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Forum Discussion: Psychiatric Genocide—Nazi Attempts to Eradicate Schizophrenia


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In our Forum discussion “journal club” series, the editors of Schizophrenia Bulletin provide access to the full text of a recent article. A short introduction by a journal editor gets us started, and then it's up to our readers to share their ideas and insights, questions, and reactions to the selected paper. So read on….

Torrey EF, Yolken RH. Psychiatric Genocide: Nazi Attempts to Eradicate Schizophrenia. Schizophr Bull. 2009 Sep 16. Abstract

View Comments By:
John McGrath — Posted 26 September 2009
Ezra Susser — Posted 13 January 2010
James MacCabe — Posted 22 January 2010
Linda Chafetz — Posted 22 January 2010
Tadeusz Nasierowski — Posted 5 March 2010
Rael D. Strous — Posted 14 April 2010
Sanjeev Jain — Posted 20 August 2013


Background Text
By Gunvant Thaker, Professor and Chief, Schizophrenia Related Disorders Program, Maryland Psychiatric Research Center and Deputy Editor, Schizophrenia Bulletin

In a recently published report in Schizophrenia Bulletin (available online), E. Fuller Torrey and Robert H. Yolken review existing data to estimate the extent of Nazi genocide of psychiatric patients during the period of 1939-1945. The report provides an outline of the “scientific” thinking and the societal benefit “logic” that supported the genocide, including horrific details of the methods used to implement the plans. Torrey and Yolken estimate that hundreds of thousands of psychiatric patients were killed or sterilized, including 220,000-269,500 schizophrenia patients. This constituted more than 73 percent of the patients in Germany at that time (calculated based on the studies carried out in 1929-1931 that reported point prevalence rates of 2.0 per 1,000). Postwar studies in Germany reported lower prevalence rates than comparable studies in other Western countries carried out around the same period, whereas the incidence rate, when first studied in Mannheim 20 years after the last genocide, was found to be 53.6 per 100,000. The authors note that this rate is on the higher end of other published studies. Haffner and Reimann, the original authors of the Mannheim study, also noted that the observed incidence rate in Germany in 1965 was two to three times higher than most comparable studies at that time.

In addition to the horror of reading about the systematic killing of patients based on misguided scientific thinking and the participation of clinicians in the process, Torrey and Yolken’s report is a somber and thought-provoking read. As the authors point out, in contrast to the Nazi genocide of Jews during that period, killings of psychiatric patients are not as well known. It is legitimate (as the authors convincingly argue in the report) and important to examine and understand the impact of these killings and sterilizations on subsequent prevalence and incidence rates. The prevalence rates examined more than 20 years after the last genocide were lower, as one would expect, but the incidence rates didn’t decrease, and if anything, were relatively high. This is consistent with the fact that schizophrenia survives in the population in spite of low fertility rates among patients, and suggests that the disorder is caused by common variations in a large number of genes. The relatively high incidence rates point to an important role of the environmental factors that contribute to the etiology of the disease. Finally, the report needs to be a constant reminder of potential pitfalls as we participate in making health policy decisions based on our current scientific findings.

Reference:
Hafner H and Reimann H. Spatial distribution of mental disorders in Mannheim, 1965. In: Hare EH, Wing JK, eds. Psychiatric Epidemiology: Proceedings of the International Symposium Held at Aberdeen University 22–5 July 1969. New York, NY: Oxford University Press; 1970:341–354.

Comments on Online Discussion
Comment by:  John McGrath, SRF Advisor
Submitted 25 September 2009
Posted 26 September 2009


Apart from collating the best available estimates of the incidence and prevalence of schizophrenia in pre- and postwar Germany, this article outlines the circumstances related to the systematic sterilization and murder of hundreds of thousands of Germans with schizophrenia during World War II. It is a sobering read.

View all comments by John McGrathComment by:  Ezra Susser, SRF Advisor
Submitted 13 January 2010
Posted 13 January 2010

Comment by Ezra Susser and Rebecca Smith
The authors and the editors are to be commended for publishing this paper. To our knowledge, this is the first paper to appear on this topic in the Schizophrenia Bulletin. For more than half a century, the Bulletin has been open to a wide variety of opinions and perspectives on schizophrenia from mental health professionals, consumers, and other interested groups. It is difficult to think of any (other) topic regarding schizophrenia that has not been addressed.

