Introduction

Part 2

Part 3

Appendices

Part 1

Introduction to Part 2

Introduction to Part 3

     Appendix A

Introduction to Part 1

     Chapter 6

     Chapter 9

     Appendix B

     Chapter 1

     Chapter 7

     Chapter 10

     Appendix C

     Chapter 2

     Chapter 8

     Chapter 11

     Appendix D

     Chapter 3

Conclusions to Part 2

Thesis Conclusions

     Appendix E

     Chapter 4

     Appendix F

     Chapter 5

Bibliography

Conclusions to Part 1

Books and Articles

Legal Cases

 

Appendix E: The development of euthanasia in pre-war Germany

 

 

Leo Alexander[i] has noted that euthanasia programmes were widely discussed in German medical circles prior to the Nazi rise to power:[ii]

“Sterilization and euthanasia of persons with chronic mental illnesses was discussed at a meeting of Bavarian psychiatrists in 1931.  By 1936 extermination of the socially unfit was so openly accepted that its practice was mentioned incidentally in an article in an official German medical journal.” [iii]

Edmund Pellegrino confirms Alexander’s perception and says (of the role played by the German medical establishment in such policies):

“German academics, especially psychiatrists, were leaders in theories of racial superiority, ... before Hitler came to power.  They even urged the Hitler regime to adopt these nefarious ideals. ... The German medical profession eagerly supported Hitler’s Third Reich and made itself the Reich’s willing agent.” [iv]

However, the German debate on euthanasia and ‘mercy killing’ did not originate in the 1930’s; the intellectual foundations were laid[v] in a book written by two distinguished professors Karl Binding (a jurist) and Alfred Hoche (a psychiatrist) and entitled Die Freigabe der Vernichtung lebensunwerten Lebens,[vi] which was published in 1920.  In this book Binding posed the question as to whether the legally permissible taking of life should be restricted to suicide (as was then the law). Binding argued that there should be three further exceptions:

(i)          “The first group is composed of those irretrievably lost as a result of illness or injury, who, fully understanding their situation, possess and have somehow expressed their urgent wish for release.” [vii]

(ii)        “The second group consists of incurable idiots, no matter whether they are so congenitally or have (like paralytics) become so in the final stage of suffering. They have the will neither to live nor to die. ... Their life is completely without purpose, but they do not experience it as unbearable.  They are a fearfully heavy burden both for their families and for society. ... Again I find no grounds - legally, socially, ethically, or religiously - for not permitting the killing of these people, ...” [viii]

(iii)       “I have mentioned a middle group, and I find it in those mentally sound people who, through some event like a very severe, doubtlessly fatal wound, have become unconscious  and who, if they should ever again rouse from their comatose state, would waken to nameless suffering.” [ix]

 

Hoche, building on Binding’s analysis, posed a somewhat different question:

“The primary purpose of my medical commentary on the foregoing legal considerations should be to answer the question: Is there human life which has so utterly forfeited its claim to worth that its continuation has forever lost all value both for the bearer of that life and for society?” [x]

Hoche counselled against a purely utilitarian approach, but concluded that:

“We will never cease giving the best possible care to the physically and mentally ill, so long as there is any prospect of improvement in their condition.  But perhaps we will eventually come to the conclusion that eliminating those who are completely mentally dead is no crime, no immoral act, no emotional cruelty, but is rather a permissible and useful act.” [xi].

To Hoche, an individual could be described as being ‘mentally dead’ if :

*           (with respect to external relationships) “... [he] lacks any productive accomplishments and lives in a condition of total helplessness, requiring care by another.” [xii]

*           (with respect to his inner state) "... clear ideas, feelings, or acts of will cannot arise; ... no emotional links to the environment can arise (even though they may naturally be the object of the inclinations of someone else).  But the most essential thing is ... the absence of self-consciousness. ... Just as he is incapable of any other mental process, a mentally dead person is thus inwardly unable to make a subjective claim to life.” [xiii]

 

Binding and Hoche advocated a carefully controlled process of decision-making with evaluation by a government board composed of a physician, a psychiatrist and a lawyer; unanimity being required.  Consent, which was to be required in all cases (with the exception of categories 2 and 3 above), could be withdrawn by the patient at any time.[xiv]  “The decree [of permission] itself may only say that, after thorough investigation on the basis of current scientific opinion, the patient seems beyond help; that there is no reason to doubt the sincerity of his consent; that accordingly no impediment stands in the way of killing the patient; ...” [xv]

