Euthanasia: Emerging from Hitler’s Shadow

Voluntary Euthanasia and Hitler’s Shadow

For fifty years, Adolf Hitler has cast a long and dark shadow over discussions of euthanasia. His shadow still persists, to the extent that every time euthanasia is debated, the slippery slope appears beneath our feet, and the Holocaust lies at the bottom of it.

The most oft-quoted passage about Nazism and euthanasia comes from the American psychiatrist, Major Leo Alexander, who was commissioned to report on Nazi compulsory sterilization and the so-called “euthanasia” program. According to Alexander:

Whatever proportions [Nazi] crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in the category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the nonrehabilitable sick.1

Alexander’s message was simple: to prevent Nazism from recurring, we must deny that there is such a thing as “a life not worthy to be lived.” The expression Alexander chose needs precise examination. It reads oddly in English, no doubt because it is a fairly literal translation of lebensunwertes Leben, a phrase used by the Nazis to describe those they considered not worthy of living, because they were a blot on the nobility of the Aryan Volk. Alexander points out that this expression was first applied to the “severely and chronically sick”—it would have been more accurate to say, to people who were intellectually disabled or incurably psychiatrically ill. The “euthanasia program” which the Nazis initiated in September 1939 focused on these people.

This Nazi “euthanasia” program was not “euthanasia” at all. It did not seek to provide a good death for human beings who were leading a miserable life. It was aimed at improving the quality of the Volk and eliminating the burden of caring for “social ballast” and feeding “useless mouths.” That this is so is clear from the fact that war veterans were exempted from the program, and relatives were given false information about the fate of their kin. In other words, the Nazis themselves recognized that what they were doing was contrary to the interests of the people they were doing it to, and they were not willing to publicly justify their actions. It is also not at all coincidental that this program was put into action as soon as war broke out. As the historian Michael Burleigh has pointed out:

The “euthanasia” program for adults was very much bound up with clearing the decks in order to wage war.… Mentally and physically disabled people were killed to save money and resources, or to create physical space for ethnic German repatriates and/or civilian and military casualties.… In other words, these policies reflected a non-medical agenda, even if some psychiatrists belatedly tried to give them some ex post facto rationalisation in order to defend their little beleaguered professional empires. The idea of “modernizing” psychiatric provision came to them after they had cold-bloodedly murdered tens of thousands of people, while re-creating scenes of “medieval” desolation in the asylums, with skeletal patients lying on straw in vermin-infested bunkers.²

Alexander’s view may be simply that the attitude that made the Holocaust possible was the attitude that some lives are not “worthy” of being lived because they fall below some ideal standard of racial and genetic purity. Whether this view is correct is a huge and complex historical question, but it is not my purpose to deny its validity. It may well be right. If it is, then the attitude that lies at the root of the Holocaust is, fortunately, an attitude that very few people hold today. While racism regrettably remains with us, in various ways, the defeat of Nazism was a definitive defeat for the particular variety of racism that held up one racial ideal type as embodying all the best qualities of the human species. Think, for example, of the way in which the Nazis tried to downplay the victories of Jesse Owens at the 1936 Berlin Olympics, because they were inconsistent with the idea of Aryan superiority. Can we imagine anyone today arguing that whites, or Europeans, or “Aryans,” whatever they might be, are naturally superior to all other races in athletics? Can anyone argue that the European race has a monopoly on moral virtue, or reasoning skills, or artistic talent? Our world has become much more diverse and intertwined, and we draw on talent from all parts of the world in all the fields of human endeavor. There is a wide degree of acceptance that this should be so. Part of this is also an acceptance of the benefits of racial diversity, and of a mixing between people of different ethnic backgrounds, extending, very naturally, to sexual relationships and reproduction. With the hindsight given by history, we can see that the Nazi adulation of a racially pure Aryan Volk was the last gasp of an ideal that was already flying in the face of reality. Today, it is simply absurd.

The Idea of a Life Not Worth Living

So the idea of a life not worthy to be lived, in the sense of not measuring up to some standard of value, some ideal baseline that must be met for life to be sufficiently worthy of being lived, is dead and buried. But we must distinguish this from the superficially similar, but quite distinct idea, of a life not worth living. Was Alexander intending to suggest that to avoid starting down the road that leads to the Holocaust, we must refrain from ever judging that a person’s quality of life has fallen so low that it is better for that person if he or she should die?

If this was Alexander’s view, it is surely wrong. We usually value life because it is the basis for everything else that we value, whether it be happiness, appreciation of beauty, creativity, love, or the exercise of our rational faculties. But there comes a time in the lives of many people when life can no longer support these things we value, or else is so racked by pain, discomfort, nausea, or other forms of suffering that it has more negative value than positive value. An individual who is adult and of sound mind is the best judge of when his or her life has lost what is positive about it. If in the case of a terminal or incurable severe illness it is reasonable to believe that these positive qualities can never be recovered, then it can also be reasonable to regard the days, weeks, or months that are left as being of no value, or even of negative value. Many people do so regard them. They judge their own life as not worth living, and they seek to end it. If that were not the case, Jack Kevorkian would not have people begging him for assistance, Derek Humphry’s Final Exit would not have become a best-seller, and we would not today be debating, in many different countries, the legalization of voluntary euthanasia and physician-assisted suicide.

