Nurses' Participation in the Nazi Euthanasia Programs

Nurses' Participation in the Nazi Euthanasia Programs


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Nurses' Participation in the Nazi Euthanasia ProgramsSusan Benedict, CRNA, DSN, FAAN Professor College of Nursing Medical University of South Carolina Charleston, e-mail: Benedics@musc.edu Jochen Kuhla Krankenpfleger und Lehrer fur Pflegeberufe Albert-Schneider-Strasse 17 74821 Mosbach Germany
Originally published in the Western Journal of Nursing Research, April 1999, 21(2), 246-263.This project is the result of a fellowship for Research on Medical Ethics and the Holocaust granted to Susan Benedict by the Research Institute of the United States Holocaust Memorial Museum, with funds provided by The Merck Company Foundation. Copyright, Susan Benedict Translation by Sabine Baumann.

Abstract
During the Nazi era, so-called "euthanasia programs" were established for handicapped and mentally ill children and adults. Organized killings of an estimated 70,000 German citizens took place at killing centers and in psychiatric institutions.
Nurses were active participants and killed over 10,000 people in these involuntary "euthanasia programs". After the war was over, most of the nurses were never punished for these crimes against humanity although some nurses were tried along with the physicians they assisted. One such trial was of 14 nurses and was held in Munich in 1965. Although some of these nurses reported that they struggled with a guilty conscience, others did not see anything wrong with their actions and believed that they were releasing these patients from their suffering.
The end of 1996 marked the 50th anniversary of the Doctors' Trial in Nuremberg in which physicians were convicted of crimes against humanity. Although little has been written about the role of nurses in the Nazis' so-called "euthanasia" programs and the subsequent genocide known as the Holocaust, it is important to know of the involvement of nurses and to understand - to the extent possible - how nurses came to be active participants and, in fact, intentionally killed over 10,000 people in the Nazi era (Ebbinghaus, 1987, p. 219).
The German nurse-historian, Hilde Steppe, has written: "...we have a moral obligation to the millions of victims of National Socialism, even if it only means that, through historical research, we assure that they are not forgotten. By taking responsibility for this part of our history, we can become more sensitive for the future, with eyes and ears open for all social injustices" (Steppe, 1992, p. 753).
The purpose of this paper is to increase the awareness of the nurses' involvement in these crimes against humanity and, in so doing, present various factors that could have affected the individual nurses' decisions to commitment these actions against patients in their care.
BackgroundBefore the time of the genocide of millions known as the Holocaust, the German government established "euthanasia" programs for handicapped German children and adults. Nurses were participants in both. In reality, these programs had little to do with the contemporary understanding of the word "euthanasia". In actuality, the programs were the involuntary killing of handicapped children and adults that were sanctioned by the government and society.
The origins of planned euthanasia were in place earlier than the Nazi era. "The idea of ending 'lives not worth living' did not begin with the Nazis, but had been discussed in the legal and medical literatures since the end of the First World War", with supportive articles appearing in both European and American literature (Proctor, 1992, p. 24). In 1920, Dr. Alfred Hoche, a physician, and Karl Binding published a pamphlet entitled "The Sanctioning of the Destruction of Life Unworthy of Living". The emphasis of the book was on the reduction of suffering of the acutely ill and their families (Nadav, 1994, p. 45). Later, in 1935, Hitler told the Reich physician leader, Dr. Gerhard Wagner, that he would implement euthanasia once war began (US Military Tribunal, Transcripts of the Proceedings in Case 1, p. 2482, Testimony of Karl Brandt).
The German people were exposed to the idea of euthanasia through posters, movies, and books supporting the destruction of "lives not worth living". A 1936 book entitled Sendung und Gewissen (Mission and Conscience) was published in Germany by an ophthalmologist and was widely read. This novel told the story of a young wife with multiple sclerosis who was euthanized by her physician-husband. This novel was important in preparing the ground for the euthanasia programs (Proctor, 1988, p. 183). It was made into a movie "Ich Klage an!" ("I Accuse") and was widely shown during these years. Two other popular movies of the time also dealt with euthanasia, Life Unworth Life (1934-1935) and Presence without Life (1940-1941) (Amir, 1977, p. 97). "Opfer der Vergangenheit (Victims of the Past, 1937) was produced under Hitler's direct order and shown by law in all 5,300 German theaters" (Michalczyk, 1994, p. 65). These films argued that keeping seriously ill people alive was against the basic principles of nature (Michalczyk, 1994, p. 65).
Posters were displayed throughout German showing a healthy German supporting on his shoulders the weight of handicapped individuals with the saying "You Are Sharing the Load! A Genetically Ill Individual Costs Approximately 50,000 Reichsmarks by the Age of Sixty" (Gross, 1935, p. 335). Even high school textbooks contained mathematical problems using the cost of caring for the mentally ill as examples (Dorner, 1935). The elderly and the ill, too, were considered by some to be burdens: "It must be made clear to anyone suffering from an incurable disease that the useless dissipation of costly medications drawn from the public store cannot be justified" and "...it made no sense for persons 'on the threshold of old age' to receive services such as orthopedic therapy or dental bridgework; such services were to be reserved for healthier elements of the population" (Proctor, 1988, p. 183). It is important to see these attitudes as the context for nursing at that time.
