Healing and detention were the dominant approaches adopted in the development of psychiatry from the beginning of the 19th century onwards. Even though the therapeutic options were limited, people who suffered delusions, agitated states, melancholic moods, epileptic seizures and mental disabilities were regarded as diseased individuals in need of medical help. Sanatoriums and nursing homes were established to house incurable mentally ill people for periods of years or decades, and patients were divided up according to whether they were ‘calm’ or ‘agitated’. The day-to-day lives of the permanent patients were governed by institutional rules, disciplinary measures and sedatives, while they also worked in agriculture, in workshops, in the kitchen or in the sewing room.
In the 1920s such institutions opened up to society, while patients’ stays were shortened by placing them in family care and expanding outpatient care. In the wake of the Depression of 1929, however, these reform efforts fell victim to massive austerity measures. The focus was now on the “prevention of mental illness”: eugenicists and supporters of racial hygiene had long called for the sterilization of mentally ill, mentally handicapped and socially conspicuous individuals, not least in order to relieve the state of long-term welfare costs. In addition, living conditions deteriorated drastically due to staff shortages and a reduction in nursing rates, especially for chronically ill patients and those not in work.
When the ‘Law for the Prevention of Offspring with Hereditary Diseases’ came into force at the beginning of 1934 and the population was registered according to the supposed value of each individual’s genetic make-up, psychiatry soon concentrated almost exclusively on the ‘racial hygiene of the national body’: allegedly hereditarily ill individuals were sterilized against their will, especially those diagnosed with schizophrenia, manic-depressive insanity, mental deficiency and epilepsy
It was not just the physical well-being of psychiatric patients that was at stake here, however: the debate about euthanasia – the medical ‘relief’ of the terminally ill – also called into question the right of chronically ill institutionalized patients to remain alive. In a paper written as early as 1920, psychiatrist Alfred Hoche and lawyer Karl Binding had already called for “permission to destroy life that was unworthy of living” in connection with the “mentally dead” and institutionalized patients that were a “burden on society”. There were German psychiatrists who were in support of ‘destroying life that was unworthy of living’ during the Weimar period, too, and there was very little public opposition to this idea.
After the National Socialists came to power in 1933, propaganda spread a distorted image of ‘hereditarily ill’ and ‘inferior’ people in sanatoriums and nursing homes, disseminating the idea that these individuals were an economic burden who threatened the continued existence of the German nation. In 1938, Dr. Gregor Overhamm, senior physician at Wiesloch sanatorium and nursing home, wrote the following in the case history of his patient Adelheid B., who had been in educational and therapeutic institutions since the age of eight due to a mental disability: “Still terribly difficult and disruptive. Life unworthy of living!” (BArch, R 179/22496). In a letter to the government of Upper Bavaria, the director of the Eglfing-Haar sanatorium and nursing home Hermann Pfannmüller called for “genuine cost-cutting measures” in 1939: “I consider it appropriate at this juncture to point out openly and clearly that, in the area of medical care, there is a need for us doctors to take the final step in terms of eradicating life that is unworthy of living.” He had two groups of “severely defective” people in mind: “the entirely stupid, the utterly asocial, those urgently in need of care, and those with chronic conditions bordering on idiocy” as well as the “highly criminally inclined, anti-social elements who [...] burden and overcrowd institutions to an intolerable degree” (StAM, Stanw 17460/3).
The National Socialists’ ‘euthanasia’ program was never subject to legal regulation, but it was authorized by Hitler. Planned as a ‘secret Reich matter’, it was organized by a group of experts consisting of administrators, psychiatrists, pediatricians and renowned university lecturers. In order to undertake the selection of mentally and/or physically handicapped children, a ‘Reich Committee for the Scientific Registration of Serious Hereditary and Congenital Disorders’ was set up in 1939, to which children and adolescents had to be reported. The ‘Reich Committee’ then decided on their admission to one of up to 30 specialized children’s wards throughout the Reich, where the children were usually murdered with overdoses of medication after a period of observation. Up to 5,000 children and young people were killed under the ‘child euthanasia’ program up to 1945. In the case of ‘child euthanasia’ in particular, those responsible assumed the parents’ covert consent by presenting an apparently natural death as a relief from suffering.
