The extermination of mentally ill and handicapped people under National Socialist rule

Cet article a été publié avec le soutien de la Fondation pour la Mémoire de la Shoah.

Abstract
Between 1939 and 1945 an estimated number of 300.000 mentally ill and handicapped people were murdered in the German dominion under the pretext of “euthanasia”. “Aktion T4” and “Aktion 14f13” are the best known aspects of this politics. The article describes the history of the idea of “life unworthy of life”, its radical and cruel realization in the German Reich and its occupied territories in the era of National Socialism; it differentiates between the various forms of action taken in the context of the “euthanasia” program, describes the perpetrators and their motives and attempts to commemorate the murdered individuals.  

Keywords
National Socialism, “euthanasia”, persecution of the mentally ill and handicapped, war and murder of the sick

Context and historical background: “Euthanasia” debates in Germany since 1895

Between 1939 and 1945 an estimated number of 300.000 mentally ill and handicapped people – women, men and children – were murdered: They were gassed with carbon monoxide in specially invented killing centers; they died in mental hospitals and asylums where they were deprived of food, neglected or administered lethal doses of medication. In the occupied territories of Poland and the Soviet Union they were shot by special units or task forces of the SS, gassed or murdered in another equally brutal way. Doctors, care attendants, administrative staff and members of the SS participated in the extermination programs. Even though there were differences regarding the organization and responsibilities of the murder campaigns, they all served the same purpose: the more or less organized extermination of humans considered “unworthy of life” under the premise to relieve these allegedly incurably ill from their suffering and to “clean the racial corpus from Ballastexistenzen (ballast existences)”. Because of this, killings of the asylums’ patients in the German Reich and during World War II cannot be understood if the debate on “euthanasia”, the release from suffering of the incurably ill by a physician, that began at the end of the 19th century is not taken into consideration. 1
In 1895, a student of philosophy called Adolf Jost published a book with the title “Das Recht auf den Tod” (“The Right to Die”). The individual should have the right to autonomously decide on his or her death if illness or disability made it worthless. This is complemented by the motive of pity that should oblige doctors and society to grant the release from suffering by way of homicide.  
“When we see someone incurably ill squirming with unendurable pain on his bedstead with the dire prospect of a further maybe month-long deterioration without hope of recovery; when we walk through the rooms of a bedlam house and the sight of the raving mad or the paralytic fills us with all the pity humans are capable of, then – in spite of all the prejudices we have absorbed – the thought must stir in us: ‘do not these people have a right to die, does not human society have the duty to offer this death to them as painlessly as possible?’” 2
Jost already expresses the ambivalence of the concept of “euthanasia”: The individual’s right to die is also intended to free society of those lives that it cannot profit by any more. Before World War I, the debate on “euthanasia” was limited to individual voices and circles influenced by social Darwinist thought. During the economic crisis in Germany in the years immediately following the war, the concepts and working points of the debate were radicalized. In 1920, the renowned criminal lawyer Karl Binding and the popular psychiatrist Alred Hoche published a work with the programmatic title: “Die Freigabe der Vernichtung lebensunwerten Lebens” (“Permission for the Destruction of Life Unworthy of Life”). Their point of departure was the question:
“Is there human life which has so far forfeited the character of something entitled to enjoy the protection of the law, that its prolongation represents a perpetual loss of value, both for its bearer and for society as a whole?” 3
The authors determined that incurably ill people who wished it, unconscious people who would wake to a nameless misery and the “mentally dead” beings in the mental hospitals who were nothing but Ballastexistenzen (ballast-existences) should be released from their suffering by death. The “mentally dead” neither had the will to live nor to die and thus their execution could not be considered unjust. This devaluation of humans who were weak and who depended on support and care expressed itself in the phrase of “life unworthy of life“, a phrase which indicated sinister consequences. This was the more so since economic arguments were introduced to justify the destruction of the lives of the “mentally completely dead” as imposed by the state. Hoche puts the “massive capital” in the balance that was withdrawn from the national product and wasted on the care of approximately 30.000 “idiots” and “Ballastexistenzen” – among them 3.000 to 4.000 “mentally completely dead” – for entirely unproductive purposes. 4 He comes to the conclusion that maybe one day we will realize that “the execution of those mentally completely dead is not an immoral act, no emotional brutality, but a legal and useful action.”5

The proposals made by Binding and Hoche were controversially discussed by physicians, lawyers and politicians in the Weimar Republic. The work by Binding and Hoche was considered “a real child of our dichotomous time” 6 and the derogatory terminology used to describe the mentally ill and handicapped was surprisingly little objected to. At the beginning of the 1920s, the director of a Protestant educational and care institution for feeble-minded children in Saxony carried out a survey of opinion among his asylum’s parental constituency that came to a telling result: Answering the question whether they would comply with the painless curtailment of their child’s life if experts had previously asserted that it was suffering from incurable idiocy, 119 answered with “yes” and only 43 with “no”. 7
The intensity and radicalism of the debate on Euthanasia and the “destruction of life unworthy of life” in the Weimar Republic was tensely related to the socio-economic situation. In the mid-1920s, it calmed down a little and became more acrimonious again when the global economic crisis began. The living conditions of the mentally ill and handicapped worsened when radical cuts in hospital and nursing charges as well as austerity measures introduced in mental hospitals meant that care benefits were cut and staff, food and heating reduced. Simultaneously, eugenic positions and those supporting racial hygiene gained influence: Sterilization and institutionalization in a mental asylum were the means to exclude those parts of the population that were considered hereditarily inferior from reproduction and in this way the decay of the German people in mental, physical and social respects was sought to be averted. 8 In the politically disrupted Weimar Republic at the wake of the Nazi takeover the ideas of the “destruction of life unworthy of life” and the by then scientifically established eugenics put at stake the unconditional respect for life and individual dignity. The notion to sacrifice the weak to strengthen the healthy and strong, which was inspired by racial hygienic and social Darwinist thoughts, became more attractive to doctors, politicians, lawyers, economists and scientists.
After the Nazi takeover in January 1933, racial hygiene became the dominant school of thought in the field of population and social policy. Subsidies and social benefits such as marriage loans for freshly wed couples were to be assigned according to the racial value of humans and the quality of their hereditary disposition. At the same time, the “Gesetz zur Verhütung erbkranken Nachwuchses” (“Law for the Prevention of Hereditarily Diseased Progeny”) determined which parts of the population would be excluded from reproduction by forced sterilization. Between 1934 and 1945, 350.000 to 400.000 people were sterilized against their will because they suffered from one of eight diseases that were considered to be “Erbkrankheiten” (“hereditary diseases”), amongst them “angeborener Schwachsinn” (“congenital feeblemindedness”), Schizophrenie” (“schizophrenia”) and “Erbliche Fallsucht/Epilepsie” (“hereditary falling sickness/epilepsy”). 9An elaborate racial hygienic propaganda was developed. Its aim was to legitimize the policy of sterilization in the eyes of the population and along with it went a massive degradation of those humans who were considered socially and genetically inferior. Even if terms such as “eradication” and the “cleansing of the racial corpus” were used, the postulation of the “destruction of life unworthy of life” was rarely pronounced in the public sphere. Adolf Hitler wanted to approach the question of “euthanasia” only at the beginning of the war. After the austerity policy was rigorously continued in the asylums in the 1930s, the living conditions of psychiatric patients and hospital inmates further deteriorated because of overcrowding and funding cuts. At this time, the term of “life unworthy of life” as coined by Binding and Hoche can be found in individual medical histories. For instance, the senior physician of the mental hospital Wiesloch, Dr. Gregor Overhamm, in 1938 wrote about the 32-year-old daughter of a Jewish lawyer, Adelheid B., who suffered from a mental handicap: “Continues to be dreadfully difficult and disturbing. Life unworthy of life!” 10In June 1939, it was said of the 47-year-old Helene N.: “Continues like that. Mentally dead. The case sheet should be closed because nothing will change in the future. The only entry worth its effort is the statement of the date of death.” 11 This dehumanization of the entrusted patients supported their transfer to the National-Socialists’ “Euthanasia” program.

