practitioners, not asylum directors. The information about each child was
forwarded to a central agency, the Reich Committee for the Scientific Registration
of Severe Hereditary Ailments. This committee was simply a front for a small
group of physicians who decided which children should be killed. The form was
reviewed by three physicians who decided each child’s fate. If the answer was
affirmative, the child was ordered to be hospitalized at one of the medical centers
that had been chosen as killing centers. Some of the most active physicians in this
program were pediatricians, but because killing did not involve any great medical
skill and because the killing was sometimes done at institutions that housed both
adults and children and both physically and mentally disabled, psychiatrists and
physicians with other backgrounds were also involved. Even in a dictatorship such
as Nazi Germany, it is difficult to understand how the administrators of this pro-
gram could have thought that it would remain secret. Each step—from asking the
local physicians to complete the questionnaire to arranging for transport and pay-
ment to the medical center where “care” was given (because murder itself was a

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medical procedure that required reimbursement for those that carried it out)—
needed to be covered by a veil of lies and secrecy.

The leadership of the euthanasia program included government bureaucrats and

physicians. For example, the program was overseen by the director of the Chancel-
lery of the Führer, Phillip Bouhler, who was a World War I veteran and a career
Nazi bureaucrat, and by Karl Brandt, Hitler’s attending physician. Brandt had trained
as a surgeon. His initial role was as a physician to Hitler and his retinue, but over
time Brandt spent less and less time acting as a physician and more as health ad-
ministrator, eventually becoming Reich plenipotentiary for medicine and health.
They worked together with Herbert Linden, who was a physician and administra-
tor in charge of overseeing state hospitals and nursing homes for the Ministry of
the Interior. Linden spent most of his career as a civil servant, both before and after
the Nazi seizure of power. These were the policymakers of the euthanasia program.
The implementation and management of the program was left to deputies. In
Bouhler’s case, the deputy was Victor Brack. Brack had received a diploma in
agriculture but soon after went into the service of the Nazi Party. Early in his party
career, he was Himmler’s driver. He rose in the Nazi bureaucracy to become one of
Bouhler’s deputies. Brack, in turn, delegated considerable authority to his depu-
ties, Hans Hefelmann, who had a doctorate in agriculture, and Richard von Hegener,
who had worked for a bank and as a statistician [6, pp. 39–42].

This group then proceeded to recruit physicians. Physicians were recruited

mainly for their willingness to participate and for their ideological purity. The
physicians involved in the planning stages of the program included Werner Catel,
director of the Leipzig University Children’s Clinic; Hans Heinze, a psychiatrist
and neurologist who headed the state hospital at Brandenburg-Görden; Hellmuth
Unger, an ophthalmologist who had written a novel advocating euthanasia; and
Ernst Wentzler, a Berlin pediatrician. Although established physicians, they were
all in their forties. Their relative youth meant that a larger proportion of their life
had been spent under exposure to Nazi propaganda.

As the killing program for children was being set up, a similar but larger pro-

gram aimed specifically at adults was prepared. This program was more involved
because most of the victims were housed at institutions for the chronically dis-
abled throughout Germany. The victims needed to be selected and then moved to
special institutions that served as killing centers. These special killing centers were
used in both the child and adult programs to maintain the secrecy of the program.
The killing of children was done by injection of medications and starvation. Adults
were similarly killed, with the addition of the use of poison gas. Gas chambers
were set up in the killing hospitals because they were the most efficient means to
kill large numbers of patients. Crematoriums were used to dispose of the bodies.

Eventually a large, secret bureaucracy was set up to administer and carry out

the killing of disabled patients. It had an administrative headquarters in Berlin, a
budget, and various subsidiary agencies. The organization was given the name of
T4, after the address at Tiergartenstrasse 4 in Berlin, where it was headquartered.

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Among its expenses, it had to pay for the medications used to kill the patients and
the building of gas chambers and any other facilities required. It formed a trans-
port company with buses and staff to bring the patients to the killing centers. It
paid secretaries to send out phony death notices to the families of the deceased.
They also needed to pay the physicians for their work in reviewing the question-
naires that were sent in to T4 by pediatricians and family doctors (for child eutha-
nasia) and by hospitals and nursing homes (for adult euthanasia) to select the patients
to be killed.