Fuller Torrey and Yolken draw our attention to a fact not widely known, even among mental health professionals: Hitler’s massive program for systematic slaughter of the six million Jews was in fact developed and piloted in mental patients. Before their use on a massive scale in concentration camps across occupied Europe, the gas chambers were one of several killing methods first tested in mental hospitals. This took place with the political and practical support of a dishearteningly large proportion of psychiatrists as well as other physicians.

Since the 1980s, the mass killings of mental patients and the participation of psychiatrists has been well documented and information on this topic is increasingly accessible and extensive. Nonetheless, we believe that only a minority of mental health professionals—and of individuals with schizophrenia and their relatives—are aware of what happened. The question we all need to ask ourselves is, Why?

We need to reflect on how the mass killing of people with schizophrenia has remained out of the public and professional consciousness of the mental health community over such a long period. The primary question naturally leads to subsidiary questions that are even more uncomfortable. How sharp a line can we really draw between the Nazi psychiatrists and ourselves? To what extent do we collude with the injustices that today are perpetrated against people with mental illness? Are there conditions which fostered the attitudes of the Nazi psychiatrists which may still be operating today? It may be uncomfortable for all of us to ponder these questions. It is essential, however, to do so.

Sources
The sources cited by Fuller Torrey and Yolken are well selected and judicious. Individuals who wish to explore this topic in more depth, however, may benefit from a wider list of citations. Therefore, we provide below other useful sources, including Naomi Baumslag’s powerful book, three full issues of the International Journal of Mental Health, and several websites. These additional sources are still selective rather than comprehensive.

Books
Baumslag, N. Murderous Medicine: Nazi Doctors, Human Experimentation and Typhus. 2005, Praeger Publishers, Westport CT, USAGoldensohn, L. and Gellately, R. The Nuremberg Interviews. 2004, Knopf, USA.

Websites
Reconstruction of Belzec

Nazi Documents

Nazi Extermination of People with Mental Disabilities

Judgement: The Law Relating to War Crimes and Crimes Against Humanity

The Nuremberg Trials: What Were the Crimes?

References:

Dudley, M and Gale, F. Psychiatrists as moral community? Psychiatry under the Nazis and its contemporary relevance. Australian and New Zealand Journal of Psychiatry, 2002:36; pp 585-94. Abstract

Gottesman I and Nertelsen A. Legacy of German Psychiatric Genetics: Hindsight Is Always 20:20. American Journal of Medical Genetics (Neuropsychiatric Genetics) 1996 (67) 317-322. Abstract

Singer, L. Ideology and Ethics. The perversion of German psychiatrists’ ethics by Nazi ideology. European Psychiatry, (Suppl) 1993 (13) pp 87-92. Abstract

International Journal of Mental Health, Vol. 35, No. 3, Fall, 2006

International Journal of Mental Health, Vol. 35, No. 4, Winter, 2006-2007

International Journal of Mental Health, Vol. 36, No. 1, Spring 2007

View all comments by Ezra SusserComment by:  James MacCabe
Submitted 22 January 2010
Posted 22 January 2010

I agree with Ezra that it is important to discuss this subject openly and to learn from it. In that spirit I want to share some potentially relevant findings from Sweden.

I recently studied lifetime fertility in a birth cohort of 14,000 individuals born in Uppsala, a picturesque university town near Stockholm, between 1915 and 1929 (MacCabe et al., 2009). In this cohort, we found the expected reduction in the number of offspring born to males with schizophrenia, with a fertility ratio of 0.41. However, we were surprised to find that the fertility in females with schizophrenia was reduced to the same extent as that of males. In previous studies, the reduction in fertility in females has consistently been only about half that in males (Bundy and MacCabe, submitted).

To my surprise, one of our collaborators in Sweden suggested that the explanation for this may be the forced sterilization of women with schizophrenia. I had not previously been aware that a eugenics program existed in Sweden, so I researched the subject in greater detail.