The crime: The mass extermination of the asylum inmates

In October 1939, dated back to September 1, 1939, the day the war began, Adolf Hitler signed a document with the following content:
“Reichsleiter Bouhler and Dr. med. Brandt are charged with the responsibility to extend the powers of specific doctors in such a way that, after the most careful assessment of their condition, those suffering from illnesses deemed to be incurable may be granted a mercy death.” 12
The offensive war against Poland was not only the beginning of an “external war” but also of an “internal war”. This “internal war” comprised those parts of the population that were deemed inferior for racial, genetic or social reasons. Those humans who did not serve the community anymore, who were not able to do useful work because of their illness or social deviation, were intended for extermination. Yet it was important that the exterminations would not appear as cruel crimes to outsiders but rather as releases from suffering. The destruction of mentally ill and mentally disabled people was directly related to the offensive war against the Republic of Poland: In occupied Poland, special units of the SS executed German and Polish hospital inmates by mass shootings and gassing immediately after the war had begun and thus emptied individual asylums so that they could be used by the SS and the Wehrmacht. Similarly, inmates in Pomeranian asylums were shot and hastily buried in mass graves in a forest near Neustadt in West Prussia by the SS-Sonderkommando Eimann (special unit of the SS Eimann). 13The SS-Sonderkommando Lange (special unit of the SS Lange), responsible for the murder of the patients in the Reichsgau Wartheland, used mobile gas chambers. In this way, also patients of East Prussian asylums were gassed between May and June 1940. The number of victims of this operation amounts to approximately 1.600 individuals. 14In total, at least 17.000 psychiatric patients were murdered during the German occupation of Poland, not including victims of hunger and malnutrition. 15The extermination of psychiatric patients continued in the war against the Soviet Union where task forces of the SS and the SD (i. e. the intelligence of the Nazi SS), in cooperation with the Wehrmacht murdered patients of psychiatric hospitals, Jews, Romany people, partisans and “Bolsheviks” alike. The emptied hospitals and the robbed food stuffs were allocated to the Wehrmacht. An incomplete overview documents 17.000 murdered individuals. The real number of victims is considerably higher. 16
 
In the German Reich, the planning of and preparations for the covertly executed “euthanasia” measures probably only began in spring 1939. 17Two programs can be differentiated: 
1. In the context of child euthanasia physically and/or mentally handicapped infants and small children until the age of three that were not cared for in hospitals yet were registered. The children were committed to “children’s wards for expert care“, where they were observed, selected and killed.
2. „Aktion T4“ – which was named after the address of the operational center in Tiergartenstraße 4, Berlin – was set up to register, select and exterminate psychiatric patients who were institutionalized in mental hospitals and intended for the murder with carbon monoxide gas in especially established killing centers.
Both programs, “child-euthanasia” and “Aktion T4”, were organized in the Kanzlei des Führers (Chancellory of the Führer or KdF), an agency headed by Philipp Bouhler and directly subordinated to Hitler, in cooperation with the Reich’s Interior Ministry.    

At the end of the 1930s, a number of requests reached the KdF in which parents asked if their severely handicapped children could be granted a “mercy death”. Amongst them the “Case of the Child Knauer” featured as precedence. The father of the physically and mentally handicapped infant had approached Adolf Hitler. After an examination carried out by Hitler’s personal physician Karl Brandt, the child was euthanized in the University of Leipzig pediatric clinic. 18 Beginning of August 1939, all doctors and midwives were obliged to report mentally and/or physically handicapped children to the “Reichsausschuss zur wissenschaftlichen Erfassung erb- und anlagebedingter schwerer Leiden” (“Reich Committee for the Scientific Registering of Serious Hereditary and Congenital Illnesses”) via the local health authorities. The comparatively complex report forms were forwarded to the three expert referees of the “Reich Committee”, amongst them the director of the University of Leipzig pediatric clinic, Prof. Werner Catel. The experts decided whether the handicapped children should be consigned to a “children’s ward for expert care” in which – so it was promised to the parents – the children would receive the best possible treatment and care, but where – as a matter of fact – they were selected and killed. In most cases, the children were murdered through the administration of lethal doses of medication (Phenobarbital or Morphium-Scopolamine) – they died of pneumonia, thus suggesting to the parents a seemingly natural cause of death. Beginning March 1941, also those children and adolescents up to the age of fourteen who were already in the custody of hospitals fell into the cognizance of the “Reich Committee” and were murdered in the children’s wards. All in all, approximately thirty children’s wards for expert care were run until the end of the war, also in the occupied territories of Poland and Czechoslovakia. 19 The number of the handicapped children and adolescents killed in the children’s wards is difficult to estimate. A number of about 5.000 murdered handicapped children must be assumed. In individual children’s wards, the children were made the subject of medical experiments, e. g. when testing vaccines against tuberculosis. The KdF established two research departments to explore the causes of “mental deficiency” and epilepsy – one in the mental hospital in Brandenburg-Görden and the other in the hospital of Wiesloch. In the context of an extensive research project with the aim to be able to differentiate between hereditary and non-hereditary causes of mental deficiency at the psychiatric clinic of the University of Heidelberg – headed by Prof. Carl Schneider – 21 children were killed between 1942 and 1944. 20

