Psychiatrists & The Holocaust: BureaucRATS On A Treadmill

"Patently Ridiculous that Psychiatrists Caused the Holocaust"

NADA STOTLAND: President of the American Psychiatric Association


The Killing of Psychiatric Patients in Nazi-Germany between 1939 – 1945

M. von Cranach
Arztlicher Direktor
Bezirkskrankenhaus Kaufbeuren,
Kemnater Straße 16, D – 87600 Kaufbeuren
Tel.: 0049-8341-721101, Fax: 0049-8341-1106,
email: mcranach.bkh@t-online.de

Abstract

Between 1939 and 1945 180.000 psychiatric patients were killed in Nazi-Germany. After a brief introduction reflecting the ways of and reasons for addressing this issue today, the details of the so called euthanasia program are presented: The killing of patients by gas in special hospitals between 1939 and 1941 in its first phase and the continuation in the psychiatric hospitals until 1945. In this second phase patients were killed with lethal injections and through the introduction of a hunger diet. The fate of the Jewish patients and forced labourers as well as human experiments are mentioned. Finally some thoughts are presented to answer the question of why this could happen. The giving up of individual responsibility in an authoritarian system leads to the loss of the individual conscience and soul.

Introduction

You have asked me to speak about the fate of psychiatric patients in Nazi-Germany in the years between 1939 and 1945. I cannot speak about this darkest period in the history of psychiatry without addressing and clarifying two questions:
- how can we speak about these events? and
- why do I speak about them?
Some years ago an intellectual debate started in all serious German media called the “historians’ debate” (Historikerstreit). Some historians claimed that now, half a century away, this period has become history and should be analysed by historians with their professional objective and scientific methodology. Since then this argument is recurring again and again, lately in a somewhat different light. This position has been criticised loudly and openly by others. We cannot approach these problems from a distant and objective point of you, instead they are still present, unresolved, continuously coming to the surface with new previously unknown aspects, e. g. the fate of the forced labourers, the Swiss bank accounts, human experiments and the pharmaceutical industry, just to name a few.

You remember Jasper’s phenomenological distinction between “explaining” and “under- standing” (“Verstehen und Erklaren”). We Germans are not in the position to try to scientifically explain these events but to try to understand, a process which involves not only the mind but the heart. This process of understanding starts with looking at the facts and, as in the bereavement process, allowing for feelings of guilt, shame, aggression, loss and sadness. I am convinced, that this is the only possible way to go.

So in the following I will “look with you at the facts”, not in the role of an historian but conscious that all our research, our publications and even the present meeting are part of the still ongoing process of coping, mourning and honouring the victims, part of the process of reconciliation.

This process of reconciliation started late. When a few years after 1945 the Germans took over from the Allied Forces the administration of their country this aspect of Nazi terrorism was soon forgotten. Attempts from a few, like Alexander Mitscherlich (1960) to bring it to public attention were blocked. A few psychiatrists were sentenced, but in general there was no gap, no starting anew, instead continuity, repression and denial.

It was as late as the late seventies and early eighties of the last century that younger psychiatrists, touched by the “Zeitgeist” of 1968, left the university and took leading positions in the old overcrowded and decrepit mental hospitals to start a new community oriented psychiatry. When I became director of the mental hospital in Kaufbeuren in 1980, I soon realised that the reform I was expected to initiate could not be started without shedding light on this horrible past. I became aware, that patients had been killed in the rooms where we worked, that some of the personnel as well as patients had personally experienced these actions, that this past, long unspoken about and unresolved, was lying like an invisible fog over the whole institution paralysing the necessary reform actions. It became evident that bringing light into this darkness was a prerequisite of all reform activities. With a group of interested co-workers I started to investigate the archives of the hospital, interview witnesses, searching through the literature and official archives. Thus we first learned about the actual past of the hospital and later in a more comprehensive research about all Bavarian hospitals about the background of these events (e.g. v. Cranach and Siemen, 1999). Meanwhile a vast literature and research has been accumulated (Dorner et al, 1980, Klee, 1983, Seidel and Werner, 1991, Faulstich, 1998), and in many hospitals memorials to the deceased can be found.