Between 1935 and 1975, sterilization laws existed in Sweden that permitted compulsory sterilization on a variety of grounds, including mental illness (Armstrong, 1997; Tannsjo, 1998). Sterilizations were performed on approximately 63,000 individuals, of whom the vast majority (around 95 percent) were women (Armstrong, 1997; Runcis, 1998; Tannsjo, 1998).

I have been so far unable to obtain an estimate of how many women were sterilized based on a diagnosis of schizophrenia, but this figure is likely to be high since it is known that a high proportion of those sterilized were in mental institutions (Armstrong, 1997). It may also be relevant that the “Institute of Racial Biology,” the major center for eugenics in Sweden, was located in Uppsala (Bhatia et al., 2004; Prof. M. Runcis, personal communication).

It is sobering to realize that these laws were not actually repealed until 1975, although it is thought that the majority of sterilizations occurred well before that date.

I should also stress that these practices are, of course, completely at odds with modern attitudes in Sweden, and that Sweden was not the only country to have a sterilization program. Eugenic sterilization was legal in many states in the U.S. until surprisingly recently, and there was also significant support for eugenics in Britain, Canada, Australia, and many other western countries.

References:

Armstrong C (1997). Thousands of women sterilized in Sweden without consent. British Medical Journal. 315, 563.

Bhatia T, Franzos MA, Wood JA, Nimgaonkar VL, Deshpande SN (2004). Gender and procreation among patients with schizophrenia. Schizophrenia Research 68, 387-394. Abstract

Bundy, H., MacCabe, J.H. (Submitted 2009) The schizophrenia paradox: a systematic review and meta-analysis of the fertility of schizophrenic patients and their unaffected siblings.

MacCabe, J. H., Koupil, I., and Leon, D. A. (2009), Lifetime reproductive output over two generations in patients with psychosis and their unaffected siblings: the Uppsala 1915-1929 Birth Cohort Multigenerational Study., Psychol Med, 39(10): 1667-76. Abstract

Runcis M (1998). Sterilization in the Swedish Welfare State [in Swedish]. Ordfront : Stockholm.

Tannsjo T (1998). Compulsory sterilisation in Sweden. Bioethics 12, 236-249. Abstract

View all comments by James MacCabeComment by:  Linda Chafetz
Submitted 22 January 2010
Posted 22 January 2010

In 2003, Susan Benedict published in a nursing journal a description of the "killing programs" at Haldamar. While her report would not add materially to the impressive historical information provided by Drs. Torrey and Yolken, it may interest readers who are trying to fathom how nurses in this hospital could implement such a program. It includes some chilling personal testimony from five of these nurses, much of it obtained from records of their trials for war crimes.

References:
Susan Benedict (2003). Killing While Caring: The Nurses of Hadamar. Issues in Mental Health Nursing, 24:1, pp. 59-79.

View all comments by Linda ChafetzComment by:  Tadeusz Nasierowski
Submitted 5 March 2010
Posted 5 March 2010

Genocide of the Mentally Ill and the Holocaust
Note: Supporting evidence for the claims in this comment are provided in the commentator’s book cited below (see reference).

Edwin Fuller Torrey and Robert H. Yolken’s article, “Psychiatric Genocide: Nazi Attempts to Eradicate Schizophrenia,” could benefit from additional information. Specifically, the authors stated that, "The Nazi genocide of psychiatric patients was the greatest criminal act in the history of psychiatry." However, Fuller Torrey and Yolken focus exclusively on events that occurred in Germany, which is typically the framework used in discussing this topic. It’s important, though, to look at Nazism not only in Germany, but in all of Europe. This wider view enables us to fully understand the genocide of the mentally ill and its importance for the next actions taken by Nazis, that is, the promulgation of the Holocaust.

Along with the German invasion of Poland, the implementation of Adolf Hitler’s homicidal program began with the systematic killing of mentally ill individuals. The units responsible for the most outrageous crimes against civilians were the infamous death squads called Einsatzgruppen (“task forces” or “intervention groups”), which followed the German army, inspiring terror and wreaking havoc wherever they went.