A ‘euthanasia’ organization was set up in the Chancellery of the Führer which planned and coordinated the registration, selection and extermination of institutional patients: it was based at Tiergartenstraße 4 in Berlin, hence the abbreviation ‘T4’ and the name of the campaign, ‘Aktion T4’. In the fall of 1939, immediately after the start of the war, the first forms for the registration and selection of institutional patients arrived at the sanatoriums and nursing homes; state institutions cooperated as far as possible, with delays only occurring at some church institutions. There was no open resistance or protest on the part of the psychiatrists, though some did opt to retire in the face of pending calamity. The psychiatric experts decided on the life or death of the registered patients based solely on the information provided in the one-page registration forms. They were transferred directly or via intermediate facilities to one of the six killing centers, where they were murdered with carbon monoxide gas.
Asylum patients from Upper Bavaria, Lower Bavaria and Swabia were sent to Grafeneck killing center in the Swabian Alb and Hartheim killing center near Linz in Upper Austria. The relatives received so-called letters of consolation stating a false date of death and frequently also an incorrect place of death; the idea was to convey the idea that the patients had been ‘relieved’ from suffering, It was not possible to keep this systematic murder of the sick secret, however: there was unrest and protests among the population and also on the part of the churches. A public protest sermon given by the Bishop of Münster, Count Clemens August von Galen, in August 1941 finally provided the impetus to put a stop to the gas murders. By that time 70,273 institutional patients from the Third Reich, Austria and the annexed territories had been murdered because they were not doing any useful work, were considered incurably ill, required increased care and supervision, or were ‘disrupting’ the running of the institution. Without exception, all Jewish psychiatric patients were grouped together in collective institutions from spring 1940 onwards – based solely on their ‘racial affiliation’ – and murdered at the ‘Aktion T4’ killing centers. As such, the ‘euthanasia’ campaign can be regarded as the actual beginning of the Holocaust. ‘Aktion T4’ killing personnel were also deployed at the extermination camps in Belzec, Sobibor and Treblinka in 1942.
Even after ‘Aktion T4’ was stopped in August 1941, however, the killings continued at the sanatoriums and nursing homes themselves. This was done by administering overdoses of medication and by subjecting victims to systematic starvation. In any case, deteriorating hygienic conditions and the lack of care from 1939 onwards led to a significant increase in the mortality rate at the institutions, so it was up to doctors and nursing staff on site to decide who was to live and who was to die. In addition, the institutions in areas hit by Allied air raids were used as alternative hospitals for physically ill patients. Psychiatric patients were then transferred elsewhere and put to death at certain facilities in central and eastern Germany and in occupied Poland. The group of people in question was expanded to include welfare recipients, confused bomb victims and forced laborers.
In total, around 300,000 people fell victim to the various forms of National Socialist ‘euthanasia’, including concentration camp inmates selected by ‘T4’ doctors as well as psychiatric patients in East Prussia, Pomerania, Poland and the Soviet Union who were shot or gassed by SS ‘mobile killing squads’.
For the psychiatrists involved in the practice of ‘euthanasia’, healing and extermination went hand in hand. For example, doctors hoped that the ‘shock therapies’ introduced in the mid-1930s – seizures or hypoglycemic states induced by medication or electricity – would rapidly relieve symptoms. Since these therapies failed despite being regarded as progressive, however, their ineffectiveness highlighted the harsh reality of being diagnosed as incurable in the case of many chronically ill patients. Every possible treatment was to be tried for those who were curable, while the incurable were to be subjected to ‘euthanasia’.
After the war and the mass murder of the sick, almost all German psychiatrists remained silent about what had happened. Anton von Braunmühl became director of Haar mental hospital in 1946, having witnessed the ‘euthanasia’ murders there himself. In 1955 he wrote: “There is no doubt – and history has taught us – that all the despicable ideas and methods that were so detrimental to our psychiatry not so long ago came from outside and were propagated externally” (Braunmühl, p. 22). German psychiatry did not consider itself responsible for the patient murders. An official statement by German psychiatrists regarding the murder of psychiatric patients was not forthcoming until very late – November 2011.
