By ROBERT JAY LIFTON; ROBERT JAY LIFTON IS DISTINGUISHED PROFESSOR OF PSYCHIATRY AND PSYCHOLOGY AT JOHN JAY COLLEGE AND THE GRADUATE CENTER OF THE CITY UNIVERSITY OF NEW YORK. THIS ARTICLE IS AN ADAPTION FROM HIS BOOK, ''THE NAZI DOCTORS: MEDICAL KILLING AND THE PSYCHOLOGY OF GENOCIDE,'' TO BE PUBLISHED NEXT MONTH BY BASIC BOOKS.
Before Auschwitz and the other death camps, the Nazis had established a policy of direct medical killing - killing arranged within medical channels, by means of medical decisions, and carried out by doctors and their assistants. The Nazis called this program ''euthanasia.''
'Euthanasia,'' in its Greek derivation, means ''good death.'' The word is generally used for actions taken to facilitate the deaths of those who are already dying, and has long been a subject of debate for physicians, moral philosophers and the general public.
The Nazis, however, used the term ''euthanasia'' to camouflage mass murder. Just how the Nazis were able to do that has been made clearer by recent historical research and by interviews I was able to conduct during the last decade with German doctors who participated in the killing project.
Nazi medicalized killing provided both the method - the gas chamber - and much of the personnel for the death camps themselves. In Auschwitz, for instance, doctors selected prisoners for death, supervised the killings in the gas chambers and decided when the victims were dead.
Doctors, in short, played a crucial role in the Final Solution. The full significance of medically directed killing for Nazi theory and behavior cannot be comprehended unless we understand how Nazi doctors destroyed the boundary between healing and killing.
The Nazi principle of killing as a therapeutic imperative is evident in the words of the Auschwitz S.S. doctor Fritz Klein. Klein was asked by an inmate how he could reconcile Auschwitz's smoking chimneys with his purported fealty to the physician's Hippocratic oath, which requires the preservation of life. ''Of course I am a doctor and I want to preserve life,'' replied Klein. ''And out of respect for human life, I would remove a gangrenous appendix from a diseased body. The Jew is the gangrenous appendix in the body of mankind.''
The Nazis justified direct medical killing by use of the simple concept of ''life unworthy of life'' - lebensunwertes Leben. While this concept predated the Nazis, it was carried to its ultimate racial and ''therapeutic'' extreme by them.
Of the five identifiable steps by which the Nazis carried out the destruction of ''life unworthy of life,'' coercive sterilization was the first. There followed the killing of ''impaired'' children in hospitals, and then the killing of ''impaired'' adults -mostly collected from mental hospitals - in centers especially equipped with carbon monoxide. The same killing centers were then used for the murders of ''impaired'' inmates of concentration camps. The final step was mass killing, mostly of Jews, in the extermination camps themselves.
Once in power - Hitler took the oath of office as Chancellor of the Third Reich on Jan. 30, 1933 - the Nazi regime introduced an early sterilization law with a declaration that Germany was in grave danger of Volkstod -''death of the people,'' ''nation'' or ''race'' - and that, to combat it, harsh and sweeping measures were imperative.
Mandatory sterilization of those termed the ''hereditarily sick'' was part of the Nazi vision of racial purification. No one knows how many people were sterilized; reliable estimates range from 200,000 to 350,000 people.
For a doctor, there is a large step between ligating spermatic cords, cutting fallopian tubes, even removing uteri, and killing or designating for death one's own patients. But, by the time the Nazis took power in Germany, some of the philosophical groundwork allowing for this transition had already been laid.
The crucial theoretical work was Die Freigabe der Vernichtung lebensunwerten Lebens, or ''The Permission to Destroy Life Unworthy of Life.'' Published in 1920, it was written jointly by two distinguished German professors, the jurist Karl Binding, retired after 40 years at the University of Leipzig, and Alfred Hoche, professor of psychiatry at the University of Freiburg.
