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The Cost-Effectiveness of Killing:

An Overview of Nazi "Euthanasia"

John E. Gardella, MD

In the public debate over legalized euthanasia and physician-assisted suicide, opponents of such measures often invoke the history of medicine in Nazi Germany as an example of the danger in these practices. Those who invoke the "Nazi analogy" suggest that the sanctioning of euthanasia could lead to the wholesale destruction of those whose lives are deemed valueless or burdensome to society. Supporters of assisted dying on the other hand refer to the "Nazi albatross," and argue that the modern understanding of euthanasia bears little resemblance to the Nazi program.(1) This paper will review the history of the Nazi euthanasia program, will review its historical roots, and will contrast Nazi "euthanasia" with contemporary proposals for assisted dying.

Some writers, including Plato and Nietzsche, advocated killing the sick and the nonproductive for the economic benefit of society,(2) but the most detailed book justifying medical killing appeared in Germany in 1920 authored by the law professor Rudolf Binding and the professor of medicine Alfred Hoche. Their treatise entitled "Permitting the Destruction of Unworthy Life" prefigured the Nazi effort to rid society of the nonproductive.(3) Binding and Hoche presented not only an ethical rationale for medical killing, but also developed procedures for the selection of candidates for death.

In the opening segment of this book, the jurist Karl Binding argued for the practice of mercy killing, and finally for a "more general permission" for legalized destruction of human life.(4) Binding argued that mercy killing of the terminally ill "merely replaces the present cause of death with a different one which has the advantage of painlessness. This is not an act of killing in the legal sense but is rather the modification of an irrevocably present cause of death which can no longer be evaded. In truth it is a purely healing act."(5) The experience of the World War I was clearly a factor in Binding's thinking as he argued for a "more general permission" for killing:

Reflect...on a battlefield strewn with thousands of dead youths.... Compare this with our mental hospitals, with their caring for their living inmates. One will be deeply shaken by the strident clash between the sacrifice of the finest flower of humanity in its full measure on the one side, and by the meticulous care shown to existences which are not just absolutely worthless but even of negative value, on the other. It is impossible to doubt that there are living people to whom death would be a release, and whose death would simultaneously free society and the state from carrying a burden which serves no conceivable purpose....(6)

Professor Binding also set forth very specific procedures by which permission for medical killing could be granted. While he argued that "the state can never take the initiative in mercy killings," he advocated the formation of a government board consisting of two physicians and one lawyer to evaluate applications for mercy killings.(7) Presumably applications for mercy deaths would have originated from family members, since those with "incurable idiocy" would have been incompetent to participate in the application process.(8) Unanimity by the board would have been required before the patient could be granted "final release."(9)

In the second part of this treatise, Dr. Hoche wrote from the standpoint of medical ethics: What the physician may do...emanates from peer opinion, which holds that physicians are obligated to observe the universal ethical norms, and to heal the sick, eliminate or mitigate pain, and preserve and prolong life as much as possible.(10)

But Dr. Hoche pointed out that the "most universal principle is not without exception," and that physicians may in some instances be compelled to destroy life "in the interest of a higher good." He then went on to define those who may be killed "for a higher good," including "complete idiots," and the institutionalized mentally ill who are "empty human shells," whose "existence weighs most heavily on the community."(11) While Dr. Hoche justified killing such patients, clearly the "higher good" for which their lives were to be forfeited was economic:

In part, this burden (of caring for the institutionalized) is financial and can be readily calculated by inventorying annual institutional budgets. I have allowed myself to take up the task of collecting materials bearing on this question by surveying all relevant German institutions, and thereby I have discovered that the average yearly cost for maintaining idiots has till now been thirteen hundred marks. ...[I]t is easy to estimate what incredible capital is withdrawn from the nation's wealth for food, clothing and heating --- for an unproductive purpose.(12)