The proposals of Binding and Hoche drew considerable support from within Germany and from the international community - including many in the American Psychiatric Association[xvi] - though there were some who suggested that it would lead to a ‘slippery slope’.  By 1933 a sufficient social momentum had developed in favour of euthanasia to enable the German Ministry of Justice to propose that it "... be made possible for physicians to end the tortures of incurable patients, upon request, in the interests of humanity." [xvii]  These proposals, though not enacted into law, were put into practice[xviii] first in relation to child euthanasia, which was permitted for disabled and ‘defective’ infants and children; subsequently an adult program for the ‘easy death’ of mentally ill and incurably sick Germans was instituted on grounds of compassion.  Later, Jews and other ‘undesirables’ were included in the euthanasia programme but this was for racial and eugenic reasons.[xix]

Child euthanasia developed[xx] initially not by bureaucratic fiat, but as a response to a groundswell of public demand.  In 1938 a father wrote to the German Government asking that his mentally retarded daughter who had been born without an arm and a leg, be granted a ‘mercy death’; he was not alone in his demands.  Many parents sought such deaths for their disabled children and many ‘wrote to hospitals to ask if their child could be relieved of his or her misery and be granted euthanasia.’ [xxi]  Thereafter, the mercy killing of children became commonplace; shortening their lives was considered to be a humane measure.[xxii]

Pellegrino argues that many of the doctors involved in the Nazi euthanasia programmes believed that :

“... they were doing the right thing ... The German physicians indicted at Nuremberg had been taught by some of the world’s best historians of medicine and ethics.  They could not plead ignorance of ethics and, in fact, made constant allusions to medical ethics and the Hippocratic tradition in their testimony. ... they justified their actions by what they considered to be moral reasons that have received insufficient attention.” [xxiii]

This, rather than the belief that all the Nazi doctors were ogres and sadistic killers, is the perspective that best allows the lessons of the Nazi experience to be learned.[xxiv]

The Nazi child euthanasia programme involved little overt killing.  The actions - increasing doses of painkillers and withdrawal of food - could even find a tentative accommodation within some variants of the ‘double effect’ argument.  Friedlander shows that the euthanasia programme for disabled children was effected either by slow starvation or by the use of increasing doses of morphine, sedatives or sleeping tablets.[xxv]  The physicians described such a process as ‘treatment’, they reported a ‘natural death’ and subsequently argued that such death occurred indirectly by virtue of complications such as pneumonia, and that, accordingly, the death was not a direct killing.  Furthermore, the belief that these practices were motivated solely by the interests of the wider society and were unconcerned with the perceived ‘quality of life’ of the children involved is simplistic; that this is so is evident from, for example, the fact that Jews were excluded from the euthanasia programme; and from the controversy over whether ‘mongoloid’ children should be included in the programme, some of those involved in directing the programme arguing - ultimately unsuccessfully - that ‘mongoloid’ children should be excluded because they had a special appreciation for music and love of life.[xxvi]

The development of adult euthanasia was, to some extent, also fuelled by the demands of some citizens that their handicapped relatives be ‘released from their suffering[xxvii] though the programme was widened considerably to include both psychiatric patients and those who were not ‘racially pure’.  According to Friedlander the fiction of a natural death was officially maintained as was the suggestion that only ‘brain dead patients’ were included, although he notes that expert testimony in the post-war courts was to the effect that at most 7% could be so classified.[xxviii]  The adult euthanasia programme was to a large extent suspended due to public controversy; however, the child euthanasia programme continued. 

The development of the euthanasia programme to include the killing of Jews and others is well documented but such ideas were only first developed in 1941[xxix] long after the child and adult euthanasia programmes had commenced.  It is important to recognise that the development of the ‘final solution’ for the Jews was not fuelled by ideas of ‘mercy death’ - Jews were wholly forbidden from participation in either the adult or child euthanasia programme - but by ideas of racial purity; Rothe quotes Simon Wiesenthal as saying:

“The Nazis considered euthanasia a quasi-ethical sort of murder, and reserved it for members of their own kind.” [xxx]

 

Some Conclusions

 

*           Though the euthanasia programme undoubtedly set the stage for the anti-Jewish holocaust and is crucial for its understanding, the converse is not so.  Neither racism nor antisemitism was a factor in the development of euthanasia in Germany; the full development of the child euthanasia[xxxi] programmes could have occurred even in the absence of Nazi racial policies.