Hoche argued in the book that a policy of killing was compassionate and consistent with medical ethics. He pointed to situations where doctors were obliged to destroy life - interrupting a pregnancy to save the mother, for example. He went on to claim that various forms of psychiatric disturbance, brain damage and retardation indicated that the patients were already ''mentally dead.'' He characterized these people as ''human ballast'' and ''empty shells of human beings'' - terms that would later reverberate in Nazi Germany. Putting such people to death, Hoche wrote, ''is not to be equated with other types of killing.'' It is, he wrote, ''an allowable, useful act.''
Binding and Hoche turned out to be the prophets of direct medicalized killing. Prior to the Nazis' assumption of power, such thinking was not a majority view in German psychiatry and medicine. But under the Nazis, there was increasing discussion in medical and political circles of the legitimacy of mercy killing, of Hoche's concept of the mentally dead, and of the enormous economic drain on German society caused by the large number of impaired Germans. A mathematics textbook of the period even asked students to calculate how many government loans to newly married couples could be granted for the money it cost the state to care for ''the crippled, the criminal, and the insane.''
The killing of children - indeed the entire Nazi ''euthanasia'' program - began simply with a petition to allow the ''mercy killing'' (Gnadentod, literally ''mercy death'') of an infant named Knauer, who was born blind, with one leg and part of one arm missing, and apparently an ''idiot.'' The petition was made by the baby's grandmother (some claim it was the father) but it was clearly encouraged by the regime.
In late 1938 or early 1939, Hitler ordered Karl Brandt, his personal physician and close confidant, to go to the clinic at the University of Leipzig where the child was hospitalized, to consult with the physicians there and to determine whether the information submitted about the child was accurate. If the facts about the child's condition were correct, Brandt recalled in 1947 at the Nuremberg Medical Trial (one in the series of Nazi war-crimes trials that was devoted solely to the prosecution of medical crimes), then in Hitler's name ''I was to inform the physicians . . . that they could carry out euthanasia.'' Brandt was also empowered to tell the doctors at Leipzig that any legal proceedings against them would be quashed by order of Hitler.
According to Brandt, the doctors agreed ''that there was no justification'' for keeping the child alive. In his recollection of the incident at the Nuremberg Medical Trial, he added that ''in maternity wards, in some circumstances, it is quite natural for the doctors themselves to perform euthanasia in such a case without anything further being said about it.''
On returning to Berlin, Brandt was authorized by Hitler, who did not want to be publicly identified with the project, to establish a child-killing program with the help of Philip Bouhler, chief of Hitler's Chancellery.
It seemed easier to start with the very young.
The child-killing program began with newborns, then proceeded to children up to the ages of 3 and 4 and soon to older ones. The authorization for the killing project was, at first, oral, secret and ''kept in a very narrow scope,'' covering ''only the most serious cases,'' according to Karl Brandt's Nuremberg trial testimony. It later became loose, extensive and known among a wider and wider circle of physicians and officials.
In 1939, a small group of doctors and Chancellery officials held discussions to lay out a structure for the project. A group of medical consultants known to have ''positive'' attitudes toward the project was assembled; among their number were administrators, pediatricians and psychiatrists.
It was decided that the program would be run secretly from the Chancellery, although the health division of the Reich Interior Ministry would help to administer it. For that purpose, an organization was created: the Reich Committee for the Scientific Registration of Serious Hereditary and Congenital Diseases. The name was meant to convey the sense of a formidable medical-scientific board, although its leader, Hans Hefelmann, had a degree in agricultural economics.
The impression of medical propriety was maintained in a confidential directive sent on Aug. 18, 1939, by Minister of the Interior Wilhelm F. Frick to the heads of non-Prussian state governments. The directive ordered ''the earliest possible registration'' of all children under 3 years of age in whom ''serious hereditary diseases'' were ''suspected''; included on the list of diseases were idiocy and mongolism (especially when associated with blindness and deafness), microcephaly, hydrocephaly, paralysis, and spastic conditions and malformations of all kinds, but especially of the limbs, head and spinal column. The registration was necessary ''for the clarification of scientific questions in the field of congenital malformation and mental retardation.''
Midwives were required to make these reports at the time of a child's birth, and doctors were to report all impaired children up to the age of 3. District medical officers were responsible for the accuracy of the reports, and the chief physicians of maternity clinics and wards were notified that the reports - which took the form of questionnaires from the Reich Health Ministry - were required.