In his conclusion, Dr. Hoche wrote that a "mentally dead person," being incapable of higher cerebral function, has no "subjective claim to life" and can be sacrificed in the name of "a higher civil morality."(13) The Binding-Hoche book was controversial and their proposals for the destruction of "worthless" lives did not gain widespread support in German medicine. Critics of their treatise spoke against the "utilitarian shopkeeper" mentality exhibited by Binding and Hoche.(14) While the fledgling Nazi party did not specifically refer to the Binding-Hoche treatise in any public statements or writings, "euthanasia" was endorsed by Hitler in a most extreme form. In a speech before the Nuremberg Party rally on August 5, 1929 Hitler was explicit:

If Germany were to get a million children a year and were to remove 700-800,000 of the weakest people then the final result might be an increase in our strength. ...As a result of our modern sentimental humanitarianism we are trying to maintain the weak at the expense of the healthy. It goes so far that a sense of charity, which calls itself socially responsible, is concerned to ensure that even cretins are able to procreate while more healthy people refrain from doing so, and all this is considered perfectly understandable. Criminals have the opportunity of procreating, degenerates are raised artificially and with difficulty. And in this way we are gradually breeding the weak and killing off the strong.(15)

With the Nazi assumption of power, the first effort to rid society of inferiors was the Sterilization Law of July 14, 1933. The law, modeled after American legislation, mandated the involuntary sterilization by vasectomy or tubal ligation of those suffering from "genetic" diseases. At the time, genetic diseases were thought to include alcoholism, "feeblemindedness," and a variety of mental disorders. During the 1930s, it is estimated that some 400,000 people were sterilized in Germany for these reasons. To further the cause of population growth, the regime severely restricted access to contraception, and outlawed voluntary sterilization as well as abortion unless performed as a life-saving measure.(16) These measures were inadequate for the Nazi leadership which advocated more drastic means of racial purification.

More aggressive means of ridding German society of the non-productive were not long in coming. According to post-war testimony by Dr. Karl Brandt, at the 1935 Nuremberg Party Congress, Hitler informed the Reich Doctors' Leader, Gerhard Wagner, that in the event of another world war he would take up the question of euthanasia and "solve the problem of the asylums in a radical way."(17) Hitler expected that in the upheaval of war the opposition of the churches would be muted. At this same Party Congress, Dr. Wagner assailed the doctrine of equality, which valued the lives of the sick, and the "unfit" on a par with the healthy. While not specifically mentioning euthanasia, Wagner went on to emphasize the high cost of caring for the "genetically disabled," and to point out how such care was diverting resources from the "healthy members of the population." Dr. Wagner assured his listeners that measures were being taken to reverse this trend.(18)

In August 1939, the Interior Ministry sent a confidential directive to doctors, midwives, and other health officials ordering them to register all children under three with congenital malformations or mental deficiency. Information on these children was sent back to Berlin where it was reviewed by a panel of three medical experts who decided whether the child was to be killed. The decision was made without any direct examination of the children, and without the consent of the infant's parents or guardian. Those children selected for death were transported to one of the designated killing centers in Germany. The parents were led to believe that the transfers were to allow for "the best and most efficacious treatment available." After the children arrived, the process of euthanasia was delayed for weeks to convey the impression that treatment was being rendered. The actual killing process was often initiated by innuendo and was accomplished with escalating doses of luminal. Dr. Hermann Pfannmuller did not waste medications on his "patients," but rather chose to starve them to death, thereby ridding Germany of "a burden for the healthy body of our Volk." The parents of the deceased child were informed via form letter that the infant had died of pneumonia or another fabricated cause and that the body had to be cremated immediately to lessen the chance of epidemic.(19)

