Comment on E.F. Torrey and R.H. Yolken: “Psychiatric Genocide: Nazi Attempts to Eradicate Schizophrenia” (Schizophr Bull. 2010;36/1:26–32) and R.D. Strous: “Psychiatric Genocide: Reflections and Responsibilities” (Schizophr Bull. Advance Access Publication on February 4, 2010; doi:10.1093/schbul/sbq003)

Abstract

Torrey and Yolken wonder whether the killing of mentally ill persons in Nazi Germany reduced the risk for schizophrenia in the following generation. Epidemiological data from Germany do not permit reliable comparisons. Torrey and Yolken point out that horrible crime is still only little known. Strous and several contributors on the Schizophrenia Research Forum confirm that view. The history of ideas shows that social Darwinism in the educated classes and the doctrine of degeneration in psychiatry widely influenced thinking prior to World War II. Psychiatrists, lacking effective treatment for steadily growing numbers of the mentally ill, were susceptible to these ideologies. In a first step, several countries introduced compulsory sterilization as a genetic means of preventing diseases believed to be hereditary. Hitler's megalomaniac idea of creating a new human species by steering human evolution through the elimination of “unfit” genes in the mentally ill and inferior races led to the breach of human rights. His euthanasia program—the biggest crime ever perpetrated on the sick—turned out to usher in the gas chambers of the Holocaust.

The article by Torrey and Yolken¹, which has triggered an interesting discussion on the Schizophrenia Research Forum, addresses the question whether the “Nazi attempts to eradicate schizophrenia” by killing several hundreds of thousands of mentally ill persons reduced the risk of schizophrenia in the following generation in Germany and highlights the fact that, unlike the Holocaust, this gruesome crime is still hardly known today.

Concerning the first topic, Torrey and Yolken estimate that of those several hundreds of thousands of people killed, 220 000–259 000 suffered from schizophrenia, which amounted to 73% of all those living with the disorder in Germany at that time.

The authors base their estimate on the epidemiological studies (surveys of mentally ill persons) conducted by C. Brugger in 1931, 1933, and 1937 in Germany^2–4, which yielded a point prevalence rate of 2%. To draw a comparison with the postwar era, they refer to our Mannheim Study of 1965⁵, which arrived at an annual incidence rate for schizophrenia of 53.6 per 100 000, about twice the rates reported by the majority of comparable studies in that period. Besides the fact that point prevalence and annual incidence rates are not really comparable, this comparison also has other weaknesses. The studies used different diagnostic spectra. Brugger applied diagnostic definitions of the German Psychiatric Association, based on Kraepelin's classification system, and his rate of 2% covered all types of psychoses. The Mannheim Study used a diagnostic definition of schizophrenia only and a tightly woven net of case finding. In addition, Torrey and Yolken probably overestimate the number of victims with schizophrenia (see below).

At present, it can neither be proven nor disproven by reliable data whether the compulsory sterilization of persons suffering from schizophrenia, supposedly a congenital disease, and the mass killing of people with schizophrenia in the Nazi era considerably reduced the risk for schizophrenia in the next generation.

It is equally difficult to prove the point raised by MacCabe⁶, namely, that in Sweden the reduced fertility of women with schizophrenia in the period of 1915–1929 might have been accounted for by reduced fertility rates for men with that disorder as a consequence of the policy of compulsory sterilization adopted earlier in Sweden. Here, too, epidemiological data collected by comparable methods and fertility data for the generations preceding and following the period of sterilization are missing. Nor is there a reliable answer yet to Gunvant Thaker's⁷ inquiry why the incidence rates remained high in the generation following the mass killing. However, the fact that recent methodologically sound epidemiological studies conducted in Germany (eg, the ABC [Age, Beginning, Course] Schizophrenia Study⁸: 0.13 per 1000) and studies conducted with similar methods in other countries (eg, the World Health Organization 10-Country Study⁹: 0.09 per 1000) have yielded annual incidence rates for schizophrenia of more or less similar magnitude indicates that the attempts of the Nazis to reduce the reproduction rate of people with schizophrenia on a large scale between 1939 and 1945 did not reduce the risk of schizophrenia at least in the second generation.