By June 1940, the questionnaires were expanded to include not only a child's specific illness or condition, but details about family history - including hereditary illnesses and alcohol, nicotine or drug abuse - as well. The revised reports also required a more detailed evaluation of the child's condition by a physician, indicating possibilities for improvement, life expectancy, prior institutional observation and treatment, details of physical and mental development, and descriptions of convulsions and related phenomena.
The actual killing was done in children's institutions whose chiefs and prominent physicians were known to be politically reliable and ''positive'' toward the goals of the Reich Committee. These killing centers were grandly referred to as ''Reich Committee Institutions,'' ''Children's Specialty Institutions'' or even ''Therapeutic Convalescent Institutions.'' Doctors, administrators and Reich officials proceeded as if the children were to receive the blessings of medical science.
No such separate institutions existed, of course. The children marked for death were usually dispersed among ordinary pediatric patients at children's hospitals.
The falsification was clearly intended to deceive the children, their families and the general public. But, by expressing literally the Nazi reversal of healing and killing, the deceptions also served the psychological needs of the killers. A doctor could tell a parent that ''it might be necessary to perform a surgical operation that could possibly have an unfavorable result''; or he might explain that ''the ordinary therapy employed until now could no longer help'' their child, necessitating ''extraordinary therapeutic measures.''
The structure of the child-killing program also diffused individual responsibility. In the entire sequence - from the reporting of cases by midwives and doctors, to the supervision of the reporting by heads of institutions, to the coordination of the reports by Health Ministry officials, to the child's appearance at the Reich Committee institution for killing - there was no need for any single participant to feel personally responsible for the murder of another human being. Each participant could feel like no more than a small cog in a vast, officially sanctioned, medical machine.
Before being killed, children were generally kept for a few weeks in the institution, to convey the impression that they were to undergo some form of medical therapy. The killing was usually arranged by the institution's director or by a doctor working under him. Frequently, the order to kill a child was delivered by innuendo, rather than as a specific directive.
Killing was generally done with tablets of Luminal - a barbiturate - dissolved in tea or another liquid. Luminal would be given to a child repeatedly over two or three days, until the child lapsed into continuous sleep and then died.
For children who had difficulty drinking, Luminal was sometimes injected. If the Luminal did not kill the child quickly enough, the child would be given a morphine-scopolamine injection. An ordinary disease, such as pneumonia, would be listed as the cause of death; there was a kernel of truth within that lie, since the immediate cause of death following an overdose of a drug like Luminal often was pneumonia.
From the start of the program in 1939, the criteria for killing children continually expanded, and came to include various minor handicaps. The program culminated with the killing of youths designated as juvenile delinquents.
Jewish children could be placed in the net simply because they were Jewish. At Heyer, one of the childrens' institutions, a special department was established for ''minor Jewish-Aryan half-breeds.''
Although Hitler officially ordered the termination of the general ''euthanasia'' project in 1941, partly in response to public criticism by some German clergymen, the killing of children continued. Indeed, it probably increased, but was conducted in a more haphazard fashion. Estimates based on various trial materials and other evidence indicate that 5,000 children were killed between 1939 and 1945, but the total was probably much higher.
Extending the project from children to adults meant making medicalized killing official policy. Hitler enunciated this policy in his ''Fuhrer decree,'' issued in October 1939, only two months after the order requiring the registration of infants for the child ''euthanasia'' project.
The Fuhrer decree, a personal directive from Hitler that had the authority of law, was brief; it charged Karl Brandt and Philip Bouhler, chief of the Reich Chancellery, with ''responsibility for expanding the authority of physicians, to be designated by name, to the end that patients considered incurable according to the best available human judgment of their state of health can be granted a mercy death.''
The camouflage organization created for the adult killing project was the Reich Work Group of Sanitariums and Nursing Homes. It operated from the Reich Chancellery in Berlin, at Tiergarten 4. The project was thus given the code name of ''T4.''
Questionnaires for the T4 project were devised by a small group of psychiatrists and administrators. The questionnaires were distributed, with the help of the Health Ministry, not only to psychiatric institutions but to all hospitals and homes for chronic patients. The limited space provided on the questionnaires for biographical and symptomatic information, as well as the cover letter sent with them, gave the impression that the Government was conducting a statistical survey for administrative, and possibly scientific, purposes. But the sinister truth was suggested by the great stress in the questionnaires on the need for a ''precise description'' of the patient's ability to work.
