The Nazi Euthanasia Program

Historical Background

The Path to the “Euthanasia” Killings

The concept of eliminating so-called "life unworthy of life" was not originally a Nazi idea. The term euthanasia comes from the Greek words for a “good” or “easy death” and originally referred to dying without prolonged illness or suffering. Over time, the meaning evolved to describe interventions that eased the process of dying, even if they shortened life. This definition remained in line with the ancient understanding of a peaceful death.

However, by the late 19th century, the meaning of euthanasia underwent a profound transformation, influenced by emerging ideas in eugenics, racial theory, and social Darwinism. No longer limited to relieving the suffering of terminally ill patients, the term began to encompass the deliberate killing of institutionalized individuals with mental, psychological, or physical disabilities, as well as newborns with congenital conditions. While some viewed euthanasia as a means of offering a compassionate death to the seriously ill, others saw it as a way to relieve society of those deemed a financial or genetic burden. Supporters argued that allowing the so-called "genetically inferior" to live posed a threat to the "genetic health" of the nation.

Eugenics / “Racial Hygiene”

British naturalist Francis Galton (1822–1911) coined the term ‘eugenics’ in 1883. He linked Charles Darwin’s ideas about the struggle for existence with other doctrines that postulated the inequality of different races. According to Galton, to prevent any degeneration and promote the higher development of mankind, certain undesirable groups should be eradicated through sterilization or the killing of unfit newborns (negative eugenics). In contrast, desired groups should be supported by favorable population and social welfare policies (positive eugenics).

Eugenics was an international phenomenon. Its adherents included not only conservatives and the radical right, but also liberals, social democrats and representatives of the women's movement. Laws motivated by eugenics relating to forced sterilization had been in existence in the USA since the early 20th century. There was also a strong eugenics movement  in Canada, Switzerland and Scandinavia. Forced sterilization is still allowed in the majority of US States and in a number of European countries, but not in Canada. In 2007, the German Bundestag (the German federal parliament) outlawed the German forced sterilization law.

Although the term “eugenics” was commonly used internationally, In Germany, the term ‘racial hygiene’ was introduced by physician Alfred Ploetz (1860–1940) in 1895. Following World War I, the eugenics movement experienced an upswing due to the difficult economic situation in Germany. The ideology of eugenics increasingly found acceptance not only among doctors and scientists, but also in the political sphere and among the general population. Economic arguments such as cost-benefit calculations played a key role in this

The “Annihilation of Life Unworthy of Life”

After World War I, the proponents of euthanasia became more radical: In 1920, Karl Binding (1841–1920), a lawyer, and Alfred Hoche (1865–1943), a psychiatrist, published Die Freigabe der Vernichtung lebensunwerten Lebens (‘The Approval of the Annihilation of the Life Unworthy of Life’).  They stressed the high cost of keeping mentally defective and incurably ill patients in public institutions.  They viewed involuntary euthanasia, forced sterilization, and other eugenics  measures not as a regression to barbarism, but as progress toward a better world. The ideas postulated in this paper resulted in a controversy among doctors, lawyers and politicians in the Weimar Republic. When the Great Depression began, these debates intensified.  The radical austerity measures in the psychiatric institutions – such as the reduction of care rates and cuts in stuffing, food and heating – worsened the living conditions for people with mental illnesses and disabilities.

Aktion T4

The Nazis moved from exclusion to the systematic killing of those who were unfit to work, needed extensive care or who were regarded as ‘disturbing’ under a plan later called Aktion T4. ( Code name for the program killing the handicapped and disabled was named after the address of the building where it was planned and carried out, Tiergartenstrasse 4, Berlin)  .In October 1939, Adolf Hitler signed the authorization for his personal physician Karl Brandt and the head of the Chancellery of the Führer Philipp Bouhler to begin the euthanasia program. The document was deliberately backdated to September 1, 1939, the day the war began. In fact, the German invasion of Poland not only started an outward war, but also an inward war directed against allegedly ‘worthless’ people who, due to their mental illness, mental disability or social conspicuousness, seemed to no longer carry out any socially useful work. With deadly consequences, the National Socialists waged this battle on the ‘Inferior people’ in the German Reich in the areas annexed before the war and the territories conquered subsequently.

Under the supervision of Philipp Bouhler, doctors and administrative staff at Tiergartenstrasse 4 organized the detection and selection of inpatients. Doctors played a part in the murders as the registration data they recorded formed the basis of the selection decisions. Administrators coordinated the patients' transportation to the killing centers across the German Reich. A large administrative apparatus worked to ensure the smooth running and the secrecy of the mass murders.  The perpetrators made use of a bureaucratic, dehumanizing style of language in their work. They used terms such as ‘disinfected’ and ‘attended to’ to refer to the killing of the patients. The victims were thus degraded to mere objects and their murder was dealt with as a purely administrative act.

