In the period leading up to the Second World War, and during the war itself, the medical profession in Germany was instrumental in the institution of a system which identified, transported and killed human beings either mentally ill, physically deformed or “racially and cognitively compromised” (Strous, 2006, p30). The role of psychiatric medicine was central and critical to the success of Nazi ideology rather than marginal or incidental. Psychiatrists played a central and intimate role in the facilitation of crimes against humanity. This paper will explore and try to explain some of the complex issues involved in an effort to understand a shameful, tragic interval in medicine.

Dissection of the motives and activities of doctors, especially psychiatrists, as they existed under a regime and in a society labelled as the “banality of evil” (Arendt, 1977, p135), indicates they were a product of a destructive society whose ideology they not only colluded with, but helped mould. Their rationalisations were based on corrupt ethics and faulty scientific theory which applied invalid conclusions from evolutionary biology. As a profession their philosophical constructs were flawed and immoral, contravening basic tenets of medical practice (Reinhardt, 1990, p645-647).

How did the medical profession reconcile their traditional beneficence role with a mandate of genocide in a country with supposedly the best standard of medicine, and ethics, in the world at the time (Hassenfeld, 2002, p184)? How did, arguably, the finest medical institutions in the early 20^th Century which were advancing medicine, medical science and medical education, become part of the worst program of organised mass destruction in the history of mankind (Seidelman, 2000, p331)? These complex ethical issues are difficult to comprehend but it is from this dark period of medical and human history that our modern views of human rights and medical ethics have evolved (Gostin, 1997, p1785).

The eugenics movement is critical to the understanding of why the medical profession and psychiatrists in particular, played a pivotal role in the evolution of the sterilisation and euthanasia programs of Nazi Germany (Hassenfeld, 2002, p186).

Eugenics
The British Biologist Francis Galton in 1865 first published the idea of eugenics and used the term in 1883 to describe the process of strengthening the human race through selective breeding (Sofair and Kaldjian, 2000, p312). “Social Darwinism” became popular throughout Europe and North America by the end of the 19th century with the United States at the forefront of the eugenic movement (Baumslag, 2005, p35). This large international movement was galvanised by revolutionary advances in medicine, particularly the new science of human genetics, with utopian views of perfecting humanity by manipulating hereditary characteristics (Bashford and Levine, 2010, p339).

Euthanasia was given support in 1895 when state initiated killing was advocated in a book published in Germany called “the Right to Death” (Hassenfeld, 2002, p187). Eugenics was a well accepted concept in America in the early years of the 20^th century but euthanasia lost favour after a vigorous public debate following an attempt to legalise euthanasia in Ohio in 1906 (Stern, 2005, p212-213).   

In 1920 a German psychiatrist, Alfred Hoche, and a legal scholar and retired jurist, Karl Binding, published “Permitting the Destruction of Unworthy Life” as a solution to the economic burden of institutionalised mentally handicapped patients, virtually dismissing the Hippocratic Oath (Sofair and Kaldjian, 2000, p313). They argued that, as theirs was a “life not worth living”, their destruction was not only tolerable but humane (Hassenfeld, 2002, p188).

In 1921 the German Society for Race Hygiene, founded by psychiatrist Ernst Rudin, advocated a eugenics program to strengthen a nation in political, social and economic turmoil following its defeat in World War One (Proctor, 1998, p64). Unemployment, homelessness, starvation and infectious diseases were rampant. The political and economic crises overwhelming the government of the Weimar Republic was fertile ground for the German support of eugenics. Advocates of eugenic solutions to Germany’s problems included government officials and academics in biomedical fields. Doctors began developing the pseudoscience of racial hygiene to secure scant resources and not waste them on the “sick, disabled or inferior” (Hassenfeld, 2002, p101).

A government supported scientific institute that embodied the growing state interest in eugenics was the Kaiser Wilhelm Institute for Anthropology, Human Heredity and Eugenics founded in Berlin in 1927. It was directed by Eugen Fischer who became professor of anthropology in Berlin having already been appointed professor of anthropology at the University of Freiburg in 1918. He had previously tested his theories in German South West Africa using concentration camp survivors of the Herero rebellion for his medical experiments. Fischer openly advocated the extermination of mental patients, criminals and Jews (Baumslag, 2005, p31).