After this long, but necessary, introduction let me now start with the talk you asked me to give. I will divide it into two parts: first the facts and then some thoughts on why this could happen. Time does not allow me to touch on the multifactorial sources and roots of these events, the eugenics movement and its German version, the “racial hygiene” (“Rassenhygiene”), their links with national socialism, the forced sterilisation of about 400.000 persons after 1933 (“Erbgesundheitsgesetz”) and the like. This would be a talk in itself. I will try to describe the facts in chronological order citing original documents, accounts of perpetrators and witnesses.

The facts

In September 1939, Hitler himself signed the following document (“Euthanasie-Erlass”): “Reichsleiter Bouhler and Dr. med. Brand are hereby ordered to enlarge the authority of certain physicians, whose names are to be specified, to include the granting of assistance to death to patients who are incurably diseased, after a most thorough evaluation of their condition.”

An administration (“Reichsarbeitsgemeinschaft Heil- und Pflegeanstalten”) was founded to put into practice Hitler’s decree. This administration was located in Berlin, Tiergartenstraße 4, the reason for calling this action Aktion T 4. All directors of mental hospitals were summoned to Berlin and informed about the content and the practical proceedings of this action. They were required to submit forms for all patients and declare all those who:

1) had specific mental disorders and who were not able to work or could only carry out purely mechanical tasks, or
2) had continuously spent at least five years in an asylum, or
3) were kept under custody as criminally insane, or
4) did not possess German citizenship or were not of the German or similar races, specifying the race and the citizenship.

These forms were submitted to 54 selected psychiatrists, the elite of German psychiatry, university professors and hospital directors. They had to decide, on the basis of the forms, whether a given patient would fall into the group to be liquidated by filling in a blank on the form with “yes”, “no”, or “questionable”. The national committee compiled the selected patients into lists which were sent to the hospitals, with the mandate to have the designated patients ready for transfer on a particular day. A specially formed national medical transport organisation brought the patients to six specially-equipped euthanasia institutions. These psychiatric institutions had been cleared of their former inpatients and were equipped with gas chamber installations and incinerators. Upon their arrival, the patients were immediately undressed and presented to the physician. He had the medical records and a copy of the form in front of him, and had to make the final decision on the basis of these documents and his personal impression. The patients, for whom euthanasia was ordered were photographed and then escorted to the gas chamber. In this room, which was deceptively equipped with false showers, were pipes which allowed the entry of gaseous carbon monoxide. After all patients were assembled in the room, the physician turned an the gas for about ten to fifteen minutes and observed the effect through a window until the patients appeared to have died. After about one hour, the corpses were taken out and then burnt in the incinerators.

In August 1941, this procedure, which of course could not be kept hidden from the public, was suspended. Numerous protests by the patients’ relatives, by publicly-known representatives of the churches, but also from within the party, for example by the minister of justice and by Himmler, led to the suspension. During this first phase, 73.000 patients died. In the Hadamar institution a celebration was held on the occasion of the 10.000th incineration.

How did these transports take place in the individual hospitals? Regarding the hospital in Kaufbeuren, Nurse R., a member of a religious order, reported in 1948: “Until August 1940, the patients were respected. They were well taken care of, and the director tried to improve their physical and mental health as best he could. But all of a sudden this changed. When I returned from my vacation in August 1940, eleven of the patients on my ward F 3 b, where primarily calm patients stayed, were gone. No one knew at that time where they had been taken. We believed they had been transferred to an asylum where they would be well cared for. But when, on Nov. 8, 1940, the second transport of women disappeared, and when later their clothes and underwear were returned in an incredible state — it appeared as if the underwear and clothes had been ripped off the patients — we became suspicious. The third transport of female patients occurred on Dec. 9, 1940.

