NURSES AND NATIONAL SOCIALISM
A MORAL DILEMMA: ONE
HISTORICAL EXAMPLE OF A ROUTE
TO EUTHANASIA
/
Sylvia Anne Hoskins
Key words: ethics; euthanasia; history of euthanasia; national socialism
If euthanasia were to be made legal in other countries apart from the Netherlands and
Belgium, nurses would be faced with ethical dilemmas that could impact on their
professional accountability and their personal moral beliefs. As a part of history has
demonstrated, the introduction of the practice of euthanasia could also significantly
change the relationship between nurses and patients. In Germany between 1940 and 1945,
in response to a government directive, nurses participated in the practice of euthanasia
and as a result many innocent German people were killed by what were considered to be
‘mercy deaths’. It is important to try and understand the moral thinking and examine the
complex issues at this historical junction that led German nurses to participate in the
killing of thousands of innocent people. Such reflection may help to stimulate an
awareness of the moral issues that nurses in the twenty-first century could confront if
euthanasia were to be made legal in their own country. This has implications for future
nursing practice.
Clarification of terminology
The term ‘euthanasia’ as used by the National Socialists
Friedlander states:
Also called ‘mercy death’, the term was used as a euphemism to disguise their murder
of the handicapped. They killed them for racial and eugenic reasons, not to ease
the suffering of the individual. Their killing operation was a secret government program
and not an act of individual mercy. It was not applied against persons suffering
from common physical diseases like cancer but only against those considered ‘life
unworthy of life’. The Nazis’ victims did not suffer from diseases that were terminal or
from disabilities that were necessarily incurable and their deaths were certainly not
painless.1
Address for correspondence: Sylvia Anne Hoskins, The Robert Gordon University, School of
Nursing and Midwifery, Faculty of Health and Social Care, Garthdee Campus, Garthdee Road,
Aberdeen, AB10 7QG, UK. E-mail: [email protected]
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Meaning of the term ‘euthanasia’
Euthanasia is understood as an action or an omission, which of itself or by intention causes
death, in order that all suffering may in this way be eliminated. Euthanasia’s terms of
reference, therefore, are to be found in the intention of the will and in the methods used.2
Introduction
In Germany between 1940 and 1945, in response to a government directive, nurses
participated in the practice of euthanasia and as a result many innocent German
people were killed under the umbrella of what was considered to be ‘mercy deaths’.3
This period is an important but ‘dark chapter’4 in the history of the nursing profession,
where nurses were faced with difficult ethical and moral decisions. It is necessary that
today’s nurses reflect on that time in order to have an understanding of how these
nurses co-operated with a massive political and social injustice towards certain
vulnerable sections of the German population, which resulted in the ‘systematic
annihilation of masses of people’.4
The eugenic factor
Nazi Germany was not the initiator of eugenics; the beginning of eugenics was rooted
in the nineteenth century philosophies of Herbert Spencer (1820/1903) and was
eventually promoted by his contemporaries, Francis Galton (England)1 and Count
Joseph-Arthur de Gobineau (France).5,6 Spencer introduced a biological theory
through a general interpretation of Charles Darwin’s theory,7 that the evolution of
different species occurred through a natural selection process8 and by eliminating the
weakest and perpetuating the strongest members of the social organism, thus ensuring
the ‘survival of the fittest’, the species would survive.