“Aktion T4” had the character of a mass extermination operation robbing its victims of their individuality. 21 Beginning October 1939, the Reich’s Interior Ministry and the regional and authorities of the Länder (states) responsible for the asylums sent out the first registration forms designed to select those inmates that were to be killed: This concerned all patients that had been institutionalized for at least five years and that either were not able to work or could only engage in “mechanical work”, the criminally insane and patients that were “foreign nationals or racial aliens”. 22
The one-page registration form provides information on the selection criteria of racial membership, incurability of the illness (“length of hospital treatment”), lack of productive work and “antisocial” or “criminal” behavior. In contrast to this, the selection of senile persons, veterans of the war and foreigners was deferred due to political considerations. The completed forms were registered in the “T4” office of the KdF, photocopied and sent to three of the 42 medical experts. These decided upon the death or life of the patients solely on the basis of the information provided by the registration form. A red + meant murder, a blue – survival. The final decision was made by the senior referees, among them Herbert Linden of the Reich’s Interior Ministry and Werner Heyde, head of the “T4” medical department. The analysis of 30.000 medical records of the victims of “Aktion T4” revealed that the lack of productive work in the hospital actually was the decisive criterion for selection in the “Aktion T4”. Additionally, the length of the institutionalization, the care dependency and “disruptive behavior” played a part. Only those who worked productively had a chance to survive. 23 Subsequently, transport lists bearing the names of those patients selected for death were compiled and forwarded to the concerned hospitals via the superior authorities responsible for the hospitals. A few days later, the notorious grey or red busses of the “Gemeinnützige Krankentransgesellschaft” (“Community Patients’ Transport Service”) arrived and took the patients to one of the six extermination institutions that had been established in the area of the German Reich: Grafeneck on the Swabian Alb, Brandenburg at the Havel, Sonnenstein near Pirna in Saxony, Hartheim near Linz in Austria, Bernburg at the Saale and Hadamar in Hesse. In the course of “Aktion T4”, the selection procedure was modified after many patients able to work had been deported in the first months of the year. The goal was to adjust the selection procedure so that it would be more effective: In a number of clerical hospitals and in Austria, committees of “T4” physicians were employed to select the patients directly at the locations. 24 Beginning summer 1940, the system of holding asylums was introduced: Now the patients were not directly transported to the extermination institutions, but to holding asylums where the patients waited for several weeks or months for their definite transport to death. These holding asylums disguised the transport routes and lay close to the killing centers to allow for a more flexible and effective organization of the industrially run machinery of the extermination centers. Some of the doomed patients sensed their fate and defended themselves. At their deportation, they were given sedative injections. When the patients arrived at the killing center, the nursing staff took charge of them and they were presented to the extermination physicians who checked their identity and determined a plausible cause of death for the death certificate. Before their execution, the victims were photographed. Subsequently, they were led in groups to the gas chambers that were disguised as shower rooms. The extermination doctor opened the valves of the gas cylinders and the instreaming carbon monoxide led to their deaths by suffocation. Two hours later, the gas chamber was aired and the corpses were removed by the “Brenner” (“Burners”). Specifically marked corpses had their gold teeth levered out. In individual cases, a dissection was carried out for scientific reasons. The corpses were burnt in the oven of a crematorium adjacent to the gas chamber. The killing centers’ smoke was visible in the environment and heavy with the scent of the burnt bodies that could be smelled.    
The death of the victim was processed in a bureaucratic fashion. 25 About two weeks after the extermination the relatives received a so called letter of consolation and the feigned death certificate: “To our regret we must inform you that your … ,who had to be moved to our institution following a ministerial order in accord with an instruction from the Reichsverteidigungskommissar (Reich’s defense commissioner), unexpectedly died because of … at … Considering his/her severe incurable illness, his/her death comes to him/her as a relief.” 26
The central clearing office of the “T4” received care allowances for the period of time that elapsed between the killing and the attestation of death – usually two weeks – so that the extermination program generated several million Reichsmark in revenue.
Despite all measures taken to keep the operation secret, the murders of the sick caused considerable alarm among the population. After a public protest sermon delivered by the Bishop of Münster, Graf van Galen, Hitler decreed the cessation of the gassings of “Aktion T4” on August 24, 1941. Apparently Hitler did not want to further weaken the war morale of the German people by continuing the “euthanasia” program which, in the meantime, had become public and was controversially discussed. 27 According to internal statistics compiled by the central office, 70.273 hospital patients had been killed in the six killing centers by August 1941. In the regions which had been engaged early in “Aktion T4”, such as Baden, Württemberg, Bavaria and Austria, the percentage of the killed hospital patients was 50% and higher.

