Euthanasia originally meant assisting a terminally ill individual with a painless death. In 1920 the jurist Karl Binding and psychiatrist Alfred Hoche called for the killing of “lives without value”. Nazism further transformed the meaning of euthanasia. Hitler called for euthanasia at a Nuremberg rally in a notable speech at Nuremberg. In 1935, Hitler told Gerhard Wagner, the Reich Physicians’ Führer, that he would implement euthanasia at the start of the war.

Preparations for the killing of patients began in the mid-1930s in Germany with surveys of patients held in psychiatric hospitals, and there is evidence of a debate in the medical circles around Hitler. Hitler’s escort surgeon, Karl Brandt cited the petition of parents of a severely disabled child to the Führer, requesting that their severely handicapped newborn baby be killed. This made the point that the Nazi leaders were responding to a popular wish, and Brandt dated the incident to 1938. Despite the efforts of the medical historian Udo Benzenhöfer to establish the identity of the child, this has not proved possible. Hitler sent Brandt to visit the child in July 1939, who was in the “care” of the Leipzig professor of paediatrics, Werner Catel, and the baby subsequently died. After the outbreak of war on 1 September 1939, the Führer wrote that he entrusted Karl Brandt and the administrator Phillip Bouhler with the implementation of “euthanasia” or “mercy killings” (Gnadentod), and backdated the decree to the start of the war. Brandt supported use of carbon monoxide gas chambers (causing a slow and painful death), but otherwise was not actively involved in reaching decisions on individual patients. The numbers killed in the initial phase, code-named “T4” (after the administrative office at Tiergartenstrasse 4), amount to (according to one set of records) 70,273 persons. The killings were ordered on the basis of medical records sent to the clandestine panel of adjudicating psychiatrists at the central office in Berlin. So-called schizophrenics made up 58% of the victims, and there was a slightly higher proportion of women killed. There were 6 gassing facilities in Germany and former Austria (Brandenburg – replaced by Bernburg, Grafeneck, Hartheim, Pirna-Sonnenstein, and Hadamar).

In 1941, a condemnation came from the Roman Catholic bishop of Münster, Clemens Galen, and some public opposition, particularly from distressed relatives. This resulted in an ostensible stop of T-4, but covert decentralised killings continued. Euthanasia personnel, including physicians and technicians, were transferred to the Aktion Reinhardt, which built and ran extermination camps of Belzec, Sobibor, and Treblinka. Doctors (such as the psychiatrist Irmfried Eberl), now expert in medical killing, were transferred from this so-called ‘euthanasia’ programme to apply their skills in death camps where Jews, Gypsies and others were exterminated (Eberl became the first commandant of Treblinka extermination camp). The use of carbon monoxide gas was a direct link between Nazi euthanasia killings and the Holocaust. Euthanasia continued unabated in concentration camps where prisoners were selected for killing, in the 30 so-called “special children’s wards”, and in other clinical locations. Physicians assisted by nurses killed by starvation, injection, and administering deadly drugs. The groups killed included newborn babies, children, the mentally disturbed, and the infirm. Sometimes victims were killed for merely challenging the staff in institutions, although they were in good health, and others were not the so-called incurables of the Nazi theory. Some physicians killed because of the scientific interest of the “cases”. Identifying those killed shows that networks of referral meant there was widespread complicity of physicians and nurses in euthanasia. At the same time other physicians made efforts to keep potential victims out of the euthanasia apparatus. T-4 continued as an organisation, as it established research departments at Brandenburg-Goerden hospital and at Heidelberg for research on so-called “idiot” children under Professor of Psychiatry, Carl Schneider, and involving Ernst Rüdin, the leading advocate of sterilization.

Hitler and his Chancellery used propaganda to attempt to make the German population accept the killings. The doctor and author, Hellmuth Unger, prepared a film script to elicit public sympathy for euthanasia. Unger was a press officer for the Nazi Doctors League, and author of a novel promoting euthanasia – Sendung und Gewissen. His writings glorified the medical researcher as empowered to take liberties with life.