The development of new mass murder technology required the Germans to first perform many tests and practice runs in order to acquire real-world experience. To this end, Poland, once conquered, became a laboratory in which the German aggressors could research and develop the new techniques of mass murder on Polish citizens.

As early as autumn 1939, the Germans began to kill inmates in mental institutions situated in the Polish territories conquered by the Reich, the so-called “Reichsgau Wartheland” or “Warthegau” (District of the Warta River district incorporated by the Reich). The Germans devised a plan in which the first stage was to replace the hospital management at each hospital with a German director, German administrative officer, and German male head nurse. The new director immediately issued an order forbidding all hospital discharges, under the penalty of death, and ordered staff to prepare lists of all the patients categorized into three groups according to 1) illness severity, 2) ability to work, and 3) national background (German, Polish, or Jewish). These lists were sent to the central authorities in Berlin. The next step was murder. The operation was covert and attempts were made to cover up the procedures leading up to the murders. Soldiers from special SS units accompanied inmates via truck to an unknown destination. After several hours the soldiers returned without their patients who, as it turned out later, had been massacred in an isolated location. These exterminations took place in mental institutions throughout Warthegau and Pomerania, including Owiński near Poznań, Dziekanka near Gniezno, Kościan, Warta, and Kochanówka near Łódź, Gostynin, Świecie on the Vistula River, and Kocborowo near Starogard Gdański in Pomerania. The same fate befell the inmates of social welfare institutions, such as those in Bojanów and Śrem, both in Warthegau. When deciding whom to murder, the Germans considered both ideological and practical factors. They needed hospital beds for wounded soldiers, buildings for newly established SS schools, and other institutions needed to strengthen their rule in the territories they had incorporated. The slaughter of the mentally ill was organized in Poznań by a special unit of the German secret police, the SS-Sonderkommando, headed by a commissioner (Herbert Lange) for the criminal affairs of the SS, the Obersturmführer.

The first hospital to be liquidated in Warthegau was the Mental Institution at Owińska. The lists of inmates were compiled and an SS unit was installed on the hospital grounds. Next, it was announced that inmates would be moved to other hospitals. First, 100 German inmates were transferred to a hospital at Dziekanka. Then, from October to November 1939, the remaining 1,000 were systematically transported by three trucks, each holding 25 people, to bunker number 17 at the Seventh Fort in Poznań as a first stage of the operation. Then they were driven to a forest near Oborniki Wielkopolskie. The Nazis were testing a new method of murder—gas—which they had used in World War I. To this end, a special bunker number 17 in the Seventh Fort was adapted for the purpose. Lange and his men brought 50 patients at a time to the bunker, and introduced carbon monoxide from an iron tank beside the door into the sealed bunker. The corpses were then transported to a forest near Oborniki Wielkopolskie to be buried in mass graves. It is estimated that 400 patients were murdered in the Seventh Fort. The murders conducted at the Seventh Fort marked the beginning of the industrial scale killing that became the centerpiece of the Holocaust. The first attempt to use gas in Germany took place in the T4 center in Brandenburg, shortly after the killing of patients in Owińska.

Once the Germans realized that gas chambers provided a cheap and effective method of extermination, they made them transportable. In order to more expediently murder patients from hospitals farther afield than Poznań, the Germans constructed special gas chambers on trucks so that patients could be gassed while being transported to their place of burial. These gas vans cruised throughout Warthegau like specters of death murdering their victims at times convenient to the murderers. Plated inside with brass sheets and caulked with felt, the gas vans had a system installed that introduced carbon monoxide into the interior either from an outside tank or directly from the van’s engine. As with previous extermination methods, the gassing procedures were orderly and methodical. Patients were forced into the van under an SS escort, often having received prior sedatives. The convoy would then set off to the place of burial while gassing the patients to death en route. The bodies were buried in forests in mass graves concealed by grass and small trees. There is evidence to suggest that the inmates of Owińska psychiatric hospital were the first to be killed in these gas vans.

The extermination of the inmates of mental institutions was kept secret by the German authorities and evidence of the exterminations was suppressed. The families of the murdered patients were informed by the hospital management that their loved ones had been transferred to other hospitals or had died of natural causes and had been buried. Death certificates and medical records were falsified. In 1943 and 1944, when the situation on the fronts was deteriorating and the impending German defeat was undeniable, the Germans began to actively suppress the evidence of their crimes. Mass graves were dug up and corpses burned (operation code name “1005”).