The decision to stop the “Aktion T4” had strategical reasons: The organizational structure of “T4” remained intact and the registration of the hospital patients was continued. Child euthanasia was continued unabatedly until the end of the war while the range of the children’s and adolescents’ age was extended to include 16-year-olds. Additionally, the killing centers Bernburg, Hartheim and Sonnenstein were not immediately closed. They served the extermination of concentration camp inmates that were unable to work, ill and racially or politically unwanted and had been selected by the “T4” expert referees committees. Between 1941 and 1943 alone, approximately 20.000 detainees from many nations fell prey to this so called “Aktion 14f13”. 28
Simultaneously, the extermination of adult hospital patients was continued in a decentralized fashion. The victims no longer were murdered because they had been selected by the “T4”, but were killed by lethal doses of medication, systematic starvation and neglect in the individual asylums in accordance with the asylum directorate’s decision. Historical research calls this form of the murders of the sick “decentralized euthanasia” to stress that this type of murdering patients was not organized by the head office of the “T4”. Instead, the initiative and responsibility lay with the regional administration authorities of the Länder (states) and provinces as well as with the asylums’ directorates. The decision which patient should be killed was made at the location. During “Aktion T4”, a considerable rise of the asylums’ death rate had already occurred due to malnutrition and purposefully administered lethal doses of medication, for instance in Saxony. In the hospital Wehnen, located in Oldenburg, starvation played a decisive part as a method of killing since the war had begun. 29
 Following a decree of the Bavarian Ministry of the Interior, the boards of directors of the Bavarian hospitals, especially in Eglfing-Haar near Munich and in Kaufbeuren, introduced systematical starvation, the so-called E-Kost (deprivation-diet) as a means to kill the patients in so called Hungerhäuser (starvation houses) from 1942 onward. 30
When, after “Aktion T4” had been stopped, the central office of the “T4” was run under the camouflage title “Reichsarbeitsgemeinschaft Heil- und Pflegeanstalten” (Reich Cooperative for State Hospitals and Nursing Homes), it attempted to bring the decentralized forms of the murdering of the patients under its control. It assessed the willingness amongst the asylum directors to further participate in the “euthanasia” program and also delivered the necessary drugs for the murders (morphine and scopolamine) to the chosen asylums. Yet the central office was not able to resume control over the organized murders of the sick.
As the air war waged against the German cities gathered strength in 1942, the need of civil hospital beds significantly rose in the affected regions of western and northern Germany and reached its climax in summer 1943. As early as on August 24, 1941, Karl Brandt, Hitler’s “euthanasia” commissioner, who in 1942 also became his Generalkommissar für das zivile und militärische Gesundheitswesen (Plenipotentiary for the Health and Sanitation System), was commissioned to find substitutional hospitals in the cities that were particularly affected by the air raids and to include in his efforts the mental hospitals and nursing homes. 31
Karl Brandt and the „Reichsbeauftragter für die Heil- und Pflegeanstalten“ (Reich’s Commissioner for the medical hospitals and nursing homes), the assistant head of the Reich’s Ministry of the Interior, Herbert Linden – who in turn had close connections to the central office of “T4” – were responsible for the removal of psychiatric patients from the air raid affected regions in northern Germany, the Rhineland, Westphalia and greater Berlin to make room for physically ill people and bombing victims if this was deemed necessary. The initiative for these transports lay with the municipal and regional health authorities as well as the Gauleiter who wanted to remove as many old, chronically ill and psychiatric patients from their area of responsibility as possible. 32 In this context, psychiatric patients ranged at the bottom of the hierarchy of medical care and thus became subject to a lethal competition for displacement. The regions and institutions chosen to accommodate the patients in middle, eastern and southern Germany as well as in the occupied territories of Poland solved the problem of overcrowding in their own fashion. If the relocated psychiatric patients did not die anyway of hunger or neglect, the physicians and nursing staff killed them with lethal doses of medication as, for instance, in Kaufbeuren-Irsee in Swabia, in Meseritz-Obrawalde in Pomerania, in Tiegenhof in occupied Poland, in Wiesengrund or Kosmonosy in Czechoslovakia that had been occupied in 1938. Considering only the Rhineland, between 1943 and 1944 approximately 8.000 psychiatric patients were removed and most of them died in the aftermath. The asylum Hadamar in Hesse, which had served as a killing center of the “T4” in 1941, was reactivated by the Bezirksfürsorgeverband (district’s care association) Wiesbaden to function as a killing center in 1942: The physicians now used medication to kill the patients in the context of a seemingly normal institutional routine. In accord with the “T4” and the Reich’s Interior Ministry, the patients were removed from northern Germany, the Rhineland, Baden-Alsace and Brandenburg to Hadamar to make room for substitutional hospitals in these regions. Of the 4.861 patients committed to Hadamar, 4.411 were killed by March 26, 1945. This is 91%.33
An approximation of the number of killed hospital patients assumes that roughly 90.000 died in the German Reich (not counting Austria) alone after the alleged stop of the “euthanasia” program in August 1941. 34 This comprises also the predominantly Polish or Russian forced laborers who suffered from tuberculosis or mental diseases. Beginning 1944, these were committed to assigned mental hospitals and nursing homes such as Kaufbeuren or Hadamar when their ability to work could not be restored. There they were killed with systematically administered medication. 35

The “euthanasia” program is closely related to the genocide of the European Jews: Beginning spring 1940, specific hospitals were used to accumulate patients of Jewish origin who were then indiscriminately killed in the gassing institutions of “Aktion T4” because of their sole heritage. Their murder was not only economically but also racially motivated. Accordingly, the systematic killing of hospital patients of Jewish origin can be seen as a first step toward the genocide committed against the European Jews. 36 The experiences of industrial mass exterminations made in “Aktion T4” played a crucial part in the genesis of the holocaust: For example, the three extermination camps set up in the “Aktion Reinhard”, Bełżec, Sobibór and Treblinka, were developed and run by about 120 “T4” men, among them Christian Wirth, head of office in various “T4” killing centers. He was promoted to the rank of inspector for “Aktion Reinhard” that was responsible for the death of 1.6 million predominantly Polish Jews between October 1941 and November 1943. 37  

The fate of psychiatric patients in the western European countries occupied by Germany during World War II hitherto has been little researched. As regards the Netherlands, first explorations investigating the deaths caused by starvation in the Dutch medical hospitals and nursing homes have been taken up. 38 In occupied France (including those parts of the country that were governed by the Vichy-regime) an additional 40.000 to 45.000 more institutionalized patients died between 1940 and 1944 than – considered from a statistical perspective – could have been expected to die in times of peace. In this context, it is not agreed upon if the significantly higher death rates can be traced back to an intentional food deprivation39 or to the generally considerably worse food situation caused by the conditions of war and occupation. Isabelle von Bueltzingsloewen shows how food supply became increasingly precarious in spite of some efforts made by institution directors and prefects. Due to the rationing of food, the rising prices, bureaucratic barriers, embezzlement and the inability to supply for themselves on the black market, the asylums failed to provide sufficient food for their patients. As the latter’s social isolation disadvantaged them, many of them died of consumption and malnutrition. 40

