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.

The Time of National Socialism

Forced sterilizations carried out by 1934, the Nuremberg Race Laws in 1935, and the euthanasia campaign that started in 1939, mark important steps in the racial hygiene policies of National Socialism. Essentially, the Nazi regime moved from exclusion to annihilation of "racially undesirable" and economically "inferior" groups of people during this period.

“Racial Hygiene”

“Racial hygiene” was a key element of National Socialists’ ideology, and eugenics became an essential component of their health policy. Although it drew on eugenics, Social-Darwinist, racist, and population policy ideas which had been discussed both nationally and internationally since the late 19th century, National Socialist “racial hygiene" differed significantly from that found in Germany and other countries before 1933. As a result of propaganda and the practical implementation through state action, eugenics became the raison d'état (reason of state) in Germany. Authorities, laws, propaganda, and its institutional anchoring in medicine and science contributed to the dissemination and enforcement of “racial hygiene.” While a system of incentives was supposed to encourage those regarded as "racially valuable," the people whom the National Socialists considered "racially inferior" were systematically persecuted and eventually annihilated. Jews, Roma and Sinti, as well as those denounced as "asocial" and physically or mentally disabled were marginalized and eventually "eradicated."

Forced Sterilization

On July 14, 1933, the German government enacted the Gesetz zur Verhütung erbkranken Nachwuchses (Law for the Prevention of Hereditary Diseased Offspring) to take effect on January 1, 1934. Although partly based on a 1932 Prussian State Health Council draft on voluntary eugenic sterilization, this law mandated the procedure. Soon, the government established genetic criteria and through a nationwide network, classified every individual. Regional “hereditary health” courts, composed of lawyers and doctors, ruled on the applications of institution directors or public health officers requesting forced sterilization. Midwives and teachers were also asked to report "racially undesirable" people. The law defined eight diseases as hereditary, including blindness, deafness, epilepsy, and schizophrenia. Those with physical disabilities or labeled as "inferior" – for example, due to alcoholism – as well as people labeled as "asocial" became victims of mandatory sterilization. By 1945, around 400,000 people who suffered from a physical or mental illness or were only suspected of having one were forcibly sterilized on this basis. This suspicion was enough to have the affected people committed to an institution. The majority of the people recorded through registration forms and denunciations did not have a hereditary disease.

Additionally, almost 5,000 people died due to forced sterilizations or abortions through hospital operations or X-rays. Many other victims of forced sterilization were later murdered as part of Aktion T4 (see below). Officials still deny those forced to undergo sterilization as victims of the National Socialist dictatorship. 

“Selection” in the Institution

Starting in 1933, long before the beginning of World War II, Nazis used political rationale to increase the austerity measures that had begun in the psychiatric hospitals under the Weimar Republic. For patients, this meant worse living conditions due to overcrowding, a reduction in nursing care, and other staff cuts. Patients deemed unfit to work or regarded as incurable were especially impacted by these cutbacks. Deep cuts in the food supply for the patients began in 1935 in the Wehnen sanatorium and nursing home, the Gertruden nursing home Oldenburg, and the Blankenburg monastery in the state of Lower-Saxony. Over the next few years, food rationing was tightened further and further. In 1938, the state of Saxony introduced a deficiency diet – in effect, a starvation diet – for non-working institutional residents.

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 sign meant 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.

Protests

Although the Nazis clothed the murders of psychiatric patients and nursing home residents in secrecy, the nearby residents soon became aware of them. In the area surrounding the T4 killing centers, the buses that arrived repeatedly, and the smoke from the crematoria chimneys could not be overlooked. This caused rumors to circulate. The notifications of death and the returned clothes of deported patients also revealed what was occurring. However, although the staff at the hospitals and nursing homes soon understood the truth, only a few administrators and nurses tried to halt the deportations organized under T4.

The complaints and attempts at intervention by relatives were isolated actions with varying degrees of success. Sometimes they succeeded in rescuing relatives; other times, their efforts failed. Additionally, some judges and church leaders tried to obstruct the murders or reveal them to the public.

The Church

Pastor Paul Gerhard Braune (1887–1954) ran the Hoffnungstal Institutions near Bernau and initially prevented deportations by the T4 organization. In a memorandum in July 1940 addressed to Hitler, he presented considerable evidence of the systematic nature of mass murder of patients in psychiatric clinics and homes. As a result, Braune was imprisoned by the Gestapo in the summer of 1940. During his imprisonment, leading Church representatives protested for the first time against the murder of invalids and the mentally ill, which had become more widely known. To maintain the secrecy surrounding the euthanasia murders, no trial was held, and he was released.

