Forced sterilization in Germany was the forerunner of the systematic killing of the mentally ill and the handicapped. In October 1939, Hitler himself initiated a decree which empowered physicians to grant a “mercy death” to “patients considered incurable according to the best available human judgment of their state of health.” The intent of the socalled “euthanasia” program, however, was not to relieve the suffering of the chronically ill. The Nazi regime used the term as a euphemism: its aim was to exterminate the mentally ill and the handicapped, thus “cleansing” the “Aryan” race of persons considered genetically defective and a financial burden to society.
The idea of killing the incurably ill was posed well before 1939. In the 1920s, debate on this issue centered on a book coauthored by Alfred Hoche, a noted psychiatrist, and Karl Binding, a prominent scholar of criminal law. They argued that economic savings justified the killing of “useless lives” (“idiots” and “congenitally crippled”). Economic deprivation during World War I provided the context for this idea. During the war, patients in asylums had ranked low on the list for rationing of food and medical supplies, and as a result, many died from starvation or disease. More generally, the war undermined the value attached to individual life and, combined with Germany's humiliating defeat, led many nationalists to consider ways to regenerate the nation as a whole at the expense of individual rights.
In 1935 Hitler stated privately that “in the event of war, [he] would take up the question of euthanasia and enforce it” because “such a problem would be more easily solved” during wartime. War would provide both a cover for killing and a pretext—hospital beds and medical personnel would be freed up for the war effort. The upheaval of war and the diminished value of human life during wartime would also, Hitler believed, mute expected opposition. To make the connection to the war explicit, Hitler's decree was backdated to September 1, 1939, the day Germany invaded Poland.
Fearful of public reaction, the Nazi regime never proposed a formal “euthanasia” law. Unlike the forced sterilizations, the killing of patients in mental asylums and other institutions was carried out in secrecy. The code name was “Operation T4,” a reference to Tiergartenstrasse 4, the address of the Berlin Chancellery offices where the program was headquartered.
Physicians, the most highly Nazified professional group in Germany, were key to the success of “T-4,” since they organized and carried out nearly, all aspects of the operation. One of Hitler's personal physicians, Dr. Karl Brandt, headed the program, along with Hitler's Chancellery chief, Philip Bouhler. T-4 targeted adult patients in all government or church-run sanatoria and nursing homes. These institutions were instructed by the Interior Ministry to collect questionnaires about the state of health and capacity for work of all their patients, ostensibly as part of a statistical survey.
The completed forms were, in turn, sent to expert “assessors”—physicians, usually psychiatrists, who made up “review commissions.” They marked each name with a “+” in red pencil, meaning death, or a “-” in blue pencil, meaning life, or “?” for cases needing additional assessment. These medical experts rarely examined any of the patients and made their decisions from the questionnaires alone. At every step, the medical authorities involved were usually expected to quickly process large numbers of forms.
The doomed were bused to killing centers in Germany and Austria walled-in fortresses, mostly former psychiatric hospitals, castles, and a former prison—at Hartheim, Sonnenstein, Grafeneck, Bernburg, Hadamar, and Brandenburg. In the beginning, patients were killed by lethal injection. But by 1940, Hitler, on the advice of Dr. Werner Heyde, suggested that carbon monoxide gas be used as the preferred method of killing. Experimental gassings had first been carried out at Brandenburg Prison in 1939. There, gas chambers were disguised as showers complete with fake nozzles in order to deceive victims—prototypes of the killing centers' facilities built in occupied Poland later in the war.
Again, following procedures that would later be instituted in the extermination camps, workers removed the corpses from the chambers, extracted gold teeth, then burned large numbers of bodies together in crematoria. Urns filled with ashes were prepared in the event the family of the deceased requested the remains. Physicians using fake names prepared death certificates falsifying the cause of death, and sent letters of condolences to relatives.