It was especially difficult for us nurses to deliver these patients, for whom we had cared for many years, like cattle into an almost-certain death. The personnel of the buses from Berlin were rough and frightening characters, partly women, partly men. They grabbed the patients roughly and tied them down in the cars, sometimes even with chains. I had the impression that they were disguised SS people. The ambulance cars did not arrive at the main entrance, but came before dawn, collected the patients in the inner yard of the so-called country house, and left the hospital before daybreak. The patients gradually suspected what was going on, got terribly frightened and cried and screamed at times. The selection of patients took place according to lists that were on hand in the office of the inspector. Many patients suspected their fate in advance. One female patient who was transferred from ward F 3 b to the so-called country house, from where the transports departed, said: “Now I know what is ahead of me”. Prior to her transfer, she asked for a good-bye pancake and went to confession. During confession, she cried bitterly. Some time after her deportment, her sister was notified that the patient had died as a result of dysentery.”

The uneasiness among the personnel grows; nurses try to persuade relatives to take their patients home, which in several cases occurs. Many relatives receive the following letter: “This is to inform you that your son, in connection with economically-necessary measures for the clearance of patients from some facilities, has been transferred to another institution unknown to us. The patient transfers have been ordered centrally according to instructions from the National Secretary of Defence. The hospital has absolutely no influence concerning the transfer or non-transfer of its patients. You will be notified about the condition of your son by the receiving institution at an appropriate time.”

Many relatives, deeply worried and suspecting the real reason for the transfer, wrote the director of the hospital, for example, this mother: “I received your letter today just as I was about to take the noon train to the hospital to visit my dear child. I was terrified by such a letter almost to the point of paralysis, which is really a horrible thing for a mother. If I would have known that my daughter would be pushed around again to some other place, I would have insisted on taking my child home.

I would not have minded the work. As you tell me, you don’t know where my child has been brought to. You surely wouldn’t let a child leave your hospital without knowing where it is being transferred to, and so I absolutely want to know where she has gone. The hospital is the place where I thought she would be taken care of best. In the beginning, when my child was first admitted, I was very worried because many people twisted my mind with horrible tales. But after visiting my dear child Elizabeth many times, I thought my fears had been in vain, that it wasn’t the way people had said. My belief so far had been that the girl was in good hands with you. I want you to bring my child back to your hospital; I will assume the responsibility for this and will then be able to visit her again. It is impossible for me to inform my relatives about this; they would all criticize me too much as a mother for not knowing where my daughter is. At present I cannot do anything; I first have to know where she is. As I already mentioned, I can’t believe you would give a child away without asking the parents first. If anything should happen to the girl, we would surely be able to have her buried; I am always so afraid because the girl is so weak.” Her letter remained unanswered.

These transports were suspended in August 1941 and the first phase of the nationwide euthanasia program was ended. It was replaced by a second plan of action which was carried out in the psychiatric hospitals. After 1945 the director of an asylum in Bavaria stated the following: “In November of 1942, all hospital directors in Bavaria were summoned to a meeting at the Ministry of the Interior, Department of Health, in Munich. The meeting was immediately declared to be a state secret. The chairman then declared that far too few patients were dying in the asylums and that it was unnecessary to treat many of the diseases that occurred. The director of the asylum in Kaufbeuren then gave a brief talk on his own practice: initially, he had been opposed to euthanasia, but then he had become informed about the official program, and now regretted the abolishment of euthanasia. In his own asylum, he was now giving the patients that would formerly have been selected for euthanasia an absolutely fat-free diet, emphasizing the words fat-free. Within three months, these patients died of starvation. He recommended this procedure to all asylums as being in keeping with the needs of the present. Thereupon, the chairman ordered the introduction of this so- called starvation diet in all asylums, and stated that there would be no written order, but that the asylums would be checked for adherence to this command.” The director of another asylum reported on the same conference: “When the specific diet recommendations were presented, all the directors who were present, with the exception of two, behaved in a very reserved way. The Secretary of the Interior closed the conference with the recommendation that a fat and vitamin-free diet — I remember this formulation exactly — be introduced in all asylums. He did not give an explicit order, but he was obviously demanding that this was to be done. It was clear to me that the introduction of the diet “recommended” by the Secretary of the Interior was meant to promote the death of the patients that were no longer productive, and thus to provide a replacement for the former euthanasia program. I myself have never introduced this diet in my asylum.” He added to this statement that, in his opinion, the supply difficulties due to the war did not warrant such a measure, which would cause the liquidation of a part of the patient population.