Spencer’s philosophy justified the exclusion of some groups from society and
determined that it was only when the social organism changed and developed to
moving closer to its fullest potential that society, and therefore the individual, would
attain human happiness and fulfilment. He claimed that, in order to achieve human
happiness, the individual’s progress was dependent on a moral and intellectual
progression, qualities that were specific to only certain biologically evolved individuals. Spencer reasoned that society’s progress was judged on the pursuit and
attainment of collective knowledge and argued that this could not be achieved if the
‘lesser-evolved’ individuals failed to contribute to the progress of society. He deemed
that these lesser-evolved individuals were inferior human beings who impaired the
evolutionary progress of the social organism. Spencer also considered it as being
morally right to use these lesser-evolved humans as slave labour in order to assist the
middle and upper classes in attaining their goal of happiness and fulfilment. He
concluded that, if society was biologically weak in nature, the process of eliminating
the weakest was a natural phenomenon and was ‘morally right’ to ensure not only the
progress but also the survival of the race. This philosophy gradually came to be known
as ‘Social Darwinism’.9
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The sterilization programme
In 1933 in Germany, the principles of Social Darwinism were gradually applied to the
human population. Germany progressively adopted a eugenics programme through
the involuntary sterilization of certain sectors of its people, namely some of the ‘poor
persons and misfits’, who were seen to be increasing in numbers and overtaking
the healthier, more intelligent people in the population.10 There was little indication
that the eugenics programme, initially implemented to strengthen the purity of the
German nation and to protect it from the contamination of other races (especially
Jews), was the beginnings of a gradual change in the sociopolitical scene that would
eventually lead to a ‘secret’ euthanasia programme.5
By July 14, 1933, the Law for the Prevention of Hereditarily Diseased Progeny
(Offspring with Hereditary Diseases)11 was introduced. It fostered the compulsory
sterilization of ‘persons suffering from a variety of mental and physical disorders’ and
affected 375 000 Germans.1 Hereditary diseases were defined in German law at that
time as being: ‘congenital feeblemindedness, schizophrenia, manic-depressive psychosis, hereditary epilepsy, hereditary St Vitus’s dance (Huntington’s chorea),
hereditary blindness, hereditary deafness, severe hereditary physical deformity and
severe alcoholism on a discretionary basis’.1 Congenital feeblemindedness was also
seen to include ‘moral feeblemindedness’ and, as a result, many people who were
considered to be antisocial were also sterilized. This included ‘homeless persons,
prostitutes, beggars, vagabonds, petty criminals and long-term unemployed’.3 It is
worthy of note that, although many of these people were from a poorer social class,
mental illness and hereditary diseases were not restricted to the poor. The sterilization
programme had an impact on all levels of society.
Society and the ‘moral good’
The Law for the Prevention of Hereditarily Diseased Progeny was promoted as being
for the good of society, a philosophy that derived from the principles of Herbert
Spencer. This camouflaged the eugenic principles inherent within the law and the view
that the individuals affected were regarded as having less value to society than other
people,10 resulting in them being excluded from society and stripped of their freedom
and human rights.
The state physicians who selected the people for sterilization made decisions on
their behalf and denied them freedom of choice and the right to informed consent.
Applications for sterilization would then be forwarded to the Hereditary Health
Courts and each would be assessed on the individual’s suitability. Once the
assessments were made and the names of the people for sterilization pronounced,
the surgical procedures would take place at an appointed hospital or clinic within a
period of two weeks.3
Resources and costs
As Hitler and the National Socialists embarked on war in 1939, they sequestrated
much of the country’s physical and material resources to ensure a constant supply to
the front-line troops. However, realizing the potential cost of the war and the necessity
to secure adequate funding, they identified that feeding people who were considered
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to be biologically ‘inferior’ and had no value to society was wasting much of the
nation’s resources. These were mainly people in psychiatric hospitals or with physical
and mental disabilities, as well as elderly dependent people.
Through a carefully managed campaign, the State encouraged the German people
to consider the cost of feeding such people in relation to the cost of making
essential weaponry and feeding an army of soldiers. They convinced them that the
‘inferiors’ were not fully human10 and reinforced this claim by highlighting the
indecent habits of some psychiatric patients who were seen to eat and cover their
living quarters with their own excrement. They also impelled the German people to
consider the need to release dedicated nurses and doctors from caring for these inferior
people, charging that they should instead utilize their professional knowledge and
their energy in caring for the injured soldiers who would be returning from front-line
duties. Fuelled by the discussion on cost and resources and the plight of the injured
soldiers, the German people were subtly prepared through the media propaganda
machine for the next Nazi initiative.11
The euthanasia initiative
In the winter of 1939/1940, the Nazi regime implemented their euthanasia programme.