The experience gained by Lange’s Sonderkommando during the extermination of the mentally ill was to be used for the “liquidation” of the Jews. On the initiative of the Warthegau authorities, a first stationary center for the extermination of Jews was established at Chełmno on the Ner River (Kulmhof). Herbert Lange was appointed the organizer and first commanding officer of the Kulmhof Camp. He murdered prisoners in the same way he killed the mentally ill.

Germany’s offensive on the Soviet Union was a decisive new stage in WWII. The former allies, who partitioned Poland according to the Ribbentrop-Molotov Pact, were now enemies. In their invasion of the USSR, the Germans copied the strategy they had used in military operations against Poland. This time, however, they made a greater effort to ensure better cooperation between the Wehrmacht and the Einsatzgruppen which, as in the case of Poland, were responsible for ethnic cleansing intended especially against Jews but which included the mentally ill. Soon enough it became evident that killing children and women by firing squads was psychologically difficult for the perpetrators. This was the reason why Walter Rauff, head of technical service at the Second Department of the Reichssicherheitshauptamt (Reich Security Main Office), suggested the Einsatzgruppen operating in the East use the gas vans that had proved so efficient for clearing the psychiatric hospitals in German-occupied Poland. The mental asylums in Warthegau had provided an effective method of mass killing that was subsequently used for the extermination of the mentally ill in six centers of the Operation T4 in Germany, for the extermination of the mentally ill in occupied USSR and, later in the Holocaust of the Jews.

In the territory of the General Government (a part of German-occupied Poland that was not incorporated directly to the Third Reich), however, the Germans kept to traditional methods of killing the mentally ill. The most direct way of killing was shooting, then came starvation, scopolamine or phenobarbital injections, and purposeful neglect of hygiene so that patients died of infectious disease.

Operation Reinhard conducted by the Germans in 1942-1943 in the General Government was the core of the Holocaust program. Jews were targeted for death in ghettos or death camps (Auschwitz, Bełżec, Majdanek, Sobibór, Treblinka). It is significant that all the commandants of the extermination camps at Treblinka (Irmfried Eberl, Franz Stangl), Bełżec (Gottlieb Hering, Christian Wirth) and Sobibór (Franz Reichleitner, Franz Stangl) were veterans of Action T4 in Germany, and at least half of the staff of the camps were people who had been involved as cremators, guards, or drivers of gas vans or storekeepers in Action T4.

This clearly and indisputably connects the extermination of the mentally ill with the Holocaust, and justifies the hypothesis that the Holocaust would have been impossible without the prior extermination of the mentally ill.

The other group inserted by the Nazis into this chain of death was forced laborers from Poland and other countries of East-Central Europe, exploited for the benefit of the Third Reich. Malnutrition, inadequate clothing, extremely bad living conditions, and no medical care contributed greatly to the ill health of forced laborers. The German decision-makers concluded that the simplest way to eliminate the laborers would be to murder them in former euthanasia centers. There is conclusive evidence that Polish and Soviet forced laborers were killed in the euthanasia centers at Hadamar and Hartheim. Thus, the mentally ill, Holocaust victims, and forced laborers shared the same fate.

References:

Nasierowski T. Zagłada osób z zaburzeniami psychicznymi w okupowanej Polsce. Początek ludobójstwa (The extermination of people with mental disorders in occupied Poland. The beginning of genocide). Warszawa, Wydawnicto Neriton; 2008.

View all comments by Tadeusz NasierowskiComment by:  Rael D. Strous
Submitted 14 April 2010
Posted 14 April 2010

Reprinted courtesy of Schizophrenia Bulletin
Rael D. Strous. Commentary on Torrey and Yolken: "Psychiatric genocide: Nazi attempts to eradicate schizophrenia." Schizophr Bull. 2010;36:26-32.

