Life Unworthy of Life: The Nazi Programs to Kill People with Disabilities

At the beginning of the 20th century, eugenics – the belief that the human population could be manipulated through selective breeding – was on the cutting-edge of modern science. Following the example set by American eugenic sterilization and anti-miscegenation laws, and empowered by the rise of the ultra ethno-nationalist Nazi party, German scientists helped Third Reich officials to implement a series of eugenic laws designed to craft the ideal German ‘Volk.’ But within a few years, these eugenic programs became far more radical, intent on the liquidation of the disabled population of Germany.

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Sarah: Because of the nature of this episode, I want to say just a few things before we get started. First, I want to be very clear that this episode might be triggering or disturbing for some. If you’re listening with little kids or are sensitive to this kind of thing, be forewarned. Second, I want to note that language is going to be a real challenge in this episode. In many cases, we’ll need to use the language that the perpetrators used, which is obviously not ideal, and often totally inappropriate for use today. We’ll try to be as transparent about that as we can. And finally, I want to say that this is an absolutely horrific topic – and we’ll treat it as such. But we still might slip up in our reading or pronunciation and laugh about it – please remember that we’re human, and this is tough for us, too. If we giggle once or twice, it’s not because we find any of this material funny, but because part of being human is laughing sometimes, even in the face of real darkness. Ok, moving on.

Sarah: In 1938, a German couple, their last name Knauer, welcomed a new baby into their family. Their joy was quickly replaced by horror and grief when they realized that their newborn child was severely disabled, with malformed arms and legs. The child also suffered from convulsions. The child’s father took the baby to the Leipzig University Children’s Clinic, where he asked director Werner Catel not only if he would admit his baby to the hospital – but also asked if he would help his baby die. Catel refused; it was illegal to kill a baby, no matter how their level of disability. Mr. Knauer went directly to German chancellor, Adolf Hitler, writing a plea to the Führer to ask that he allow his child to be euthanized. The Knauer family’s plea ended up in the hands of Phillipp Bouhler, the head of the Hitler’s private chancellery. Bouhler brought the plea directly to Hitler, who decided he must respond.

Averill: Hitler asked his private physician, Karl Brandt, and instructed him to investigate the case, consult with the doctors in Leipzig, and if he found that the child truly was doomed to a life of pain and inability, Hitler gave Brandt authority to kill it. Brandt followed these orders to the letter, and within a few weeks, the Knauer baby was killed.

Sarah: Inspired by the doomed Knauer infant and his father, who so tragically and desperately wanted his child to die, Hitler decided that such decisions should not be made on an ad hoc basis, and thus took the Nazi race hygiene and eugenics project into its first murderous step: the organized, deliberate, and state-sponsored killing of children with disabilities. Within four years, this program would expand to include both children and adults that the National Socialist state declared “life unworthy of life,” resulting in the killing of around 200,000 men, women, and children. In today’s episode in our eugenics series, we’re talking about eugenics and its monstrous German result: the Nazi euthanasia program.

I’m Sarah

And I’m Averill

And we are your historians for this episode of DIG

Averill: Let’s start by setting the stage. We will come back to those decisions in 1938, but we can’t understand how we got to the killing of the Knauer baby without understanding first the transnational eugenics project taking place around the world, as well as the unique eugenics project growing within the Nazi regime. We’ve talked about some elements before, but let’s recap anyway. Starting in the mid-19^th century, with the work of Charles Darwin, people in both Europe and the United States started to become increasingly interested in trying to use the principles of Darwinism to understand how humans, and by extension, societies, evolved. When Darwinian theories were combined with the work of other scientists, such as Gregor Mendel, who pioneered the science of genetic inheritance through his work with pea plants, people around the world began to think about how Darwinian concepts like evolution and survival of the fittest might connect to genetics. It was Darwin’s relative, Francis Galton, who first coined the term “eugenics,” or the science of manipulating human breeding to curate a better populace. In the early 20^th century, eugenics was a tremendously exciting science, with the potential to improve everything from public health to education to national treasuries. We’ve talked about this in a million different ways in past episodes –from talking about Margaret Sanger and the American Birth Control League to the Nuremberg Laws.

Sarah: The idea was that any number of social ills might be cured through the careful control of human breeding. Just as Mendel was able to shift and change and manipulate his garden peas through selective breeding, so could nations control their populations by controlling reproduction. Doctors and scientists considered all sorts of things were considered hereditary traits – eye color and hair color and things like that, yes, but also things like intelligence and behavior. As a quick reminder – and I think all of us will probably say this in our episodes, but I want to make sure that someone listening just to one episode has this context – there are two kinds of eugenics: positive and negative. This has nothing to do with whether they are good or bad, but instead refers to what kind of action they involve. Positive eugenics focuses on encouraging or incentivizing reproduction from the good members of society. The example I always give is ‘better baby contests’ in the United States. State or county fairs would have these contests where mothers would enter their fat, white babies to prove that they were capable of producing exemplary children for the betterment of the American populace. (Side note! I was in a baby contest! I was the friendliest baby!)