On September 1, 1939, Adolph Hitler issued an ‘authorization’ to some of his most
senior physicians, the head of the Chancellery of the Führer, Philipp Bouhler, and
Professor Karl Brandt, stating that anyone they considered ‘incurable’ could be
‘granted a mercy death’.1 Bouhler and Brandt then selected specific doctors to
undertake the task of killing the ‘incurables’. As the euthanasia programme was not
legally sanctioned, the ‘authorization’ was nothing more than a psychological exercise
to quell the concerns of the doctors who feared that they would be prosecuted if they
complied with killing patients.1,11
Burleigh writes: ‘It was murder even in terms of the laws of the Third Reich’.11
Mentally and physically disabled children and adults were primarily regarded as
‘incurable’ and as having ‘life unworthy of life’.12 The killing of the disabled children,
those with Down’s syndrome, hydrocephalus and other physical and mental
disabilities, came first, followed by the killing of disabled, mentally ill and elderly
adults. The victims selected for euthanasia were generally unaware that they were
going to be killed because the killings took place in hospital settings, which were
regarded as places of safety. It was a total betrayal of trust; German nurses and doctors
killed their patients.
By 1941, some 200 000 disabled Germans had been sent to the euthanasia centres12
across Germany and put to death by a variety of methods. These included starvation,
poisonous gases and lethal injections of morphine-scopolamine,13 medications that
were to be commonly used together with phenol in the euthanasia programme at the
death camp of Auschwitz.12 The operation was known as ‘Aktion T-4’, named after
the house at Tiergartenstrasse 4 in Berlin that served as the headquarters for the
operation.11 Burleigh writes that two of the T4 co-ordinators, Viktor Brack of the
Chancellery of the Führer and his chief associate, Werner Blankenberg, derived a
formula ‘on the basis of a ratio of 1000:10:5:1. Out of 1000 people 10 require psychiatric
treatment; of these 5 in residential form; of these, one patient will come under the
programme’ and would be selected for euthanasia.11 Applying this to the German
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population at that time, the figure was estimated at 65 000/75 000 people. However, a
decision had to be made on who would carry out the killings.
Voluntary and involuntary participation of nurses
Coerced by the promise of power and exemption from front-line duties, several
doctors agreed to participate in the killings. One of these was Dr Aquilin Ulrich, who
willingly participated in gassing an estimated number of 5000 people.11 Like many
doctors, he managed to justify his actions by claiming that the programme was either
supported by the churches, especially the Protestant churches, or supported by the
law. However, the doctors were not the only ones who killed patients; many
experienced nurses participated, some willingly, in the euthanasia programme. One
nurse was Pauline K, who had been a psychiatric nurse for 15 years. She chose to
participate in the euthanasia programme at several of the euthanasia centres, stating
that she did not have any moral reservations. Another nurse was Irmgard Huber, also
a psychiatric nurse who was chief nurse at Hadamar. After the war, when Huber was
tried for her part in the euthanasia programme, she refused to accept that she was
guilty. She insisted that her part was only to receive instructions from the doctors to
kill certain patients11 and to pass these instructions on to the nurses.
The killing of the children
By the end of World War II in 1944, in the paediatric units of hospitals such as
Eichberg, Kalmenhof, Eglfing-Haar, the Langehorn state hospital and the Rothenburgsort children’s hospital1 over 5000 children had been killed by the doctors and nurses
who were entrusted with their care.1 These children had been sent to the paediatric
units with the consent of their parents, who were told that they would be transferred to
receive specialist treatment. In some cases, the children were subjected to painful
experimentation before they were killed. Many were given daily doses of sedation,
which would detrimentally affect their respiratory volume, ensuring that they would
eventually succumb to fatal chest infections. Their parents would then be informed of
the children’s deaths and they would be deluded into thinking that their child had
died in a caring environment.11
Nurses’ despair, conflict and betrayal
After the war, some nurses made excuses for their collaboration with the Nazis during
this time, saying that they were co-operating in the killings for reasons beyond their
control. Many nurses expressed their feelings of guilt, despair and depression for
having co-operated and stated that it was not their intention to kill, but that they were
only part of the machinery of killing.
It was a difficult time for nurses as they strove to survive in the degenerating
conditions in hospital wards and nursing homes. Many turned to the Church for
leadership and guidance but did not necessarily receive the support they required.