Psychiatric Genocide: Reflections and Responsibilities
Torrey and Yolken should be commended for adding to the burgeoning reports in the recent psychiatric literature describing the genocide committed by our colleagues during the Nazi era. That it has taken close to 60 years to confront this dark period in the history of psychiatry does not diminish the importance of finally dealing with it. It is painfully shameful that close to 300,000 individuals with schizophrenia were either sterilized or killed at the behest of members of our profession. These include physicians at all levels, from the resident to the senior professor, and including the support of all ancillary staff, from nurses to transport teams to the hospital janitor. In order to ensure that this period never returns, the facts must be made known to newer members of our profession.

Of the estimated 600-700 psychiatrists practicing in Germany at the time, it is not known how many refused to participate in this extreme injustice to their patients or protested privately against it. Only a very few were known to protest publicly. These include, most notably, Martin Hohl, Hans Creutzfeldt, Gottfried Ewald, and Karsten Jasperson (Strous, 2006 ). Thus, Torrey and Yolken may not be correct in stating that only "some psychiatrists were fully cooperative."

As Torrey and Yolken allude to, the enterprise of mass murder by means of gas chambers, used so morbidly successfully on Jews, originated in psychiatric hospitals under the facilitation and direction of psychiatrists. Only one physician was appointed commander of a Nazi death camp—and he was a psychiatrist (albeit with minimal training). Dr. Irmfried Eberl established Treblinka at the age of 32, and there he was responsible for the killing of approximately 280,000 individuals within a few weeks (considered to be the most "rapid and efficient" murder of Jews during the Holocaust). Eberl earned the position of Treblinka commandant following his success as head of two psychiatric hospitals, at Brandenburg and Bernburg, where he coordinated the murder of tens of thousands of mentally ill patients within the context of the euthanasia program. However, few in medicine in general and psychiatry in particular know his name and of the genocidal damage he did to the ethical practice of the profession (Strous, 2009).

Several interesting points emerge from the Torrey and Yolken paper that require comment. First, it would be wrong to suggest that eugenic ideas were limited to those psychiatrists practicing in Nazi Germany. Much of the lead for eugenics originated outside of Germany in the early nineteenth century, and most of the initial momentum for it among other countries came from Britain, the United States, and Canada. For example, the French- American Alexis Carrel, awarded the Nobel Prize for Physiology or Medicine in 1912, wrote in his 1935 book Man, The Unknown, which was later translated into German in 1936, that the criminally insane should be "humanely and economically disposed of in small euthanasia institutions supplied with proper gasses" (Carrel, 1935). In 1938, William Gordon Lennox, the prominent American neurologist who pioneered the use of electroencephalography in epilepsy, recommended euthanasia as a "privilege of death for the congenitally mindless and for the incurable sick who wish to die." He added in 1950 that mercy killing is advisable for "children with undeveloped or malformed brains" as a way of opening up space in "our hopelessly clogged institutions" (Dowbiggin, 2003). Finally, the British neurologist and chairman of Cornell's department of neurology, Robert Foster Kennedy, in a 1942 paper published in the American Journal of Psychiatry, stated that "defective children," "Nature's mistakes," over the age of five, should be euthanized (Joseph, 2005). There were even physicians with "Jewish blood" who were associated with eugenics statements, including the sterilization advocate Franz Kallman, mentioned in the paper. Kallman's father was Jewish and had to flee Germany to the United States, where he built his prominent academic career. While others advocated euthanasia, it was primarily German doctors during the Nazi era who actualized the ideas by performing euthanasia, thus permitting their philosophical/theoretical constructs to affect patient management. While several Jewish doctors were known to have supported eugenic principles, none were known to have participated actively in the euthanasia program since, among other reasons, by the year 1935, no new licenses to practice medicine were being issued to Jews in Germany, and by autumn of 1938, the license to practice medicine by Jews was revoked entirely (Kater, 1989).

A further point of interest is the initial reason why the mentally ill became a focus for the Nazi administration. While there was some degree of overcrowding in the psychiatric institutions, the primary reason given for the consideration of eugenics was not a concern for the well-being of the patients due to overcapacity of the wards; rather, it was for economic reasons—a concern that resonates today among many hospital administrators but that was taken to its extreme during the Nazi era.