Averill: An important component to all of this was the veneer of scientific objectivity. For example, researchers used diagnostic tests like the Intelligence Quotient (or the IQ test) to determine where people fell on a hierarchy of capacity – while these kinds of tests gave the impression of being objective, they were actually deeply shaped by preexisting social prejudice. For example, during WWI, the United States Army allowed Harvard psychologist Robert Yerkes perform IQ tests on nearly 2 million enlisting soldiers. Unsurprisingly, Yerkes found that certain groups consistently performed poorly – specifically, immigrants from Southern and Eastern Europe – while native born whites tended to do much better. Yerkes insisted that this reflected these groups’ hereditary inferiority, not the fact that, y’know, English wasn’t their first language and they didn’t have the same access to American education, etc. etc. etc. The result of the IQ testing was then touted as proof that immigrant populations were dangerous to the white American race.  They had the potential to interbreed with whites and dilute their superior bloodlines. They were also weaker and more sickly, and thus prone to spreading sickness to white Americans. Even more importantly, these inferior people reproduced rapidly and without consideration to the quality of their offspring, tended to be impoverished, and thus had a high likelihood of going on the public dole, draining the system for generations while contributing nothing. To the eugenicists, this all seemed like evidence that these inferior people would hold the whole nation back in its progress.

Sarah: It may seem odd to start with American examples, but we aren’t choosing them arbitrarily – and I promise it’s not because I’m an Americanist! American scientists and reformers were leaders in the global eugenics project. For example, the Americans were early adopters of the conclusion that the best way to stem the uncontrolled breeding of inferior groups was through sterilization. Indiana passed the first sterilization law in 1907, and within two decades, half of American states had a sterilization law. Of course, probably the most well-known sterilization law was the one in Virginia that led to the Supreme Court case, Buck v. Bell, in which SCOTUS upheld the state’s right to control the reproduction of citizens through sterilization, with or without their consent, as a measure for the public good. It’s also the case that gave us Oliver Wendell Holmes Jr.’s famous statement in support of eugenics: “three generations of imbeciles is enough.”

Averill: Much like in the US, before World War I, the German eugenics movement was embraced by pretty much everyone across the political spectrum. Unlike the US, however, before World War I, the German eugenics movement was less concerned with race and more concerned with class – the poor seemed like the potential problem because of the fear that they would be a drain on the public purse, not a particular group of people deemed ethnically problematic. This isn’t to say that the Germans didn’t think about race at all – they certainly believed that white people were superior to dark-skinned people, after all, they developed racial hierarchies during their imperial projects in Africa – but race didn’t seem like a pressing problem for Germans like it did for Americans, who had a far more racially diverse population. There was a split between German scientists, however, over one aspect of race: the question of whether or not a Nordic, or as they soon began to call it, Aryan ‘race’ were superior to others. Increasingly, the pro-Nordic scientists began to embrace the term Rassenhygiene, or race hygiene, to describe their particular approach to eugenics. During most of the first half of the 20^th century, the two terms, Eugenik and Rassenhygiene, were used interchangeably – that is, until the rise of the Third Reich.

Sarah: One of the most important German eugenic scientists was Eugen (Yoy-gen) Fischer. In 1908, Fischer conducted a study on the offspring of Dutch colonizers and Khoikhoi, who Europeans usually referred to as Hottentots. His published study, which cemented his career and made him the leading German eugenicist, also significantly impacted the direction German eugenics took in the years following. In particular, Fischer’s work informed the creation of the Nuremberg laws, which Averill talked about in great detail in an episode a while back. Fischer also cemented the place of race in German eugenics, and upheld the superiority of the Aryan race. He wrote this in his 1908 study: “We still do not know a great deal about the mingling of the races [Rassenmischlung]. But we certainly know this: without exception, every European nation that has accepted the blood of inferior races – and only romantics can deny that Negroes, Hottentots, and many others are inferior – has paid for its acceptance of inferior elements with spiritual and cultural degeneration.”

Averill: The racial element of eugenic thought crystallized during the upheaval of the Weimar Republic. As disaffected Germans turned toward nationalism to help them make sense of their World War I defeat, the concept of German racial superiority and a society based on racial purity was appealing. This nationalistic racist ideology became known as volkisch. Later, the Nazis morph the concept of volkisch the term Volk, which referred to the German people as a strong, racially homogenous whole. The leading scientists who embraced a volkisch version of eugenics included Eugen Fischer, who worked for the Kaiser Wilhelm Institute for Anthropology in Berlin-Dahlem; Ernst Rüdin, a founding member of the Society for Race Hygiene and later director of the Kaiser Wilhelm Institute for Psychiatry in Munich; Otmar von Verschuer, a doctor known for his interest in twin studies who worked with Fischer in Berlin; and Hans Günther, professor at University of Jena and University of Berlin. All of these men would go on to join the NSDAP (Nazi party) and be powerful scientific advisors to Adolf Hitler.  They would also become the architects of the Nazi program to purge inferior peoples from the German public.