On August 3, 1941, Bishop Clemens August von Galen of Münster (1878-1946)  publicly denounced the killings in a sermon. Thousands of copies of the sermon were printed and circulated. Galen himself was not punished because Hitler did not want to clash openly with the Catholic Church. His outspoken criticism created popular unrest and eventually led to the end of the centrally organized T4 murders on August 24, 1941. Despite the official halt to the T4, euthanasia killings continued under a different, decentralized form throughout Germany.

Jurists

Lothar Kreyssig (1898–1986) was a judge of a court of guardianship at the District Court of Brandenburg. In 1940, Kreyssig became aware of the systematic murder of patients in psychiatric clinics and homes through his work as a judge dealing with guardianship matters. He steadfastly refused to acknowledge the legality of these murders. He instructed the directors of clinics and homes in his area of jurisdiction not to hand over patients. Kreyssig protested to the Reich Minister of Justice and filed a criminal complaint against Philipp Bouhler. Kreyssig stood alone among the judges and public prosecutors in demonstrating resistance. He was sent into retirement in the summer of 1942.

In 1940, Linz's chief prosecutor, Ferdinand Eypeltauer (1893–1979), received a notification from a family whose son had been murdered in the Hartheim killing center. Eypeltauer initiated an investigation, but was ordered to halt the proceedings in 1941. In the following war years, Eypeltauer was, however, also responsible for death sentences against forced laborers.

Activists

In Alkoven where the Hartheim killing center was located, a resistance group organized by Ignaz Schuhmann (1909–1945) and Leopold Hilgarth (1895–1945)  gave a rallying cry for resistance against the Nazi regime by means of graffiti and flyers. The group was betrayed; Hilgarth and Schuhmann were arrested by the Gestapo in June 1944. Two months later, the Volksgerichtshof (People's Court) of Vienna accused and tried the two men for treason. They were convicted, sentenced to death, and executed on January 9, 1945.

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 of the people imprisoned at the concentration camp 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, needing significant levels of care, or being disruptive. Jewish patients were killed solely because of their religion. Many of the victims were divorced or unmarried. However, even the intervention of worried relatives was often not sufficient to save patients.

Victims and Their Families

Groups of victims

Adult psychiatric patients who had been institutionalized for a significant length of time were most likely to become victims of Aktion T4. Selected according to utilitarian considerations, they were classed as useless if they were unable to work in the institution. Others were labeled disturbing because they interfered with the operation of the ward. Those listed as in need of care caused the nursing staff extra work while others who were designated as "incurable," were no longer of medical interest to the doctors. Most T4 victims were classified in one of these groups.

Minors and pupils in care were killed both in children's wards and within the framework of Aktion T4. An important factor for being selected was the so-called Bildungsfähigkeit (ability to learn) – and thus the assumed future benefit of the minors to society. If they were deemed incapable of learning, they were at great risk of being murdered.

Beginning in 1941, the T4 doctors became responsible for selecting for death incarcerated individuals who were Jewish, unable to work, or who they viewed as "asocial." They were murdered in the killing centers at Pirna-Sonnenstein, Bernburg, and Hartheim.

Family members

Patients who had spent many years in institutions were particularly vulnerable to selection by the T4 as they had often lost contact with their families. Family ties could sometimes make a difference.  Protests directed towards the heads of the institutions or petitions to government offices sometimes saved patients from being murdered. However, the interventions of families could also be fruitless, their success mainly depending on the attitude of the institution directors and authorities 

Families reacted in different ways to the news of their relatives' deaths. Some were stoic; others expressed relief or even consented to the death. Some relatives saw the killing of their family member as a release from suffering; others felt they had been liberated from a burden. Similar reactions were seen in the parents of children who were murdered under the Reich Committee procedures.

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.” Brandt was later 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 conducted research on the brains of the murdered. Male and female nurses helped the medical staff to carry out the murders using gas. They also killed with injections or tablets.