The Registration Form Procedure

The process of identifying patients to be euthanized began with the registration form the doctor filled out at the admitting hospital. This form was sent to euthanasia headquarters where copies were shared with three of the forty assessing doctors, mostly successful psychiatrists, who were recruited to select the ‘euthanasia’ victims. After reviewing the registration forms, each indicated his decision in the box at the bottom left-hand corner of the form. A red plus sign meant the murder of the patient; a blue minus the patient's survival. If their decision was not unanimous, the medical head of T4 made the final decision in his role as senior medical expert.

The T4 Murders

The Nazis converted five psychiatric facilities (Grafeneck, Bernburg, Hadamar, Hartheim, Pirna-Sonnenstein) and a former prison (Brandenburg) into killing centers to carry out Aktion T4. Outwardly, these appeared to operate as state hospitals and (nursing) homes. In reality, each killing center employed more than fifty men and women who worked as doctors, nurses, clerks, drivers, security guards and so-called disinfectors to burn the bodies.

By the summer of 1940, the T4 had established intermediate institutions near  each killing center to collect patients for a few weeks before being murdered. This helped conceal the operations and allowed each murder facility to adapt to its ‘killing capacity’. The T4 organized the final transfers of the patients to one of the killing centers using buses of the Reichspost (Reich post office).

Once the victims were gathered, the process they underwent was almost identical in each of the six killing centers. Arriving patients were tricked into believing that they were entering a normal hospital. An employee checked their personal details and photographed each patient; then the patient undressed for an initial examination by a doctor. Nurses led the patients into the gas chamber which was disguised as a shower room.  After they were killed, SS men broke the gold teeth out of the bodies. In order to eliminate the traces of the crime, the dead were cremated.

Bureaucratic Procedures

After murdering the patients, the administrators at the killing center contacted the victims’ relatives and the authorities. Each killing center was affiliated with a registrar's office responsible for recording the deaths. Distribution department employees noted the hometowns of the victims on cards. If these indicated a cluster of deaths based on date or location, the T4 staff would forge the documents to alter the date of death or exchange the files of the murdered with another registry office so as to certify a fake place of death.

In the letter of consolation informing the victims' families about their relatives’ deaths, they were told that the cremation had already taken place. The death was described as a release from suffering. Each letter contained two death certificates issued by the special registrar's office set up in the killing center, containing false details about the cause, place and date of death.

The urn containing the ashes of the deceased was sent to the home cemeteries if the relatives requested it. However, in actual fact, the urn did not contain the ashes of the person, but was filled with ashes that just happened to be at hand. The victims' valuables were released only at the express request of the relatives. Concealing the killings bureaucratically not only maintained the secrecy of ‘Aktion T4’, but also helped finance the program because the authorities used false pretenses to steal the patients’ care-allowances while they still lived.

Death Toll

More than 200,000 patients were recorded on the registration forms during the years Aktion T4 existed.  Between 1939 and 1941, Aktion T4 targeted institutional patients and murdered 70,000 people using gas in the six secret killing centers. Later, the T4 personnel also murdered about 20,000 concentration camp inmates in the killing centers of Bernburg, Pirna -Sonnenstein and Hartheim. After the centrally organized ‘Aktion T4’ was halted in August 1941, the killings continued in the hospitals and nursing homes. The group of victims was extended to include old people, those injured by bombs, forced laborers and children in care. Doctors and nursing staff members killed about 90,000 more institutionalized patients through deliberate neglect, starvation and with drugs.

Further Murder Campaigns

In 1939, shortly after World War II began, the SS murdered thousands of German and Polish psychiatric patients in Poland. Under the code name of ‘Reichsausschuss zur wissenschaftlichen Erfassung von erb- und anlagebedingten schweren Leiden’ (Reich Committee for the Scientific Registering of Serious Hereditary and Congenital Illnesses), the murder of more than 5,000 children and adolescents in the children's wards, all with mental and physical disabilities, began in the territory of the Reich and in annexed Austria. Once again, as in Aktion T4, doctors and midwives filled in a questionnaire to register the children concerned. Medical experts then selected which girls and boys to kill using sedatives or starvation.       

Master shoemaker Martin Bader wrote to his family from the Schussenried institution in 1939: “I only pity my children when they once again have to say, ‘My father died in a madhouse.” He was gassed to death by the staff at the Grafeneck killing center in 1940.

The victims of the euthanasia murders came from all social strata. Patients risked being murdered if the doctors at the hospital viewed them as not contributing valuable work, who needed significant levels of care, or who were disruptive, were at risk of being murdered. Jewish patients were killed solely because of their religion. Many of the victims were divorced or unmarried or had no one who cared about them. However, even the intervention of worried relatives was often not sufficient to save patients.