Sarah: Over the Weimar period, the race hygiene wing of German science grew. Numerous centers were founded (like the ones we mentioned that all those men worked at) to study race science, and by 1923, German universities offered dozens of classes on race hygiene. In 1921, three leading eugenicists, Fischer, Erwin Bauer, and Fritz Lenz, published one of the two texts that become foundational to Nazi race science: Outline of Human Genetics and Racial Hygiene. The concepts outlined in the book appeared later in another foundational Nazi text: Hitler’s Mein Kampf. But I mentioned that there were two texts that became foundational specifically to Nazi science – the other was the 1920 book by Karl Binding and Alfred Hoche, Authorization for the Destruction of Life Unworthy of Life. Binding was a legal scholar, and Hoche was a psychiatrist. The text focused not on the issue of race in the German eugenics project, but on the issue of disability, specifically, the population Germans who lived in institutions, with psychiatric or intellectual disabilities. The book explicitly argued that the law should allow for the death of so-called ‘incurable feebleminded.’ Binding reasoned that suicide should be considered a human right, and expanded that right to the right to die to avoid an otherwise long or painful death (his example is cancer). But then Binding and Hoche expanded this even further, arguing that there was a category of people called lebensunwert, or “life unworthy of life.” This included people dying slowly of painful diseases like cancer, but also people who were so inferior, so disabled, that they also deserved to die. To quote historian Henry Friedlander, “He used to the argument that the terminally ill deserve the right to a relatively painful death to justify the murder of those considered inferior.”

Averill: After this point, the idea of euthanasia became sort of fuzzy and unclear. When we talk about euthanasia today, we’re often talking about our pets – putting them to sleep painlessly so they don’t have to suffer anymore. We might also talk about physician assisted suicide. But what Binding and Hoche proposed in this text was not that. Instead, they put forth the idea that euthanasia should be used to relieve not the individual patient, but the people. By killing people deemed lebensunwert, they could help to ensure a stronger, pure Volk. While Binding looked at this from a legal standpoint, Hoche added his expertise as a physician. Hoche (unsurprisingly) rejected the tradition of “first do no harm,” as required by the Hippocratic Oath. Instead, Hoche argued, doctors always needed to balance individual needs against the greater good. Moreover, Hoche argued that this would be a good thing for the medical profession because by killing these “useless eaters,” they would have the opportunity to gather useful anatomical specimens for research – which would help future doctors understand what caused disability and work to prevent it.

Sarah: As the Weimar gave way to the Nazi regime in 1933, German scientists found that their wildest dreams were directly in line with Nazi ideology. After all, the Nazis openly called for a rise of the Volk, the pure, strong and united German people – the eugenicists made their living trying to find ways to use science to achieve such a thing. And while the Americans never really went so far as to openly call for euthanasia – with one glaring exception being radical eugenicist Harry Heiselden, who famously withheld care from a very sick infant and wrote gleefully about it in his book The Black Stork – the more radical eugenicists found a natural home with the radical politics of the NSDAP. The German scientists benefitted from the funding and support offered by the Third Reich. In return, the scientists offered their expertise to the Nazis, teaching classes on race hygiene, conducting scientific research that benefitted the Reich, and working to create the race and ability categories that could be used to exclude those deemed outside of the Volk. For instance, one of the things that eugenicists were obsessed with – both in Germany and out – was genealogy, the careful study of entire family lines to determine their fitness and purity. These family histories were then used in Germany to determine who was in, and who was out, of the Volk. As Henry Friedlander notes, “they fully supported the regime’s policy of exclusion, designed to improve the racial stock of the German nation.”

Averill: The project to cleanse the Fatherland began not with killing but in the same way that it started in the United States: with forced sterilization. In July 1933, just months after Hitler’s appointment as chancellor, Germany began to require that all those diagnosed with certain mental and physical disabilities, including schizophrenia, ‘congenital feeblemindedness,’ manic-depression, epilepsy, Huntington’s disease, blindness, deafness, hereditary deformity and alcoholism, be sterilized to prevent them from having children. A few months later, the Marriage Health Law required that all those seeking marriage licenses had to undergo screening to prevent so called ‘degenerate’ people from marrying healthy Germans. [[Should note: the US had some laws that required this, too, it’s why many states required blood tests for marriage licenses.]] They interpreted degeneracy quite broadly, including mental and physical disabilities, but also criminal and ‘asocial’ tendencies, which most eugenicists agreed were inherited in the same way as eye or hair color. In 1935, the Nuremberg Laws were passed, which I discussed in an episode a while back. These laws focused on protecting German bloodlines from being diluted by interbreeding with inferior racial groups, which according to the Reich included the Jews, the Roma, the Sinti, and blacks. So while Nazi ideology about ability, health, and race were all sort of interconnected, I think it’s really important to note that the laws requiring sterilization for the disabled applied even to those who were ethnically German.