The perpetrators and their motives

Reichsleiter (Reich leader) Philipp Bouhler, who headed the KdF, and Karl Brandt, Hitler’s personal physician, later also appointed to Generalkommissar für das Sanitäts- und Gesundheitswesen (Reich Commissioner for Sanitation and Health), were among those predominantly accountable for the National Socialist murders of the patients. While Philipp Bouhler committed suicide in 1945, Karl Brandt was charged in the Nuremberg Doctors’ Trials and sentenced to death. He defended his participation in the “euthanasia” program as follows: Euthanasia was not about the disposal of a person in general: “[…] but it was about freeing him from the burden of suffering.” 41
In the Nuremberg Doctors’ Trial, Karl Brandt stylized himself as an idealist with humane intentions42, the operative execution of the “euthanasia” program, he argued, lay with Philipp Bouhler and the KdF. The “euthanasia” department “T4” was headed by Viktor Brack, an industrial engineer who had close relations with Reichsführer-SS Heinrich Himmler. Viktor Brack was also sentenced to death in the Nuremberg Doctors’ Trial and was executed in 1948 like Karl Brandt. The “T4” apparatus with its central office in Tiergartenstraße 4, Berlin, comprised about 60 to 80 people: Physicians, administrative staff, workmen and drivers. In the “T4” killing centers, two physicians each, nursing staff, administrative and office staff, registrars, drivers, security guards and people responsible for the cremation of the corpses were present, all in all 60 to 100 people. This staff was recruited by the “T4”, conscripted partially by the Gauleiter (Gau leaders) of the NSDAP and enjoyed numerous privileges: Its members did not have to fight on the front line and staff outings as well as celebrations were organized in regular turns.
The 42 medical experts, amongst them renowned tenured professors of psychiatry, were subordinated to the medical department of the “T4” headed by Prof. Dr. Werner Heyde, from Würzburg, until 1941, followed by Prof. Hermann Paul Nitsche. Among the “T4” experts are dedicated proponents of racial hygiene, opportunistic and ambitious careerists such as Friedrich Mennecke, director of the Eichberg asylum as well as meticulous clerks that were used to obey and to fulfil their duty such as Hermann Pfannmüller, director of the mental asylum Eglfing-Haar. In an act of preemptive obedience, he suggested to his superior authority, the government of Upper Bavaria, a “real austerity measure”: “At this point, I for once consider it appropriate to openly and expressly point out the necessity that, when treating the life unworthy of life, we physicians take the final appropriate action of eradication.” 43
Many psychiatrists felt that the “euthanasia” program allowed them to participate in a comprehensive “work of salvation”. Amongst the older “T4” psychiatrists, Hermann Paul Nitsche or Valentin Faltlhauser from Kaufbeuren supported the reform attempt to establish the offene Fürsorge (open care), Familienpflege (family care) and early release in psychiatric practice. 44 The aforementioned professor Carl Schneider from Heidelberg advocated the active treatment of patients and the Arbeitstherapie (work therapy) in the 1930s. To him – as to many other “T4” psychiatrists – healing and killing did not represent opposites. 45 The funds saved by the killing of those incurably ill were to be invested in an intensive therapy of curable patients using modern shock therapies (insulin coma therapy, pentylenetetrazol therapy, electroconvulsive therapy) and work therapy. In a position paper published by Carl Schneider, Hermann Paul Nitsche and Ernst Rüdin on the state of psychiatry in 1943 the following is stated:
“However, the euthanasia measures will also be more generally comprehended and complied with the more it can be ascertained and made known that in every case of mental illnesses all means available to heal the sick or at least to improve their situation to such a degree that they can engage in their profession or in another form of economically valuable action have been exhausted.” 46
However, the ideology of the “destruction of life unworthy of life” was a decisive motive not only for the “T4” physicians to participate in the murder of the sick. Likewise the staff participating directly in the execution of the murders had internalized the racial hygienic and economic devaluation of the people concerned. Thus Georg Frentzel who took part in the destruction of the psychiatric patients in Mogilev/Belarus as a member of task force 8 said in the inquiry led against him in the GDR: “Because of their illness these people carried “unhealthy hereditary traits”, therewith, they were inferior, incapable of work and, moreover, were useless eaters.” 47

The Victims

The victims of National Socialist “euthanasia” were among the weakest members of society. Being mental ill or handicapped they would have needed care and support. Yet, as a matter of fact, their institutionalization in the asylums for years or even decades deprived them of their accustomed environment and often alienated them from their families. The victims were women, men and children, from infants to aged people; they came from all layers of society. Research showed that the origins of the victims of “Aktion T4” concerning their social class corresponded to the class stratification of the population of the German Reich. Victims of “T4” were not disproportionally people from the lower classes. 48 Among the “T4”victims, women (54%) outbalanced men (46%). Women bore a higher risk to be selected for extermination because of their sex. 82% of the “T4”victims were single, divorced or widowed – representing a significantly higher percentage than that of the overall population: Due to their often years-long or even decades-long institutionalization many “T4” victims were socially isolated. 49 Two groups were especially prone to be selected for extermination in “Aktion T4”: On the one hand, there were the chronically ill long-term patients diagnosed with schizophrenia that were described as “Endzustände” (“final states”) or as “abgelaufene Fälle” (“expired cases”) because they were not considered worth therapy anymore and were viewed as “useless” because they could not engage in “productive work” in the asylums anymore. On the other hand, there were the patients diagnosed with “idiocy” whose lack of intelligence was considered particularly severe and who therefore were thought to be “mentally dead”. At the beginning of “Aktion T4”, criminals who had been consigned to the asylums due to adjudication were the most likely to be run through the selection process: Without distinction, they were deported from the individual asylums such as Bedburg-Hau or Waldheim to the killing centers. Subsequently, their frequently good work performance gave them a chance to survive. Beginning 1944, they were used in the concentration camps for the “Vernichtung durch Arbeit” (“destruction through work”).   
In the course of the war, the range of asylum inmates who became victims of the “euthanasia” program expanded. More and more confused elderly people, partly bomb victims, children in care and mentally or physically ill forced laborers were committed to the asylums and died there because of neglect, malnutrition and overdosed drugs.
Contrary to the extermination program devised by the “T4“ organizers that rid humans of their individuality, each victim had his or her own story, like Benjamin Traub, from Mülheim an der Ruhr, who came from a Baptist family of preachers. He was committed to the asylum Bedburg-Hau after a deep spiritual crisis at the age of 16 where he temporarily recovered and where he could stay in touch with his family. He was killed in the gas chamber of Hadamar on March 13, 1941. 50The “T4” victims suffered from anxieties and lived in their own world anyway as, for instance, the 35-year-old telegraphist Leopoldine, from Vienna, who was killed in the gas chamber of Hartheim in Upper Austria. The picture taken of her before the murder reveals a deep and existential agitation that had already dominated her restricted life in the asylum Steinhof in Vienna. 51Some might have felt well and secure in their asylum as, for instance, Wilhelmine Haußner who was committed to the catholic asylum Schönbrunn in Upper Bavaria because of her restlessness and her delayed intellectual development at the age of 5. There she was often visited by her family. She had to leave Schönbrunn in 1941 and was transferred in a group transport to the asylum Eglfing-Haar where she was overdosed in the “children’s ward for expert care”. 52 Some tried to escape the hopeless conditions in the asylum as did the actress Emmy R., from Hamburg, who had been imprisoned because of her derogatory comments on the NS-regime. She was committed to the asylum Eglfing-Haar because she was considered not criminally responsible. In 1944, she arrived at the Hungerhaus (starvation house) for women and was deprived of food until she died. 53 Grigorij S. was one of the forced laborers killed in the context of the “euthanasia” program. He was born in the Ukraine and had to work for the IG-Farben conglomerate in Wiesbaden. On March 2, 1945 he was brought to Hadamar because he had developed active tuberculosis and was overdosed a couple of days later. 54