While the children's program was initially restricted to three years olds and younger, this age limit was soon broadened. Extending the killing to adults was done via a "Fuhrer decree" from Hitler to Reich Leader Philip Bouhler and Dr. Karl Brandt in October 1939; no law was ever debated or passed by the Reichstag authorizing medical killing. Hitler's decree did not require any physician to participate in the euthanasia program, but rather "extended the powers" of specific doctors to grant a "mercy death" to those "deemed to be incurable." The decree was backdated to September 1, 1939 to cover the initial phases of the invasion of Poland during which some 4,000 adult mental patients were shot by Einsatzgruppen.(20)

Within Germany itself, camouflage organizations were set up to cover the financing of the operation and the transport of mental patients to the killing centers. The entire operation was named Aktion T4 after Tiergarten 4 --- the address of a confiscated Jewish home in Berlin which housed the administrative offices of the project. Forty-eight doctors were recruited to review nearly 300,000 applications for euthanasia from the psychiatric centers; of these about 75,000 patients were selected for death. In January of 1940, Dr. Karl Brandt, Dr. Leonardo Conti (the successor to Dr. Gerhard Wagner) and others tested a novel means of mass killing --- the administration of carbon monoxide in a gas chamber disguised as a shower. This "experiment" was conducted at the psychiatric hospital at Brandenburg much to the satisfaction of Viktor Brack who insisted that future gassings be carried out under physician supervision, according to the motto: "Syringes are a matter for doctors." The experience at Brandenburg was replicated at five other psychiatric hospitals throughout Germany each of which was outfitted with a gas chamber. At the Hadamar facility, the extermination of the 10,000th patient was celebrated with a small ceremony and a bottle of beer for each of the hospital staff.(21)

Secrecy and falsification permeated every phase of Aktion T4. Despite the public deception, rumors and suspicion about the killings began to grow as early as 1940. In the spring of that year, a number of parents brought murder charges against the directors of two institutions, but the courts dropped charges when they were informed by the Reich Minister of Justice that Hitler had authorized the operation and guaranteed the immunity of the participants.(22) Some of the asylums from which mental patients were selected for killing were church-run organizations, but the churches were for the most part anxious to avoid confrontation with the Nazi regime. A few church officials were, however, unwilling to remain silent. Pastor Braune, the vice-president of the main Protestant welfare organization, personally delivered a written protest to Hitler and was subsequently arrested by the Gestapo in August 1940. The Roman Catholic Church likewise opposed the program and issued an official protest at a bishops' conference in August 1940. However most protests were behind the scenes and were aimed at seeking special favors from the regime, such as excluding Catholic priests from the program or securing an agreement to allow for the administration of the sacraments to those chosen for euthanasia.(23)

The most famous public statement against Aktion T4 came from Clemens Graf von Galen in a sermon delivered on August 3, 1941. In that sermon, the Catholic bishop spoke in accurate detail about the workings of the euthanasia program and condemned its underlying rationale:

Have you, have I, the right to live only so long as we are productive.... If you establish and apply the principle that you can kill 'unproductive' fellow human beings, then woe betide us all when we become old and frail! ...If one is allowed to forcibly remove one's fellow human beings then woe betide loyal soldiers who return to the Fatherland seriously disabled, as cripples, as invalids.(24)

The concern about the fate of wounded soldiers was valid, for it was rumored that mercy killings of this kind were happening. Galen's sermon, much to the distress of the Nazi leadership, was copied and circulated by the thousands. Not long thereafter, Hitler issued an order halting Aktion T4. It is uncertain whether this was done in response to these protests or because Aktion T4 had met its goals. Whatever the reason, Hitler's order only ended the gassing of mental patients.(25) Mass murder, however, was barely underway.

From 1941 onward, mental patients were killed by neglect and starvation and when this method proved too slow, progressive doses of luminal or morphine and scopolamine were used. This phase of "wild euthanasia," as it was called in Nazi documents, was sanctioned by authorities in Berlin. The selection process was not longer centralized, but was carried out by individual physicians using their own discretion, but always using the criterion of productivity. Sometimes patients were selected to die because they were difficult to manage or exhibited homosexual behavior. It is not known how many patients died in this phase of "wild euthanasia," but it clearly numbered in the tens of thousands. Apart from the mentally ill and handicapped children, "wild euthanasia" was extended to sickly slave laborers, children from reform schools, and the elderly --- especially those in institutions for the poor.