From the start, the T4 reporting process was haphazard. Physicians and administrators were required to return the forms quickly; one institutional doctor had to fill out 1,500 questionnaires in two weeks. Early confusion about the purpose of the forms led some doctors to exaggerate the severity of their patients' conditions, in the belief that they were protecting them from a plan to release them from institutions in order to send them to work.
Four or five copies of every questionnaire were made in the Reich Interior Ministry. Three of the copies were sent to a trio of medical ''experts'' (Gutachter), who reviewed the reports independently to provide an ''expert evaluation'' of each patient. The other copies were retained and used as records prior to and after the patient was killed; the original was usually kept in the central files at T4 headquarters in Berlin.
In a thick, black frame at the lower left-hand corner of the forms, each of the ''experts'' would write an ''x'' in red pencil, meaning death; ''-'' in blue pencil, meaning life; or ''?'' sometimes accompanied with the comment ''worker.''
If anything, the evaluations by the experts were even more mercurial and superficial than those of the doctors and administrators who initially filled out the questionnaires. Each expert was sent at least 100 questionnaires at a time. During one 17-day period, one of the experts was required to complete 2,109 evaluations.
The experts did no examinations and had no access to medical histories; they made decisions solely on the basis of the questionnaires. Their occasional disagreements had only to do with definitions and policy; the pressure was always to order a patient's death. At his 1946 trial, Friedrich Mennecke, one of the experts, recalled the implicit directive that ''one should not be petty . . . but instead, liberal'' in rendering a ''positive judgment.''
Transportation arrangements for patients marked for death were a caricature of the psychiatric transfer process. The organization created for this function, the Common Welfare Ambulance Service Ltd., sent out ''transport lists'' to the hospitals from which it was to collect patients. It also issued instructions to the hospitals that patients must be accompanied by their case histories, personal possessions and lists of valuables held for them. In addition, it prohibited the transfer of patients whose lives would be endangered by lengthy transport -a show of medical propriety designed to avoid the awkwardness of a patient dying en route.
S.S. personnel manned the buses, frequently masquerading as doctors, nurses, or medical attendants by wearing white uniforms or white coats. Reports of ''men with white coats and S.S. boots'' came to characterize much of the ''euthanasia'' project.
To hide patients from the public, bus windows were covered with dark paint, fixed curtains or blinds. The medical staffs of the institutions from which patients were taken, as well as the patients themselves, of course, were not told the destination of the buses.
Six main killing centers were established between January 1940 and January 1941. Typically, the centers were converted mental hospitals or nursing homes, although one had been a prison. All were in isolated areas and had high walls. Some had originally been constructed as castles.
Initially, patients were taken directly to the killing centers. This practice was eventually discontinued, and patients were kept for brief periods at ''observation institutions'' or ''transit institutions'' - often large state hospitals near the killing centers - before being sent to their deaths. The observation institutions provided an aura of medical legitimacy, an ostensible check against mistakes. In fact, no real examinations or observations were made.
The bureaucratic mystification was furthered by letters sent to the families. First, they were notified of a patient's transfer from the psychiatric institution or hospital ''because of important war-related measures.'' When the patient reached the killing center, the family was sent a second letter, announcing his or her ''safe'' arrival; this notice also informed the families of the impossibility of visits or inquiries because of ''Reich defense reasons'' and ''the shortage of personnel brought about by the war.'' However, family members were told that they would be informed ''immediately'' of changes in a patient's condition or in the visiting policy. The second letter was signed, with a false name, by either the killing doctor or the chief of the killing center.
A third letter, again sent under a false name by the ''Condolence Letter Department,'' notified the family of the patient's death.
That death generally occurred within 24 hours of a patient's arrival at the killing center. Under T4 policy, a doctor had to perform the actual killing, in accordance with the motto enunciated by Viktor Brack, head of the Chancellery's Department II, which had responsibility for the T4 program: ''The syringe belongs in the hand of a physician.'' A syringe was the exception; it was usually a matter of opening a gas cock.