It is estimated that from the beginning of the adult killing operation in January

1940 to August 1941, when Hitler ended the program due to public opposition,
over 70,000 adults individuals were killed. Although the official T4 program ended,
the killing of disabled children and adults continued on the initiative of individual
physicians in the hospitals and asylums.

The use of gas to kill the disabled was the forerunner of its use in the concentra-

tion camps. Before mass killing in the concentration camps had begun, selected
prisoners were brought from the camps to the killing hospitals to be murdered
under the program “Special Treatment 14f13” [6, p. 142].

This bureaucracy operated as a new system parallel to the established system of

institutional care for the disabled in Germany, except that the new system was not
concerned with caring for the disabled but rather with killing them.

Throughout the “euthanasia” project, the pattern was for senior doctors to make
policy and render decisions, to serve as high consultants and experts, while younger
doctors did the actual killing. . . . Killing doctors came to be chosen apparently
for their combination of inexperience and political enthusiasm. [7, pp. 72–73]

Physicians

How important were physicians in running a program that consisted of murdering
patients? Was medical training necessary to kill? As Friedlander stated “One did
not need a medical degree to open a gas valve” [6, p. 219]. Friedlander continued:

There were of course, reasons for the presence of physicians. They were needed
to check the medical records that arrived with the victims so that serious errors in
selection could be avoided. They were also needed to determine what fraudulent
diagnosis would be the most credible on the death certificates. . . . Finally, they
were needed to give the killing center the appearance of a regular hospital to the
outside world. [6, p. 219]

To kill the patients, one had to get at them. Physicians ran the hospitals and

asylums where the patients lived. Physicians needed to be enrolled and co-opted to
kill those in their care. Hitler’s order that physicians would be in charge of the
killing made the murders appear to be medical procedures and, therefore, easier to
justify, tolerate, and carry out than if they were simply called executions. Also,
once the physicians were given that power, they did not want to give it up to
nonphysicians.

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The physicians maintained power by insisting that the program be run as a

medical program that was concerned with improving the health of the populace.
Whereas sterilization was a medical procedure that was commonly done on a vol-
untary basis, euthanasia had never been officially sanctioned and was more diffi-
cult to justify as a medical procedure. That the whole massive euthanasia program
needed to be kept secret made it clear to those involved that they were participat-
ing in something extraordinary and extralegal.

Why did physicians participate? Medical practitioners in Germany had been

exposed to the ideas of sterilization of defective and degenerative individuals and
to euthanasia of such individuals by the discussion and debate about these issues
that occurred throughout the 1920s. In the 1920s, important institutes for the study
of racial hygiene had been established at German universities, courses on the sub-
ject were taught at many German universities, and several medical journals de-
voted to eugenics or racial hygiene were being published. By 1936, under the
Nazis, professorships in racial hygiene had been established at 10 universities and
racial science was taught in the medical faculties of all other German universities
[3, p. 79]. After the Nazis came to power, debate concerning the validity of racial
science ceased, replaced by a one-sided propaganda campaign presenting the Nazi
point of view. The Nazis were masters of propaganda, using modern means such
as radio, television, and film to win the population to their side. Therefore, one
reason for the large participation of physicians in the Nazi party was that its racial
ideology had made significant inroads into the medical profession of Germany.

What were the other reasons for the large participation of physicians in the

Nazi party? One was the intimidation and enthusiasm caused by Gleischaltung,
the Nazi coordination of all aspects of German life to carrying out Nazi ideology.
The Nazi policies toward physicians were similar to the way they treated most
professional and nonprofessional associations. The physicians were required to
practice in accordance with Nazi doctrine. This requirement resulted in the
Nazification of existing medical organizations, the creation of Nazified physicians’
organizations styled along Nazi principles, and the suppression of rival medical
organizations that did not accept Nazi ideology. Through a gradual process, the
Nazis attempted to centralize and control all aspects of the medical profession [1,
pp. 19–25]. This centralization of power enabled the Nazis to control not only who
could become a practicing physician but also the practice of medicine itself along
the lines of Nazi principles.