The second issue raised by Torrey and Yolken, namely, that this awful crime perpetrated on the mentally ill is not well known, is more or less confirmed by 4 contributions on the Schizophrenia Research Forum: Thaker,⁷ MacCabe,⁶ Susser and Smith,¹⁰ and Nasierowski¹¹. Susser and Smith write that Hitler's systematic killing of 6 million Jews “was in fact developed and piloted” by the murder of mental patients. Nasierowski¹¹, too, describes how the killing of the mentally ill preceded the Holocaust and the gas chambers in the concentration camps, although concentration camps were set up (the first in Dachau in 1933) long before the killing of the mentally ill was initiated (in 1940). In late March 1941, the gassing of inmates from concentration camps started in the gas chambers of the psychiatric killing institutions no longer operating at full capacity due to a slowdown of the euthanasia program, apparently with the support of a “euthanasia-friendly” psychiatrist, Werner Heyde. It is estimated that some 10 000 concentration camp inmates were killed by gassing in the course of the euthanasia program.

R.D. Strous’ detailed discussion of the topic that Torrey and Yolken's article is devoted to underscores the fact that we are here dealing with the greatest crime ever perpetrated on the sick: the murder of 200 000–260 000—the exact number is unknown—mentally ill persons in Germany in the Nazi era. The fact that German historians, psychiatrists, and politicians have addressed this dark chapter has produced a vast body of literature. But most of this material is available in German only.^12–15 An exception was the “Exhibition—in memoriam—commemorating the victims of the Nazi euthanasia program,” which was organized by the German Psychiatric Association at the XI World Congress of Psychiatry in Hamburg in 1999. It illuminated the background, execution, and consequences of that crime.

In his informative article, R.D. Strous describes some developments that led to this unprecedented crime. The present contribution takes a look a few steps further back.

The neo-Darwinian outlook on human life, which strongly influenced the educated classes in the outgoing 19th and the early 20th century, originated in Robert Malthus’ (1766–1843) early theory of the evolution of man driven by the struggle for shrinking food supplies, Gregor Mendel’s (1822–1884) discovery of the hereditary laws, and Charles Darwin’s (1809–1882) evolutionary theory. These theories and discoveries dramatically advanced knowledge on the human species and led beyond the previously embraced belief of man's creation by God.

There are 2 psychological factors worth mentioning that influenced the way social Darwinism was adopted and incorporated in psychiatry. In the wake of the Industrial Revolution, countries with existing systems of psychiatric care experienced a massive increase in admissions to asylums for the insane. For example, in Germany, the number of asylums rose from 93 to 233 and that of their inmates from 47 228 to 239 583 in the period from 1880 to 1913.¹⁶ In the light of the theory of evolution and B.A. Morel’s (1809–1873) theory of degeneration, this was seen as a sign of a massive increase in mental disorder resulting from a “genetic decadence” of the population. The actual reason for this increase was, however, that mentally ill and disabled persons ceased to be cared for mainly by the multigenerational rural families because they decreased rapidly in number and the small, 1-generation families of industrial town-dwellers were unable to assume this task.

The theory of evolution together with Friedrich Nietzsche’s (1844–1900) morality of strength and power helped to spread the conviction that modern medicine and the welfare of the disabled had stalled human evolution ultimately preventing the rise of a new and fitter human race. As Strous points out, the eugenics movement—first called so by Francis Galton (1822–1911), Charles Darwin’s half cousin—set out to prevent the alleged accumulation of unfit genotypes. Attempts to breed healthier, stronger, and wiser human beings by promoting the spread of “good” genes were propagated as positive eugenics. In this way, Galton believed, it would be possible to improve the quality of the British population and increase Great Britain’s competitiveness. He proposed that the proportion of highly talented, intelligent individuals and of “the fittest” race in the population be increased by adopting appropriate policies. It was in this tradition that Hitler pursued his objective of racial hygiene and created the “Lebensborn” (Fountain of Life) organization, where young German women of Aryan looks (blue eyed, blond haired) could be visited by Aryan members of the SS (elite security unit and concentration-camp guards) and the children thereby conceived be given birth to.