Perpetrators and Profiteers

Viktor Brack (1904-1948) was a high-ranking SS officer who served as one of the head administrators in the euthanasia program  In the headquarters in Berlin and in the killing stations, about 500 people were directly involved in the organization and the smooth running of ‘Aktion T4’. The judiciary covered up the campaign of murders.

Karl Brandt  (1904-1948), one of Hitler’s attending physicians and co-director of the euthanasia program and general commissioner of health and sanitation, stated at the Doctors' Trial in Nuremberg in 1947: ‘What was behind this was: to help the man who cannot help himself and who is eking out an existence with appropriate agonizing suffering,” [he was sentenced to death for crimes against humanity] Many doctors cooperated out of personal careerism, authoritarian thinking or inner conviction. For them, healing and annihilation belonged together. As medical experts, they selected the victims. In the T4 institutions, doctors turned on the gas, murdered with drugs or let the inhabitants starve to death. They conducted experiments on patients doomed to die or research on the brains of the murdered. Male and female nurses helped the medical staff to carry out the murders using gas. They killed with injections or tablets.

Annotated Bibliography

Axel Fahl-Dreger, Ingo Harms, Wege des Gedenkens. Die Opfer der NS-Euthanasie aus dem Landkreis Vechta, Visbek 2024

https://www.t4-denkmal.de and its accompanying book Tiergartenstrasse 4.  Memorial and Information Point for the Victims of National Socialist “Euthanasia” Killings by Gerrit Hohendorf, Christof Beyer, Jens Thiel, Maike Rotzoll,  2016.

Burleigh, Michael. Death and Deliverance: 'Euthanasia' in Germany, c.1900 to 1945. Cambridge: Cambridge University Press, 1995.

This book examines the systematic euthanasia programs implemented in Nazi Germany between 1939 and 1945, contextualizing them within broader cultural, medical, and ideological shifts from the early 20th century to the end of World War II. The book explores the intellectual roots of eugenics, the medical profession's complicity, and the bureaucratic machinery that enabled the mass murder of the disabled and other marginalized groups. Burleigh critically analyzes how these policies reflected the Nazis' obsession with racial purity and their dehumanizing approach to life deemed "unworthy." The work is a profound investigation of the intersection of medicine, ethics, and totalitarianism.

Burleigh, Michael and Wolfgang Wippermann. The Racial State: Germany 1933–1945. Cambridge: Cambridge University Press, 1991.

This book provides a comprehensive analysis of how Nazi Germany was structured as a racial dictatorship. It examines how racial ideology permeated every aspect of life, shaping policies on governance, law, education, religion, and social norms. It delves into the mechanisms and consequences of the Nazis' attempts to create a homogeneous "Aryan" society through exclusion, persecution, and genocide. It deals with the systematic persecution not only of the Jews, but also with the fate of lesser-known groups such as Sinti and Roma, the mentally handicapped, the "asocial," and homosexuals. By linking ideology with state practices, the authors reveal the chilling extent to which the Nazi regime's racial obsessions dictated its policies and actions, ultimately leading to the Holocaust and other atrocities. 

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

This book traces the development of Nazi policies that culminated in the Holocaust .  It explores in chilling detail how the Nazi program of secretly exterminating the handicapped and disabled evolved into the systematic destruction of Jews and the Roma and Sinti. Tracing the rise of racist and eugenic ideologies in Germany, the author describes how the so-called euthanasia of the handicapped provided a practical model for mass murder, thereby initiating the Holocaust. Based on extensive research in American, German, and Austrian archives as well as Allied and German court records, the book also analyzes the involvement of the German bureaucracy and judiciary, the participation of physicians and scientists, the motives of the killers, and the nature of popular opposition. The author also sheds light on the special plight of handicapped Jews, who were the first singled out for murder.

Kühl, Stefan.The Nazi connection:  Eugenics, American Racism, and German National Socialism. New York: Oxford University Press, 1994.

This book explores the transnational influences between American eugenics and Nazi racial policies. The author delves into how American scientific racism and eugenics programs served as models for Nazi Germany's racial ideologies and practices. He examines the intellectual exchange, financial support, and collaboration between American and German eugenicists, highlighting the disturbing ways these ideas informed the Nazis’ pursuit of racial purity, including sterilization laws and genocide. The book provides a critical analysis of the ethical failures in science and the dangerous consequences of intertwining pseudoscience with politics

Lifton, Robert J. The Nazi Doctors: Medical Killings and the Psychology of Genocide. New York:  Basic Books, 1986.

This book examines the role of physicians in the Nazi regime, focusing on their involvement in medical killings and genocide. The author explores how doctors, bound by their profession’s ethical principles, became agents of mass murder through programs like euthanasia and the Holocaust. The book delves into the psychological mechanisms that enabled these physicians to reconcile their actions with their sense of identity, including ideological indoctrination, compartmentalization, and moral disengagement. Combining historical analysis with psychological insights, The author provides a profound exploration of how ordinary professionals became perpetrators of extraordinary atrocities.