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Challenging Contemporary Physicians’ Disability Bias: Understanding and Applying Lessons from Krankenmorde

by Simrun Bal, 2023 Medical Fellow

It is a sunny day in Brandenburg, Germany, and we are visiting the Memorial to the Victims of Euthanasia Murders (Gedenkstätte Opfer der Euthanasie-Morde). The memorial is the site of a former gas chamber where more than 9,000 ill and disabled patients were murdered with poison gas as part of the Aktion T4 (Operation T4) beginning in 1939. Despite the sunshine that surrounds us, it feels stark and empty here. The wind blows and a haunting feeling comes over us.

As we look around at the site of this former gas chamber, we note the many suburban homes all around parts of the town, where residents walk and go about their daily lives. There is a hospital around the corner. What did passerby notice? How did physicians become complicit in this euthanasia center, one that nurtured killing techniques later used in death camps? What can contemporary physicians caring for patients with disabilities learn from this unfortunate legacy?

Studies of contemporary physicians demonstrate that many doctors hold biased perceptions of patients with disabilities, with one recent survey in Health Affairs suggesting that among 714 American physicians, 82.4% felt that individuals with significant disabilities have worse quality of life compared to that of nondisabled individuals.1,2 Only about half, or 56.5%, of physicians in the same study “strongly agreed” that they welcomed patients with disabilities into their practice.1,2 When comparing surveys about different occupations in the US, however, the public considers physicians highly trustworthy, noting that doctors care for patients’ best interests and provide fair and accurate information.3 Bias by physicians against individuals with disabilities may create and further propagate healthcare inequities, and it is thus crucial to reflect on lessons learned from the Holocaust, specifically in a group of criminal actions conducted by the Nazi regime collectively known as Krankenmorde (Sick-murders), in understanding the potential risks of physician bias.

Between 1933 and 1945, the National Socialist regime murdered an estimated 300,000 individuals and sterilized approximately 360,000 people. This collection of crimes against those with physical and psychiatric disabilities, as well as the ill more broadly, constitutes the Krankenmorde, the murder of the sick and disabled.4

Many may be surprised to know that in the 1920s and 1930s, interest in “eugenic science” flourished both in the United States and Germany. American leaders used eugenicist ideas to justify racist immigration policies and sterilizations. These efforts had a long legacy, ranging from 1907, when Indiana passed the world’s first compulsory sterilization law, to the 1960s. In the U.S. Supreme Court case Buck v.

Bell, which focused on the forced sterilization of patients in mental institutions, Chief Justice Oliver Wendell Holmes wrote in the majority opinion that “three generations of imbeciles are enough.”5 

German thinkers were influenced by these trends in the US. After World War I, many German politicians felt that the best “genetic stock” had perished in the war and that Germany faced a concerning future, given its recent defeat and the need to pay war indemnities.6 This way of thinking reinforced the myth that Jews had contributed to the defeat of Germany.

Theorizing in this context, in 1920 Karl Binding (a respected jurist in Germany) and Alfred Hoche (a psychiatrist) published a document called Die Freigabe der

Vernichtung lebensunwerten Lebens (Allowing the Destruction of Life Unworthy of Living). In this document, they argued that “the value of an ill or disabled individual was diminished if his or her social contribution to the nation was outweighed by the expense of caring for them”; their work described such individuals as “useless eaters,” a phrase later picked up by German films and other propaganda.7

The 1933 Gesetz zur Verbütung erbkranken Nachwuchses (Law for the Prevention of Genetically Diseased Offspring) drew inspiration from sterilization laws in the United States. It declared that there were eight “hereditary” illnesses: intellectual disability, schizophrenia, epilepsy, manic-depressive disorder, severe alcoholism, and two physical disorders. This law involved compulsory sterilization. Each decision regarding state-enforced sterilization involved hereditary health courts (which were composed of physicians and a judge). About 90% of cases referred to the courts proceeded to state-enforced sterilization.8 What’s more, these laws further justified the compulsory sterilization of individuals on a racial basis, such as Sinti,

Roma, Jewish, and mixed-race children of German women and French troops from West Africa (so-called “Rhineland Bastards”).9

This valorization of murder did not end there. In October 1939, Adolf Hitler provided a short, backdated directive (dated September 1939, the date of Germany’s invasion of Poland) to Philipp Bouhler and Karl Brandt, authorizing certain physicians to provide a “mercy death” to those “persons, who, according to human judgment, are incurable”10 Thus began the Krankenmorde.11