Bernberg Euthanasia Facility
The Children's Euthanasia Program Because of the prevalence of the negative attitude of the public toward the handicapped, "Parents were made to feel shame and embarrassment at having to raise an abnormal or malformed child" (Proctor, 1992, p. 25). The children's euthanasia program in Germany during the Nazi era is reported to have had its origin in the request by a father of a deformed and retarded child to Hitler to have this child killed. Hitler asked his personal physician to investigate the situation and the child was eventually killed. In 1936-1937, a secret "Reich Committee for the scientific registering of serious hereditary and congenital illnesses" was established in Hitler's Chancellory. This committee of three with medical and psychiatric expertise discussed euthanasia and, in 1939, drafted a prospective law calling for the "destruction of life unworthy of life". This prospective law would have provided legal sanction for "killing people suffering from serious congenital mental or physical 'malformation', because they required long-term care, aroused 'horror' in other people, and were situated on 'the lowest animal level'" (Burleigh, 1994, p. 98).
In 1939, a Ministry of Justice commission proposed the following: Clause 1: Whoever is suffering from an incurable or terminal illness which is a major burden to him or others, can request mercy killing by a doctor, provided it is his express wish and has the approval of a specially empowered doctor.
Clause 2: The life of a person who because of incurable mental illness requires permanent institutionalization and is not able to sustain an independent existence, may be prematurely terminated by medical measures in a painless and covert manner (Burleigh, 1994, p. 99).
It became compulsory to register all "malformed" newborn children with the Reich Committee. The Reich Committee for Research on Hereditary Diseases and Constitutional Susceptibility to Severe Diseases "was an organization for the killing of children who were born mentally deficient or bodily deformed. All physicians attending at births, midwives, and maternity hospitals were ordered by the Ministry of Interior to report such cases"... (Office of US Chief of Council for the Prosecution of Axis Criminality, Document Number 630--PS, 17 September 1945). Three referees - two pediatricians and one physician director of a psychiatric institution - were to decide which of the reported children were to be killed. These physicians made the decisions without seeing the children and based solely upon the diagnoses of the midwives and reporting physicians.
When the Public Health Offices were notified of a decision they were to arrange for the child's admission to one of approximately thirty inpatient pediatric clinics. The Reich Committee promised the parents that the child would be treated by specialists in the clinic and this promise often allowed the parents to believe they were acting in the child's best interest. "Other parents were talked into parting with their child by their family doctor, or by public health or national Socialist People's Welfare nurses doing the round of family home visits or servicing mothers' advisory centers" (Burleigh, 1994, p. 102).
The Killings At the specialized centers, children who were designated by the Reich Committee for euthanasia were killed shortly after arrival by medication or were starved to death. In the pediatric unit of Haar, for example, 332 children died of deliberate starvation or by an overdose of Luminal [Phenobarbital]. This drug was mixed into the children's food every morning and night until they became unconscious and developed pneumonia. Some were also given injections of morphine and scopolamine (Burleigh, 1994, p. 102).
The nursing staff of the pediatric unit of Haar was led by a senior nurse, Emma D., and two younger colleagues, Emma L. and Maria S. They were forced to swear an oath of loyalty, pledging eternal silence regarding what went on in the clinic, under pain of death. Initially, however, they swallowed the line that what they were doing was scientifically important, rationalizing the high number of deaths as being merely what one might call collateral casualties. Although they sometimes requested transfers, and undoubtedly found the work disturbing, nonetheless they also regarded it as necessary to 'release' the 'regrettable creatures' in their care from their suffering. Like many nurses who worked in these clinics, they received a 25RM-per-month [approximately $80 US] supplementary payment, know pejoratively as 'Schmutzgeld' [dirty money]. The doctors sometimes received a 250RM [approximately $800 US] Christmas bonus. In some clinics (notoriously the Kalmenhof at Idstein), the tensions of the job were soothed by a visit to the wine cellars to mark every fiftieth killing with copious amounts of wine and cider (Burleigh, 1994, p. 104-105).
An estimated 5,000 children were killed during the so-called children's euthanasia program (US Military Tribunal, Transcripts of the Proceedings in Case 1, p. 177, Testimony of Karl Brandt).
The "T-4" Adult Euthanasia Program In 1939, Hitler issued an order to expand the euthanasia program to "the worthless lives of seriously ill mental patients" which would "result in certain savings in terms of hospitals, doctors and nursing staff" (Friedlander, 1995, p. 63). In order to do this, the Reich Committee was expanded from the original three members to include a number of academics and asylum directors. The organization went by the name "Aktion T-4", named after the location of the offices, Tiergartenstrasse 4 in Charlottenburg [a district of Berlin].