*           Many involved in the euthanasia programmes were motivated, however misguidedly, by compassion.  Friedlander mentions[xxxii] that the doctors involved in the euthanasia programmes occasionally gave lethal injections to severely injured German soldiers, suggesting that any attempt to assert that the doctors were motivated solely by ill-will is untenable.  The exemption of Jews from the ‘mercy death’ programmes - in the context of considerable anti-Jewish sentiment - is further evidence that these programmes were not perceived in terms of punishment or conferring disadvantage, but rather as conferring advantage.

*           Though euthanasia - as advocated by Binding and Hoche - had some societal, or 'statist', aspect to it that might serve to distinguish it from current definitions of the ‘right-to-die’- which stress personal autonomy and individual rights - this is more apparent than real.[xxxiii]

 

These conclusions show that arguments to the effect that the development of euthanasia in Nazi Germany were sui generis and, accordingly, of no relevance to modern bioethical debates, cannot be sustained; indeed, a clear lesson can be drawn in relation to the ease with which ‘slippery slopes’ can develop from small, seemingly innocuous, beginnings:

“Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they all started from small beginnings ... it is important to realise that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude towards the nonrehabilitable sick.” [xxxiv]

Derr believes that the most important lessons to be drawn are:

“Lesson 1: What has happened, can happen. ...

Lesson 2: If a culture adopts the practice of active euthanasia ... the killing should be done by nonphysicians and without physician involvement. ... It was Hippocrates’ genius to realise that if medicine is to avoid playing the role of society’s executioner, it must renounce killing utterly and without exception.  The fatal error of German medicine ... was to think it could accept a little killing ...” [xxxv]


 



[i] Leo Alexander MD, was Chief Medical Consultant for the Office of the United States Chief of Counsel for War Crimes of the Nuremberg War Crimes Tribunal.

[ii] Leo Alexander, ‘Medical science under dictatorship’ New England Journal of Medicine, (1949) at p.45.

[iii] ibid. p.39.

[iv] Edmund Pellegrino, ‘The Nazi Doctors and Nuremberg: Some Moral Lessons Revisited’, editorial, Annals of Internal Medicine, (1997), at p.308.

[v] See, for example:

*      Mark Rothe, Amicus Curiae brief to the US Supreme Court in the case of Vacco v Quill (1996).

[Internet source: http://wings.buffalo.edu/faculty/research/bioethics/brf-rot2.html  20 pp]

*      Henry Friedlander, (The Origins of Nazi Genocide, p.14) also gives examples showing that eminent German scientists of the 1920’s urged that the law should permit the mercy killing of the disabled. 

*      Dr. William Reville - reviewing Robert Proctor’s Racial Hygiene: Medicine under the Nazi’s - summarises Proctor’s argument as being that “... the development of Nazism was much less the imposition of the will of a fanatical minority on a majority, and much more an organic growth of ideas, trends and movements already present in mainstreams Germany than is commonly supposed.”  [The Irish Times; 14-6-96].

[vi] Published in translation under the title ‘Permission for the destruction of Life Not Worth Living’ in 8 Issues in Law & Medicine, 221 (1992); 231-265.  This book comprises two essays: the first by Professor Karl Binding and the second by Professor Hoche. 

[vii] ibid. p.247.

[viii] ibid. p.248-9. [emphasis in the original] 

[ix] ibid. p.249. [emphasis in the original]  This category is reminiscent of those who, in current terminology, would be described as having a ‘null quality of life’; such a description being, of course, an ‘absolute quality of life’ judgement.

[x] ibid. p. 258. [emphasis in the original] 

[xi] ibid. p. 262. [emphasis in the original] 

[xii] ibid. [emphasis in the original] 

[xiii] ibid. [emphasis in the original] 

[xiv] ibid. p.252.

[xv] Rothe op.cit. p.7.

