In the contemporary West we judge cultures as "advanced" or "civilized" in part by the manner in which they care for their weakest and most vulnerable members. Cultures that disrespect their dying, elderly, and disabled, or that do not provide for them in a caring and compassionate manner, generally are seen as backward, if not downright oppressive. Traditionally, we have measuired our own progress toward a genuinely humane and enlightened society against these standards.

That may be changing.
    -Wesley Smith, Forced Exit

On that day. a Sunday, my friend Frances went to a hotel, checked in, got into bed, took some sleeping pills, pulled a plastic bag over her head, and died.

The equality-of-human-life ethic requires that each of us be considered of equal inherent moral worth, and it makes preservation and protection of human life society's first priority. Accepting euthanasia would replace the equality-of-human-life ethic with a utilitarian and nihilistic "death culture" that views the intentional ending of certain human lives as an appropriate and necessary answer to life's most difficult challenges.

Science under dictatorship becomes subordinated to the guiding philosophy of the dictatorship. Irrespective of other ideologic trappings, the guiding philosophic principle of recent dictatorships, including that of the Nazis, has been Hegelian in that what has been considered "rational utility" and corresponding doctrine and planning has replaced moral, ethical and religious values. Nazi propaganda was highly effective in perverting public opinion and public conscience, in a remarkably short time. In the medical profession this expressed itself in a rapid decline in standards of professional ethics. Medical science in Nazi Germany collaborated with this Hegelian trend particularly in the following enterprises: the mass extermination of the chronically sick in the interest of saving "useless" expenses to the community as a whole; the mass extermination of those considered socially disturbing or racially and ideologically unwanted; the individual, inconspicuous extermination of those considered disloyal within the ruling group; and the ruthless use of "human experimental material" for medico-military research.

This paper discusses the origins of these activities, as well as their consequences upon the body social, and the motivation of those participating in them.

Preparatory Propaganda

Even before the Nazis took open charge in Germany, a propaganda barrage was directed against the traditional compassionate nineteenth-century attitudes toward the chronically ill, and for the adoption of a utilitarian, Hegelian point of view. Sterilization and euthanasia of persons with chronic mental illnesses was discussed at a meeting of Bavarian psychiatrists in 1931. By 1936 extermination of the physically or socially unfit was so openly accepted that its practice was mentioned incidentally in an article published in an official German medical journal.

Lay opinion was not neglected in this campaign. Adults were propagandized by motion pictures, one of which, entitled "I Accuse," deals entirely with euthanasia. This film depicts the life history of a woman suffering from multiple sclerosis; in it her husband, a doctor, finally kills her to the accompaniment of soft piano music rendered by a sympathetic colleague in an adjoining room. Acceptance of this ideology was implanted even in the children. A widely used high-school mathematics text, "Mathematics in the Service of National Political Education," includes problems stated in distorted terms of the cost of caring for and rehabilitating the chronically sick and crippled, the criminal and the insane."

Euthanasia

The first direct order for euthanasia was issued by Hitler on September 1, 1939, and an organization was set up to execute the program. Dr. Karl Brandt headed the medical section, and Phillip Bouhler the administrative section. All state institutions were required to report on patients who had been ill five years or more and who were unable to work, by filling out questionnaires giving name, race, marital status, nationality, next of kin, whether regularly visited and by whom, who bore financial responsibility and so forth. The decision regarding which patients should be killed was made entirely on the basis of this brief information by expert consultants, most of whom were professors of psychiatry in the key universities. These consultants never saw the patients themselves. The thoroughness of their scrutiny can be appraised by the work of on expert, who between November 14 and December 1, 1940, evaluated 2109 questionnaires.

These questionnaires were collected by a "Realm's Work Committee of Institutions for Cure and Care." A parallel organization devoted exclusively to the killing of children was known by the similarly euphemistic name of "Realm's Committee for Scientific Approach to Severe Illness Due to Heredity and Constitution." The "Charitable Transport Company for the Sick" transported patients to the killing centers, and the "Charitable Foundation for Institutional Care" was in charge of collecting the cost of the killings from the relatives, without, however, informing them what the charges were for; in the death certificates the cause of death was falsified.

What these activities meant to the population at large was well expressed by a few hardy souls who dared to protest. A member of the court of appeals at Frankfurt-am-Main wrote in December, 1939:

There is constant discussion of the question of the destruction of socially unfit life--in the places where there are mental institutions, in neighboring towns, sometimes over a large area, throughout the Rhineland, for example. The people have come to recognize the vehicles in which the patients are taken from their original institution to the intermediate institution and from there to the liquidation institution. I am told that when they see these buses even the children call out: "They're taking some more people to be gassed." From Limburg it is reported that every day from one to three buses which shades drawn pass through on the way from Weilmunster to Hadmar, delivering inmates to the liquidation institution there. According to the stories the arrivals are immediately stripped to the skin, dressed in paper shirts, and forthwith taken to a gas chamber, where they are liquidated with hydro-cyanic acid gas and an added anesthetic. The bodies are reported to be moved to a combustion chamber by means of a conveyor belt, six bodies to a furnace. The resulting ashes are then distributed into six urns which are shipped to the families. The heavy smoke from the crematory building is said to be visible over Hadamar every day. There is talk, furthermore, that in some cases heads and other portions of the body are removed for anatomical examination. The people working at this liquidation job in the institutions are said to be assigned from other areas and are shunned completely by the populace. This personnel is described as frequenting the bars at night and drinking heavily. Quite apart from these overt incidents that exercise the imagination of the people, the are disquieted by the question of whether old folk who have worked hard all their lives and may merely have come into their dotage are also being liquidated. There is talk that the homes for the aged are to be cleaned out too. The people are said to be waiting for legislative regulation providing some orderly method that will insure especially that the aged feeble-minded are not included in the program.