In July 1939, these men were told that a number of psychiatric patients had to be killed to make hospital space for war casuals and to free up nursing staff (Burleigh, 1994, p. 119). Six killing centers were set up in existing psychiatric hospitals - Grafeneck, Brandenburg, Hartheim, Sonnenstein, Bernburg, and Hadamar (Office of US Chief of Council for the Prosecution of Axis Criminality, Document Number 630-PS, 17 September 1945).
In 1941, Hadamar "celebrated the cremation of its ten-thousandth patient in a special ceremony, where everyone in attendance - secretaries, nurses, and psychiatrists - received a bottle of beer for the occasion" (Proctor, 1992, p. 25).
Although the children were killed with injections or starvation, these methods were not efficient for the large number of adults at the killing centers. In these locations, gas was used. Patients were transported by bus from local and regional hospitals to the killing centers. "At the killing center, the arriving patients were met by the staff and led to the reception room by a male or female nurse, who might have accompanied them on their trip" (Friedlander, 1995, p. 94). Patients were examined individually by a physician, photographed, and measured. They were then taken to gas chambers which were disguised as shower rooms. "The patients were already prepared for the showers because, while they were undressing, the nurses had told them that they would be bathed" (Friedlander, 1995, p. 95). "Most patients accepted the nurses' explanation that they were going to the showers..." (Friedlander, 1995, p. 96). "On rare occasions, nurses might even have to remove bodies from the gas chamber, a job usually reserved for unskilled laborers" (Friedlander, 1995, p. 101).
By 1941, more than 70,000 patients from German mental hospitals had been killed (US National Archives and Records, Record Group 338, Microfilm Publication T-1021, Roll 18, Frame 98). Later the killing centers were used for the killing of selected concentration camp prisoners in the "Special Treatment 14f13" euthanasia program (Office of Chief Counsel for War Crimes, Document Number 3354).
Memorial to the victims of the "euthanasia" program. According to records kept by the Nazi regime, 9,385 mentally and physically handicapped persons were murdered here between November 21, 1940, and August 24, 1941. Some 5,000 concentration camp prisoners were also sent to the Bernburg euthanasia facility.
The "Wild" Euthanasia Programs Hitler ordered the organized euthanasia program for the adults to end in August 1941. The killings had become public knowledge and opposition to the programs came from individuals and churches; however, the children's euthanasia program continued without interruption and the stop order applied only to the killings in the gas chambers of the killing centers. "As with the children, after the stop order, physicians and nurses killed handicapped adults with tablets, injections, and starvation. In fact, more victims of euthanasia perished after the stop order was issued than before" (Friedlander, 1995, p. 151).
Just as the children had never been killed in gas chambers, but by medication or starvation, the "selected" adults were killed by physicians and nurses in designated institutions. This decentralized euthanasia program was called by the killers "wild" euthanasia (United States National Archives and Records, Record Group 238, Microfilm Publication M-1019, Roll 46). Killing hospitals were set up at Hadamar, Meseritz-Obrawalde, and Tiegenhof (Dziekanka) but killings were not limited to these institutions. Many handicapped patients were killed at other hospitals throughout the region (Friedlander, 1995, p. 152).
During the "wild" euthanasia phase, handicapped patients that were to be killed at the killing centers arrived by transport, often in the middle of the night. The staff selected for killing patients who were unable to work as well as "patients who caused extra work for the nurses, those who were deaf-mute, ill, obstructive, or undisciplined, and anyone else who was simply annoying" (Friedlander, 1995, p. 160). Those selected to be killed were "taken to so-called killing rooms where physicians and nurses killed them using orally-administered drug overdoses or lethal injections." "After they had been killed by the male and female nurses" (Friedlander, 1995, p. 161), fraudulent death certificates were prepared and the bodies were cremated. Families were notified of the deaths of these relatives and could receive an urn of ashes purported to be those of their loved one. In reality, the urns contained combined ashes of many people from the crematorium.
At the beginning of 1942, the first trains with about 700 patients arrived at Obrawalde. At the end of the year and especially in 1943 these trains arrived more and more frequently. From all parts of Germany patients were abducted to be killed in Obrawalde. All the nurses and orderlies - according to their statements - had to "unload" the patients. The ill persons were in horrible condition: many were emaciated and they were very dirty. This condition contributed to the fact that the nursing personnel were able to distance themselves emotionally from those people who had been brought into such a condition beneath human dignity and that the personnel, without considerable pressure, could be convinced to kill thousands of people (Ebbinghaus, 1987, p. 224). "When questioned, the senior nurse Ratajczak estimated that 18,000 people had been killed at Obrawalde. Her estimate corresponds to other statements. In later legal proceedings mostly a number of 10,000 patients killed by nursing personnel at Meseritz-Obrawalde are stated" (Ebbinghaus, 1987, p. 219).