A male nurse reports: “As far as I can remember, the so-called E-diet was introduced in 1943. It consisted of black coffee or tea for breakfast and boiled vegetables for lunch and dinner; for example, stinging nettle spinach, cabbage or potatoes. Intermittently, the patients on the E-diet were allowed to eat quite a lot, so that we nurses said to each-other that the patients would be nourished better if the food was distributed more evenly. But as it was the patients on the E-diet had to suffer on the one hand from severe hunger, and on the other, had their stomachs suddenly overloaded, so that they were not only affected by the insufficiency of their diet but also by the irregular feeding pattern. Therefore, we nurses suspected that this system was intended to damage the patients and promote their death.”

The director decided which patients were to be put on the E-diet and the implementation of these orders was checked up on by the administration. Another male nurse reports: “With regard to the E- diet, I can repeat the following, which was told to me by the kitchen nurse: at one time, there were two pots of meat broth in the kitchen. The nurse begged the administrative inspector to be allowed to serve the broth to the patients on the E-diet, since they were almost assaulting each other due to hunger. He started to shout and curse — one could even say scream — that he would rather spill the broth into the trash dump than give it to the patients on the E-diet.”

The hospital clergyman reports: “I would like to illustrate the cynical character of the people in charge by the fact that the patients on the E-diet, who for months did not get any meat, were given meat on Ash Wednesday and Good Friday.”

Nurses report that they tried to give food to patients secretly; relatives were urged to send food parcels, which was strictly forbidden, according to later statements by hospital personnel to the legal investigators. The E-diet, which was adhered to until the end of the war, increased the mortality rate in the hospital by a large factor. In 1943, 1944 and 1945, a total of 1808 patients died in Kaufbeuren. The free beds were immediately filled by patients from other psychiatric clinics which were cleared to be used for different purposes, and also by so-called “Eastern workers” (Ostarbeiter), Russian, Polish and Baltic forced labourers, who had become mentally ill in the camps where they had been interned. A directive from Berlin expected from the directors to stop any treatment if the patient was unable to return to work within four weeks. This meant death.

In 1944, a new form of euthanasia was introduced. A nurse reports: “I had been working for 15 years in the Berlin-Buch asylum when I was ordered, around Christmas of 1939, to report to the Columbus House in Berlin with enough clothing for four weeks. On the order, it was stated that would then be sent to work outside of Berlin for several months. In the Columbus House, we — 23 persons in all — were informed that the “Fuehrer” had promulgated a law to do away with mental patients. We were further informed that this law could not be published because of the war situation. Our task would not be to kill the patients, but rather, would be of a purely nursing nature.