The German government prepared the population for what was to come by introducing a systematic and widespread propaganda campaign with scientific and economic rationale for their scheme in order to foster public support. They instilled into the common discourse films (short and feature-length such as The Genetically Diseased [Erbank] and I Accuse [Ich klage an]) and posters indicating the financial cost of treating a mentally ill patient and what this translates into with respect to education and military expenditure. For example, they reported that funds required to maintain one "life-unworthy retard," born out of wedlock in an asylum, for 22 years "would support 40 poor families with many children." This culminated in Hitler's letter of October 1939, backdated to September 1, 1939, in which he "permitted" medical staff to kill their mentally ill patients. Thus, the psychiatrists and supporting staff were never ordered to kill the mentally ill. Because the Fuhrer allowed them, they would be granted immunity from prosecution. It should be remembered, however, that administrators of the T4 program defined strict conditions that would qualify a patient for euthanasia, such as hospitalization for five years, schizophrenia, and criminal insanity. When it came to Jewish individuals with mental illness, however, no such strict criteria were required. They were all put to death under the guise of the euthanasia program.

Sadly, many of the families of these Jewish patients came to fund much of the entire T4 program. This came about by one of the greatest deceptions of this period. Jewish patients were rounded up and removed from their institutions in group transports. They were gassed in the early days of the T4 program, and letters were sent to their families and caregivers in Germany (many of whom had already left for other countries such as the United States without being permitted visas for their mentally ill family members). These letters from the T4 administrators instructed that money for their upkeep be sent to the hospital in Poland (Chelm) where their family members were now being cared for. The truth was that they had already been killed months earlier.

Hitler stopped the first phase of the euthanasia program in 1941 following sporadic protests, including most prominently by Bishop van Galen and the Brandenburg judge Dr. Lothar Kreyssig. It should be noted, however, that little protest of this sort took place against the similar but later and larger-scale gassing of the Jews based on the same technical approach.

The authors are brave in moving beyond the genocide to address a scientific question. They are correct in commenting that an appropriate response by the psychiatry profession to the Nazi genocidal program in mentally ill individuals would be rather to consider gene-environment interactions in the pathophysiology of schizophrenia. In fact, contemporary efforts to identify clear genetic association and causation in schizophrenia indicate how wrong the assumed science of eugenics was.

Some would argue, however, that the most appropriate response would be to focus on ethical lessons that we can glean from this period. How was it that so many (senior and junior) psychiatrists, many with phenomenal international reputations, participated in and even initiated much of the genocide against mentally ill individuals? How was it that it has taken so long for psychiatry to confront this dark episode in our not-so-distant past? What can we learn from this period and how can we convey these lessons to successive generations of physicians? This was the first time in history when mental health practitioners engaged in the systematic annihilation of their patients. How can we ensure that it never happens again? During this period, psychiatrists incorrectly engaged philosophical constructs in defining their clinical practice and invested all their energies in preventing schizophrenia rather than in treating their patients (of which treatment modalities were very limited at the time; see Seeman, 2005). Most importantly, they allowed political pressures to influence their clinical management, which is always dangerous as well as ethically problematic.

The attitude of psychiatrists to their patients with schizophrenia during this period indicates in a most wicked fashion how science may be affected by external considerations. As stated by many before, the teaching of ethics and the battle against stigma cannot be undertaken in a vacuum of precedent where the profession has transgressed. Otherwise, ethics training becomes an empty intellectual exercise. The German code of medical ethics already as early as 1931 was known to be one of the strictest and most advanced in the world. German doctors in the 1930s were well aware of this code and were surely trained intensively in its intricacies. We now know how much difference it made. We cannot allow the profession to fall again.

References:

Torrey EF, Yolken RH. Psychiatric genocide: Nazi attempts to eradicate schizophrenia. Schizophr Bull. 2010;36:26-32. Abstract

Strous RD. Hitler's psychiatrists: healers and researchers turned executioners and its relevance today. Harvard Rev Psychiatry. 2006;14:30-37. Abstract

Strous RD. Dr Irmfried Eberl (1910-1948): Mass Murdering MD. Israel Med Assoc J. 2009;11:216-218. Abstract

Carrel A. Man, The Unknown. New York and London: Harper and Brothers; 1935.