Anna G. had been a nurse at the Heil- und Pflegeanstalt Treptow (Healing and nursing institution - a state hospital and nursing home) for more than ten years. When it closed, she and other nurses were transferred to Obrawalde. She was accused of participating in the killing of 150 patients.
When the round was finished, the patients selected by Dr. Mootz had to be taken to the extra room. Generally the nurse on duty had to undress the patients and take them to the extra room. Depending on the circumstances, there were different methods. If the patient was very confused or ill to such an extent that she didn't think about it, after having her undress, I just took her to the extra room. If the patients were in their right minds and could see through everything, we told them that their health condition had improved in a manner that they only would have to take a cure in order to get discharged. The patients believed us in most cases and undressed themselves voluntarily, so we didn't have any difficulties with them. We really wanted to make the last way as easy as possible for the selected patients. In this connection I remember that one patient was a strict Catholic and the last day she asked for a priest to get the last sacraments. I remember very clearly and can say with absolute certainty that the priest was informed before the killing and that the patient, who at least that day was completely in her right mind, got the last sacraments from the priest.
I can't remember that I ever appointed a younger nurse to help me. Young nurses deliberately weren't appointed to participate in the killings because we feared they couldn't be able to keep their mouths shut.
If my memory serves me right, the patients supposed to be killed weren't taken to the extra room together. I think the second patient was only taken to the extra room when the first one was starting to fall asleep. We then covered her with a towel.
The killing of patients was never done by only one nurse. Practical experience had shown that it was absolutely necessary for the killing to be done by at least two nurses. I will give the reasons for this necessity. Nurses are also only humans and the strength of their nerves is limited. I think the two nurses had to support and help each other when doing the killings. The killing of a person is a hard strain on the nerves of the person doing it. After all, it could have been possible that the strong nerves of one nurse wouldn't have been enough. I will express by this that one nurse could have fainted or she could have shrunk back. But when two or more worked together, the other would have helped to surmount the weak moment. But the cooperation was not only absolutely necessary for psychological, but also for practical, reasons. I didn't experience it one single time that a patient would take such a large quantity of dissolved medicine voluntarily. It's a fact of experience that medicine doesn't taste good and people generally are not readily prepared to take medicine. The same can be said with regard to injections. Almost all of our patients were scared of injections. In order to give the dissolved medicine, particularly the injections, and the cooperation of at least two nurses was necessary.
When giving the dissolved medicine, I proceeded with a lot of compassion. I had told patients that they would have to take a cure. Of course I could tell these fairy tales only to those patients who were still in their right minds to the extent that they could understand it. I took them lovingly and stroked them when I gave the medicine. If, for example, a patient did not empty the entire cup because it was too bitter, I talked to her nicely, telling her that she had already drunk so much that she would drink the rest, otherwise her cure couldn't be finished. Some could be convinced to empty the cup completely. In other cases, I gave the medicine by the spoonful. Like I already told you, our procedure depended on the condition of the patients. Old women, for example, who had to be fed couldn't drink on their own so it wasn't possible to give them the medicine by the spoonful. They were not to be tortured more than necessary and I thought it would be better to give them an injection. In this connection, I would like to say that, like me, Luise E. [Erdmann], Margarete Ratajczak, and Erna E. thought that the patients were not to be tortured more than necessary (Ebbinghaus, 1987, p. 239).
The accused was asked if patients knew what was going to happen to them. She responded: The patients didn't notice it for a long period. Later there were a few of them who did notice it. Possibly they realized that the physician pointed his finger to individual patients and talked about them to the senior nurse and those patients were taken to the so-called small room. It is also possible that the patients, or a few of them, observed that the patients didn't come back alive from that room. When I gave the above-mentioned patient the injection, I didn't talk to her anymore. The patient also didn't talk anymore. It was a patient in a condition that had to be described as bad. I think the patient didn't notice anything. In general, some patients anxiously already had lifted themselves in the bed. Some drank the medicine on their own. Also, the dose varied from one patient to the other.
In one case, on request of the patient, I called a priest. It was the same priest I already mentioned before and who is living now in East Germany. A colleague told me that this patient would ask for me so I went to see her. The patient told me that it was her turn the next day. I didn't know that. She asked me to get a priest because she wanted to confess. The patient knew exactly what was going on. She asked me to tell her relatives as soon as she was dead that she had passed away peacefully. She also asked me to give her the rosary after her death (Ebbinghaus, 1987, p. 241).
Why The Nurses Participated After almost fifty years of postwar proceedings, proof has not been provided in a single case that someone who refused to participate in killing operations was shot, incarcerated, or penalized in any way, except perhaps through transfer to the front which was, after all, the destiny of most German soldiers. But it is possible that putative duress did apply, that is, these young, impressionable nurses might have believed that the intimidating Christian Wirth [ the supervisor at Hartheim hospital] would place them in a concentration camp" (Friedlander, 1995, p. 235-236).