Even though some hospital directors had notified their clergy, the churches did not
prevent the killings of 70 000 handicapped patients in the period 1940/1941, nor did
they stop the killings of other patients from 1942 to 1945. Although the churches in
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general responded to the concerns of the hospital directors by writing to the authorities
and questioning the killings, their actions were relatively ineffective.1
Some church leaders of both religious denominations (Catholic and Protestant)
publicly opposed the activities of the German Reich. On 3 August, 1941, the Bishop of
Münster, Westphalia, Clemens Count von Galen, openly condemned the killings in his
sermon in the Lamberti Church in Münster. From the pulpit the Bishop passionately
highlighted Biblical themes of God’s hatred of injustice and pronounced his personal
opposition to the doctrine of killing innocent invalids and elderly people.11 In order to
highlight the repugnance of the killings, he drew on the parallel between killing
unproductive elderly people and the possibility of having to kill unproductive
wounded soldiers returning from the front line.
Two other outspoken church leaders were Pastor Paul-Gerhard Braune, the
nonmedical administrator of the Hoffnungstal Institution in Berlin, and Reverend
Fritz von Bodelschwingh, director of the Bethel Institution at Bielefeld. Both were
leaders of the Confessional Church.12 Reverend Bodelschwingh formed friendly
relations with several Nazi officials such as Matthias Göring and Karl Brandt, and
used these relationships to express his objections to the euthanasia programme. As a
consequence of his outspoken objections, he saved many people from being put to
death. Pastor Braune formed a close working relationship with Reverend Bodelschwingh, mainly sourcing and exchanging important information that could be used to
support their objections. Braune wrote a document, addressed to Adolf Hitler, which
attacked the euthanasia programme with all its deceptions and highlighted in clear
and passionate language the moral questions with regard to the total ‘violation of the
sanctity of life’ and the concern for the moral welfare of the German people.12
Reorganization of the euthanasia programme
Eventually, the euthanasia programme lost its secrecy as the public became aware of its
existence in six of the well-known specialist hospitals in Germany: Hartheim,
Sonnestein, Grafeneck, Bernburg, Brandenburg and Hadamar. These were all
converted mental hospitals or nursing homes utilized for the purpose of carrying
out the euthanasia programme.12
Later in 1941 Hitler ordered the T4 operation to be temporarily halted. This was not
the end of the euthanasia programme, just a brief respite before it was decentralized
and the killings continued unofficially in several designated hospitals in areas
throughout Germany. One of these hospitals was the official psychiatric hospital,
Meseritz-Obrawalde in the Prussian territory of Pomerania.12 In 1941, Walter
Grabowski1 was appointed as administrator of Meseritz-Obrawalde and subsequently
organized the killing of over 10 000 people with the co-operation of the hospital’s
doctors and nurses. By 1942, trains and trucks carrying handicapped patients were
arriving from all parts of Germany, usually under the cover of darkness.
Nurses on trial: testimonies
Acknowledging the research of Professor Susan Benedict,14 text edited by Angelika
Ebbinghaus, Opfer und Täterinnen (Victims and criminals), was recovered for
this article.13 The following is a discussion of one chapter, ‘Dokumentation:
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Krankenschwestern vor Gericht’ (Documentation: hospital nurses before the Court),13
which recounts the stories of those nurses who were subjected to legal proceedings after the war for their participation in the killing of 10 000 patients at
Meseritz-Obrawalde in Germany. In trying to understand how nurses moved from
the role of compassionate carers to the role of killers, an examination of this chapter
exposes that the nurses were influenced by several factors. They also developed
coping strategies to support and aid them in their role. One of these was their ability
to distance themselves from the children who arrived at Meseritz-Obrawalde.
Nationalistic ideology
This was confirmed by the testimony of Dr Hilde Wernicke and the institute nurse
Helene Wieczorek, who were arrested and charged for their complicity in the killings
at Meseritz-Obrawalde. They stated that the children arrived at the hospital severely
undernourished and in a ‘state of exhaustion and most died very soon after
admission’.13 The nurses did not express either regret for the killing of the children
or for the children’s poor state of physical and mental health on arrival at the hospital.
There was little evidence of any compassion or any attempt to relieve these children
from their suffering. The children were subject to the ‘pathological ideology’15 that
dominated the hospitals and concentration camps of Nazi Germany, and nurses acted
out that ideology.