Euthanasia found its way to the concentration camps under the program code-named 14f13. 14f referred to the code number for the Inspectorate of Concentration Camps, and 13 referred to the "special treatment of sick and frail prisoners." The program was devised by Himmler and Philip Bouhler and was designed to rid the camps of sick prisoners. Prisoners were selected for "special treatment" by roving T4 doctors, who then transferred those selected to the remaining gassing centers at the psychiatric hospitals. The euthanasia program thus perfected the means and methods for mass murder; its personnel and techniques were soon to be used for the killing of millions in "the final solution of the Jewish question The links between the 14f13 operation and the Holocaust are obvious. Both were designed to rid German society of the unwanted, and the euthanasia program had demonstrated the feasibility of mass killing to accomplish this goal. It is not surprising then, that when the decision was made to murder all European Jews and other unwanted ethnic minorities, the gas chambers at the psychiatric institutions were disassembled and reconstructed at Treblinka, Auschwitz, and the other death camps. The personnel including the doctors and nurses who ran the killing apparatus at the psychiatric hospitals were transferred to the death camps in the East. The first commandant of Treblinka was Dr. Imfried Eberl who had demonstrated the feasibility of mass killing with carbon monoxide at the psychiatric institution at Brandenburg.(27_

The euthanasia program was finally halted with the capitulation of Nazi Germany in May 1945. In 1946, 26 doctors and public health officials were prosecuted in Nuremberg in what has been termed the "Doctor's Trial." While the murder of German civilians and other nationals under the guise of euthanasia was part of the indictment, the prosecution focused on the doctors' role in human experimentation. This tactic was chosen because survivors of the medical experiments were available to give testimony. In charging the physicians with euthanasia, the Nuremberg prosecutors argued that the doctors had violated the international rules of warfare, the Hague Convention and the German Criminal Code. In the prosecution's view, the Hitler decree of September 1, 1939 did not have the force of law, and violated the German Criminal Code. Furthermore, the prosecutors argued that Dr. Brandt et al had violated even the Binding-Hoche criteria for euthanasia which held that the "mentally dead person" in lacking a will to live could be put to death for the good of the state. According to the prosecution, the coercion and deception that permeated every phase of the euthanasia program would have been unnecessary had the victims or their families desired a "mercy death."(28)

The doctor-defendants never expressed any regret, nor did they deny their actions. They argued that they were following lawful orders and that in the euthanasia program they were motivated by the desire "to solve an old medical problem." In addition, the physicians argued that in a time of struggle for national survival, exceptions to ordinary moral standards were justified. The doctors argued that it was justifiable to call upon individuals to forfeit their lives for the sake of national preservation. The Nuremberg tribunal did not respond to each argument set forth by the defendants but rather responded with the Nuremberg Code which emphasized the primacy of the informed, voluntary consent of the patient in governing physician behavior. The Code rejected the utilitarian argument that the few may be involuntarily sacrificed for the benefit of the many.(29)

Clearly Nazi "euthanasia" differed in many respects from modern practices and proposals for assisted dying. While the "Fuhrer decree" of September 1, 1939 allowed physicians to grant a "mercy death" to those with incurable illness, in practice Aktion T4 sacrificed the lives of the handicapped for the sake of collectivist goals. The program had little if anything to do with mercy and everything to do with saving money and freeing medical resources for the German war effort. In their quest for savings, Nazi doctors ignored their patients' self-determination, and deceived family members about the fate of their loved ones. In the Nazi era, quality of life judgments were made, not by patients or family members, but rather by central planners guided by utilitarian principles. In making their life or death decisions, the Nazi doctors judged the quality of their patients' lives only in the narrow sense of whether they were productive and of value to the state. Put differently, the Nazi doctors applied benefit-cost analysis by weighing the value of their patients to the state against cost of caring for them. Finally in contrast to the contemporary euthanasia debate, Aktion T4 was developed in a totalitarian dictatorship which never exposed this policy to public scrutiny and cloaked every phase of the program in secrecy and deception.