After Hitler’s directive, the Ministry of the Interior sent registration forms to hospitals and nursing homes around Germany and described which patients were to be “reported” by their treating physician. It even laid out particular data that required reporting (certain medical conditions, duration of stay in the facility, criminal history, employment history, work capacity, Jewish status, etc.).12 The forms were then returned to Tiergartenstrasse 4; this “headquarters” led to the codename Aktion T4. There was a T4 medical committee, comprised of respected physicians and jurists, who then made assessments about life or death based on the registration form. They did not even examine the victims in person.13

A “mercy death” involved transport from the medical facility (such as a nursing home) to a killing center. The transport ‘s purpose remained hidden through a fake organization called Gemeinnützige Krankentransport GmbH (Charitable Ambulance), which organized buses (painted grey) to transport victims.14 Victims then arrived through these “ambulances” to the killing centers, where they were locked inside a gas chamber and died through the inhalation of carbon monoxide. Their family later received a “death notice” with a false reason for their passing.15 It is estimated that in total during the Krankenmorde more than 300,000 individuals were killed. 

These actions lay the groundwork for the Holocaust.16 In the words of Leo Alexander, an American psychiatrist and neurologist who wrote the Nuremberg Code after World War II:

“[Krankenmorde were…] merely the entering wedge for exterminations of far greater scope in the political program for genocide of conquered nations and the racially unwanted. The methods used and personnel trained in the killing centers for the chronically sick became the nucleus of much larger centers in the East, where the plan was to kill all Jews and Poles and to cut down the Russian population by 30,000,000.”17 

Did anyone resist? Who, if any, stood against this state-endorsed euthanasia program? Perhaps the most well-known example was the Bishop of Münster, Clemens von Galen, who gave three sermons in the summer of 1941 that condemned the Nazi regime. One sermon directly described the T4 killings; he inspired the Scholl siblings and many others. The bishop, unlike many others, did not experience Nazi retribution. Other such figures include Karsten Jasperson (a physician and clinical director of an asylum in Germany), Karl Bonhoeffer, and Ernst Arlt. Jasperson refused to cooperate with local authorities and encouraged colleagues not to participate or change their patient records (to prevent “mercy killings”). Bonhoeffer was a professor of psychiatry and the father of Dietrich Bonhoeffer. He initially supported sterilization but later resisted the T4 program and advised his son to also try to save patients. Arlt was an Austrian psychiatrist who opposed the murder of patients; he contended that many great German individuals (such as Nietzsche) would not have survived, and that “incurability” changed with medical advancements. He resisted by contacting patients’ families, exhorting them to take their at-risk family members home.18

How should the program and those who fought against it inform the current landscape of physician bias against a vulnerable group, those who have what we consider “disabilities”? In reflecting on my experience as a participant in FASPE, there are many ways I have come to believe this legacy and resistance can inform and illuminate our current landscape; in the interest of space and clarity, I have summarized these thoughts in three main themes for others to consider:

  1. It is crucial to question the intricacies of power and professionalism.
  2. We must not focus on the “utility” of each patient but rather on the provision of “care” for each patient, who deserves healthcare as a human right regardless of their ability to “contribute to society.”
  3. Promotion of humanization of the “other” is key in addressing exclusion and persecution.

Power and Professionalism

As a medical professional myself, it is sobering to reflect on the collusion of “colleagues” in these euthanasia programs. Medical professionals abused their power in a society in which physicians were trusted, seen as benevolent and reputable. They colluded with other systems of authority that were well-regarded in Germany too, such as the legal apparatus (e.g., hereditary health courts), the economic system (e.g., propaganda bragged about the money saved by “mercy killings”), and others. In reflecting on this aspect of Aktion T4, we must thus consider how we conceptualize power and what the value of power is among “professionals.” It is crucial for us not to be led astray by power and to question those with such authority, such as our colleagues in medicine, the law, and economics. By the same token, power can be part of resistance, and it is key for physicians, as professionals, to realize their potential, to accept resistance as a core duty.

Healthcare as a Right for All

Underlying much of Aktion T4 is rhetoric about the utility of each patient: what can each person contribute? What is their work capacity? Is the patient a “useless eater”? Physicians must remember that at the heart of medicine lies healthcare for the individual patient, regardless of what they can contribute or their potential usefulness. Medical professionals must attempt to prioritize the person in front of us, illuminated by compassion and non-maleficence.