The following reasons for not refusing to participate were provided by the nurses of Meseritz-Obrawalde hospital: Helene Wieczorek [accused of killing 'several hundred' patients]: Director Grabowski told us we had to help the senior nurses - it was too much for them. We also would have to give the injections. First I refused and he said that there was no point in it because, being a civil servant of many years standing, I would perform my duty, especially in times of war. He added, it would be a law that the incurable mentally ill persons were to be released from their suffering. (...) I only did my duty and I did everything on order of my superiors. The Director Grabowski always warned us of the Gestapo. He said he would inform the Gestapo if we didn't do what he ordered (Ebbinghaus, 1987, p. 219).
Luise Erdmann. [The main defendant of the trial, accused of participating in the killing of 210 patients]: Through the behavior of Dr. Wernicke I realized that incurable patients were to be released by giving them Veronal [barbiturate acid] or another medicine. I also declare that I, neither by Dr. Wernicke nor any other person at the home, have been informed about the euthanasia. I wasn't sworn to secrecy in this respect... I was of the opinion that one took it for granted or believed that I would approve of euthanasia. My attitude to euthanasia was, should I become incurably ill - I don't make a difference between mental or physical illness - I would consider it as a release if a physician or, on direction of a physician, another person would give me a dose releasing me from everything. Despite my attitude to euthanasia, I have - when confronted with the problem - fought out serious inner conflicts. Euthanasia, in the form I experienced it at that time, after all was a killing of people and I asked myself if a legislator had the right at all to order or permit the killing of people. Never, however, did I hear about a corresponding law on the use of euthanasia but, on the other hand, Dr. Mootz explained to me once that there was no need for reservation as, should the situation arise, he would cover up for me. From this statement I concluded that there had to be legality for euthanasia (Ebbinghaus, 1987, p. 232).
In my first questioning I expressed that, for me, there were justified and unjustified cases of euthanasia. In my opinion, I described so clearly what I understand by justified and unjustified cases during my first questioning, that I don't need to give an additional explanation in this matter. A refusal in those cases which I regarded as justified would have been illogical so I don't have to give further explanation of this.
It was different with the cases where I didn't regard the killing as necessary or appropriate. When I did participate in those killings and thus acted against my inner attitude and conviction, this happened because I was used to obey strictly the orders of the physicians. I was brought up and instructed to do so. As a nurse or orderly, you don't have the level of education of a physician and thus one can't evaluate if the order of the physician is right. The permanent process of obeying the order of a physician becomes second nature to the extent that one's own thinking is switched off. (Ebbinghaus, 1987, p. 234).
I was and still am without interruption of the Protestant faith. I must say that basically I describe the whole Protestant faith also as my faith. I would like to express by this that the commandment "Du sollst nicht toten" (Thou Shall Not Kill) is truth for me. When I did the killings, I must admit that I offended this commandment. But as I expressed in my questioning, I didn't do it with a light heart but only after serious inner fights I obeyed the orders. ... I had to consider that one physician who, after all, also is only a human being, could make mistakes in diagnosis or prognosis. I realized that I offended seriously the divine and moral law by participating in the killings. I would only moderate my guilt by trusting strictly that the physician didn't make a mistake. But as I couldn't completely exclude a mistake, I prayed to my God to forgive me in such a case. In addition, I have to suppose that the ill people selected to be killed by the physicians were such seriously ill people that even in case of a mistake I had to see it as a release for them.
I estimate it important to say that the attitude of people to life and death depends on the situation. I spent my whole life in nursing and experienced more than usual the living and dying of people. I'll not express by this that by experiencing it I became harder, but only that my attitude and position to these human problems was a different one. I was aware of the fact that a person was killed but I didn't see it as a murder but as a release (Ebbinghaus, 1987, p. 236).
Anna G. [accused of participating in the killing of 150 patients]: It is true that I was brought up as a Christian and that for my whole life I was convinced of the Christian faith. On the other hand, during my work, especially on the ward for the insane, I have seen such horrible misery and have seen all of the different sicknesses until the terminal stage. In view of these experiences, I have seen it as an act of mercy and a release when the killings were done.... I herewith declare that I have never been forced by anybody to participate.... I would never have committed a bank robbery or other theft because that is just not done. In addition, theft wouldn't have belonged to my tasks. I would never have committed a theft because I know one isn't allowed to do it (Ebbinghaus, 1987, p. 236).
Martha W. [accused of participating in the killing of 150 patients]: I've always disapproved of euthanasia. In the course of my work as a nurse, I could see that a lot of patients were sent to the mental institution who before had been very estimable people. It was a big injustice for me to kill those people because of their illness. When I'm reproached for the fact that I was brought up as a Catholic and the commandments also represent my convictions, this is correct. Until today, it is my conviction that people are not allowed to interfere. Nevertheless, I participated in the killings and I recognize that I acted against the commandments and my conviction and have burdened my conscience seriously. The only explanation I can give is that I didn't have enough time to think about it at that time because the nurses were put under a lot of stress (Ebbinghaus, 1987, p. 240).