Now even the law is starting to recognize that there is such a thing as a life not worth living. I referred earlier to the decision of the highest court in Britain, the House of Lords, in the case of Tony Bland, a young man in a persistent vegetative state. That decision, I argued, was explicitly based on the view that contïnued life is not always a benefit to the person living it. The law lords held, unanimously, that when this is clearly the case, it is not a criminal offense for a doctor to withdraw food and fluid, with the explicit intention of ending the patient’s life. Nor is this decision an isolated one. It has subsequently been applied in another British case (Frenchay Healthcare National Health Service Trust v. S [1994] 1 WLR 601), while a series of decisions by the British court of appeal concerning severely disabled infants has also accepted the principle that sometimes life is so “demonstrably awful” that it is not worth living.

In the Netherlands, the trial of Dr. Henk Prins has raised similar issues in the more direct and open fashion that we are now coming to expect from the Dutch. In March 1993 Dr. Prins, a Dutch gynecologist, gave a lethal injection to a four-day-old baby called Rianne. Rianne was born with a severe form of spina bifida and hydrocephalus. Clinical examination and a CT scan showed serious brain damage. Prins was part of a team of four doctors and a pastor that decided not to operate on the wound on her spine because of the severity of her handicaps. Rianne’s parents agreed with this decision. Prins then discussed with the parents two possible courses to take. One was to allow the child to die slowly over a few weeks or months from untreated infections, and the other was to ensure that the child died swiftly. The parents chose the second option, and when Rianne was four days old, Prins gave her a lethal injection. He then reported what he had done to the authorities. He was prosecuted but acquitted, on the grounds that he had faced an unavoidable conflict of duties, in that he had a duty to prolong life but also a duty to alleviate unbearable suffering. The prosecution appealed, but the court of appeal in Amsterdam upheld Prins’s acquittal, and the Dutch supreme court has declined to hear the case.3

The idea of “a life not worth living,” which is implicit in these decisions, takes the viewpoint of the subject of the life. For Tony Bland, the House of Lords was saying that life was not worth living because he was permanently unable to experience anything at all. For Baby J, a brain-damaged, prematurely born infant who at five months of age was unable to breathe without a ventilator, was blind, was unable to sit up, and would probably be deaf, but was capable of feeling pain, the British court of appeal thought that life was not worth living. For Baby Rianne, the Amsterdam court of appeal held that it was not in her interests for her life to be prolonged.

It is, of course, possible to say that these developments show that we are already moving down the slippery slope toward Nazism. As an example of this position, consider a recent lecture by Klaus Dörner, given at a congress to mark the fiftieth anniversary of the Nuremberg doctors’ trial, and entitled “Wenn Ärzte nur das beste wollen …” [“If doctors only want the best …”]. Dörner, a German psychiatrist, has published extensively on the Nazi crimes against the incurably psychiatrically ill and intellectually disabled. Most of Dörner’s lecture expounds his view that the origins of these Nazi programs are to be found in the Enlightenment quest for a rational and well-ordered society, which required a solution to the “social question” of what is to be done with those who do not contribute to, or fit within, the framework of such a society. (This point of view is rather different from that of Michael Burleigh, to which I referred earlier.) Dörner then turns his attention to more recent developments in bioethics, which he finds reminiscent of the ideas that led to the Nazi crimes. He attacks the churches for bowing to medical opinion in accepting that brain death is equivalent to death. He points to the draft “European Convention on Human Rights and Biomedicine,” which allows, under certain conditions, research to be carried out on human beings incapable of consent. Finally and most forcefully, he attacks the growing movement to permit the withdrawal of nutrition from people in a persistent vegetative state. Here he refers to a proposal before the German Federal Chamber of Doctors which would, by adopting Swiss guidelines on assistance in dying, allow the withdrawal of nutrition from people in a persistent vegetative state in Germany as well. “With this,” he says, “it would in Germany also be possible, for the first time since 1945, to extend assistance in dying to people who are not dying.” He then argues that this will flow on, perhaps first to patients suffering from Alzheimer’s disease, and then to the incurably psychiatrically ill and intellectually disabled. With that, he maintains, we will have returned to Nazi ideas of assistance in dying.4

Dörner shows us, I believe, the choices that we face. Advancing medical technology forces us to make decisions that we did not have to make before. At the end of the Second World War there was no need to choose between those who need organ transplants to survive and those whose brains have irreversibly ceased to function but whose bodily functions are being maintained by intensive medical care. Nor were we able to scan the brains of patients in a vegetative state in order to diagnose some as having no chance of recovering consciousness. So, if like Dörner we take Hitler’s shadow as the dominant factor whenever we make life-and-death judgments about others, we will have to let people in need of organ donations die because brain death is not really death. We will have to give up hope of finding better treatments for stroke victims, because we will be unable to try out these treatments on patients who have just suffered a stroke and are unable to give consent to taking part in a research program. We will have to continue to feed and care for people like Tony Bland for the rest of their natural life, which may be fifty or sixty years.