Sarah: We won’t go into great detail here on the sterilization laws, because Averill did talk quite a bit about them, and gave some great statistics on just how many people were sterilized, in her previous episode. But I do want to go into greater detail on that one point – that this was targeted at people who were ethnically German. We tend to think that the Nazi project to cleanse and protect the Volksgemeinschaft was all about purging those who were considered racially inferior, specifically the Jews. But the quality of the Volk wasn’t just defined by racial purity – it also had a sort of intangible quality that had to do with one’s ability to contribute to the betterment of the Volk. Historian Edith Scheffer refers to this quality as gemüt, a word that had a long history in German culture. The meaning of gemüt shifted over time, from Immanuel Kant declaring that it was the origin of a person’s “transcendental faculties” to the nineteenth century connotations of sociability, having strong bonds with friends and family, being friendly and connected. During the Third Reich, gemüt became a critical part of being a part of the Volk. In a 1938 German dictionary, gemüt was defined as “a term perculiar to the Germans and not translatable into any language, involving the feeling of inwardness of the soul with which the German man experiences himself and his entire being, rooted deeply in his racial feelings and values.” Another dictionary stated that having gemüt would “endow the environment with a spiritual quality,” and “feel a cosmic empathy for, and to integrate himself into, the natural and human world that envelops him.” Gemüt, therefore, came indicate your connectedness or integration into the German community both racially, socially, and even spiritually.

Averill: And this makes sense when you think about how very collective and social the Nazi state was – youth men were expected to join the Hitler Youth, which trained them to be good German citizens and soldiers and filled them with a sense of loyalty and nationalism. Similarly, girls were expected to join the Bund Deutscher Mädel, or the League of German Girls, which trained them to be healthy and capable mothers and wives. Adults were supposed to work in support of the collective good, fight in the armies or study in the universities or manufacture Volkswagens to advance in the interests of the Volk. So disabled people posed a number of threats to the German state: if they were physically disabled, they might not be able to perform work to support the collective, and instead, become “useless eaters,” consuming resources and offering nothing in return. Those with hereditary diseases had the potential to infect the racially pure and healthy Volk. And those with intellectual or psychiatric disabilities, or even those who were deemed Aszocial for being criminals, or being promiscuous, or just even being troublesome at school or home, were problematic because they did not have gemüt. In fact, this was the greatest quality that Austrian physician Dr. Hans Asperger used to diagnose children with what he called autistic psychopathy, or what we might now label autism. Autism, according to Asperger, was effectively a spectrum of gemüt. Those who lacked gemüt could not be integrated into the Volk, but others diagnosed with autistic psychopathy but with still some level of sociability, could.

Sarah: Let’s go back to the Knauer baby. When Mr. Knauer begged the doctors, and later, the representatives of the Reich, to kill his baby, it gave Hitler and his doctors the perfect segue into the next phrase of their eugenics project, essentially fulfilling the desires of Binding and Hoche: the implementation of a system of what they called mercy killing, focused on children. The project was spearheaded by a group of doctors, psychiatrists, and members of Hitler’s chancellery, including his private physician Karl Brandt and advisor Viktor Brack. The project would be top secret, and so they created a structure of fake agencies with fake addresses to use as cover; the doctors who signed most of the paperwork involved all used code names. Starting in the summer of 1939, the Reich sent out a decree called “Requirement to Report Deformed &etc Newborns,” which required that doctors and midwives make a report of all children born with deformities, paralysis, Mongoloidism (now called Down syndrome), or other disabilities to the “Reich Committee for the Scientific Registration of Severe Hereditary Ailments” offices. (Side note: there was no “Reich Committee,” it was only a cover for the KdF, or the Kanzlei des Führers, Hitler’s inner circle.) They also asked that they report all patients under the age of three with similar conditions, but eventually, as the war dragged on, older children, and children with other types of ailments were also included.

((Important side note on the Knauer baby: There are a lot of conflicting stories about this baby. Some historians present it more or less how I’ve presented it – as the first euthanasia case, with the parents, not the Reich, the impetus behind the decision. In 2003, the German government archives announced that they had identified the child – it turns out, Knuaer was yet another pseudonym. The child was actually named Gerhard Krestchmar, son of a farmhand. Another important addition here is that some scholars, including Patricia Heberer, who works at USHMM and who is an expert on the children’s program, has argued that the Knauer case was a trial balloon, not the actual inspiration – records indicate that the child’s case was presented in 1939, not 1938, after the children’s program was already in the planning phases. Therefore, the Nazis used the story of Gerhard Kretschmar, with a faked date of 1938 and an probably exaggerated story about his parents begging for the release of a ‘mercy death,’ as a way of demonstrating that this program was in response to a preexisting desire to ‘release’ life unworthy of life.))