Although Germany had a tradition of deference to authority, it also had a tradi-

tion of rebellion. The Nazis came to power as a revolutionary party and a party of
the modern age, not as party that wanted to reinstate the past. Nazism sought to
overturn tradition and forge a new movement of Germans. When it was out of
power, it was a party of revolution, but once in power, it would tolerate absolutely
no rebellion against itself.

Physicians who had been party members before the rise to power were often

rewarded for their loyalty. Those that joined the party after the rise to power and

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those who were enthusiastic supporters of Nazi ideology, even if they were not
party members, found advancement. Advancement was often based on merit and
ability, but enthusiasm for the party and the state could lead to positions of power
and responsibility even if the physician was mediocre. Those who were compliant
but not enthusiastic were generally left to continue as they were doing. Those who
objected or rebelled were not allowed to practice or were arrested. Of course, Jews
and political undesirables were marginalized or excluded soon after the Nazis came
to power.

Nazification included orienting thinking toward the idea that the welfare of

society took precedent over the welfare of the individual and that the goal of medi-
cine should be toward attaining the healthiest society, even if this meant individual
sacrifice. In Nazi theory, the state, or the Volk, took precedence over the individual.
This understanding led to the idea that the emphasis of care should be to rehabili-
tate those who were capable of rehabilitation and to minimize or deny care to
those who were chronically ill. The primary measure of the degree of illness was
the work productivity of the individual.

Another reason for physician participation in the Nazi programs is one that

applies to all groups and individuals, which is, simply, that the dominant ideology
of a state tends to become shared by large numbers of members of that state. Whether
the ideology is imposed from above or grows from below, once it is dominant, a
large percentage of the population will follow it. Thus, a good number of physi-
cians were simply following the dominant ideology of their period. That the ideol-
ogy was so very successful in providing wealth (i.e., the improvement in the German
economy) and initial political success (i.e., the increase in German power and the
physical expansion of the country) was extremely helpful for its success among
the populace. The ideology also fulfilled a spiritual need among the populace. It
gave them something to believe in following the failures of Germany in World War
I and the political and economic crises of the Weimar Republic and the Great
Depression. Hitler considered Nazism a secular movement that fulfilled a spiritual
need. By fulfilling this longing to be led and to belong to a successful group,
Nazism was an ideology that that had a religious component and that could usurp
the function of the current religions. Reification of this idea can be seen in the
fanaticism of some of the Nazi followers and ideologues, similar to other religious
or political fanatics.

On a cruder and more practical level, a physician who embraced Nazi ideology

could expect professional and financial advancement.

For the killing jobs, T4 needed physicians who were young, aggressive, and am-
bitious. . . . The young physicians participated in part because their teachers
advocated the killings and helped formulate policy. But these younger men, and
not their older colleagues, had to carry out those policies, becoming the true
technicians of mass murder. . . . Older men with established careers did not want
to take such [killing] jobs. T4 therefore recruited younger men who still needed
to establish themselves. Such men had to be ambitious for advancement in the

SPRING 2007

15

new Germany and thus willing to take on a job that they considered more impor-
tant that fighting on the front. [6, pp. 216, 221, 231]

Professional advancement came in the form of a good paying job, an appoint-

ment as director of an institution (i.e., a killing center) and the possibility of en-
gaging in research at the killing centers. However, the “promises that the medical
staff of the killing centers would hold seminars, engage in research, and employ
pathologists did not materialize” [6, p. 222].

Although for some physicians the route to participating in the euthanasia pro-

gram was simply to go along with a prevailing philosophy, it appears that all par-
ticipants needed some belief in the morality of what they were doing. How did
these physicians deal with their roles as killers?

The dedicated Nazi physician would go along with whatever the party direc-

tives were. Because the ideology of the movement dictated that the Volk needed
improvement and that the chronically disabled were a drain on the productive
members of society, it seemed reasonable that those disabled should be elimi-
nated. These doctors were Nazis first and physicians second and could be ex-
pected to be enthusiastic supporters of whatever tasks with which they were
entrusted. The sadistic physician could easily give expression to cruel impulses in
the Nazi regime. The idealistic physician had a harder task. The Nazi ideology had
a strong idealistic component, albeit only meant for Aryans, that often required
terrible sacrifices, including the sacrifice of the moral principals of physicians for
the greater moral good of the Volk.