The philosopher Peter Singer has written that the Nazis never did have a euthanasia program in the proper sense of the word.(30) They did, however, have an amoral but cost-effective method of dealing with the financial burden of the chronically ill. It has been suggested that our medical profession finds itself on a slippery slope as we become more accepting of assisted dying. A review of the Nazi experience with "euthanasia" demonstrates that our medical profession can fall victim to pervasive moral corruption when doctors place the needs of the state above the needs of individual patients. It is easy to read this history with a sense of moral superiority, but one wonders how our government and medical profession would respond to the burden of caring for the non-productive in a time of economic calamity and struggle for our national survival.

References

1. Humphry D. and Wickett A. The Right to Die. Eugene, Oregon, Hemlock Society, 1987, pp. 20-32.

2. Emanuel E. Euthanasia: Historical, Ethical and Empiric Perspectives. Archives of Internal Medicine 1994;154:1890-1901.

3. Binding K. and Hoche A. Permitting the Destruction of Unworthy Life. Trans. Walter E. Wright. Issues in Law and Medicine 1994;8:231-265.

4. Ibid., p. 242.
5. Ibid., p. 240.
6. Ibid., p. 246.|
7. Ibid., pp. 251-253.
8. Ibid., p. 248.
9. Ibid., p. 252.
10. Ibid., p. 256.
11. Ibid., pp. 256-261.
12. Ibid., pp. 260-261.
13. Ibid., p. 262.

14. Burleigh M. Death and Deliverance: 'Euthanasia' in Germany 1900-1945. New York, New York, Cambridge University Press, 1994, pp. 21-22.

15. Noakes J. and Pridham G. (editors). Documents on Nazism, 1919-1945. New York, New York, Viking Press, 1975, p. 1002.

16. Proctor R. Racial Hygiene: Medicine under the Nazis. Cambridge, Harvard University Press, 1988, pp. 95-117.

17. Noakes and Pridham, op. cit., p. 1004.
18. Proctor, op. cit., pp. 181-182.

19. Lifton R. The Nazi Doctors. New York, New York, Basic Books, 1986, pp. 51-62.

20. Noakes and Pridham, op. cit., p. 1021.

21. Ibid., pp. 1018-1021.

22. Proctor, op. cit., pp. 191-194.

23. Noakes and Pridham, op. cit., pp. 1034-1035. P> 24. Ibid., p. 1038.
25. Ibid., p. 1039.
26. Ibid., pp. 1043-1046.
27. Lifton, op. cit., pp. 123-124.

28. Trials of War Criminals before the Nuremburg Military Tribunals Under Control Law No. 10. Vol. 1. Washington, D.C., U.S. Government Printing Office, 1949, pp. 804-818.

29. Caplan A. The Doctor's Trial and Analogies to the Holocaust in Contemporary Bioethical Debates. in Annas G. and Grodin M. (editors). The Nazi Doctors and the Nuremberg Code. New York, Oxford University Press, 1992, pp. 265-270.

30. Singer P. Practical Ethics. New York, Cambridge University Press, 1993, pp. 213-217. Dr. Gardella practices internal medicine at Presbyterian-Matthews Hospital in Charlotte, North Carolina. E-mail: JohnG6557@aol.com. This article was published in the Medical Sentinel, Volume 4, Number 4, July/August 1999, pp. 132-135.

Schiavo Thoughts: Feeding Tubes
Before I post about this morning's ruling from the Eleventh Circuit, which you can read here, I'm going to offer some thoughts on an issue that has been the subject of countless emails I've received: feeding tubes.