The reactions of relatives, society and resistance

Despite all efforts to keep “Aktion T4“ secret, the concerned families and circles of the clergy very soon knew about the real causes of the rising number of deaths among the asylum inmates. In individual cases, relatives were able to save their family members from the gas chamber at the last minute. The mother of Alfred N., from Ulm, who suffered from a head injury he had sustained in World War I, telegraphed Adolf Hitler so that her son was sent back from the killing center Grafeneck to the asylum Schussenried. 55 However, not all protest letters and attempts to take the threatened family members out of the asylum and bring them back home were successful. In contrast, a larger part of the relatives accepted the news of the sudden death of their family member and failed to express a publicly visible reaction. On the other side of the range of reactions are utterances of relatives who were relieved to hear of the “release from suffering” or even approved it. For instance, the parents of Katharina W., from East Prussia, wrote to the Saxon transit center on August 23, 1941:
“Yesterday your dispatch with the news of the demise of our dear and only daughter Katharina reached us, who for us actually more than died 22 years ago because to know a beloved relative is incurably mentally ill in an asylum is more painful than her death. For this reason we are now naturally filled with grief, but we feel that the death of our daughter is, first of all, a final relief for her.” 56 
All in all, the relatives of the victims showed a broad array of reactions to the murders of the patients ranging from protest to acceptance and approval even though this array can, at the present state of research, not be quantified. 57 Concerning “child euthanasia”, apart from protests of parents, explicit requests to “release” their handicapped children are recorded. The father of the two-year old Heinz F. wrote to the head of the children’s ward in Eichberg on October 25, 1941:
“Thus we have only one request to make to you, as there is no chance of rescue and recovery or a healing over time; So don’t let the dear, young boy suffer for too long from his heavy burden.” 58
Only few resisted the “euthanasia” program as did the nurse Anna Wödl, from Vienna, who organized a small demonstration in front of the asylum Am Steinhof; the local resistance group gathered around the brothers Schuhmann who denounced the “euthanasia” murders in the killing center Hartheim on leaflets or the Circuit Judge Lothar Kreyssig, from Brandenburg, who prohibited the relocation of patients he assisted in the function of official guardian. In 1940, the Protestant parson and director of the Hoffnungsthal Foundation Lobethal, Paul Braune, in consultation with Friedrich von Bodelschwingh, director of the Bethel Institution, wrote a memorandum against the killings of the asylum patients that contained detailed information and had it sent to the Reichskanzlei (Reich Chancellery). As a consequence, he was imprisoned by the Gestapo (Secret State Police) for three months. While representatives of the Protestant and Catholic Church mostly limited themselves to non-public, diplomatic efforts to achieve the cessation or modification of the “euthanasia” program, the public protest sermon of Bishop Clemens Graf von Galen, from Münster, which he held on August 31, 1941, was crucial for the cessation of the murders of the patients. 59
 The sermon described the facts of the murders of the sick in much detail and condemned them:
“And now the fifth commandment: ‘Thou shalt not kill’, is set aside and broken under the eyes of the authorities whose function it should be to protect the rule of law and human life when men presume to kill innocent fellow-men with intent merely because they are ‘unproductive,’ because they can no longer produce any goods.” 60
The text of the sermon was secretly copied and spread throughout the German Reich. The bishop, who was very popular in the Catholic region of Münster, remained unaffected, but people who distributed the sermon were persecuted and imprisoned. Nothing is known of an active resistance of the psychiatrists against the “euthanasia” program. At the most, directors of asylums asked to be retired to avoid being involved in the murders of the sick. The German jurisdiction covered the murders of the asylum inmates although these, according to the law in force, complied with the statutory offense of murder. 

Postwar developments: Reactions of the jurisdiction

American and German courts immediately after the war arrived at unequivocal judgements when proposing their jurisdictional evaluation of National Socialist “euthanasia” crimes: They saw them as murders of innocent people and as crimes against humanity. Accordingly and to give an example, in the “euthanasia” trial in Dresden in 1947 the deputy director and medical head of the “T4” central office, Hermann Paul Nitsche, and other physicians and nurses from Saxony were sentenced to death and executed. Yet beginning 1948/49, the medical perpetrators could count on surprisingly mild verdicts especially as regards the western German jurisdiction. They were partly excused with reference to the high standing ethical problem of euthanasia. Furthermore, the perpetrators could call on the mistake of law or the collision of duties as reasons to be exempted from guilt which then led to their acquittal. Although the “destruction of life unworthy of life“ was illegal, the physicians were thought to have been incapable of recognizing the unlawfulness of their deeds or it was assumed that they had stayed in charge of their office to prevent worse or even to save some of the victims. In many cases the charges were dropped or investigations were not even taken up. Accordingly, Prof. Werner Catel, one of the senior figures responsible for “child euthanasia” remained undisturbed and became tenured professor for pediatrics in Kiel in 1954. Due to the efforts undertaken by the Hessian Solicitor General Fritz Bauer, the Department of Public Prosecution in Frankfurt attempted to legally reappraise the network of the “euthanasia” crimes at the beginning of the 1960s, but the chief culprits shunned their responsibility mostly by committing suicide or by claiming to be unfit to stand trial. The legal reappraisal of the “euthanasia” crimes touched bottom when three doctors formerly employed at the killing centers of “Aktion T4” were charged at the Land court Frankfurt and won acquittals because it was assumed that due to their lack of experience they might not have recognized the victims’ possible will to live and because they believed in the legitimacy of euthanasia as propagated by Binding and Hoche. The verdict reached in the appeal at the Federal Court of Justice in 1988 did not improve matters because very low prison sentences were pronounced. 61
The leniency with which the West German jurisdiction treated the perpetrators is reflected in the lack of compensation for the victims of National Socialist racial hygiene and the politics of “euthanasia”. Neither did those people robbed of their ability to reproduce in the name of the Law for the Prevention of Hereditarily Diseased Progeny receive any financial compensation for their suffering nor did the relatives of the victims of “euthanasia”. Despite being granted a hardship provision, victims of forced sterilization and the families of the victims of “euthanasia“ have not been granted equal status with other victims of National Socialist prosecution. 62