Humanizing the “Other” 

Throughout Aktion T4 and other phases of the Holocaust, the Nazi regime focused on persecuting and eliminating the “other.” What does it mean to be “other”? This is the question we must continuously reflect upon. Our instinct may be to be suspicious or scared of what we consider to be different, but by opening ourselves to the possibility of a shared humanity among others, we realize that we cannot justify persecution or exclusion. We realize that the human being in front of us has sisters, brothers, parents, hobbies, a story, and much more.

Without a basis of shared humanity and compassion, it is easy to see the “small beginnings” that Leo Alexander describes as the root of the crimes discussed here. In his words, “it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the nonrehabitable sick.”19

I would like to end this reflection with a poem. This piece is a reminder that we today must learn the lessons of history by understanding the legacy of Krankenmorde. We must personally and collectively ensure that we question power and professionalism, that we prioritize the individual patient in front of us while challenging exclusion and persecution. We must, at bottom, emphasize humanism in our healing.

“Dog Fox Field” by Les Murray20

The test for feeblemindedness was, they had to make up a sentence using the words dog, fox and field.
- Judgment at Nuremberg

These were no leaders, but they
were first into the dark on
Dog Fox Field:

Anna who rocked her head,
and Paul who grew big and
yet giggled small,

Irma who looked Chinese, and Hans
who knew his world as a fox knows a field.

Hunted with needles, exposed, unfed,
this time in their thousands they bore sad cuts

for having gazed, and shuffled,
and failed to field the lore of
prey and hound

they then had to thump and cry
in the vans that ran while
stopped in Dog Fox Field.

Our sentries, whose holocaust does
not end, they show us when we cross
into Dog Fox Field.

Image: Birches near the House of the Wannsee Conference (picture credit: Simrun Bal)

I chose this image as the ending to this paper because of the birch groves that I saw in Auschwitz and Birkenau and all that they represent. In the words of Barbara Zaiac, the Auschwitz-Birkenau Museum and Memorial Vegetation Conservation Specialist, “[the trees were] silent witnesses to Nazi crimes.”21

Simrun Bal was a 2023 FASPE Medical Fellow. She did her residency and chief residency at Dartmouth and now practices internal medicine at a Department of Veterans Affairs’ clinic in Burlington, Vermont.

Notes

  1. Lagu, et al. 2022. “I am not the doctor for you: physicians’ attitudes about caring for people with disabilities.” Health Affairs 41(10). https://doi.org/10.1377/hlthaff.2022.00475
  2. Iezzoni, et al. 2021. “Physicians’ perceptions of people with disability and their healthcare.” Health Affairs 40(2). https://doi.org/10.1377/hlthaff.2020.01452
  3. https://www.pewresearch.org/science/2019/08/02/findings-at-a-glance-medical-doctors/
  4. Light E, Robertson M, Lipworth W, Walter G, Little M. Bioethics and the Krankenmorde: Disability and Diversity. The International Library of Bioethics. 8 July 2022.
  5. Buck v. Bell, 274 U.S. 200 (1927)
  6. Robertson M, Ley A, Light E. 2019. The First Into the Dark: The Nazi Persecution of the Disabled. UTS ePress. https://www.jstor.org/stable/j.ctv1w36p9p
  7. Ibid, p. 25
  8. Ibid, p. 32
  9. Ibid, p. 32
  10. Ibid, p. 25; notes from visit to the memorial
  11. Ibid, p. 25
  12. Ibid, p. 25
  13. Ibid, p. 40
  14. Ibid, p. 41-42
  15. Notes from visit to the memorial. 
  16. Robertson M, Ley A, Light E. 2019. The First Into the Dark: The Nazi Persecution of the Disabled.UTS ePress. Page 43. https://www.jstor.org/stable/j.ctv1w36p9p
  17. Leo Alexander (1949), “Medical Science Under Dictatorship,” NEJM 241. Qtd also in The First Into the Dark, p. 145-146.
  18. Robertson M, Ley A, Light E. 2019. The First Into the Dark: The Nazi Persecution of the Disabled. UTS ePress. Page 51-53. https://www.jstor.org/stable/j.ctv1w36p9p
  19. Leo Alexander (1949), “Medical Science Under Dictatorship,” NEJM 241. Qtd also in The First Into the Dark, p. 145-146.
  20. Murray, L. A. (1991). Dog fox field. Carcanet. https://www.lrb.co.uk/the-paper/v11/n04/les-murray/twopoems
  21. https://www.auschwitz.org/en/museum/news/the-death-of-silent-witnesses-to-history,466.html