We then had to swear an oath to the “Fuehrer” and oblige ourselves under penalty of death to keep silent. We had to sign a paper regarding this obligation. Neither I nor any of the other persons present tried to reject this obligation. From the Columbus House, I was brought directly to Grafeneck near Muensingen, where I stayed from January until December, 1940. After the closure of the Grafeneck asylum, I was transferred to the Hadamar asylum, where I was on duty until May, 1943. In mid-April, 1944, I was transferred to the Kaufbeuren asylum with orders to euthanasize mentally ill patients. In Kaufbeuren, I reported to the hospital director, who told me that he had especially asked for nurses from Berlin to perform euthanasia in Kaufbeuren. He said that he had very many chronically-ill and infectious patients, and that it would be my task to medicate these patients under his guidance. According to the obligations that I had been placed under, it was clear to me that the medications would have the purpose of liquidating the patients. However, I did not consider this to be murder, but rather, an assistance to death and a release from suffering. I was put in charge of the female ward on the first floor of the building. All the patients transferred to the so- called country house on doctors’ orders were destined to be euthanasized. However, they were not all euthanasized, but rather, the director made another selection after an observation period, so that two patients were in fact discharged and perhaps several others were transferred back to the main building. These were special cases due to the fact that patients from other asylums were directly admitted to the country house, and it was later found that some of them could be excluded from euthanasia. I was ordered to euthanasize patients by the director during rounds or by the office of the administrative inspector. When confronted with the number of 254 euthanasized patients now, I must say that this large number surprises me, but that I cannot deny it, since I did not keep my own records. The patients were given Luminal or Veronal and sometimes Trional in pill form, as well as Luminal and Morphine-Scopolamine in liquid form. Morphine-Scopolamine was given when Luminal or Veronal alone did not yield the desired effect. The quantity and dosage of the medication given to the patients for whom euthanasia had been ordered was my own responsibility.

However, the doctor in charge usually controlled the course of each death, and often asked me what I had given to the patients. The director was generally not interested in this. I usually started with two 0,3 Luminal pills a day and augmented this dosage according to the course of the “illness”. The final result of this medication was a deep leaden sleep from which the patients never woke up. Death sometimes occurred very quickly, as early as the first day, but mostly on the second or third day. I received the medication supply from the director, who handed it directly to me, sent it to me, or else I collected it at the office of the administrative inspector.”

From the interrogation protocols, we can conclude that all clinical personnel knew about this action. It is reported that some nurses tried to hide patients during the director’s rounds out of fear that they would be put “on the list”. From witnesses’ reports we know that patients themselves were aware of the nature of these wards. Some of the working patients had to bring the corpses to the cemetery, and for some time had to dig the graves, until a crematorium was built. The hospital priest reports: “When, in 1944, several funerals were held on the same day and each corpse was brought individually to the distant cemetery, and for each funeral the cemetery bell was rung, so that the whole procedure lasted for hours, I was told by the administrative inspector on the order of the director to stop ringing the bells in the future, in order not to attract attention. Since I did not give in, we compromised on ringing the bells only once on the occasion of the first funeral. I was even asked to go to the cemetery in ordinary clothes and inconspicuously, but I refused. From then on, the corpses were already brought to the cemetery before the funeral procedure, or three coffins were brought there simultaneously. Moreover, the patients were no longer allowed to walk behind the hearses to the funerals as before.” The priest also states that, by ringing the bells, he wanted to alert the population to these intolerable circumstances; given that the community was in such close contact with the hospital, one has to assume that they knew what was happening anyway.

Anonymous postcards were sent to the clinic protesting against the procedures in question. These postcards served as reminders for the few nurses directly involved with these procedures of their obligation to keep silent, as well as to an “improvement” in the E-diet for a short while.

The difficult situation of the hospital priest is apparent in the following statement: “As early as May, 1944, I learned that a new crematorium was going to be built in Kaufbeuren, and I was rightfully concerned that a new chapter of destruction would begin. I pleaded for the Catholic patients so that their relatives would be able to request burial rather than cremation, and the administrative inspector stated that such a request would be granted. Indeed, I was able to save deceased Catholic patients from incineration in November and December after the inauguration of the crematorium on November 9, 1944. But after January 1, 1945, only those patients were buried for whom there was a written request in their records; however, given the postal situation at that time, a request could not arrive in time for patients from the Rhine Valley or from Baden.”