In the German occupied East, large numbers of patients were killed in Poland and the occupied Soviet Union. The deaths encompassed children’s euthanasia between October 1939 - April 1945 with an estimated minimum number of 5000 child deaths, although numbers are likely to be twice this. The T-4 programme of special killing centres between early 1940 and August 1941 was responsible for 70273 adult and juvenile deaths and the decentralised programme code-named 14-f-13 from April 1941 to 1944 was responsible for the killing of ca. 50000 concentration camp prisoners. The killings of prisoners of war and the forced workers from the East were identified as a distinct phase of euthanasia. The Aktion Brandt initiative to clear hospital beds from August 1943 to the end of 1944 coincided with renewed intensification of euthanasia killings, which continued throughout the war. Overall, it is estimated that about 220,000 victims were killed. Of these brains and other body parts were retained for research. Many specimens were buried only in 1990, and the most recent burial of retained specimens was in May 2013 in Vienna.

Euthanasia was widely carried out in the German-occupied East in Poland and the Soviet Union. A high excess mortality has been identified in France, and patient deaths arose from hunger, and wartime shortages. One estimate is of ca. 40,000 French victims of deprivation as opposed to deliberate killing.

After the war, a series of trials were conducted against the perpetrators of euthanasia in Austria, Germany, and Poland. There were numerous acquittals and shielding of those responsible. The German Psychiatric Association claimed falsely in the 1950s that its members opposed euthanasia. The case against Heinrich Gross, a neuroanatomist in Austria who dissected the brains of many child victims of euthanasia in Vienna during and after the war when he ran a histo-pathological research institute sited at the hospital Am Spiegelgrund in Vienna where many victims were killed, was prevented until his death in 2005 by his plea of mental incapacity. In 1987, an association for those damaged by Nazi euthanasia was founded and limited compensation was paid to relatives. There has been only limited compensation to the relatives of those killed, and only rarely memorials naming individuals who were killed, as was notably the case for the Spiegelgrund victims at the Otto Wagner Hospital in Vienna. There is no death book commemorating victims of Nazi euthanasia as the German authorities consider it illegal to publicly release the names of murdered victims. A counter-argument is that non-disclosure perpetuates the stigma of mental illness.

Post-war “voluntary euthanasia” advocates in North America and Europe (notably the Netherlands) argue that their procedures have nothing to do with the Nazi measures, in that they seek the consent of the person or when this is not possible of relatives. On the one hand, there are terminally ill persons who themselves insist that the pain and level of disability makes them wish to end their lives. Yet the concepts of a life without value, expert medical advocacy in favour of euthanasia, and relatives finding the severely ill person a burden are difficult to exclude from the decision-making procedures. For these reasons euthanasia remains a contested topic and the Nazi abuses a salutary warning in favour of caution in complex and difficult end of life decisions.

-Paul Weindling

• Udo Benzenhöfer, ‘Der Fall “Kind Knauer” ‘, Deutsches Ärzteblatt, vol. 95 (1998) B-954-5.

• Isabelle von Bueltzingsloewen, L’Hécatombe des fous. La famine dans les hôpitaux psychiatriques français sous l’Occupation (Paris: Flammarion, 2007)

• Michael Burleigh, Death and Deliverance. ‘Euthanasia’ in Germany 1900-1945 (Cambridge: Cambridge University Press, 1995)

• Henry Friedlander, The Origins of Nazi Genocide. From Euthanasia to the Final Solution, Chapel Hill: University of North Carolina Press, 1995

• Paul Weindling, Health, Race and German Politics between National Unification and Nazism, 1870-1945 Cambridge Monographs in the History of Medicine, (Cambridge: Cambridge University Press, 1989

• Paul Weindling. Nazi Medicine and the Nuremberg Trials (Basingstoke: Palgrave, 2004)