For me, those choices are not difficult, and I am not at all persuaded that the practices Dörner criticizes have any tendency to lead to Nazi-like attitudes. But there are some questions that are more difficult. Among them are questions concerning the treatment of infants with Down syndrome. Those who know and care for people with Down syndrome agree that it is a life with more limited opportunities than those available to most other people, but Down syndrome is not a condition that leads to a miserable life for the person with the syndrome. People with Down syndrome often have a happy and cheerful disposition. Hence it would be difficult to argue plausibly that ending the life of a person with Down syndrome was in the interests of that person, or that life with Down syndrome is a life not worth living.

Down syndrome happens to have been one of the first abnormalities to be detected in the fetus by means of prenatal diagnosis. In most developed countries prenatal diagnosis is now routinely offered to pregnant women over a certain age, usually thirty-five but in some countries less than that. The fact that older women are tested reflects the fact that older women are more likely to bear a child with Down syndrome. In other words, it is a policy that reflects the view that it is desirable to detect Down syndrome in the fetus. When Down syndrome is detected and abortion is available, the overwhelming majority of women, in most countries in excess of 90 percent, choose abortion. The fact that so many women carrying fetuses with Down syndrome choose not to give birth to the child surely tells us something about their attitude to life with Down syndrome, and their desire to avoid, if possible, being the mother of such a child. At the same time, the widespread acceptance of the practice of termination of pregnancy for precisely these reasons shows that we are willing to allow parents to make this choice. Indeed, it is interesting to note that the right to terminate a pregnancy after an abnormal fetus has been detected is much more widely supported than the general right to terminate a pregnancy because the woman does not wish to be pregnant. Thalidomide cases were a major impetus behind the liberalization of abortion laws in Britain, the United States, and many European countries.5 In a recent Swedish study entitled The Moral Roots of Prenatal Diagnosis, Christian Munthe points out that in the Swedish debate about abortion in the early 1970s, Christian opponents of a parliamentary proposal to allow unrestricted abortion up to the eighteenth week of gestation explicitly exempted from their opposition cases of abortion where the fetus has, or probably has, a disorder or disease.⁶

Abortion tends to be seen in terms of the right of the pregnant woman to control her own body, rather than a decision about whether the prospective life of the child is worth living, and decisions about fetuses are not seen in the same light as decisions about people after birth. These issues are raised less ambiguously when life-and-death decisions must be made after the child has been born. The highly controversial Baby Doe case, which occurred in Bloomington, Indiana, in April 1982, was such a case. It involved a deliberate decision to allow an infant with Down syndrome and an intestinal blockage to die—a decision that was held to be justifiable by the parents and their family doctor and was upheld by the supreme court of Indiana, although it led the Reagan administration to try to stop the refusal of lifesaving treatment to disabled infants.⁷

It is at this point that the issue becomes most difficult. On the one hand, apart from the fact that an infant can be given up for adoption, I cannot see much difference between the widely accepted termination of a pregnancy because the fetus has Down syndrome and the much more controversial decision not to prolong the life of a baby with the same condition. And I have to agree with Dr. Henk Prins when he says: “Giving the injection was not the killing decision. The killing decision was to withhold treatment.”8 On the other hand, in a case like that of Baby Doe, what we are really talking about is ending the life of an infant, not for the sake of the infant as such, but because its life will be far more limited than the life that the parents had envisaged for their child.

A Tentative Conclusion

The way in which this debate continues shows that it has largely emerged from Hitler’s shadow. So it should. I say this, not because I think we should forget about the Holocaust; on the contrary, it is important to keep reminding ourselves, and our children and grandchildren, of the nature of this terrible episode that shows, better than any other in this century, the worst of which we are capable. Yet we cannot build effective barriers against a return to the past by doing things that are plainly futile, like maintaining the lives of those who will never recover consciousness. We must strive to build a defensible ethic for these difficult questions, and so find our own way forward. The debate over euthanasia—and more generally, over medical decision-making at the end of life—is emerging from Hitler’s shadow precisely to the extent that we can now move to a more open and complex discussion of what is and what is not sound in the stands we take about ethical issues regarding the end of life. Here I agree entirely with a comment made by Prins in an interview with Arlene Klotzko. Klotzko asked Prins if allowing quality of life to play a role in life-and-death decisions raised slippery-slope problems. Prins said, “Yes, but life is inevitably a slippery slope and everyone is on a slippery slope. If we do not put things out in the open—think and talk about them—the danger of the slippery slope is greater.”⁹