Little is known about the number of Jewish patients killed in this period. From our research in Bavaria we know that some Jewish patients were killed together with the other patients during the first euthanasia phase. On the 4th of September, 1940, all Bavarian hospitals were addressed by the Minister of the Interior to transfer all Jewish patients to the central Munich psychiatric hospital. This was done immediately and on the 20th of September, 14 days later, 193 Jewish patients were transported to an unknown destination. Some weeks later relatives were informed that the patient had died in the hospital of Cholm/Poland, a concentration camp as we know today. We don’t know the background of this decision; the whole history of the Jewish patients has not been written yet. The director of the Munich hospital answered in a letter to a complaining relative: “The transfer (of the Jewish patients) has not only administrative reasons, but it makes sense in so far as many arian patients and nurses repeatedly refused to share the same hospital with Jewish patients.”

Special units for children were opened in several psychiatric hospitals. Children, mostly suffering from a mental handicap were transferred to these units and killed with opiate and barbiturate injections.

I am sure that more chapters of this terrible story have to be written in the future. It is only in the last years that we have learned of human experiments being conducted with psychiatric patients, e. g. the Schaltenbrand (Shevell a. Evans, 1994, and v. Cranach, 1999) experiments, or the involvement of the pharmaceutical industry (I.G. Farben) in testing drugs on patients. In this second phase 110.000 patients died, the total amount of victims between 1939 and 1945 mounting to 180.000.

Why did psychiatrists kill their patients?

Klaus Dorner, one of the main researchers in this field, has presented the idea that a main motivation of the perpetrating doctors was their therapeutic overactivism, to cure the curable and kill the incurable, so as not to be confronted with their failures. This explanation has some plausibility as some of the most active perpetrators were the leading psychiatric reformers in the twenties and early thirties. But there are several arguments refuting this hypothesis. The main argument against this explanation being that the killing of patients was not a medical act, not euthanasia in the strict medical sense, no “mercy killing”. It was carried out in a most brutal, dehumanising manner, with no perceivable signs of compassion and dignity. With “unrestrained brutality, viciousness and lust to murder” to use Mitscherlich’s (1960) words.

Let me quote two examples. Let us look at a typical case note to reveal the quality of the doctor-patient, in this case doctor-victim relationship.

Ernst L. was 13 years old when he was admitted to Kaufbeuren in 1942. He was transferred here from an institution for juvenile care in Upper Bavaria, since he had been found to be unmanageable there and a psychiatric evaluation was desired. There is no life history either in this psychiatric evaluation or in his medical records. The evaluator: “L. is of average intelligence, he is unclean, an untidy boy; he has practically no sense of personal hygiene or cleanliness of his clothing. He apparently has a pathological addiction to steal, since he takes everything he sees without reflection or reason. His guardedness and dishonesty are typical of him. He only admits a mistake when confronted with it. When interrogated, his undutiful and aggressive attitude is especially notable. He is not without some good will. After each misdeed, he promises improvement, but his will is too weak as opposed to his negative disposition. He endangers his peers by telling dirty stories.

Towards adults, he behaves respectfully but dishonestly. He performs practical tasks well as long as he is supervised. As soon as one’s back is turned, however, he stops working and becomes mischievous. This completely unreliable boy represents a danger to the public and must be kept in custody. His continued presence in the center for juvenile care would be intolerable in the long run; it would be desirable to find another place for him soon. It can no longer be responsibly tolerated that the orderly upbringing of an entire group be adversely affected by such an extremely abnormal and antisocial boy, for whom no success in improvement of his character is to be expected.”

The medical records from the last year of his life: June 10, 1943: “A lively, crafty boy, full of small outbreaks of spite and malice, appears arrogant and impudent, while trying to dominate. Tends to be discontented and negativistic. He needs to be handled with strictness; considers friendliness as weakness.”

July 25, 1943: “Easily irritated, helps the ward nurse in small ways, unstable, alternates between a lively, labile mood and a sullen ill humour, steals what he sees, takes advantage of small weaknesses in his environment, difficult to treat.”