Averill: The requirement did not indicate why the Reich was collecting this information, but it would have certainly been in keeping with larger eugenic efforts to keep records and make family trees. When a doctor or midwife submitted a form, Dr. Hans Hefelmann and Dr. Richard von Hegener collected the forms from a post office box, then delivered them to three “experts,” Dr. Wener Catel (a pediatrician), Dr. Hans Heinze (a psychiatrist), and Dr. Ernst Wentzler (a pediatrician). These three doctors reviewed all of the reports. They marked each report with a plus sign, a minus sign, or an O. Pluses meant that they would be “included” in the program – meaning that the child would be killed. Minuses meant that the child would live. An ‘o’ or a note of ‘observation’ meant that doctors and nurses should further watch and evaluate the child. Each form went through all three doctors, so they were aware of how the others were voting – this certainly must have influenced them to not cause problems by disagreeing.

Sarah: The Reich Committee created special wards at hospitals and clinics around Germany, and later in Austria after the Anschluss. This required bringing other doctors and hospital administrators into the secret, and getting them on board with establishing killing wards within their hospitals. Many were more than willing to participate. In all, twenty two killing wards would be established for children. Children who were deemed disabled were reported to the Reich Committee, and then brought to a hospital with a killing ward. Often, this meant convincing the parents – typically by lying and saying the child would be receiving some kind of specialized medical treatment. Then the Reich Committee would send the hospital an authorization – and they used this term specifically to keep up the fiction that the Reich was only acquiescing to a desire from parents and families to “allow children to die,” which was absolutely not what was happening. Once the authorization was received, children were sentenced to die, but typically only slowly. The doctors and nurses of the Reich wanted to deaths to appear as natural as possible, and so they killed by using fairly low dose injections of barbituates, such as Luminal or Veronal, or morphine, over the course of several days. Sometimes, they crushed pills up and mixed them into their food or drinks. Sometimes, the children fell into a deep sleep. More often, food was also withheld so the children lost weight, became sick, got secondary infections, then developed pneumonia and, finally, died. In interviews after the war, many nurses – who were often on the frontlines of committing these acts – explained their actions by trying to cast this process as kind and painless. After all, they reasoned, these were “mercy killings.”

Averill: The program was supposed to be efficient and organized, but in reality, most of it came down to circumstances and ad hoc, human decision making. For instance, because reporting was required and many doctors and midwives did not know what the reporting was actually for, they sometimes thought that the reports were going to result in advanced medical treatment. In those cases, sometimes they exaggerated, or at the very least did not hold back, in describing symptoms. Physicians sometimes disagreed about what kinds of disabilities warranted death. What was more problematic for the Reich was the children’s parents. Although they tried to fashion the whole project as based on parents like Mr. and Mrs. Knauer who asked for their child’s death, and after the war, many doctors try to frame their participation in that light, the reality was that most parents did not want their children to die, and did not know that hospitalizing their children meant their certain death. This meant that the Reich Committee had to add one more layer of lies by coming up with a believable cause of death for children who were otherwise healthy. For example, at Spiegelgrund Children’s Clinic in Vienna, Austria, where Hans Asperger sent dozens of children between 1940 and 1945, at least 789 children died. Three quarters of that number had an official cause of death listed as pneumonia. While we know that certainly a good number of those children did die of pneumonia, it was of course not noted that the pneumonia was the intended result of slow, steady food restriction and barbiturate poisoning.

Sarah: The children were only the first step in the Third Reich’s project to rid Germany of “life unworthy of life.” Since Binding and Hoche’s first suggestion in their 1920 treatise, the desire to “euthanize” those considered a drain on the system had been discussed in the Nazi upper echelons. In the summer of 1939, when everything was in place to begin killing the children but no children had even yet died, Adolph Hitler began plans to expand the program to include adults. He met with Leonardo Conti, a doctor, a longtime member of the NSDAP, a member of the SA and SS, and eventually the Chief of Health for the Reich, as well as two political advisors in the summer of 1939 and began to plan an adult euthanasia program. Hitler stated that “he considered it appropriate that life unfit for living of severely insane patients should be ended by intervention that would result in death.” To illustrate his point, he described patients in institutions who ate their own feces – after the war, many doctors and administrators implicated in the euthanasia program repeated this example, but it’s unlikely that it was based in reality. Eventually, the task of leading the program fell to Philipp Bouhler and Karl Brandt, both of whom had important positions in the children’s program.

Averill: Like in the children’s program, they had to convince doctors and hospital administrators to participate in the scheme, but understandably, many of them hesitated – not because they were unsure about killing their disabled patients, but because they were afraid of prosecution. To appease them, Brandt and Bouhler asked Hitler to make a written order explicitly authorizing them to undertake a euthanasia program. Having a written record was something the Nazi high command was trying to avoid – think about all the fake names and post office boxes they used in the children’s program – but the adult program required a greater buy in from collaborators, and so needed a greater level of assurance of its legality. In October 1939, Hitler wrote a memo on his personal stationary, backdated to September 1, 1939, the day that the invasion of Poland began the war. The memo read as follows: “Berlin, 1 Sept 1939. Reich Leader Bouhler and Dr. med. Brandt are charged with the responsibility of enlarging the competence of certain physicians, designated by name, so that patients who, on the basis of human judgment, are considered incurable, can be granted mercy death after a discerning diagnosis. signed, A. Hitler.”