Psychiatrists were instrumental in forging eugenic policy, particularly Ernst Rudin, a highly respected psychiatric geneticist, who became director of the prestigious Munich Psychiatric Institute. This institute was considered to be a field leader in genetic psychiatry attracting visiting scholars from Britain, Sweden and America.

Rudin was the author of the official manual implementing compulsory sterilisation of individuals with psychiatric or hereditary disorders, including those deemed genetically inferior (Friedlander, 1995, p254). The sterilisation program was a critical link to euthanasia. It was one of the first laws promulgated by Hitler in July, 1933 and thus medicine became a driving force behind the application of eugenic principles (Strous, 2006, p31).

This was an era when science and the biological sciences in particular, were seen by many as holding solutions to the nation’s problems. Eugenics made racism respectable but the moral implications for the medical profession were significant. Eugenics treated individuals as a means to an end negating Immanuel Kant’s categorical imperative that people should be treated as subjects to be respected (Pilgrim, 2008, p279).

Eugenic thinking was incorporated into the ideology of the Nazi Party which transformed racial hygiene ideas, practices and institutions to fit their political agenda and mesh with their racial ideology (Kuntz, 2004, p9). Eugenic practices appeared in some other western countries, particularly America and Northern Europe (Stern, 2005, p212-213). In Britain the concept of euthanasia became acceptable in the 1930’s and “The Voluntary Euthanasia Legalisation Society” was founded by Charles Killick Millard (Bashford and Levine, 2010, p315-317). Rudin himself was invited as a plenary speaker to the World Congress of Genetics in Edinburgh in 1939 on the eve of World War Two.

Although eugenic practices occurred in other western countries, their regulations were generally varied and flexible. It was only in Germany however that forced sterilisation became public policy enshrined in law (Hassenfeld, 2002, p186). A progressively comprehensive program of sterilising those that were seen as “genetically flawed” was signed into law and undertaken (Hassenfeld, 2002, p186). This included homosexuals, the disabled, Jews and gypsies (Gostin, 1997, p1785) despite the law referring to supposedly inherited disorders and severe alcoholism.

The Nazi takeover resulted in a plethora of eugenic and specifically anti-Semitic legislation (Bashford and Levine, 2010, p338). The Nuremberg laws of 1935 were designed to racially “cleanse” Germany and excluded Jews from being German citizens (Gottesman, 1996, p319). This was a crucial step in their dehumanisation and subsequent portrayal as harbingers of infectious disease, especially typhus (Weindling, 2000, p278).

Medicine and Nazi Germany
Hitler asked the German medical profession to “address the race question” when he came to power. He rapidly took control of medical schools and public health departments as well as centralising the insurance and payment systems (Sofair and Kaldjian, 2000, p313). Hitler ordered Jewish doctors to be discharged from their government and university positions. Many academics that harboured anti-Semitic views collaborated with the Nazi regime, removing Jewish colleagues from academic positions and integrating anti-Semitic material into revised racial hygiene textbooks and lectures.

This forcible removal of older, established academics and practitioners, who were Jewish, resulted in the loss of a significant number of Germany’s medical leaders (Connors, 1990, p526). Jewish medical students were expelled and by 1938 the profession was largely “Aryanised”. Ambitious younger doctors joined Nazi causes to further their careers and their wealth. Financial incentives were added to Nazi promises to restore their perceived lost status under the Weimar regime. Joining the Nazi party encouraged a government sponsored practice (Sofair and Kaldjian, 2000, p313).

Instructions in eugenics became compulsory for medical students and by 1935 students were required to wear Nazi uniforms and undergo Nazi indoctrination. Biology, anthropology, philosophy and politics were combined into a frightening mixture of pseudoscience undermining bona fide medical education. Nazi medical propaganda was also directed at existing medical practitioners (Bloch, 1973, p301) and public health facilities increasingly became an instrument of Nazi ideology (Browning, 1992, p145).