Erna D.: Please believe me, that I didn't do it readily because I really detested it. I repeat, I didn't do it readily. In fact, I can't say why I didn't refuse (Ebbinghaus, 1987, p. 243).
Margarete T. [accused of killing 150 patients]: I was brought up as a Christian and still today I'm a very religious person and, as far as possible, I attend the service regularly. For this reason, when the killings began at Ward U1, I felt deeply guilty and still do today. (...) Due to the many years of working as a nurse, practically from since I was young, I was educated to strict obedience, and discipline and obedience were the supreme rules among the nurses. We all, including me, took the orders of the physicians, head nurses, and ward nurses as orders to be strictly obeyed to and didn't or couldn't form our own opinion about the legality of these orders. (...) I was a civil servant at that time and, on one hand, I was sworn to secrecy and, on the other hand, I was obliged to obey given orders. I think at that time, I've always lived in conflict with my own opinion and the fact that I was a civil servant. On the one hand I saw the killing of people, even though it was incurable mentally handicapped people who exclusively were accommodated on Ward U1 as a big injustice and often asked myself why it was done. On the other hand, I was a civil servant and obliged to do my work and didn't see a possibility of getting around the orders. (...) You ask me if I had also committed a theft on order, I say that I wouldn't have done it. I saw, however, the act of giving medicine, even in order to kill mentally handicapped persons, as an obligation I wasn't allowed to refuse. In case of refusal, I always imagined my dismissal from the job of nurse and civil servant, which is why I didn't refuse (Ebbinghaus, 1987, p. 244).
Meta P. [when asked why she became implicated in the killing of patients]: Among the nurses there was strict discipline and every subordinate nurse was obliged to strictly execute the orders of the superior (Ebbinghaus, 1987, p. 244).
Berta H. [accused of participating in the killing of 35 patients]: In other words, at that time I thought, I wouldn't be guilty if I didn't do the actual killings. To my own conscience, I always felt a little bit guilty and I tried to cope with it as far as possible to forget everything (Ebbinghaus, 1987, p. 244).
Martha Elisabeth G. [accused of killing 28 patients]: Certainly I felt guilty about it at that time and, although I didn't do any killings by myself, I did help and I had a certain felling of guilt. I'm only an ordinary nurse,...and never realized that, legally speaking, I had become implicated in the killings. When I had to assist in the killings, I acted under duress and never with the intention to kill a person. (...) At that time, nobody would have helped us at Obrawalde if we had refused to do the work and there wasn't anybody to pour out one's heart to and who we could trust. As a sort of slaves we were completely at the mercy of the rulers and their political line (Ebbinghaus, 1987, p. 245).
Edith B.: Although I knew, respectively assumed from hearsay, that at Ward U2 (...) killings were done and the patients I moved to that ward possibly were condemned women, I didn't see anything wrong with it (Ebbinghaus, 1987, p. 245).
Margarete Maria M. [accused of killing three patients]: If I had refused to execute her [another nurse's] orders, I would have been dismissed. I could have quit the job, but at that time I was obliged to support my grandparents in Meseritz (Ebbinghaus, 1987, p. 245).
Gertrude F. [accused of killing five patients]: When I did it by preparing the medicine, I did it without any knowledge of legal consequences. The preparation of medicine in order to give it to the patient actually was one of my duties which was one of the reasons why I didn't realize that I did something wrong. I wasn't able to see a direct connection between my work and the killings. In addition you have to consider that I had worked in a mental institution for years and that the nurses were obliged to strictly obey their superiors, the senior nurses, the physicians and, last but not least, the director of the institution. In addition, I was the youngest nurse at our ward. Still today, I haven't completely become aware of my wrongdoing (Ebbinghaus, 1987, p. 245).
Erna Elfriede E. [accused of participating in the killing of 200 patients]: They didn't make me swear on a secret matter of the Reich and I wasn't sworn to silence. (...) I considered the killings as injustice. Something like that was not supposed to happen, because nobody was allowed to order it. I was brought up quite as a Christian. I already learned as a child what one may and mustn't do. I learned that one mustn't steal and mustn't kill. [When asked why she didn't refuse to participate in the killings] Because I was ordered to do it. When I am asked again, why I didn't refuse, although I realized that it was an injustice, I can't give an answer to this question. I do and did in the past have a strong feeling of guilt but it is impossible for me to give a reason for the fact that I didn't refuse. It simply was ordered and I had to execute the orders (Ebbinghaus, 1987, p. 246
Analytic Framework for Understanding the Nurses' Participation Ideological Commitment It is essential to understand the societal values of the Nazi era. The concept of the "life not worthy of life" was a widely held value. The severely mentally and physically ill were considered to be living less than a human existence. This devaluation of the handicapped had its origins in the eugenics movement which was widely embraced in Europe as well as the US. The Third Reich's quest for the development of a superior race called for the elimination of those judged to be "inferior", whether because of handicap, race, or ethnicity.