Survival: following doctors’ orders
There are various reasons given by the nurses for their complicity in killing their
patients. Many did not object to the killings, while others indicated that they wished to
survive a situation they found untenable. In the German hospital system at that time,
similar to that in other countries, nurses were trained to obey doctors’ orders. This was
evidenced in Nurse Wieczorek’s statement to the investigating judge:
Dr Mootz and Dr Wernicke checked the sick and those capable of work were specially
chosen as not to be killed. The others were killed a few at a time with morphinescopolamine. At first Senior Nurse Ratajczak and Luise E administered the injections. Then
Director Grabowski came to me and other Station Nurses, I cannot say when, and said that
we must help the Senior Nurse, it was too much for her, what with the things and all that
goes with them, we must also administer the injections. I refused at first, and he said there
was no point in that, that I was a long-serving officer, I must do my duty, especially in
times of war. He also said that it was a law that mentally incurable sick should be released
from their sorrows.13
Further on in Nurse Wieczorek’s statement, she explains her reason for co-operating
with the doctors:
I have only [done] my duty and done everything [at] the directions of my superiors.
Director Grabowski always threatened us with the Gestapo. He told us that the Gestapo
would take us by the neck, if we did not do what he wanted.13
It is difficult to discern whether Nurse Wieczork would have been punished in some
way, as there is little evidence to support this claim. However, her perception of the
possibility of punishment could have influenced her decision to collaborate with the
killing of patients.1
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Nurses’ collaboration with the killings was generally voluntary in the hospitals and
children’s wards.1 This was due to the choice given to the doctors who were free to
accept or decline the commission to participate in the euthanasia programme. This
same choice was passed on to the nurses. However, the nurses who worked in the
killing centres such as Meseritz-Obrawalde were often ‘ideologically motivated and
indifferent to life’1 and chose to participate. These specialist nurses did not view the
work of killing patients as morally wrong.
One nurse recruited for the task, Paul Reuter, agreed to participate in the killings at
Hadamar when he was informed that the patients he would kill were ‘life unworthy of
life’.11 Some nurses chose to participate as an alternative to being sent to the front line.
Another nurse, Maria Appinger, worked in a children’s killing ward until 1943 but
then chose to leave nursing, while other nurses stated that they had been selected for
their single status and issued ‘emergency service assignments’. This latter group
indicated that they were threatened with an assignment to a concentration camp as a
prisoner if they refused to participate.1
The specialized nurses
Whatever the reason for participating, the co-operation of the nurses, many of whom
had worked in state hospitals and nursing homes prior to the 1942 killings, was
essential for the execution of the euthanasia programme at Meseritz-Obrawalde. The
nurses chosen for the task generally had many years of nursing experience. There was
an intentional selection process in targeting older nurses, who were considered as
being more confidential and would be less likely to discuss the secretive business of
the hospital.13 One Senior Nurse (female) Ratakczak inferred that, out of 18 000
patients brought to Meseritz-Obrawalde, 10 000 were killed by nursing personnel.13
Friedlander stated that the post-war German judiciary supported this figure, stating
that ‘more than 10 000 handicapped patients were killed at Meseritz-Obrawalde’.1 This
figure is particularly alarming when viewed in the light of Friedlander’s research,
which reveals that, in 1939, Meseritz-Obrawalde housed only 900 patients, although
during the war the hospital stretched its bed capacity to accommodate 2000 at any one
time.1
Domination, lies and maleficence
In order to gain complicity from their patients, the nurses informed them that the
medication given to them on a daily basis was entirely for their benefit. The
medication, a sedative used in anaesthetics called veronal13 would then be increased
in dose after a designated period of two or three days and the patient would die.
However, some patients were given only one lethal dose of veronal medication with
resulting instant death. Other patients were given morphine-scopolamine by injection13 and when at a later stage the medication ran out, they were injected with air.13
Both morphine-scopolamine and air injections caused instant death. Whatever means
of killing was used, most patients were unaware of their impending death.
In their testimonies, the nurses stated that two nurses always undertook the killings,
as there was a concern that the killing of a patient would be a ‘strain on the nerves of
the person doing it’.13 By involving another nurse, there was an alliance, a co-operation
that indicted not one nurse in the act of killing, but two. However, they also
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acknowledged that, as well as psychological reasons, there was a practical reason for
the participation of two nurses. They implied that in some cases the patients were
physically ‘forced’ to receive the lethal medication prescribed for the termination of
their lives.13 They considered it acceptable to lie to the patients to ensure their
complicity. When the truth could no longer be concealed, and the patient, in guessing
the truth,13 resisted from accepting the medication, the nurses used their physical
power to force the patient to receive the lethal dose.