Prosecution, Compensation, and Remembrance

Prosecution

Most euthanasia trials that resulted in death sentences occurred in the years immediately after the end of the war in the courts of the Allies. Between 1945 and 1947, nurses Karl Willig, Karl Erhard Gäbler, Heinrich Ruoff, and Helene Wieczorek, Alfons Klein (the administrative manager of Hadamar), Dr. Hilde Wernicke from Meseritz-Obrawalde, and Paul Hermann Nitsche (the medical director of T4) were executed. In the Doctors' Trial in Nuremberg in 1947, Karl Brandt and Viktor Brack, the two men in charge of the euthanasia murders, were sentenced to death.

After 1949, fewer criminal proceedings occurred and the sentences were markedly milder. The courts had previously viewed the facts of the cases as indicating murder, but in later trials, the perpetrators were accused of manslaughter. The courts viewed that the perpetrators had been ignorant that their actions were illegal. The judges regarded "the destruction of life unworthy of life" not fundamentally "immoral" – which is why perpetrators such as Werner Catel never stood trial in 1949. Other trials in the 1960s – largely driven by Attorney General of Hesse Fritz Bauer – mostly ended in no sentences. Assessors certified that T4 perpetrators such as Georg Renno were unfit to attend trial.

During the first post war euthanasia trials, few perpetrators were sentenced to imprisonment or death, with most trials ending with acquittals or short prison sentences. Judges found that the offenders had probably not realized that their actions were illegal. Often, the courts did not allow surviving patients to appear as witnesses. Most doctors were never brought to trial. The field of psychiatry in Germany faced its past at a very late date, and the German Bundestag only outlawed forced sterilization in 2007.

After 1945

Even after 1945, eugenics continued to impact patients in psychiatric institutions. In both the Federal Republic of Germany and the German Democratic Republic, psychiatric patients continued to be marginalized and stigmatized, often facing deprivation and strict demands of obedience. Not until the 1970s did the situation in institutions and homes begin to slowly improve.

Compensation for the Victims

The compensation policy established by West Germany deliberately excluded relatives of victims of the euthanasia murders as well as those who had been forcibly sterilized by the Nazis. The Federal Compensation Act of 1953 did not recognize their suffering. In fact, the Law for the Prevention of Genetically Diseased Offspring continued to exist in parts of the Federal Republic until 1974, although it had been repealed in the Soviet occupation zone before the GDR was even established.

Debates in West Germany about compensation payments frequently demonstrated an endorsement of eugenic sterilizations even into the 1960s. The same assessors who had been responsible for their forced sterilization now decided as to whether applicants deserved compensation. For example, former hereditary health judges Werner Villinger and Helmut Ehrhardt appeared as experts before the German Parliamentary Committee for Restitution in 1961. The committee refused compensation for the victims.

In 1987, the victims founded the Bund der Euthanasie-Geschädigten und Zwangssterilisierten 
(Federation of the People Damaged by Euthanasia and who Underwent Compulsory Sterilization) to continue their fight for recognition as victims of the Nazi regime. A year later, the Bundestag declared the forced sterilization law a "National Socialist injustice." In 1998, it formally revoked the judgments of the hereditary health courts, but it took until 2007 before they revoked the law. Nonetheless, according to the Federal Compensation Law, the victims of euthanasia and forced sterilization still are not entitled to compensation, although they may receive some recompense after a hardship ruling.

Remembrance

The first memorials commemorating the victims of the euthanasia killings were erected in the 1950s and 1960s in the Federal Republic, the German Democratic Republic, and Austria. Memorial stones, plaques, and other forms of remembrance mostly omitted any specific information or explanation. The euthanasia victims were barely included within the culture of commemoration.

Since the 1980s, initiatives for memorial sites and monuments have increased. Today, there are exhibitions at each of the former killing stations providing detailed information about what occurred. Many psychiatric hospitals and institutes in Germany have established memorials and exhibitions to commemorate the patients who, as part of Aktion T4, were deported or killed due to the National Socialist health policy. More recently, eastern European countries have erected memorials to the German euthanasia campaign.

The disclosure of the names of murdered mental patients has, to date, not occurred. Data protection requirements complicate mentioning the euthanasia victims by name, unlike other victims of the National Socialist regime whose names are acknowledged. The omission of the names of the victims of Aktion T4 continues to deprive them of their dignity. Several memorial sites do have memorial books, some of which are publicly available. Stolpersteine (stumbling stones) in many cities mention the names of the victims in front of the place of their last residence. Furthermore, since 2014, there is a federal Memorial and Information Site for the Victims of the National Socialist Euthanasia Murders.