Dec. 9,1943: “A recent attempt to put him to work was quite unsuccessful. He stole what he could, was especially interested in keys, got into the apple cellar, distributed apples to other patients. Lies chronically, is thievish and brutal. Considering his clearly antisocial nature, he can nolonger be used for housework.”

July 8,1944: “New attempt to put him to work failed. L. began to steal, hid, caused trouble, was mischievous.”

Aug. 9, 1944: “Exitus.”

Another example. The director of the psychiatric hospital Haar near Munich declared the following during his interrogation after the end of the war: “In our opinion, only those patients were eligible for euthanasia for whom there was no hope of improvement; for example, absolutely untreatable schizophrenics, severe cases of idioty and hopeless cases of organic psychoses. These were the cases in the ward for incurables, who were completely unable to take care of themselves and needed constant professional care on a locked ward. We psychiatrists refer to these patients as asocial.”

These examples show that doctors stopped seeing patients as patients, instead they describe their victims with common value judgements. They devaluated them, they made them “unworthy” (“unwert”) in order to be able to kill them. They did not kill patients, they did not act in the role of doctors, they acted as citizens killing “unworthy life”.

This can be further shown by looking at the concrete circumstances in which the killing took place. A nurse reported after 1945 about the death of Ernst Lossa: “Lossa, who was aware of the cases of unnatural deaths, who also might have seen that the sick were given special injections or tablets; was obviously selected to be removed. He himself sensed that he must soon die. Lossa was well liked by all the nurses because of his character, despite his stealing talent. On the afternoon of August 8th, 1944, in the garden of the institution, he gave me a photograph of himself with the inscription “in memory”. I asked him why he gave me the photograph and he said he believed he would no longer live a long time. He told me he would like to die as long as I was still there, because Lossa knew that I would put him in a coffin in a orderly way. Heichele had the night shift in the week in question. When I came into the patients room early on the morning of the Aug. 9th, I noticed that Lossa was not in his bed. I found him then in the children’s ward. I was shocked when I looked at him. His face was coloured blue-red, he had foam, around the mouth and neck, he looked as if powdered, he breathed with great difficulty. When I spoke to him he did not react anymore and in the course of the day at about 4 p.m., he died without regaining consciousness.”

Four weeks after the capitulation the Americans inspected for the first time the hospital. I quote from the report of an American officer: “When asked to see the second doctor in charge investigators were nonchalantly informed that the had hanged himself the night before. No one seemed to be aroused or emotionally upset at his violent end. Such was the callous attitude the doctors and nurses had for violent death. Observers found, in an uncooled morgue stinking bodies of men and women who had died days before. Their weight was between 26 and 33 Kilos. Among the children still living was a 10 year old boy whose weight was less than 10 Kilos and whose legs at the calf had a diameter of 2 1⁄2 inches. Informant stated that tuberculosis and other disease are rampant. Scabies, lice and other vermin were encountered throughout, linen was dirty and quarantine measure non-existent upon investigators’ arrival. The attitude of one doctor towards the women patients in one ward, who were partially demented but not dangerous, was especially worthy of note. When they rose in military fashion upon his arrival this second chief of the institution pushed them aside to clear his way from the staircase. When investigators gave this Doctor a push and, in a friendly manner asked the patients to disregard him and sit down, they all were sane enough to laugh hoarsely and enjoy the change of status.”

These last examples don’t describe medical situations. The curable-incurable hypothesis is only a marginal explanation. R. J. Lifton (1986) saw the key to understanding how Nazi-doctors came to do the work of Auschwitz in the psychological principle of “doubling”. A “Faustian bargain” dividing the self in a part responsible for victimisation and mass murder in exchange of the self becoming the implementer of a cosmic and utopian scheme of racial cure. Reading the biographies of the euthanasia actors some doubts appear about the appropriateness of this second part of the bargain. Was it really the concrete Nazi utopia for which they sold their soul, or was it a deeper and abstract feeling of being a part of the whole, being redeemed of individual limitation, becoming immortal, so to say.