Sarah: Important aside: In the final days of the war, when the Nazis were trying to cover their tracks, all copies of this letter were destroyed, along with tons and tons of other documents. But one copy survived – a photocopy that Philipp Bouhler sent to Franz Gurtner, Reich minister of Justice. It was discovered later tucked away safely in his papers.

The operation to kill disabled adults was code named Aktion T4, a name derived from the address of the house in Berlin where it was headquartered: Tiergarten Straße Number 4. The adult program required more centralized administration than the ultra-secretive children’s program. It even had a business manager, Gerhard Bohne, a finance office, and a motor pool; workers were paid salaries. Eventually, they even had a vacation home set up for staffers to use for get aways. Like the children’s program, the Reich created front operations to hide the real purpose of T4. Fake organizations included the Reich Cooperative for State Hospitals and Nursing Homes, the Charitable Foundation for Institutional Care, the Charitable Foundation for the Transport of Patients, Inc., and the Central Accounting Office for State Hospitals and Nursing Homes. It’s particularly disturbing that all of these were disguised as organizations to aid disabled and institutionalized people.

Averill: Starting in the fall of 1939, the ministry that oversaw the program asked local governments to report all institutions containing “mental patients, epileptics, and the feebleminded.” When they received these lists, the central office sent out questionnaires to the hospitals, asking for information on all patients who fell into particular categories: epileptics, syphilitics, the feebleminded, schizophrenics, those who were senile, as well as anyone who was non-Aryan. Doctors completing the questionnaires were also asked to indicate whether individual patients could perform any labor. The doctors, again, did not necessarily know what the questionnaires were for, and sometimes tried to indicate that their patients could not perform labor thinking that perhaps they were saving them from work camps. In reality, they were making it more likely they would be killed. Even then, the questionnaires had very limited space, meaning that doctors had no choice but to be brief in their comments.

Sarah: In the children’s program, only three doctors determined the fate of the patients. But there were far more adults, meaning that the administrators had to recruit more doctors to agree to be evaluators. They organized two groups of evaluators: senior and junior doctors, all recommended through their professional networks, carefully vetted for party loyalty, and who each agreed to participate. Henry Friedlander is very emphatic about this: they all had the option to leave, all of them opted to stay. No one was forced to participate. Decisions to kill went through two rounds of evaluation. First, it went through a round of ‘junior’ experts. Almost all – in fact, all but three – of the physicians used as experts were in this junior group. The junior experts evaluated hundreds of reporting forms, sent from hospitals and institutions from all over Germany. Friedlander uses Hermann Pfannmüller, one of these junior experts, as an example. Pfannmüller received huge stacks of evaluation forms, sometimes 200-300 at a time, and returned them very quickly to Berlin to be processed. Postwar investigations showed that Pfanmüller had evaluated “2,058 patients between November 12 and December 1 1940, which mean that he made 121 decisions a day about the life and death of patients or one decision every five minutes in a ten-hour day.”

Averill: Most experts who worked for the T4 program did not see themselves as killers. Indeed, Pfanmüller defended himself after the war by saying that he was only a “medical expert just as any medical expert appearing in a case before a court.” But for every form he evaluated, a human being either got to live, or was sent to a killing center to be murdered by the Nazi state. [Pause] After the junior experts signed off, the forms went to the senior evaluators – all three of them. These men more or less just signed the forms en masse. People were evaluated based on their ability to work – they were not really expected to ever truly join the ranks of the Volk, but they might at least perform useful labor. From that point, the patient’s fate was sealed. The central T4 offices would then handle the logistics. It arranged for the institution holding the patients to prepare them by gathering all their belongings and records and labeling them clearly on the back with a piece of tape bearing their name. They were then dosed with sedatives to keep them calm and easily managed. A gray bus from the Gekrat (a subdivision of the T4 program in charge of transportation) arrived at the institution, was loaded with distressed and confused patients, and drove them to one of the hospitals that were designated to serve as killing centers: the first was Hadamar, followed by Grafeneck, Brandenburg, Hartheim, Sonnenstein, and Bernberg. And we know that at least some of the patients knew what was happening. One female patient, as she was being boarded onto the Gekrat bus, asked “Is it my fault that I am born this way, and that they do this to me?” Another wrote to his mother as he waited his transport: “Dear mother! I want to write these final lines to you, because I must leave here and do not know the destination. It is difficult for me. I thank you all whole heartedly and say farewell, if not in this world, then hopefully in heaven. With heartfelt greeting, your grateful son.”