Many doctors were attracted to Nazi ideology and the medical profession had one of the highest rates of party membership of any profession. By 1942 45% of German doctors were members of the Nazi Party (Ernst, 1996, p579). Medical practitioners were seemingly easily recruited, including those from the highest level of academic medicine, and it is estimated that the majority of the medical profession was involved in subsequent activities involving genocide (Drobniewski, 1993, p541).

The Nuremberg Laws of 1935 meant marriage had to conform to racial guidelines with certification issued by medical practitioners. In 1936 the “Section for Research on Race Hygiene and Population Biology of the German National Department of Health” was established under the direction of a psychiatrist, Robert Ritter, and a program of genetic and racial surveillance expanded rapidly (Hassenfeld, 2002, p186). The stigma of being Jewish was considered acquirable through contact with blood or through sexual intercourse, making sex and marriage between Jews and gentiles a criminal offence (Polsky, 2002, p176).

Doctors were broadly influenced by life under Hitler as much as the general population. This included writings permeated with biomedical metaphors identifying persons as subhuman and disease ridden (Connor, 1990, p526). These groups (Jews, Gypsies, homosexuals) were blamed for all manner of social ills as well as the poor state of the economy. Nazi medical theorists exploited and refined eugenic literature “documenting” differential racial susceptibility to disease with unwanted ethnic minorities stigmatised and cast as parasites (Proctor, 1995, p170-175).

The role of the media was pivotal and Nazi medical misinformation was heavily directed at existing medical practitioners. The use of propaganda was skilful in inspiring fear of the Jews with the perception of the threat of an international Jewish “conspiracy”. Racial hygiene, Aryan supremacy and the “sub humanity” of the Jews was widely publicised drawing on a background of smouldering European anti-Semitism. Medical practitioners were no less susceptible to these campaigns and indeed were frequently at the forefront of the development of such doctrines (Drobniewski, 1993, p542).

Doctors progressively became informers for the state and medical confidentiality, a mainstay of traditional Hippocratic practice, disintegrated in Germany (Browning, 1992, p145). Medical ethics, demanding that a doctor should always respect a patient’s autonomy and dignity, was lost (Horton, 2004, p1084). The traditional doctor-patient relationship, a universal cornerstone of medicine, had effectively been destroyed laying the groundwork for a logical progression from compulsory sterilisation to involuntary euthanasia and genocide (Gallagher, 1995, p94).

Capping this process of medical politicisation and professional disintegration was the impact of World War Two. Increasing civilian and military casualties created more demand for doctors who were speedily but poorly trained at Nazi infiltrated, and controlled, medical schools and research institutes.

Four theories offer differing perspectives to explain how medical practitioners came to endorse programs so at odds with their traditional beneficence roles (Dadrian, 1986, p182). The first argument is that there was a re-interpretation of medical ethics to coincide with the prevailing agenda – that eugenic and genocide policies placed the health of the state ahead of the individual. Secondly the “slippery slope” theory proposed that transgressions begin on a small scale and gradually build, particularly if there is empowerment under the law against medical, ethical and societal moral codes (Drobniewski, 1993, p542).

The third theory reflects motivation by fear of personal or professional harm. Doctors during the Third Reich may have faced internment in a concentration camp, or other disciplinary measures, if they failed to comply with state rules. Finally some doctors may have wanted to participate in genocide activities, either for personal or professional gain, or for “scientific” opportunity.

Clearly there were very few dissenters and critics within the medical establishment and there was almost no organised resistance from the medical profession. There were some rare individuals who refused to participate and even aided victims; the result was often arrest, incarceration and execution (Baumslag, 2005, p40). A small organisation of medical students, “The White Rose”, who denounced the regime and its unethical practices, were condemned by a Nazi “people’s court” and executed by beheading in public in February, 1943 (Kater, 1989, p168).

A decisive role was played by the law and judicial processes under the Third Reich. The diminution of sanctions with leniency to anti-Jewish atrocities, coupled with rewards of promotion and honour, were powerful supporters of genocide (Drobniewski, 1992, p542). The Nazi government enshrined in law the so called sub-humanity of Jews and other groups who could then be exploited for property seizure, slave labour and experimentation. The passing of these laws empowered medical practitioners and shifted the balance politically and legally toward euthanasia and genocide (Strous, 2006, p36).