[xvi] Until the late 1930’s when news of the German experience started to spread; see Rothe op.cit. p.6.

Bryan Magee (Confessions of a Philosopher, p.338) notes that:

“Early in the twentieth century it was common for writers who were then or later of international reputation to advocate the mass killing of ordinary people in order to raise the standards of those remaining.”.

Magee cites D. H. Lawrence, Bernard Shaw and H. G. Wells as having such views, adding:

“I once spent a morning in rancorous argument with Robert Graves because of his attachment to the same sentiment.”

[xvii] Rothe op.cit. p.9.

[xviii] The guidelines authorised a doctor to perform certain procedures if he was satisfied that they were appropriate, they did not direct that he do so; see Rothe op.cit. p.11.

See also Patrick G. Derr. ‘Hadamar, Hippocrates, and the Future of Medicine: Reflections on Euthanasia and the History of German Medicine.’ 4 Issues in Law and Medicine, (1989), at p.488:

“The tragedy is that the psychiatrists acted on their own.  They were not carrying out a death sentence pronounced by somebody else.  They laid down the rules for deciding who was to die; ... they were the executioners who carried out the sentence ...”

[Patrick Derr is Associate Professor of Philosophy at Clarke University and was the editor of the translation of Binding and Hoche mentioned above.]

[xix] Rothe op.cit. p.8-9.

Rothe quotes ( op.cit. p.13) Simon Wiesenthal as saying:

“The Nazis considered euthanasia a quasi-ethical sort of murder, and reserved it for members of their own kind.”

See also Derr op.cit. p. 488:

“We know, for example, that the moral collapse of German medicine was not caused by antisemitism.  Ironically, as Wertham has noted: ‘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.’ ”

[xx] Rothe op.cit. p.10.

[xxi] Rothe (op.cit. p.10) cites authorities for this assertion. 

The Nazis: a Warning from History’ Part 2 (shown on BBC2 29-7-00) described how thousands of letters arrived each week petitioning Hitler for favours; in late 1938 a father of a mentally disabled child wrote and asked the Fuhrer’s permission to have the child killed; the letter was shown to Hitler and he agreed.

This programme made no mention of the proposals by Binding and Hoche dating from 1920 or the subsequent debate amongst medical practitioners; it left viewers under the impression that the mercy killing debate originated with Nazism.

[xxii] Rothe (op.cit. p.10) cites evidence given to the Nuremberg Military Tribunal for this assertion.

[xxiii] Pellegrino op.cit. p.307-8.

[xxiv] Rothe (op.cit. p.11) quotes the testimony of a doctor (who had been involved in the euthanasia programme) to the Nuremberg hearings:

"I was motivated by absolutely humane feelings.  I never had any other intention.  I never had any other belief than that those poor miserable creatures - that the painful lives of these creatures were to be shortened."

See also Binding op.cit. p 252:

The act of euthanasia must be a consequence of free sympathy for the patient.  [emphasis in the original] 

[xxv] Friedlander (op.cit. p.61) suggests that the best estimate of the total number of children involved in these programmes is 5,000.

see also Rothe op.cit. p.15 who notes that the techniques used in the adult euthanasia programme (subsequent to 1942) were lethal injections and the ‘withholding of nutrition and hydration’. 

[xxvi] Friedlander op.cit. p.58.

[xxvii] Friedlander op.cit. p.171.

[xxviii] Friedlander op.cit. p.170.

[xxix] Rothe op.cit. p.14.

[xxx] Rothe op.cit. p.13.

[xxxi] The development of the adult euthanasia programme is more problematic in that it was, to some extent, justified in terms of ‘racial purity’.

[xxxii] Friedlander op.cit. p.297.

[xxxiii] Rothe (op.cit. p.7) comments:

“The distinction, however, may not be that sharp.  Contemporary proponents of the ‘right to die’ do not rely exclusively on the autonomy, but on the perceived worthlessness of the lives in question, and the economic costs of sustaining them.”

See also Derr op.cit. p.494:

“Still, it is worth remembering that the engine which drove the early moral transformation of German medicine was not the ideology of racial discrimination, but medical economics.”

[xxxiv] Alexander op.cit. p.46.

[xxxv] Derr op.cit. p. 491-4.