Sarah: Initially, T4 administrators and doctors planned to use a shortened version of the killing method used on the children: overdoses of drugs. But it would be expensive, time-consuming, and cumbersome to kill adult patients slowly, so they envisioned a system of injecting patients directly with barbiturates. This would still be a little onerous, and would require doctors and nurses do the killing directly. Although it’s not exactly clear, after the war, several testified that it was Adolf Hitler himself who first recommended gas. In order to decide which was the better option, Karl Brant and Leonardo Conti conducted an experiment comparing the deaths from injected drugs to inhaled gas at Brandenburg in 1939/1940. Brandt and Conti themselves performed the injections. They waited and watched, and according to their recollection, it took the patients a long time to die. Two patients needed to be injected again to finish the job. On the other hand, the patients who had been gassed (using CO gas) died within a couple of minutes. They had been escorted into a room fashioned to look like a shower. After they inhaled the gas, they died – again, according to the Nazi chemists observing – quietly and calmly. From there, the room would be cleared of gas, the bodies removed, and while the process differed a little bit depending on the individual killing center, they were almost always taken to be cremated, sometimes in the institution, sometimes in a building or even a home nearby. It was usually fairly obvious to people living in the area what was going on at the hospital. At Harheim, for instance, villagers took note of the constant smell and dark black smoke rising from a hospital out building.

Averill: The process of killing with CO gas was tweaked and perfected in these killing centers. What began as ad hoc spaces that could be sealed, and even one instance where a gas chamber was jerry rigged with a pipe leading from a truck exhaust in through a window, ended up becoming specially designed rooms, made to look like showers, with specialized airlocks and carefully measured gas pumped in, controlled from another room. Henry Friedlander refers to this as the “hardware” and “software” of killing – the built structures like crematoria and gas chambers served as hardware, and the gas and even the human labor required constituted the software. The entire process was designed to simulate a normal hospital transfer. Patients were gathered onto the Gekrat busses and delivered to the killing centers. Then, they would be unloaded and taken to undress, ostensibly for a medical examination and new, hospital approved clothing. All their belongings would be carefully labeled and set aside. Then, a doctor would briefly examine them. This made patients feel a bit more at ease because it also fit into their expectations of a hospital transfer – in reality, doctors were gathering information to help them generate a believable fake cause of death. (You don’t want to say a patient died of a sudden attack of appendicitis if they have an appendicitis scar already.) Often, patients were then photographed or filmed, not to provide a record, but more often to be used as eugenicist propaganda. Then, patients would be shuffled into a shower room, the door sealed shut, and the patients killed with lethal gas.

Sarah: The next step was to notify the family – but of course, they couldn’t say why the patient had actually died. They also had to have a reasonable and believable cause of death. After the war, one clerk testified that the most common “causes of death” were “heart attack, circulatory collapse, pneumonia [and] stroke.” The T4 central office actually issued memoranda to physicians working in the killing centers with guidelines for faking death certificates. Then, the staff of the killing center in the “department of condolence letters” would write a short form letter to the family of the dead patient, explaining their loved one’s death and explaining that the family should consider the death as a release. In one letter the staff at Brandenberg wrote this to a bereaved family: “In spite of all medical efforts, we were unable to save your husband … But as the nature and severity of your husband’s illness did not encourage hope for improvement, and thus there was no longer any expectation that he could ever be release from an institution, one can understand his death as deliverance, as it delivered him from his suffering and spared him from institutionalization for life. May this thought be solace to you.”  Typically, they also told families that belongings could not be collected, usually because there was a fictitious outbreak of infection.

Averill: The whole program – including both the children’s program and the adult T4 program – were supposed to be top secret. This is hard for us to wrap our minds around today because in retrospect, we tend to think of the Nazis as brazen, uber confident murders – they certainly were, but that doesn’t mean that they didn’t understand completely that if these projects were discovered, there would be recriminations. This was especially true of these euthanasia programs, which didn’t include racialized others, but members of families that often were otherwise welcomed entirely into the German Volk. Parents like Mr. and Mrs. Knauer were not common – even among people who were invested in the Nazi regime, the idea of murdering a beloved but disabled family member might be unpopular. However, the effort to keep the program secret totally failed. Locals around the killing centers easily guessed what was happening when they added up all the evidence – the Gekrat busses delivering patients never seen again, the smell, and the thick smoke. The program also required a lot of labor, which meant a lot of complicity. There were lots and lots of people who might share information with their friends or family members. And the effort to distance the Nazi party from the program by using front organizations, code names, and pseudonyms was unconvincing – after its harsh rhetoric on “life unworthy of life,” it was a no brainer to see that the party was responsible for the steady disappearance of disabled people from institutions around Germany.

Sarah: Plus, there was some significant dissent. Parents of disabled children scrambled to save their children from the killing centers, although many of them failed. The Catholic Church also spoke out against the program – in December 1940, the Vatican issued a decree denouncing the euthanasia program as “against natural and Divine law,” but most German clergy did little to effect change. One German bishop, bishop of Münster, Clemens August Graf von Galen, gave a powerful sermon which he then wrote out and sent directly to Hitler. While the sermons weren’t printed in the German press, the Royal Air Force eventually started dropping printed copies over German troops in an attempt to undermine support for the Reich. Church leaders in Germany increasingly spoke out, but this did little to affect the course of the program. Either way, the T4 program was suspended in August 1941. The reason for the suspension is different depending on which historian you read, but I think the general consensus is that it was the loss of that top secret status that lead to its ultimate demise, although a shift in focus toward the Final Solution, with its grander scope, probably also had something to do with it.