Nazi Doctors in the Death Camps
Many neurologists, psychiatrists and neuropathologists participated in the sterilisation, euthanasia and experimenting programs on humans. Some of these doctors were chosen as personnel in charge of extermination in the concentration camps (Galende, 2008, p131).

Medical Practitioners supervised the daily “ramp” selections as well as the gas chambers. It was policy and practice that at least one doctor had to be present during executions by gas (Gostin, 1997, p1785). It was often doctors themselves who administered lethal injections and completed false death certificates whilst carrying out daily inspections in the camp infirmary (Strous, 2006, p30).

SS doctors also carried out unconscionable and ignominious medical experiments of the most barbaric kind in the concentration camps with deliberate disregard for these individuals in total contradiction of established medical ethics (Neuberger, 2005, p799). They plundered the remains of murdered individuals for university departments of anatomy and pathology as well as research institutes (Weindling, 2000, p358). The prominent neuropathologist, Julius Hallervorden, published a number of post war scientific articles using materials obtained in such a manner (Shevell, 2001, p164).

Apart from the substantial ethical issues, data collected from these appalling experiments was often of very questionable validity (Alexander, 1949, p30-41). Sigmund Rascher’s study on hypothermia was rejected by three German universities and much of the data was faked (Reinhardt, 1990, p646).

Eugen Haagen, a microbiologist, conducted “research” with a typhus vaccine at Natzweiler concentration camp leading to frequent numerous deaths and yet, when arrested for crimes against humanity, maintained his experiments served legitimate scientific ends. Haagen believed that anything was legitimate if it advanced scientific knowledge despite immoral behaviour and wilful disregard for human life (Neuberger, 2005, p799).

Psychiatric Practice and the Third Reich
The day World War Two commenced Hitler initiated a program of “mercy killing” planned well before the start of the war. This was devised by Karl Brandt, his personal physician and the supreme medical authority in Nazi Germany, as well as psychiatrists and administrators (Sofair and Kaldjian, 2000, p314). In fact the “licensing” letter signed by Hitler was probably written several weeks before the beginning of the war, but predated to the first day of World War Two.

It was carried out primarily in six main psychiatric institutions, in relative secrecy, supervised by psychiatrists under the overall direction of Werner Heyde, the Wurzburg Professor of Psychiatry (Gostin, 1997, p1785). Methods included starvation, injections and gassing (Proctor, 1988, p187).

Senior psychiatrists were involved in this process of murdering over 70,000 patients, including children, with medical and neurological disorders (Strous, 2006, p32). Brandt testified at the Nuremberg War Crimes Trials that the euthanasia program to eliminate disabled children was a natural outgrowth of the 1933 sterilisation law (Sofair and Kaldjian, 2000, p314). He did not appear insane or evil but presented what he thought was a rational argument constructed from his professional and social milieu.

Incredulously these psychiatrists conducted semi-private show tours of their institutions for thousands of Nazi personnel, both civilian and military, to illustrate the inherent “uselessness” and “subhuman” nature of the inmates (Burleigh, 1994, p217). After strong opposition by Protestant and Catholic Church leaders the program “officially” ended in 1941 but continued in a limited manner until the end of the war (Proctor, 1988, p191). In 1943 a macabre triage system was set up where institutionalised patients were increasingly killed to make room for bombing victims (Hassenfeld, 2002, p187).

The gas chamber model, disguised as a shower room and used in psychiatric institutions, was developed for large scale genocide operations in concentration camps aimed at the annihilation of individuals considered “biological threats to the German nation” (Strous, 2006, p32). The infamous Treblinka concentration camp was commanded by Imfried Eberl, a psychiatrist, who was instrumental in helping to establish the use of poison gas as a highly efficient method of killing (Strous, 20006, p33).

Why were German psychiatrists in particular, amongst the medical profession, so complicit in these atrocities?

Strous suggests that psychiatry, by its nature, will always incorporate contemporary ideology, and the current social environment, into individual treatment. Perhaps also influential in the German milieu was psychiatric involvement in aggressive military treatment practices dating from World War One to return “hysterical” soldiers quickly to combat duty (Strous, 2006, p35). Exhausted or “neurotic” German soldiers were medically terrorised back into conflict through crude, barbaric shock therapies (Burleigh, 1994, p214). This may have desensitised psychiatrists to their role in genocide.