Some physicians dealt with their conflicts by mentally transferring responsibil-

ity for the killings to others [5, p. 106]. They could tell themselves that they were
not responsible for their actions but were simply carrying out orders from a higher
authority. This authority was one that they respected and trusted to do right. The
Nazi regime was built on the Führer principle, which demanded allegiance to the
authority of the Führer and the belief that the interests of the state or Volk were
more important than those of the individual.

Other physicians could justify their actions in the name of advancing science

[5, p. 106]. They could tell themselves that the anatomical specimens obtained
from the killing centers would be used to further medical knowledge and, eventu-
ally, to save lives and improve the well being of the Volk. The famous neuroanato-
mist Julius Hallervorden had no scruples about using the brains of murdered patients
to further his research: “There was wonderful material among those brains, beau-
tiful mental defectives, malformations and early infantile diseases” [7, pp. 66–67].
The physicians who carried out the killing programs were often psychiatrists.

Psychiatrists came to play an important role in euthanasia because they were

charged with the care of the chronically mentally ill and mentally retarded, who
comprised the largest percentage of the chronically ill. Besides the mentally re-
tarded, these included individuals with schizophrenia, chronic manic depression,
and neurological conditions with significant psychiatric symptoms, such as ter-

16

INTERNATIONAL JOURNAL OF MENTAL HEALTH

tiary syphilis and epilepsy. The profession of psychiatry evolved out of the hu-
manist impulse to care for such individuals. This impulse led to the asylum move-
ment, where large groups of the chronically ill were given food, shelter, and such
treatment as was available. These asylums were often in rural settings to remove
the patients from what were perceived as the deleterious effects of the stress brought
on by urban life. Patients that did not improve under treatment were given life-
long care by the institutions. Many of these institutions were run by Christian
charitable organizations with a commitment to aid those in need. Others were run
by the government. Because much funding for such care was ultimately provided
through the government, the government had a considerable stake and a large say
in determining how these institutions were run. Psychiatrists in favor of euthanasia
were often in the forefront of promoting the limitations of charity to the chroni-
cally ill. They believed that the resources should be spent on “more deserving”
patients who had a chance of recovery and return to productive lives. The contra-
diction is between their training as a physician to heal and nurture life and the idea
that certain lives were unworthy of being lived. Friedlander stated, “Physicians as
a group are no more dedicated than other professionals and do not resist crime any
better than do chemists, lawyers or historians” [6, p. 217]. Perhaps not, but they
are trained to save lives, not take them. The difference may be compared to that
between a veterinarian and a butcher. Both are exposed to death, but their missions
are completely opposite. That so many physicians took the role of the butcher is
disheartening.

References

1. Kater, M.H. (1989) Doctors under Hitler. Chapel Hill: University of North Carolina

Press.

2. Kater, M.H. (2002) Criminal physicians in the Third Reich: Toward a group portrait.

In F.R. Nicosia & J. Huener (Eds.), Medicine and medical ethics in Nazi Germany:
Origins, practices, legacies (pp. 77–92). New York: Berghahn Books.

3. Proctor, R.H. (1988) Racial hygiene: Medicine under the Nazis. Cambridge: Harvard

University Press.

4. Burleigh, M. (1994) Death and deliverance: “Euthanasia” in Germany, 1900–1945.

Cambridge: Cambridge University Press.

5. Lipton, R.J. (1986) The Nazi doctors: Medical killing and the psychology of genocide.

New York: Basic Books.

6. Friedlander, H. (1995) The origins of Nazi genocide: From euthanasia to the final

solution. Chapel Hill: University of North Carolina Press.

7. Müller-Hill, B. (1988) Murderous science: Elimination by scientific selection of Jews,

Gypsies and others in Germany, 1933–1945. New York: Oxford University Press.

To order reprints, call 1-800-352-2210; outside the United States, call 717-632-3535.