Throughout the ''euthanasia'' project, senior doctors served as consultants and experts, made policy and rendered decisions. Younger doctors did most of the killing.
At Brandenburg, one of the killing centers, for example, Dr. Irmfried Eberl was 29 years old when he learned to operate the gassing mechanism. The man later assigned to assist him, Dr. Aquilin Ullrich, was only 26.
In a 1961 investigation of the T4 program, Ullrich testified that his duties barely required any medical knowledge. He and Eberl (who later became the commandant of Treblinka, the only doctor actually to head a death camp) did no more than make a ''superficial inspection'' of the naked patients in the gas chamber's anteroom. He subsequently realized that ''the presence of the physician at that moment was used to calm the mentally ill and camouflage the killing process.''
Every death certificate had to be falsified. Medical credibility was the primary factor in ascribing a false cause of death: The disease had to be consistent with a patient's prior physical and mental state, a disease that he or she could have contracted. Designated causes of death included infectious diseases, pneumonia and diseases of the heart, lungs, brain and other major organs. Skill at this falsification process was an important part of the ''medical experience'' of the killing doctors. To help them, physicians were given written guidelines specifying which details were necessary for consistency.
One such guideline, for example, focused upon septicemia (bacteria in the bloodstream) as a cause of death; it referred to bacterial infection of the skin as a possible source of the disease, and listed the sequence of symptoms and the therapy to be cited. The document included additional useful tips, among them the fact that unclean mental patients often have boils which they scratch, causing the infection. ''It is most expedient to figure four days for the basic illness and five days for the resultant sepsis,'' read the guide. The diagnosis, it added, ''should not be used with patients who are meticulously clean.''
The bureaucracy of deception extended to the ashes of cremated patients. Families were told that quick cremation had been necessary for public health reasons, particularly during wartime. An additional directive prohibited corpses from being cremated individually. One of the T4 program's leaders, Gerhard Bohne, testified in his 1959 in Germany that he had objected vehemently, ''for reasons of piety,'' when that policy was implemented. He claimed to have told the administrator responsible for the order: ''Even if the German people forgive you everything, they will never forgive you this.''
Inevitably, there were flaws in the bureaucracy of deception. A family would receive two urns, or be told that a patient, whose appendix had been removed earlier, had died of appendicitis.
Employees of the killing centers would drink heavily at local bars and sometimes reveal elements of their work. Sometimes, patient-transfer procedures were conducted where they could be seen - even on occasion in a town marketplace - allowing local people to witness the force used on recalcitrant victims.
And, of course, there was direct sensory evidence of the killing that no bureaucratic deception could eliminate. ''The heavy smoke from the crematory building is said to be visible over Hadamar every day,'' read one 1939 report to the Reich Justice Ministry.
Nazi authorities were aware of these bureaucratic oversights; one local party official requested ''more sensitivity'' from T4 officials in conducting the killing program. But the ''mistakes'' were partly a product of the regime's own inner conflicts and contradictions about its principle of secrecy. In spite of the elaborate cover-up that existed at every level and the pledge of eternal secrecy taken by all involved in the killing project, outsiders were allowed to visit several of the killing centers and, on some occasions, permitted to witness the killing of patients.
From the beginning of the T4 operation, Jewish patients were viewed as a group apart. Under T4, Jewish inmates of German institutions did not have to meet the ordinary criteria for medical killing. Jewish mental patients were unique among all Nazi victims in that they could embody both ''dangerous genes'' in an individual medical sense and ''racial poison'' in a collective ethnic sense.
For Jews, ''no special consultations or discussions . . . were necessary,'' according to documents prepared by West German authorities for the 1961 trial of the T4 medical director Werner Heyde. ''The total extermination of this group of asylum inmates was the logical consequence of the radical solution of the Jewish problem being embarked upon.''
The systematic ''treatment'' of German Jews under T4 began in April 1940, with a proclamation from the Reich Interior Ministry that within three weeks all Jewish patients were to be registered. In June, the first gassings of Jews took place: 200 men, women and children were killed in the Brandenburg facility; they had been transported to the killing center in six buses from the Berlin-Buch mental institution. There were more killings in July. On Aug. 30, another directive from the Interior Ministry ordered that Jews were to be segregated in specific institutions. The directive explained that employees and relatives of Aryan patients had complained about being treated and housed with Jews.