Humans with severe imperfections were to be prevented from reproducing through involuntary sterilization and others were to be eliminated. The term "useless eaters" was often applied to severely handicapped and others regarded as non-productive (Friedlander, 1995, p. 61). Added to this were also the economic needs of the time. Valuable resources were to go to the war effort and to those who could work and be productive. Perhaps these nurses saw their actions as being congruent with these values.
This is similar to the view of the ethicist Dr. Arthur Caplan who stated that, in his belief, physicians did not set aside their ethics during the Holocaust but saw their actions as congruent with their ethical commitment to heal the people ("Healing the Volk") through the elimination of undesirable elements (Caplan, 1992). Furthermore, many people believed that euthanasia was not "illegal" although a law permitting euthanasia had, in fact, never been passed in Germany (Proctor, 1988, p. 183).
The belief that they were doing nothing wrong or even doing something of benefit was apparent in the statements of several of the nurses who seemed surprised that there were "legal consequences" to their actions. Two (Edith B. and Gertrude F.) Stated that they didn't see anything wrong with it and three others saw the killings as "releasing people from their suffering". Only seven of these fourteen nurses indicated feelings of some degree of guilt over their participation in the killings.
Obedience A second aspect to consider is that of the obedience. Obedience was greatly valued in Germany and nurses were to be obedient to their senior ranking nurses as well as to physicians. In the hospitals, nurses collaborated with physicians in the killings.
This collaboration was usually voluntary. The physicians were given the choice of accepting or declining, and they in turn gave that choice to their nurses. In the hierarchical German hospital system, as in that of most other counties, nurses were trained to obey physicians and often had a dependent relationship with the physicians they assisted. Although this was hardly an excuse for following orders to kill, as the refusal of some to do so proves, it does help explain the motives of some nurses" (Friedlander, 1995, p. 231). It is difficult for us, as contemporary nurses, to imagine that degree of obedience.
Perceptions of powerlessness were evident in the statements of several of the nurses who "didn't see a way around the orders, didn't have anyone to talk to, had no one trust if they told" and "was the youngest nurse on the ward". Others, however, did not remain powerless. They relocated, changed jobs, asked for transfers, and became pregnant (Friedlander, 1995, p. 236).
Role of ReligionReligion has had an effect on the nurses' participation in three ways: as an effect upon the individual, as an element of nursing education, and by its effects upon society. Individual religious commitment and its congruence or conflict with participation in the euthanasia program as been established in the testimony of several nurses at their trials. Several of the nurses did see themselves as religious persons and some, although not all, did admit to having guilty consciences over their killings.
During this era, nursing education was based on religion. There were Catholic and Deaconess nursing programs - both of which incorporated religion into their nursing curricula. Similarly, the religious affiliation of the institutions was a factor. Catholic hospitals were not used as euthanasia sites although patients from these institutions were transferred elsewhere for euthanasia with the knowledge of those employed at the Catholic hospital. It was religion - in the person of Bishop Galen - that is thought to have contributed to a cessation of the euthanasia program (but not an end to euthanasia). Knowledge of the euthanasia programs had become widespread among the population and, in August 1941, Bishop Galen delivered a sermon in which he described the killing of patients, including their registration and transfer. Copies of the sermon were dropped by the RAF over Germany. Shortly thereafter, Hitler ordered a stop to the gassing of patients. This order did not apply to the children's euthanasia program.
Role of Nursing Education and the Nursing Professional Organizations The role of nursing education in the nurses' participation has overlap with both gender and religion. Nursing education was different for males and females. Most female nurses were educated in religious-based institutions. The professional nursing organizations that wee established during the Nazi era were separate for male and females nurses. The female nurses' organizations included the (1) Protestant Nursing Orders, (2) Catholic Sisterhoods, (3) Red Cross Sisterhoods, (4) Federation of Professional Nurses, and (5) the Sister hood of the National Socialists. In 1939, only 9% of the nurses were members of the Nazi sisterhood. The main employment of the Nazi nurses was in community health nursing because this area could provide the greatest opportunity for influencing the population. It was not, therefore, only the Nazi nurses who were involved in the euthanasia programs.
Putative DuressFear of the consequences of refusing to participate in the killings - "would be reported to the Gestapo if refused" and "afraid of losing job" - was not frequently cited by these nurses but has been given by other nurses as the reason for not refusing to help with the killings (Friedlander, 1995, p. 236). Certainly, the Gestapo was greatly feared during this era. In at least one institution, the nurses were made to sign pledges of silence under threat of death if they discussed the euthanasia program at their institution (Richarz, 1987). For the male nurses, there was always the threat of being sent to the Eastern front.