Averill: But while the T4 program was no longer officially running, the deaths didn’t stop. After its official end, the institutions began a period characterized by what many called “wild euthanasia,” where they continued to kill disabled patients in a much more ad hoc manner – through starvation, injections of barbiturates, or withdrawal of care. They continued to transfer disabled patients, but instead of transporting them all to killing centers, they were sent to various institutions – what exactly happened to them is hard to pin down because they stopped keeping careful records, but they never returned and most did not survive the war.  And of course, we know that deaths did not stop after the summer of 1941, but in general, the killing in Germany (and Poland, and the Soviet Union, and elsewhere) only expanded. We know that the intentional and focused extermination killings began in the Soviet Union in 1941 using the mobile killing units of the Einsatzgruppen in Operation Barbarossa. This was an attempt to exterminate the Jewish population by rounding up Jewish (and Roma/Sinti) residents of towns and villages as the killing units moved through the Soviet Union, Poland, and Ukraine, gathering citizens by large pits and then shooting them. But much like injections in the initial phases of the euthanasia program, shooting hundreds of people while looking them in the face, hearing their screams, and then laboriously dealing with their mangled bodies afterward, took a toll on the soldiers in these units.

Sarah: Ever focused on efficiency, the Nazis sought a better way to exterminate. They turned to their first experiment in mass murder, the T4 program, for inspiration. The idea of rounding people up, keeping them fairly confused, and delivering them to one centralized location where they could be killed using gas, seemed much simpler and more efficient. Thus, when the T4 program was suspended, many of the perpetrators of that program were transferred into the death camps to help design larger scale gas chambers and crematories. Heinrich Himmler decided to establish new killing centers, and eventually, turn some of the already established concentration camps (such as Auschwitz) into their own kind of killing centers. But they also learned in the T4 program that it was hard to murder huge numbers of people without attracting attention, and inevitably, garnering criticism. Thus, the killing centers such as Chelmno, Sobibor, Treblinka, and Auschwitz, were all established outside of Germany. At Auschwitz, the perpetrators decided to bypass the CO, which was often difficult to come by, and instead use the fumes of a pesticide that was commonly stocked in the camp: Zyklon B. So the Holocaust, in at least this particular way, was founded on the knowledge and infrastructure developed in the “euthanasia program.”

Averill: After the war, as part of the larger effort to prosecute the war crimes committed by the Nazis, a series of trials were held to hold Nazi doctors accountable. Between 1947 and 1948, 23 doctors – including Karl Brandt and Viktor Brack – were tried in Nuremberg and a couple of other occupied German cities. This is where we get a significant amount of the information we have about the programs, both because the prosecutors did an insane amount of research and because the doctors were interrogated and required to give testimony for hours at a time. In the end, 7 were sentenced to death, including Karl Brandt and Viktor Brack. Others, including Otmar von Verschuer, Eugen Fischer, and Hans Asperger, were never prosecuted because they were distant enough to appear to not be complicit. Yet others, including perhaps the most infamous Nazi doctor, Josef Mengele, escaped entirely, and were able to live out their lives without any punishment whatsoever. Many of those physicians – like Verschuer and Fischer for instance – were actually in a great position after the war, because they had four or more years of research and hands-on training as they experimented on and ‘treated’ their doomed patients. Further, they had amassed a massive collection of biological specimens, specifically brains, that they could continue to use for study. One doctor, Julius Hallervorden, collected some 700 brains from the Brandenberg killing center – they were used for scientific and medical research until they were finally laid to rest in a Munich cemetery in 1990.

Major thank you to Kierra Crago-Schneider, Karen Nakamura, Richard Wetzell, and all our wonderful friends at the United States Holocaust Memorial Museum for their incredible guidance in the Hess Faculty Seminar.

Sources:

Henry Friedlander, The Origins of the Nazi Genocide: From Euthanasia to the Final Solution (Chapel Hill: University of North Carolina Press, 1995)

Patricia Heberer, “The Nazi Euthanasia Program,” in The Routledge History of the Holocaust, ed. Jonathan Friedman (London” Routledge, 2011)

Robert Jay Lifton, The Nazi Doctors (New York: Basic Books, 1988)

Sheila Faith-Weiss, The Nazi Symbiosis (Chicago: University of Chicago Press, 2010)

Edith Sheffer, Asperger’s Children: The Origins of Autism in Nazi, Vienna (New York: W. W. Norton & Co., 2018)

Susan Bachrach and Dieter Kunz, United States Holocaust Memorial Museum, Deadly Medicine: Creating the Master Race (Charlottesville: University at Virginia, 2008)