In the fall of 1940, the Nazis began to transport Jewish patients to occupied Poland, as part of the policy of removing all Jews from Germany. In December, it was announced that Jewish patients would be transferred to a privately owned Jewish institution for mentally impaired children in Bendorf, in the Rhineland.
From Bendorf, Jewish patients were sent either to T4 killing centers or, beginning in the spring of 1942, into channels leading to the death camps. In the latter case, they were transported to Poland, in trains with 60 to 70 patients sealed in each freight car; the trains carried ordinary Jewish citizens as well.
Once the Jewish patients were herded into the trains, the pretense of medical treatment ended. The trains arrived in Lublin, where Polish Jews were being ''concentrated,'' and where property confiscated from Jews was processed with slave labor.
The T4 office set up a camouflage operation specifically for Jewish patients. On stationery with letterheads reading ''Cholm Insane Asylum,'' statements of condolence and death certificates were sent out. Couriers took the mail to Chelm (the Polish spelling) near Lublin, where the letters were mailed with the proper postmark. As far as can be determined, the ''Cholm Insane Asylum'' was a fiction. When Germany invaded Russia in June 1941, Einsatzgruppen troops under Reinhardt Heydrich liquidated hospital patients as well as Jews, gypsies and Communist functionaries. Reports from the field mentioned the need for beds for injured soldiers. But they also cited ''the German view'' that these were lives unworthy of life.
Psychological trauma suffered by Einsatzgruppen troops led Nazi authorities to lessen their reliance on shooting as a killing method. Explosives were tried - for example, in Russia, in September 1941, when mental patients were blown up. But this method was ineffective, and required too much cleaning up. Gassing, the killing method developed for adult T4 patients, was clearly preferable. Carbon monoxide was used -first in canisters and then, after further technological innovation, from the exhaust of vans.
In October 1941, Viktor Brack, head of the Chancellery's Department II, and Adolf Eichmann, the Reich's expert on Jewish affairs, decided to use the vans for killing all Jews ''incapable of working.'' Three vans were installed at the first pure extermination camp established by the Germans at Chelmno (Kulmhof), in what is now north-central Poland, which was opened in December 1941. The vans were used to kill gypsies, typhus victims, Soviet prisoners of war and mental patients, but mainly Jews.
In a replica of the T4 procedure, victims were told to shower while their clothing was being disinfected. S.S. officers wore white coats and carried stethoscopes. Prisoners had their valuables registered, then followed a sign reading ''To the Bath'' up a ramp and into the van. When no more noise was audible from the van, it was driven to the nearby woods where Jewish Kommandos unloaded the corpses into mass graves. Because of noxious gases, a crematorium was later installed.
Chelmno, in reclaimed German territory, was the first of the extermination camps. It was followed by Belzec, Sobibor and Treblinka, all of which even more closely resembled ''euthanasia'' killing centers in their use of stationary gas chambers and T4 personnel.
The ''euthanasia'' program prefigured the death camps not only in method and personnel but in reversing healing and killing in the name of biological purification.
While it has been estimated that 350 German doctors were involved in specific criminal acts, that figure may be, as one early observer recalled, no more than the ''tip of the iceberg.'' A few doctors, in various ways, resisted the Nazi projects, but German physicians as a profession offered themselves to the regime.
During the course of my research, I gained the impression that, among Germans as well as among survivors and scholars throughout the world, this involvement of physicians in killing was viewed as the most shameful of all Nazi behavior. No wonder that it still haunts German medicine, and has only recently begun to be confronted by contemporary German physicians. Yet it must be confronted, and not only by physicians. For this vision of killing in the name of healing was at the heart of Nazi mass murder. More than that, such a malignant vision seems to be part of virtually all expressions of genocide.
Nazi ''euthanasia,'' in fact, provides a key to an understanding of genocide as inclusive murder of the victim group in order to ''cure'' one's own. Since the disease one seeks to eliminate is ultimately death itself, the curative process can be endless. That murderous cure must be combated, interrupted, prevented everywhere.