Let us look at the doctors themselves which committed these crimes. In the meanwhile we know detailed biographic facts of many of the perpetrators, a biography was published of Dr. Faltlhauser (Potzl, 1995), the director of my hospital. The most striking and disturbing conclusion from this research is the fact that the main doctors responsible for these actions were not persons with an abnormal personality coming to power in an abnormal historical situation. This would be all in all a somehow comforting explanation. Instead they were cultivated, well educated, humanistic individuals with a high professional level, persons, as I would say in Germany, like you and me.

What must happen, under what conditions do persons behave in such a way? How would I have behaved? This is an extremely important question to answer, especially if we want to learn from the past to build our future. Let us ask Dr. Faltlhauser what his motivation was. He wrote in 1945 after the end of the war the following sentences: “The euthanasia of the mentally ill was carried out on the grounds of a decree by the “Fuhrer”. This decree was not only a specially binding condition, but is was also duty. The decree was the result of a hearing and was released with the agreement from the Reich’s-Ministry of the Interior and the Reich’s-Ministry of Justice. The decree had legal force. It was supported by a special law, which was unpublished, but is was declared to be binding.”

“I am a civil servant with a service time of 43 years. As a civil servant I was educated to absolutely follow the prevailing orders and laws, therefore also to consider the Euthanasia Decree as a law. In each instance there was an order because of a conscientious examination of the special case by a specialist. Here I wish to clearly interject, that I, as nearly all German directors of psychiatric hospitals, had nothing to do with the first realisation of the decree. I always dealt in the good faith of the dictates of humanity, and in the absolute conviction to do my duty in following the legal and lawful conditions. [...] My actions were not made with the intention of a crime, but in contrast they were made with the consciousness to deal mercifully with the unhappy creatures, with the intention of freeing them from their suffering where there is no known method to save, or to relieve, therefore to act with consciousness as a true and conscientious doctor. He who has experienced the terrible fate of sinking to the level of an animal in hundreds and hundreds of cases during a long service for the mentally ill only he knows really how to understand that euthanasia cannot be an offence against humanity, rather the opposite.”

A nurse formulated the same in other words: “I pitied the patients and was not asked whether I wanted to or not; I had to follow the doctors’ order. I felt obliged to abide by my oath of duty. When I am now told that my oath of duty only obliged me to keep silence, but not to actually kill, then I answer that someone had to do it and the doctor said I was the one who had been chosen. The doctor trusted me to carry out his orders.”

We recognised an extremely hierarchical system. So hierarchical as to exempt its members from all moral responsibility. The chain of responsibility ends with the “Fuhrer”, to whom everything is delegated. Rosenberg, a main Nazi ideologist, used a metaphor which exemplifies it better than many words. He said: “The new German style [...] is the style of a marching column, no matter where, or to what end, this marching column may be directed.”

The atrocities committed, the suffering and death where not perceived as consequences of one’s personal actions. Not acting individually renders superfluous the individual conscience. Giving up one’s individual conscience leads to, as Bettelheim (1982) said, a dangerous state of inner peace, which, in the absence of ambiguities, autocriticism, moral control, produces evil. Hannah Arendt (1963), witnessing the Eichmann trial, spoke of the banality, the commonness, the omnipresence of evil arising from a totalitarian system. This peace, the feeling of security and all embracing membership, the giving up of the conscience, the “marching in a column” as result of the totalitarian system are paid for with the death of the soul.

The events we have spoken about today are, as the Holocaust, an extreme example of how men can act when unchained from their conscience and their soul. As doctors, this is the lesson I have learned, we must learn to be extremely critical of utopian visions, recognise with humility our limits, be always aware that there is nothing beyond personal responsibility, and see the well being of the individual patient as the only goal of our professional actions, and first and foremost to preserve and nurse our conscience.

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Paper presented at a meeting of the Israel Psychiatric Association, Jerusalem, 6th of December 2001