The legacy of the victims

In a climate of lacking social recognition and continuing stigmatization of mentally ill and handicapped people, the victims of forced sterilization and “euthanasia” have long belonged to the “forgotten” or repressed victims of National Socialism regardless of whether the official practice of remembrance is considered or the concerned families themselves. At the same time, in recent years a growing interest of the generations born after World War II to remember those people erased from family memory, to find out more about their fates and to name the injustice they suffered, can be observed. Sigrid Falkenstein, for example, investigated the life and murder of her aunt Anna Lehnkering who was deported to the killing center Grafeneck in 1940. Cf. Falkenstein, Sigrid (2012): Annas Spuren.
The memorial and information center for the victims of the National Socialist “euthanasia” murders located in Tiergartenstraße 4, Berlin, i. e. at the historical site where the murders of the sick were organized, built in 2014, is a late sign for public remembrance of the victims of “euthanasia”. It complements the commemorative sculpture from 1989: A blue glass wall represents the remembrance of the killed people and an accessible open-air-exhibition offers information on the historical background, the execution and the aftermath of the National Socialist killings of the patients. The texts are also available in simple language and as such not only used by people with learning difficulties. Cf. Stiftung Denkmal für die ermordeten Juden Europas u. a. (Eds.) (2015): Tiergartenstrasse 4 and www.t4-denkmal.de as well as www.gedenkort-t4.eu.
What remains is the memory of exceptional people who often spent decades of their lives in the asylums where they tried to maintain their dignity under the conditions of the institution regulations as did the carriage driver Karl Ahrendt, from Mecklenburg who expressed this in a letter to the direction of the asylum Berlin-Buch in 1933: “speaking fer me humble self I therefor keep up the human existence in my self”. Aged 87, he too became a victim of National Socialist “euthanasia”. Cf. Rotzoll, Maike (2007): Karl Ahrendt.