Negative eugenics aimed at preventing the transmission of “unworthy” genes. The most frequently adopted policy was the sterilization of women considered undesirable to produce offspring. Mentally ill and disabled persons were soon subjected to compulsory sterilization. This policy was first adopted on a larger scale in a compulsory sterilization of congenitally deaf people following Graham Bell’s (1847–1922)—from 1912 to 1918 chairman of the board of scientific advisers to the Eugenics Record Office associated with Cold Spring Harbor Laboratory in New York—hereditary theory. In the early 20th century, eugenics inspired laws and initiatives pursuing the compulsory sterilization of mentally ill and disabled individuals, and/or persons with hereditary diseases were enacted in 33 federal states of the United States—the legislation was upheld by the US Supreme Court in 1927—the Scandinavian countries, and Switzerland. In Germany, “negative euthanasia” was introduced in 1933 by Hitler's “Law for the Prevention of Offspring with Hereditary Diseases,” mainly based on the eugenic theories of Ernst Rüdin (1874–1954), director of the Genealogical-Demographic Department at the German Institute for Psychiatric Research in Munich—the forerunner of the Max Planck Institute for Psychiatry.

There are no exact data available on the number of people forcibly sterilized under the Law for the Prevention of Offspring with Hereditary Diseases—besides mental retardation and epilepsy also schizophrenia and bipolar disorders and severe “incurable” alcoholism were counted as such. Estimates range from 300 000 to 350 000. The exact share of persons with schizophrenia in these figures is not yet known, but it probably ranges in the magnitude of 20%–30%. As Hitler expanded eugenics to a policy of “racial hygiene,” compulsory sterilization was also forced on members of ethnic groups who, according to Hitler, were considered “unworthy,” such as Sinti and Roma and some purportedly congenital criminals.¹⁷ The economic motives for the murder of the mentally ill mentioned by Strous played an important role in the political propaganda used for manipulating general opinion. The leading idea behind Hitler’s eugenic policies, however, was social Darwinistic in nature.¹⁸

Psychiatrists were particularly exposed to the theory of social Darwinism and its translation into eugenic policies. Responsible for large numbers of mentally ill patients, chronic cases in particular, who were kept under desperate conditions in neglected mental asylums for many years, psychiatrists were unable to offer these wretched human beings any effective treatment. It must have been extremely frustrating to be faced, throughout one's professional life, with the suffering of the patients entrusted to one's care without having at one's disposal any effective means to cure or at least to relieve their suffering. Emil Kraepelin described that situation in his memoirs as follows:

The first impressions of my new job were discouraging. The confusing thong of demented, sometimes unapproachable, sometimes obtrusive patients with their ridiculous or repellent, pitiable or dangerous oddities, the futility of the medical treatment … the complete helplessness against these types of insanity, for which there was no scientific explanation, made me feel the entire rigour of my chosen profession. As they had done in Würzburg, the chaotic and repulsive pictures of the day's work also followed me into the nights. … I gradually got used to the situation and was helped by the pleasant contact to colleagues with the same doubts. I … gained satisfaction from the perfect furnishings and equipment of the asylum, which seemed to be the best at the time: the beautiful parquet and terrazzo floors, the huge central heating. We were also proud of the scientific importance of our clinic with its anatomical laboratories and animal stalls. This field of activity compensated for the fruitlessness and unpleasantness of our daily work.¹⁹

In this context, the idea of preventing incurable mental illness on a large scale by steering the evolutionary process by eugenic measures must have seemed to be very attractive, if not fascinating, to many disillusioned psychiatrists. This background helps us to understand why even a Swiss psychiatrist of such high moral values as Eugen Bleuler (1857–1939), Zurich, wrote in his 1936 “Article on biological ethics”:

In the case of incurably mentally ill patients suffering from severe hallucinations and melancholic depression and incapacitated in their functioning I would confer upon a council of doctors the right and in very severe cases the duty to shorten their suffering—often by several years.

It offered a justification and a ready-made program for killing incurably ill people. And there were many more who thought likewise. A good example of the extent to which the eugenic ideas had already permeated the academic world is A. Hoche's (professor of psychiatry in Freiburg) and K. Binding's (professor of criminal law in Freiburg) book “Freigabe der Vernichtung lebensunwerten Lebens”²⁰ (Allowing the destruction of life unworthy of life) published in 1920.