Economic factors made have been an influence for some nurses. Nurses working on the euthanasia units received additional pay and/or bonus payments. For example, the nurses in the children's euthanasia wards at Eglfing-Haar received about $80 extra per month (Burleigh, 1994, p. 104-105). Other nurses later testified that they continued to work in the euthanasia programs because they were afraid of losing their jobs (Ebbinghaus, 1987). As civil servants, the nurses had benefits not available with all other jobs.
Conclusion Following the end of World War II, some nurses were tried with the physicians they had assisted (United States National Archives and Records, Record Group 338, Case File 12-449, US v. Alfons Klein; Testimony of Pauline Kneissler, Document NO-470 US Military Tribunal Case Number 1, Tribunal 1, US v. Karl Brandt et al). When the Russians invaded and found the conditions at Obrawalde, they made the senior nurse, Ratajczak, reenact the killings. She, along with an orderly, was shot a few days later (Ebbinghaus, 1987, p. 218). The other nurses of Obrawalde were later tried for the killings. On March 12, 1965, "all fourteen women accused in the Munchner Schwesternprozess (nurses' trial at Munich) were proven not guilty because of acting as an accessory to murder" (Ebbinghaus, 1987, p. 246).
It may never be possible to fully understand the participation of nurses in crimes that would seem to be unthinkable today yet their participation must continue to be studied so that nursing never again finds itself in the role of killer. Proponents of the "slippery slope" argument hold that the involvement of health care professionals in assisted suicide could begin the downward decline into voluntary euthanasia then involuntary euthanasia. Others believe that the circumstances in Nazi Germany will never be replicated, thus making the recurrence of the involvement of nurses and physicians in killings impossible.
ReferencesAmir, A. (1977). Euthanasia in Nazi Germany. Dissertation, State University of New York at Albany. University Microfilms International, 77-32, 241. Burleigh, M. (1994). "Wheels must roll for victory!" Children's 'euthanasia' and 'Aktion T-4'. In Death and Deliverance. Cambridge, UK: Cambridge University Press. Caplan, A. (1992). In the Shadow of the Third Reich: Nazi Medicine, a film by John Michalczyk, Boston College. Donner, A. (1935). Mathematik im Dienste der nationalpolitischen Erziehung. Cited in Proctor, R. (1988). The destruction of "lives not worth living". In Racial Hygiene: Medicine Under the Nazis. Cambridge, MA: Harvard University Press. Ebbinghaus, A. (1987). Opfer und Taterinnen. Germany: Delphi Politik. Friedlander, H. (1995). The Origins of Nazi Genocide. Chapel Hill: The University of North Carolina Press. Gross, W. (1935). Drei jahre rassenpolitische Aufklarungsarbeit, Volk und Rasse, 10(1935). Cited in Proctor, R. (1988). The destruction of "lives not worth living". In Racial Hygiene: Medicine Under the Nazis. Cambridge, MA: Harvard University Press. Michalczyk, J. (1994). Euthanasia in Nazi propaganda films: Selling murder. In Medicine, Ethics, and the Third Reich: Historical and Contemporary Issues. Kansas City: Sheed and Ward. Nadav, D. (1994). Sterilization, "euthanasia" and the Holocaust - the brutal chain. In Medicine, Ethics, and the Third Reich: Historical and Contemporary Issues. Kansas City: Sheed and Ward. Edited by J. J. Michalczyk. National Archives and Records, Record Group 338, Case File 12-449, US v. Alfons Klein; Testimony of Pauline Kneissler, Document NO-470 US Military Tribunal Case Number 1, Tribunal 1, US v. Karl Brandt et al. National Archives and Records, Record Group 338, Microfilm Publication T-1021, Roll 18, Frame 98. National Archives and Records, Record Group 238, Microfilm Publication M-1019, Roll 46. Office of US Chief of Council for the Prosecution of Axis Criminality, Document Number 630--PS, 17 September 1945. Office of Chief Counsel for War Crimes, Document Number 3354. Proctor, R. (1988). The destruction of "lives not worth living". In Racial Hygiene: Medicine Under the Nazis. Cambridge, MA: Harvard University Press. Proctor, R. (1992). Nazi doctors, racial medicine, and human experimentation. In The Nazi Doctors and the Nuremberg Code. Edited by Annas, G. and Grodin, M. New York: Oxford University Press. Richarz, B. (1987). Heilen, Pflegen, Toten. Gottingen: Verlag fur Med. Psychologie im Verl. Vandenhoeck u. Ruprecht, 188. Steppe, H. (1989). Krankenpflege im Nationalsocialismus, Frankfurt am Main: mabuse Verlang. Steppe, H. (1992). Nursing in Nazi Germany. Western Journal of Nursing Research, 14(6). US Military Tribunal, Transcripts of the Proceedings in Case 1, p. 2482, Testimony of Karl Brandt.