Meticulous records discovered after the war documented 70,273 deaths by gassing at the six “euthanasia” centers between January 1940 and August 1941. (This total included up to 5,000 Jews; all Jewish mental patients were killed regardless of their ability to work or the seriousness of their illness.) A detailed report also recorded the estimated savings from the killing of institutionalized patients.
The secrecy surrounding the T-4 program broke down quickly. Some staff members were indiscreet while drinking in local pubs after work. Despite precautions, errors were made: hairpins turned up in urns sent to relatives of male victims; the cause of death was listed as appendicitis when the patient had the appendix removed years before. The town of Hadamar school pupils called the gray transport buses “killing crates” and threatened each other with the taunt, “You'll end up in the Hadamar ovens!” The thick smoke from the incinerator was said to be visible every day over Hadamar (where, in midsummer 1941, the staff celebrated the cremation of their 10,000th patient with beer and wine served in the crematorium).
A handful of church leaders, notably the Bishop of Münster, Clemens August Count von Galen, local judges, and parents of victims protested the killings. One judge, Lothar Kreyssig, instituted criminal proceedings against Bouhler for murder; Kreyssig was prematurely retired. A few physicians protested. Karl Bonhöffer, a leading psychiatrist, and his son Dietrich, a Protestant minister who actively opposed the regime, urged church groups to pressure church-run institutions not to release their patients to T-4 authorities.
In response to such pressures, Hitler ordered a halt to Operation T-4 on August 24, 1941. Gas chambers from some of the “euthanasia” killing centers were dismantled and shipped to extermination camps in occupied Poland. In late 1941 and 1942, they were rebuilt and used for the “final solution to the Jewish question.” Similarly redeployed from T-4 were future extermination camp commandants Christian Wirth, Franz Stangl, Franz Reichleitner, the doctor Irmfried Eberl, as well as about 100 others—doctors, male nurses, and clerks, who applied their skills in Treblinka, Belzec, and Sobibor.
The “euthanasia” killings continued, however, under a different, decentralized form. Hitler's regime continued to send to physicians and the general public the message that mental patients were “useless eaters” and “life unworthy of life.” In 1941, the film Ich klage an (I accuse) in which a professor kills his incurably ill wife, was viewed by 18 million people. Doctors were encouraged to decide on their own who should live or die. Killing became part of hospital routine as infants, children, and adults were put to death by starvation, poisoning, and injections. Killings even continued in some of Germany's mental asylums, such as Kaufbeuren, weeks after Allied troops had occupied surrounding areas.
Between the middle of 1941 and the winter of 1944–45, in a program known under code “14f13,” experienced psychiatrists from the T-4 operation were sent to concentration camps to weed out prisoners too ill to work. After superficial medical screenings, designated inmates Jews, Gypsies, Russians, Poles, Germans, and others were sent to those “euthanasia” centers where gas chambers still had not been dismantled, at Bernburg and Hartheim, where they were gassed. At least 20,000 people are believed to have died under the 14f13 program.
Outside of Germany, thousands of mental patients in the occupied territories of Poland, Russia, and East Prussia were also killed by the Einsatzgruppen squads (SS and special police units) that followed in the wake of the invading German army. Between September 29 and November 1, 1939, these units shot about 3,700 mental patients in asylums in the region of Bromberg, Poland. In December 1939 and January 1940, SS units gassed 1,558 patients from Polish asylums in specially adapted gas vans, in order to make room for military and SS barracks. Although regular army units did not officially participate in such “cleansing” actions as general policy, some instances of their involvement have been documented.
In all, between 200,000 and 250,000 mentally and physically handicapped persons were murdered from 1939 to 1945 under the T-4 and other “euthanasia” programs. The magnitude of these crimes and the extent to which they prefigured the “Final Solution” continue to be studied. Further, in an age of genetic engineering and renewed controversy over mercy killings of the incurably ill, ethical and moral issues of concern to physicians, scientists, and lay persons alike remain vital.