Individuals with mental illness were seen as targets for eugenics and this concept already existed in the minds of many psychiatrists before Hitler came to power. Indeed racial hygiene was promoted by Eugen Bleuler, a respected German psychiatrist in the early 20th century (Strous, 2006, p34). The Nazi racial hygiene program, although morally and scientifically invalid, allowed the establishment of new institutes with increased funding for “research” with prominent psychiatrists taking leadership roles (Hassenfeld, 2002, p187).

The involvement of academic psychiatry further legitimised, in turn, the scientific basis for eugenic treatments. This then led psychiatrists to become involved in formulating pseudoscientific criteria to identify those human beings as “unworthy of living” (Bacharach, 2004, p419). Psychoanalysis was also perceived as “Jewish” and officially banned in 1938 in Germany.  Many psychiatrists regarded the emphasis on empathy in Freudian analysis as inconsistent with the growing genetic understanding of mental illness, underpinning the Nazi regime’s euthanasia policy (Lifton, 1986, p47-48).

Can the behavioural characteristics of doctors, and psychiatrists in particular, who were involved in genocide be determined? Can these individuals be identified, counselled and dissuaded from medical training?

An “authoritarian syndrome” has been described where some medical practitioners have a rigid connection to the conventional values of society and identification with the existing social order. Often there is associated aggression with a strict adherence to a moral or religious code and a strong belief they are more virtuous than others. These individuals are intolerant of minorities and submissive to a higher authority. Furthermore, they become more aggressive when they believe this authority vindicates their actions. A sense of belonging to a special group is a key feature making them feel elitist, self-righteous and morally superior (Drobniewski, 1993, p541-542).

In addition the quest for scientific advancement, unhindered by consideration of its source, combined with an environment of prejudice and bigotry, may decouple standard ethical medical behaviour (appendix 1). Others have suggested aggressive and violent behaviour is learned from one’s social group, together with the inhibitions that keep these behaviours in check (Drobniewski, 1993, p542). Clearly a number of these inhibitions were removed in Nazi Germany.

The core statement of existentialism is that a human’s actions are not determined by outside forces: the individual is free to make choices for which they are responsible. According to Sartre the social roles and moral systems humans adopt are for protection from moral accountability for one’s actions (Sartre, 1993, p160-169). German psychiatrists should have recognised the moral validity of their choices. Implicit in this would have been the constant need for reappraisal of their changing humanity (Sartre, 1993, p1640). Clearly this did not occur and, as Szasz has stated, “When the values underlying certain activities are widely shared, those who participate in their pursuit may lose sight of them altogether” (Szasz, 2004, p47).

Parsons discusses the motivational balance and the generation of an ambivalent motivational structure in a society. He also defines deviant behaviour as failure to fulfil the institutionally defined expectations of the roles in which the individual is implicated in society (Parsons, 1987, p147-150). Deviations from ideal behaviour involve value judgements and deviance in a group can assert a claim to legitimacy in terms of the value system of the society (Redlich, 1952, p553). I believe this prevailed in Nazi Germany distorting that society’s normative values which became racially prejudiced, bigoted and paranoid.

The deviance of German psychiatrists, in my view, helped the development of an abnormal social structure to become institutionalised under the Third Reich. They made little or no delineation between the mentally ill and the morally reprehensible, between the physically disabled and the ethically “unclean”. These psychosocial and ethical constructs were determined by German society under the influence of the Nazi regime.

Psychiatrists, as well as the medical profession as a whole, allowed the prevailing political system to influence and govern medical practice. They were impelled by pressure from peers, unquestioning obedience and racial ideology. Dissociation and denial were facilitated by deceptive language, bureaucratic proficiency and deviant notions of a “greater cause” (Dudley and Gale, 2002, p585-594).

Medical ethics as it existed in Germany prior to the Third Reich was sophisticated, however it became an example of how ethics training without a focus on history, and separated from a context of mature understanding and self reflection, is ineffectual (Strous, 2007, p5). Good ethical judgment cannot exist outside the fundamental tenets that all doctors must adhere to in order to prevent repeating one of the cruellest episodes of human history (Drobniewski, 2003, p53).