Justification of actions
Concordance and subordination
Some German nurses embraced the euthanasia programme and accepted the process
of killing innocent people. Pauline K, who worked at Grafeneck, Hadamar, Bernbur
and Kaufbeuren-Irsee, systematically killed people for four years. It is reported that,
when she took annual leave, the ‘mortality charts dipped’.11 Another nurse, Anna
Katschenka, assisted in the killing of handicapped children at the Am Spiegelgrund
hospital in Vienna. Her willingness to kill these vulnerable children was fuelled by an
abnormal friendship and dependence on the hospital psychiatrist Erwin Jekelius.
Jekelius had treated Anna Katschenka successfully for depression and, when an
opportunity came to work with him, she volunteered her services as a nurse to assist
him in his work. When Jekelius left the hospital for another post, Anna Katschenka’s
dependency transferred to his successor, Ernest Illing, and she continued to kill
handicapped children.1 She justified her actions by stating that Jekelius had assured
her that it was only the most severely handicapped children that had been selected for
killing.
Distorted compassion
In the midst of the killings some nurses believed that they were actually helping their
patients and demonstrated a distorted compassion while administering the lethal dose
of medication to the victim:
Other patients again prevented us [from] lifting them up and [giving] them a glass, [so that
we could] do some good to them, such as feed them. Yet others were not in a position to
drink or refused [to] drink. In this case the medium had to be given with a spoon.13
Duty, the law and conscience
One nurse considered that killing was a release for the seriously ill patients. She did
add that ‘seriously ill’ included mental as well as physical illness. Rather than question
her moral position, she exonerated herself by explaining that the doctor who stated he
would ‘cover up for her’13 had to be acting legally and therefore her actions had to be
within the law. She saw this as justification for the killings. Another nurse vindicated
herself by denouncing her own educational ability in comparison to that of the doctors.
She furthered her exculpation by emphasizing that nurses were not as well educated
as physicians and therefore it was necessary to obey the orders of the physicians since
they were more qualified to make the decisions.13
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Another nurse recognized that she would be offending the law of God by
participating in the killings and that this weighed heavily on her conscience. However,
she appeased any feelings of guilt by stating that she had trusted the physician
to ensure that he diagnosed correctly and supplemented her appeasement by asking
God for forgiveness if the physician had misdiagnosed.13 The exoneration was
completed when the nurse concluded that, even if mistakes were made, she saw
the patients’ deaths as a release for them and not as murder. One particular nurse,
Louise E, explained that she approved only of the killing of patients who were
considered to be terminally ill and who would probably have died within a three-week
period. Her explanation for killing those patients who suffered from nothing more
than bedsores or gangrene was that the hospital had been short of medication and
bandages and that they could not be treated. She considered it appropriate to kill those
patients.13
Dying and death
Injustice: resignation and desperation
Some patients were acutely aware of their impending death. In response to a question
in Court whether the patients had noticed if anything was happening to them, nurse
Martha W stated:
The patients did not notice for a long time. Later, some had noticed . . . The patient said to
me, Nurse, tomorrow it will be my turn. I did not know about it. She asked me to call a
priest, since she wanted to go to confession. The patient knew exactly what was going on.
She said to me that when she was dead I should say to her relatives when they came that
she went gently to sleep, she also asked me that I would give her rosary to them when she
was dead.13
Many patients were deprived of the opportunity to prepare for death and, instead of
dying peacefully, died in total fear. Frieda Nardoni, an Italian citizen and prisoner was
forced to work in the Hadamar state hospital. One of her jobs was to hold the patients
so that the nurses could give the lethal injections. Friedlander writes that Nardoni had
witnessed the patients begging for their lives, pleading their case to the nurses that
they were not sick and that they did not wish to die. Their pleas were all to no avail
and they were killed without mercy.1
The destruction of life: applied biology
The euthanasia programme impacted on the lives of thousands of German people.
However, the National Socialist’s deputy party leader, Rudolf Hess, justified
the euthanasia programme by declaring National Socialism to be ‘nothing but applied
biology’.12 By this he meant that the laws of life were biological laws and that it
was a natural process to eliminate the weaker members of society. Hess regarded
the individual as secondary to the social organism and judged a person’s value on
the contribution he or she made to society. Hess’s views devalued the sanctity of life
and rejected the uniqueness of the individual. It was therefore easy to justify the
destruction of the human in purely biological terms.