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• 1. Cf. Schmuhl, Hans-Walter (1987): Rassenhygiene, Nationalsozialismus, Euthanasie, pp. 106-125; Schwartz, Michael (1998): “Euthanasie“-Debatten in Deutschland; Benzenhöfer, Udo (1999): Der gute Tod?, pp. 92-108; Hohendorf, Gerrit (2013): Der Tod als Erlösung vom Leiden, S. 27-71.
• 2. Jost, Adolf (1895): Das Recht auf den Tod, p. 6. (Emphasis in original)
• 3. Binding, Karl; Hoche, Alfred (1920): Die Freigabe der Vernichtung lebensunwerten Lebens, pp. 27; 51. Translated in Burleigh, Michael (1995): Death and Deliverance, p. 17.  (Emphasis in original)
• 4. Ibid. p. 54.
• 5. Ibid. p. 57, emphasis in original.
• 6. Gaupp, Robert (1920): Die Freigabe der Vernichtung lebensunwerten Lebens, p. 336.
• 7. Meltzer, Ewald (1925): Problem der Abkürzung „lebensunwerten Lebens“, p. 88.
• 8. Cf. Weingart, Peter; Kroll, Jürgen; Bayertz, Kurt (1988): Rasse, Blut und Gene und Weindling, Paul (1989): Health, race and German politics.
• 9. Cf. Bock, Gisela (1986): Zwangssterilisation im Nationalsozialismus.
• 10. Qtd. in Hohendorf, Gerrit (2009): Adelheid B.
• 11. Qtd. in Hohendorf, Gerrit (2013): Der Tod als Erlösung vom Leiden, p. 66.
• 12. Qtd. in Klee, Ernst (2010): „Euthanasie“ im Dritten Reich, p. 114. English translation in Burleigh, Michael (1995): Death and Deliverance, p. 112.
• 13. Cf. Rieß, Volker (1995): Die Anfänge der Vernichtung „lebensunwerten Lebens“, pp. 53-117.
• 14. Cf. Topp, Sascha; Fuchs, Petra; Hohendorf, Gerrit; Richter, Paul; Rotzoll, Maike (2008): Die Provinz Ostpreußen.
• 15. Cf. Jaroszewski, Zdzisław (1993): Die Ermordung der Geisteskranken in Polen 1939-1945, p. 226f..
• 16. Cf. Winkler, Ulrike; Hohendorf, Gerrit (2010): „Nun ist Mogiljow frei von Verrückten“.
• 17. Due to a lack of written documents, it is difficult to reconstruct the planning phase of National socialist “euthanasia“, cf.  Benzenhöfer, Udo (2001): Planung der NS-„Euthanasie“.
• 18. Cf. Benzenhöfer, Udo (2008): Der Fall Leipzig. So far it has not been possible to assess the specific date of the case “Child Knauer” and his real name because the identification of the child has as yet not proven sustainable.
• 19. Cf. Topp, Sascha (2004): Der „Reichsausschuß zur wissenschaftlichen Erfassung erb- und anlagebedingter schwerer Leiden“.
• 20. Hohendorf, Gerrit; Roelcke, Volker; Rotzoll, Maike (1996): Innovation und Vernichtung and Hohendorf, Gerrit; Rotzoll, Maike (2014): Medical Research and National Socialist Euthanasia.
• 21. On the „Aktion T4“ and the National Socialist murders of the sick generally see Burleigh, Michael (1994): Death and Deliverance; Friedlander, Henry (1995): The Origins of Nazi Genocide; Klee, Ernst (2010): „Euthanasie“ im Dritten Reich; Hohendorf, Gerrit (2013): Der Tod als Erlösung vom Leiden, S. 72-131. 
• 22. Qtd. in Klee, Ernst (2010): „Euthanasie“ im Dritten Reich, S. 92.
• 23. Cf. Rotzoll, Maike; Fuchs, Petra; Richter, Paul; Hohendorf, Gerrit (2010): Die nationalsozialistische „Euthanasieaktion T4“ and Rotzoll, Maike et al. (Eds.): Die nationalsozialistischen „Euthanasie“-Aktion „T4“, pp. 297-324.
• 24. Cf. Neugebauer, Wolfgang; Czech, Herwig (2010): Die „Aktion T4“ in Österreich.
• 25. Cf. Hinz-Wessels, Annette; Fuchs, Petra; Hohendorf, Gerrit; Rotzoll, Maike (2005): Zur bürokratischen Abwicklung eines Massenmords.
• 26. Qtd. in Klee, Ernst (2010): „Euthanasie“ im Dritten Reich, p. 148.
• 27. Cf. Faulstich, Heinz (1998): Hungersterben in der Psychiatrie, pp. 271-288 and Süß, Winfried (2003): Der Volkskörper im Krieg, pp. 27-151.
• 28. Cf. Ley, Astrid (2011): Die „Aktion 14f13“ in den Konzentrationslagern.
• 29. Cf. Harms, Ingo (1996): „War mööt wi hier smachten ...“.
• 30. Cf. Faulstich, Heinz (1998): Hungersterben in der Psychiatrie, p. 317ff  und 633ff. On Eglfing-Haar see Schmidt, Gerhard (1965): Selektion in der Heilanstalt.
• 31. Cf. Faulstich, Heinz (1998): Hungersterben in der Psychiatrie, pp. 598-602.
• 32. Historical research often refers to “Aktion Brandt” to indicate that substitutional hospitals were created by murdering resettled psychiatric patients. Whether the so called „Aktion Brandt“ was intended as a systematic revival of the murders of the sick, is a matter of debate, cf. Aly, Götz (1985a): Medizin gegen Unbrauchbare, pp. 56-63; Walter, Bernd (1996): Psychiatrie und Gesellschaft, pp. 744-766; Süß, Winfried (2003): „Volkskörper im Krieg, pp. 319-369 und Lilienthal, Georg (2010): Von der „zentralen“ zur kooperativen Euthanasie“.
• 33. Cf. Lilienthal, Georg (2006): Gaskammer und Überdosis, pp. 168-171.
• 34. Cf. Faulstich, Heinz (2000): Die Zahl der „Euthanasie“-Opfer.
• 35. Cf. Hamann, Matthias (1985): Die Morde an polnischen und sowjetischen Zwangsarbeitern.
• 36. Cf. Friedlander, Henry (1995): The Origins of Nazi Genocide und Hinz-Wessels, Annette (2013): Antisemitismus und Krankenmord.
• 37. Cf. Berger, Sara (2013): Experten der Vernichtung.
• 38. Cf. aan de Stegge, Cecile (2014): Die Situation der Psychiatrie in den Niederlanden während der deutschen Besatzung. 
• 39. Lafont, Max (2000): L’extermination douce.
• 40. Bueltzingsloewen, Isabelle von (2007): L’Hécatombe des Fous.
• 41. Qtd. in Dörner, Klaus; Ebbinghaus, Angelika; Linne, Karsten (Hg.) (2000): Der Nürnberger Ärzteprozeß, S. 2/2436, see also 2/2450.
• 42. Cf. Schmidt, Ulf (2007): Karl Brandt.
• 43. Staatsarchiv München, Staatsanwaltschaft München 1b Js 1791/47, Ermittlungsverfahren gegen Hermann Pfannmüller, Vol. 3, Bericht Dr. Schmidt.
• 44. Cf. Schmuhl, Hans-Walter (1991a): Reformpsychiatrie und Massenmord, pp. 240-249.
• 45. Cf. Aly, Götz (1985): Der saubere und der schmutzige Fortschritt.
• 46. Qtd. in Hohendorf, Gerrit (2013): Der Tod als Erlösung vom Leiden, p. 128.
• 47. Qtd. in Winkler, Ulrike; Hohendorf, Gerrit (2010): „Nun ist Mogiljow frei von Verrückten“, p. 88.
• 48. Cf. Hohendorf, Gerrit (2013): Der Tod als Erlösung vom Leiden, S. 114.
• 49. Ibid. p. 113. Cf. also Rotzoll, Maike (2010): Einige kollektivbiografische Charakeristika. 
• 50. Cf. Traub, Hartmut (2013): Ein Stolperstein für Benjamin.
• 51. Cf. Fuchs, Petra et al. (Eds.): „Das Vergessen der Vernichtung ist Teil der Vernichtung selbst“, p. 271.
• 52. Cf. Hohendorf, Gerrit (2013): Der Tod als Erlösung vom Leiden, p. 308.
• 53. Cf. Tiedemann, Sibylle v. (2014): Emmy R..
• 54. Cf. Baader, Gerhard; Cramer, Johannes; Winter, Bettina (1991): „Verlegt nach Hadamar“, p. 145.
• 55. Cf. Aly, Götz (2013): Die Belasteten, p. 39.
• 56. Qtd. in Hohendorf, Gerrit (2013): Der Tod als Erlösung vom Leiden, p. 118.
• 57. Cf. Nowak, Kurt (1991): Widerstand, Zustimmung, Hinnahme und Rauh, Philipp (2007): „Ist mein Bruder in der Anstalt noch seines Lebens sicher?“.
• 58. Qtd. in Hohendorf, Gerrit (2013) Der Tod als Erlösung vom Leiden, p. 83, cf. also Lutz, Petra (2006): Mit Herz und Vernunft.
• 59. Cf. Nowak, Kurt (1978): „Euthanasie“ und  Sterilisierung im Dritten Reich, pp. 161-172..
• 60. Sermon of the Bishop Clemens Graf von Galen in the Lambertikirche in Münster at August 3,1941, cf: Dörner, Klaus et al. (Eds.) (1989): Der Krieg gegen die psychisch Kranken, pp. 112-128, here p. 121.
• 61. Cf. Benzler, Susanne (1988): Justiz und Anstaltsmord und Loewy, Hanno; Winter, Bettina (Eds.) (1996): NS-„Euthanasie” vor Gericht.
• 62. Cf. Tümmers, Henning (2011): Anerkennungskämpfe.