Dowbiggin I. A Merciful End: The Euthanasia Movement in Modern America. New York: Oxford University Press 2003:198.

Joseph J. The 1942 'euthanasia' debate in the American Journal of Psychiatry. Hist Psychiatry. 2005;16:171-179. Abstract

Kater M. Doctors under Hitler. Chapel Hill: University of North Carolina Press; 1989.

Seeman MV. Psychiatry in the Nazi Era. Can J Psychiatry. 2005;50:218-225. Abstract

View all comments by Rael D. StrousComment by:  Sanjeev Jain
Submitted 29 July 2013
Posted 20 August 2013

These discussions are extremely valuable, as they illustrate what the "logical" solution to reduce the "burden" of mental illness was not so very long ago (Aziz, 1976).

However, enough information about the incidence and prevalence of mental illness, and fluctuations caused by the death of a large proportion, was available by the turn of the twentieth century, and thus the theoretical premise of the Nazi experiment was inherently flawed even at the beginning.

The prevalence of mental illness, and in general those who needed institutional care, had been a feature in many census operations across the world ever since formal demographics began in the early nineteenth century. Thus, estimates and variations in the prevalence of severe disabilities had been reported from the time formal census reports began in India in 1851. The severe famines in the late nineteenth century provided a natural experiment about the consequences of a significant reduction in numbers of mentally ill over a short period. These famines in southern India reduced the numbers of mentally ill often by a startling proportion, but the numbers and proportions reverted back to pre-famine levels within two decades. In the famines of 1877-1878 in southern India, it was noted that almost 70-80 percent of those classified as insane in the community died, so that there was a marked decrease in the proportion of mentally ill in the census returns of 1881 as compared to 1871. These variations were followed up, and the census of 1901 noted that the numbers had almost returned to previous levels. Similar findings were reported in the famine of the 1890s in western India, with numbers returning to normal by 1911 (Thirthalli and Jain, 2009).

It was well recognized that in times of deprivation, those with mental illness had disproportionate mortality, but the reasons for the quick return to pre-famine levels were not evident. Other trends, e.g., changes in gender ratio of children born during and immediately following famine (more female births) were observed, and it was suggested that this was an attempt by "nature" to correct the population numbers.

Even the medical consequences of starvation (again, one of the experiments conducted under Nazi research) had been evaluated, with autopsy reports commenting on the change in body structure (including brain size and structure) being reported immediately following famine (Digby, 1878; Porter, 1889).

Though the reasons for this rapid return to pre-famine levels were unclear and the underlying genetic basis rarely commented upon, this was probably due to inadequate understanding of genetics itself.

But, importantly, the empirical observation that the reduction in the number of mentally ill had no discernible effect on the prevalence of mental illness, after a short period, in subsequent generations was well established. The census documents of British India were public documents distributed and used widely.

This makes the theoretical presuppositions of the extermination of the mentally ill to reduce morbidity in future generations by using genetic theories that ignored epidemiological data an example of ideology-driven "science" being used for social transformations (a common enough theme in the twentieth century).

As the discussions point out, focusing on the financial "burden" of disease was a prelude to dehumanization of both patients and society.

This was, unfortunately, not the only time that the impact of disease was identified as a "global burden" by economic and health planners in the last century. Thus, some of the attitudes that guide disease constructs in psychiatry, current psychopathology assessment, disability evaluation, and social benefits need to be monitored. This is equally necessary when entire family and societal genetic data are now considered a prelude to creating "disease free" individuals and societies.

References:

Aziz, Philippe: Doctors of Death, Vol. 4; (Trnsl: Eduard Bizub, Philip Haentzler). Ferni Publishers, Geneva, 1976.

Digby, William: Famine Campaign in southern India 1876-1878. Longman, Queen and Co. London, 1878.

Thirthalli J, Jain S. Better outcome of schizophrenia in India: a natural selection against severe forms? Schizophr Bull. 2009 May; 35(3):655-7. Abstract

Porter, Alexander: The Diseases of the Madras Famine 1877-78, Superintendent, Government Press, Madras, 1889.

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