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Nurses’ moral accountability
Had the nursing profession taken a collaborative stand against the killings, the
euthanasia programme may have been difficult to implement. However, it is necessary
to remember that, unlike nurses of the twenty-first century who have professional
status and are accountable for their practice, the German nurses of that era had no
professional status and were completely subordinate to doctors.6
It is also important that the National Socialist’s euthanasia programme is not
misapplied to today’s debate on euthanasia and assisted suicide.1 The edict to allow
‘mercy deaths’ was nothing more than a disguise to implement a eugenic programme.
The term ‘mercy deaths’ was a mere camouflage with which to give credibility to the
programme and persuade doctors and nurses to collaborate. Friedlander points out
that the important lesson to contemplate from this time is that:
Government programmes launched by the Nazi regime to exclude and kill clearly show
that there are private spheres of human life where no state interest is sufficiently
compelling to justify intervention.1
If, as Friedlander argues, decision making on euthanasia should be left to the
individual or to a relative,1 it has to be recognized that, in order to fulfil a patient’s
request to be killed, a doctor or nurse must be prepared to kill the patient. Even if this
were legal, many nurses may perceive killing a patient as being contrary to their
personal views and beliefs and in opposition to the ethical principles of beneficence
and nonmaleficence that underpin all nursing practice. This was not so in Nazi
Germany, where history has shown that in hospitals, wards and special killing centres,
many of the nurses’ primary intentions were to assist the doctors in killing patients.
They saw their responsibility as being to the doctor, not to the patient.
In the Netherlands and Belgium, where euthanasia is not illegal, there is a possibility
that nurses could be faced with dilemmas similar to those of the German nurses.
A recent study in the Netherlands involving 410 physicians revealed that, in giving
terminal sedation, 47% of the cohort group partly intended to hasten death and 17% of
the cohort group explicitly intended to hasten death.16 Although there are clear
guidelines on the use of terminal sedation (‘defined as the administration of drugs to
keep the patient in deep sedation or coma until death, without giving artificial
nutrition or hydration’16), the study showed that some doctors chose to ignore the
guidelines and intentionally hastened death. What is not reported in the study is
whether the nurses were invited to contribute to the decision-making process or
whether they collaborated willingly with the medical decision, a decision that could
impact on their role in caring for patients.
The International Council of Nurses Code of ethics for nurses states that ‘inherent in
nursing is respect for human rights, including the right to life, to dignity and to be
treated with respect’.17 In Meseritz-Obrawalde there was no respect or dignity in the
manner of the killings, and human rights and the right to life were absent. In
examining this period of history it is evident that nurses can be influenced by social
and political factors. The link between the past, the present and the future lies within
the perceived status of nurses and their relationship with the medical profession, as
well as the accountability of professional nurses to individual patients.
In contemplating the past, nurses have the opportunity to examine the serious moral
and ethical questions that faced the German nurses and ask whether they would be
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SA Hoskins
faced with similar dilemmas if euthanasia were to be made legal in their country. They
must also question their ability to uphold the principles of beneficence, nonmaleficence, respect for autonomy, and justice in the light of such legal changes and, when
discussing euthanasia with their patients, whether it would be possible to ensure that
the principles of veracity and fidelity always underpinned their nursing actions.
Nurses must reflect on the complex decision making that confronted the German
nurses of the National Socialist era and ask themselves, if euthanasia were to be made
legal, is it possible that nurses may be faced with the same difficult ethical and moral
decisions and would this lead to a political and social injustice towards certain
vulnerable sections of their people? These considerations are important at a time when
euthanasia is not legal in the majority of countries but where the current trend is
moving towards its legalization.
Acknowledgements
I wish to thank my two PhD supervisors, Rev. George Woodall, Maryvale Institute
Birmingham, and Prof. Cecily Begley, Trinity College Dublin, for their support and
encouragement while writing this article.
Pages 218/47 of reference 13 (Ebbinghaus, 1987) were translated into English for
the author by David Parry. The author has made use of this translated passage in this
article with his permission.
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Editor’s note
See also the report of the First International Conference on Nursing and Midwifery in
the Third Reich, ‘Complicity and Compassion’, on pages 107/108.
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