Fundamentally there was a breakdown in the doctor-patient relationship with medical practitioners, and psychiatrists in particular, becoming agents of the state rather than acting on behalf of their patients (Hassenfeld, 2002, p193). A doctor’s most important obligation is never to abandon their patient, and never to exploit a patient’s inherent vulnerability, but to safeguard them against harmful actions. This basic understanding was lost in Nazi Germany.

Psychiatrists were never ordered to murder but were legally empowered to do so and willingly, often enthusiastically, complied (Drobniewski, 1993, p542). Two of the major pillars of Western Civilisation, the law and medicine, had collaborated to create one of mankind’s bleakest periods. This remains an unfathomable paradox (Pellegrino and Thomasma, 2000, p262).

Lessons have been learned from this infamous period in medicine. There has been a dramatic change in medical ethics since the end of the Second World War and exposure of the events of the Holocaust (appendix 2). The improper behaviour of psychiatrists was based on several fundamental errors of scientific, professional and ethical conduct that have now been addressed by world declarations and agreements.

Germany’s economic crisis following World War One, together with the rise to power of radical nationalism, perverted the theoretical basis of the eugenics movement. Pseudoscientific genetic research became a misconstrued justification for improving the “Aryan Nation”. This came at the expense not only of the mentally ill and disabled, but of normal, healthy people classified as “subhuman” on the basis of so called racial hygiene. Scientific, ethical, legal and religious values were replaced by economic utility. Hitler’s regime gained significant control over the medical profession who willingly participated for financial and ideological reasons (Sofair and Kaldjian, 2000, p318).

From involuntary sterilisation to euthanasia and finally genocide, psychiatrists played a central and intimate role in the facilitation of crimes against humanity (Strous, 2006, p31). Subtle, scientifically framed versions of racism and anti-Semitism were presented by medically trained experts who developed and promoted Nazi policies, giving them legitimacy in the eyes of the German public. These policies were explicitly expressed in biological and medical terms.

The basic understanding of ethical medical practice was lost in Nazi Germany which, as a society, had reconstructed the definitions of mental and moral health. Paradoxically psychiatry was both central to the formulation of this construct, with its deviant normative values, as well as a product of it. The collusion of psychiatry with Nazi ideology, aided and abetted by a corrupt legal system, was a social and moral issue resulting in crimes against humanity.

Justice Robert H Jackson, reflecting on the Nuremberg Trials, stated: “The wrongs which we seek to condemn and punish have been so calculated, so indignant, and so devastating, that civilisation cannot tolerate them being ignored because it cannot survive them being repeated” (quoted by Gostin, 1997, p1785).

Medical ethics is never ethnic, cultural or time sensitive and a medical practitioner should always respect autonomy, beneficence and patient confidentiality with dignity (Horton, 2004, p2). The basis for ethical behaviour should remain constant, irrespective of time or place. Kant’s categorical imperatives to practice within a framework of moral judgement and to never treat a person as a means to an end, must never be breached, whatever the circumstances (Shell, 2003, pp55,72).

Political and economic pressures should not govern clinical practice nor should preventative medicine be instituted at the expense of treating illness. Philosophical constructs and ideas should never define clinical practice and the interests of science, whatever its quality, must never take priority over the interests of the individual patient (Strous, 2007, p2-3). Scientific advancement can never be freed from ethical consideration of the source of the data (Drobniewski, 1993, p542).

The Nuremberg Code of 1947 defined ten principles of medical experimentation including voluntary consent and minimising harm. The World Health Organisation in the mid 1960’s introduced the more extensive Helsinki Declaration and in 1979 the Belmont Report outlined the three central principles governing ethical research: autonomy, beneficence and justice.

Ethical guidelines for the practice of psychiatry were outlined in the Declaration of Hawaii in 1977 and updated in Vienna in 1983. The World Psychiatric Association, in the Declaration of Madrid in 1996, adopted a comprehensive code of professional behaviour for psychiatrists (Strous, 2006, p35-36).