Here one sees what "euthanasia" means in actual practice. According to the records, 275,000 people were put to death in these killing centers. Ghastly as this seems, it should be realized that this program was merely the entering wedge for exterminations for 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 the much larger centers on the East, where the plan was to kill all Jews and Poles and to cut down the Russian population by 30,000,000. [...]

It is rather significant that the German people were considered by their Nazi leaders more ready to accept the exterminations of the sick than those for political reasons. It was for that reason that the first exterminations of the latter group were carried out under the guise of sickness. So-called "psychiatric experts" were dispatched to survey the inmates of camps with the specific order to pick out members of racial minorities and political offenders from occupied territories and to dispatch them to killing centers with specially made diagnoses such as that of "inveterate German hater" applied to a number of prisoners who had been active in the Czech underground.

Certain classes of patients with mental diseases who were capable of performing labor, particularly members of the armed forces suffering from psychopathy or neurosis, were sent to concentration camps to be worked to death, or to be reassigned to punishment battalions and to be exterminated in the process of removal of mine fields.

A large number of those marked for death for political or racial reasons were made available for "medical" experiments involving the use of involuntary human subjects. From 1942 on, such experiments carried out in concentration camps were openly presented at medical meetings. This program included "terminal human experiments," a term introduced by Dr. Rascher to denote an experiment so designed that its successful conclusion depended upon the test person's being put to death. [...]

Under all forms of dictatorship the dictating bodies or individuals claim that all that is done is being done for the best of the people as a whole, and that for that reason they look at health merely in terms of utility, efficiency and productivity. It is natural in such a setting that eventually Hegel's principle that "what is useful is good" wins out completely. The killing center is the reductio ad absurdum of all health planning based only on rational principles and economy and not on humane compassion and divine law. To be sure, American physicians are still far from the point of thinking of killing centers, but they have arrived at a danger point in thinking, at which likelihood of full rehabilitation is considered a factor that should determine the amount of time, effort and cost to be devoted to a particular type of patient on the part of the social body upon which this decision rests. At this point Americans should remember that the enormity of a euthanasia movement is present in their own midst. To the psychiatrist it is obvious that this represents the eruption of unconscious aggression on the part of certain administrators alluded to above, as well as on the part of relatives who have been understandably frustrated by the tragedy of illness in its close interaction upon their own lives. The hostility of a father erupting against his feebleminded son is understandable and should be considered from the psychiatric point of view, but it certainly should not influence social thinking. The development of effective analgesics and pain-relieving operations has taken even the last rationalization away from the supporters of euthanasia.

The case, therefore, that I should like to make is that American medicine must realize where it stands in its fundamental premises. There can be no doubt that in a subtle way the Hegelian premise of "what is useful is right" has infected society, including the medical portion. Physicians must return to the older premises, which were the emotional foundation and driving force of an amazingly successful quest to increase powers of healing if they are not held down to earth by the pernicious attitudes of an overdone practical realism.

What occurred in Germany may have been the inexorable historic progression that the Greek historians have described as the law of the fall of civilizations and that Toynbee has convincingly confirmed--namely, that there is a logical sequence from Koros to Hybris to Ate, which means from surfeit to disdainful arrogance to disaster, the surfeit being increased scientific and practical accomplishments, which, however, brought about an inclination to throw away the old motivations and values by disdainful arrogant pride in practical efficiency. Moral and physical disaster is the inevitable consequence.

[S]uicide per se is not the issue. Jumping off a bridge is an individual act. Being killed by a doctor or committing PAS [Physician Assisted Suicide] is a joint endeavor between two or more people, a conspiracy if you will, to commit a form of homicide. The point is not the propriety of suicide itself, but whether we should have the legal right to have ourselves killed by another person. Looked at from another angle, the question is whether the broad prohibition against killing by private persons, self-defense and defense of others being the exceptions, should be discarded to permit third parties to collaborate and participate in the deaths of sick, disabled, or incompetent people -- and this on the basis of beliefs that certain lives are not worth living.

This question is of monumental importance. If we remain a society of "ordered liberty" envisioned by the Founders, a nation created to promote the greatest common good while allowing for as much individual liberty as is consistent with this broader purpose, we will reject euthanasia and assisted suicide as a danger to vulnerable persons, as a threat to basic institutions, and as a dangerous frayer of the social fabric. If, on the other hand, our nation above all else exists primarily to maximize the autonomy of the individual, regardless of its overall impact, indeed, if the state's purpose is merely to prevent one autonomous individual's fist from hitting another autonomous individual's nose, then legalized euthanasia makes sense.