The appalling thing is that the expert opinion had also entered the minds of ordinary people. In 1922, Dr Ewald Meltzer (1869–1940), head of the Saxon asylum Katharinenhof with some 200 children and adolescents mainly suffering from mental retardation, asked the parents whether they would consent to a painless termination of their child's life. Seventy-three percent responded “yes.” But none of those driven by these same motives had yet put them to practice. ²¹

It was against the backdrop of this already quite widespread ideology of “negative eugenics” among psychiatrists and parts of the general population that Hitler stepped in with his human rights infringing plans.²²

This history of ideas helps us to understand Hitler’s first step, the compulsory sterilization of people with allegedly hereditary illness and of members of “unworthy” racial groups to prevent them from procreating, his second step, the murder of large numbers of mentally ill and disabled people, and, finally, the unfathomable fact that numerous psychiatrists participated in these crimes.

It was by a dictatorial Führer edict, backdated to September 1, 1939 to coincide the beginning of the war, and not by a law adopted in Parliament—so as not to cause any commotion abroad—that Hitler initiated his murder program in October 1939:

Reichsleiter Bouhler and Dr. Brandt are charged with the responsibility for expanding the authority of physicians, to be designated by name, to the end that patients considered incurable according to the best available human judgment of their state of health can be granted a mercy death.

From late 1933 on, doctors at mental hospitals and homes for the mentally disabled had to fill in a questionnaire for each chronically mentally ill or disabled patient no longer fully fit for work. The questionnaires were then submitted to psychiatrists chosen as experts. The list included patients with schizophrenia, epilepsy, mental retardation, final states of neurological diseases, mentally ill criminals, and all psychiatric patients interned for more than 5 years. The experts drew a red cross on the questionnaires of those patients they selected for being killed. Several professors of psychiatry served as such experts, for example, Prof. Werner Heyde (Würzburg), Prof. Max de Crinis (Berlin), Prof. Karl Schneider (Heidelberg), and Prof. Paul Nitsche (Head of the Public Mental Hospital Pirna-Sonnenstein, successor to Heyde as the “Medical Director of the Euthanasia Program”). Schneider and De Crinis committed suicide after the war. Paul Nitsche, after having been sentenced to death in Dresden, was executed in 1948. Heyde successfully hid his identity for a long time and finally hanged himself in prison in 1964.

In 1947, the United States made an attempt at bringing these crimes to justice at the Nuremberg Nazi doctors’ trial.^23,24 After the birth of the German state, further trials took place at German courts. The death sentences issued in single cases at that time were later converted into prison sentences of mostly several years.²⁵

Of course, there were numerous psychiatrists—Strous lists some of them by name—who dissociated themselves from these crimes. Besides archbishop von Galen, some other bishops and clergymen preached from the pulpit against the murder program. It was due to the widespread public protest that Hitler officially called off the euthanasia program in August 1941. But behind the scenes, the killing of mentally disabled children by lethal injections, the mass shootings at Polish mental hospitals, and the hunger programs at German mental hospitals continued unabated with severe consequences.^26,27 Nasierowski¹¹, too, describes in detail how mentally ill patients were murdered in large numbers at Polish mental hospitals and how this horrible crime was organized and put to practice.

The motives behind Hitler’s translation of the social Darwinistic and eugenic ideas into criminal activity were not only racial and economic but also ideological in nature. In his megalomania, he not only strived for conquering Europe but also wanted to steer the evolution of man. In his speech at the National Socialist party convention in Nuremberg in 1938, he declared:

The greatest revolution ever experienced in Germany is the programme of population and racial hygiene that has now been commenced for the first time in a systematic way. For it will create a new type of man.

After the murder of mentally ill persons, the Holocaust, the largest war of annihilation ever waged and his own doom Hitler’s endeavors to create a new human species ultimately resulted in the death of some 55 million people.²⁸

Strous calls on us psychiatrists to prevent such a crime from ever happening again. It is the moral legacy of our past. Understanding the history of ideas leading up to it perhaps helps us to achieve this goal.