Some people believe that feeding tubes are different from ventilators and other machines that keep us breathing, or machines that make our hearts beat. Some people just seem uncomfortable that removing those other devices leads to an expeditious death, whereas removing or declining to insert a feeding tube -- when a patient cannot otherwise ingest food and water -- leads to a slow death. Some assume that death is painful.

I don't want to comment on the morality surrounding feeding tubes and their use or nonuse. This is a legal blog, so I'm going to offer a few legal observations in this area.

First, a Florida law enacted in 1999 makes it clear that the "life-prolonging procedures" a person may refuse include "artifically provided sustenance and hydration." This point is made on the Info Page I created to help explain the law at issue here.

But numerous people have pointed out that this law was passed by the Florida Legislature and signed by Governor Bush only in 1999 -- years after Terri's collapse and even longer after Terri made whatever statements she made about such things. They contend that this 1999 law shouldn't apply to Terri.

Let's take a step back. Statutes are one form of law in Florida, but there is another form of law that's higher: the Florida Constitution. In 1980, Florida's citizens amended Florida's constitution to add a right of privacy to Floridians' fundamental rights. The Florida Supreme Court addressed this right in the 1990 case In re Browning. Florida's high court determined that the constitutional right of privacy includes the right to decline any medical treatment, including the use of a feeding tube. The court said:

Recognizing that one has the inherent right to make choices about medical treatment, we necessarily conclude that this right encompasses all medical choices. A competent individual has the constitutional right to refuse medical treatment regardless of his or her medical condition. The issue involves a patient's right of self-determination and does not involve what is thought to be in the patient's best interests.

* * *

We see no reason to qualify that right on the basis of the denomination of a medical procedure as major or minor, ordinary or extraordinary, life-prolonging, life-maintaining, life-sustaining, or otherwise.

* * *

Courts overwhelmingly have held that a person may refuse or remove artificial life-support, whether supplying oxygen by a mechanical respirator or supplying food and water through a feeding tube. We agree and find no significant legal distinction between these artificial means of life-support.
(emphasis added) (citations omitted).

So, as explained by the Florida Supreme Court in 1990, the right to decline medical treatment -- including use of a feeding tube -- has been the law of Florida since no later than 1980. Under the Florida Constitution, feeding tubes are medical treatment that may be refused. What the statutes say on this point cannot overcome the rights conferred by the Constitution.

As many know, the federal constitution does not have an express right of privacy, but the federal courts have found many privacy-like interests to be liberty and due process interests protected by the federal constitution. When the U.S. Supreme Court decided Cruzan v. Missouri in 1990, Justice Sandra Day O'Connor authored a concurring opinion discussing Nancy Cruzan's federal right to decline use of a feeding tube. Justice O'Connor explained:

Artificial feeding cannot readily be distinguished from other forms of medical treatment. Whether or not the techniques used to pass food and water into the patient's alimentary tract are termed "medical treatment," it is clear they all involve some degree of intrusion and restraint. Feeding a patient by means of a nasogastric tube requires a physician to pass a long flexible tube through the patient's nose, throat and esophagus and into the stomach. Because of the discomfort such a tube causes, "[m]any patients need to be restrained forcibly, and their hands put into large mittens to prevent them from removing the tube." A gastrostomy tube (as was used to provide food and water to Nancy Cruzan) or jejunostomy tube must be surgically implanted into the stomach or small intestine. Requiring a competent adult to endure such procedures against her will burdens the patient's liberty, dignity, and freedom to determine the course of her own treatment. Accordingly, the liberty guaranteed by the Due Process Clause must protect, if it protects anything, an individual's deeply personal decision to reject medical treatment, including the artificial delivery of food and water.
(emphasis added).

I hope this helps clear up what the law is in this area.

...posted by Matt Conigliaro http://abstractappeal.com/archives/2005_03_01_abstractappeal_archive.html#111158613257156180