A Life in Medicine Read online

  In the late 1938 or early 1939, Hitler ordered Karl Brandt, his personal physician and close confidant, to go to the clinic at the University of Leipzig, where the child was hospitalized, in order to determine whether the information submitted was accurate and to consult with physicians there: “If the facts given by the father were correct, I was to inform the physicians in [Hitler’s] name that they could carry out euthanasia.” Brandt was also empowered to tell those physicians that any legal proceedings against them would be quashed by order of Hitler.4

  Brandt reported that the doctors were of the opinion “that there was no justification for keeping [such a child] alive”; and he added (in his testimony at the Nuremberg Medical Trial) that “it was pointed out [presumably by the doctors he spoke to] that in maternity wards in some circumstances it is quite natural for the doctors themselves to perform euthanasia in such a case without anything further being said about it.” The doctor with whom he mainly consulted was Professor Werner Catel, head of the Leipzig pediatrics clinic and a man who was soon to assume a leading role in the project. All was to be understood as a responsible medical process, so that—as Brandt claimed was Hitler’s concern—“the parents should not have the impression that they themselves were responsible for the death of this child.”5 On returning to Berlin, Brandt was authorized by Hitler, who did not want to be publicly identified with the project, to proceed in the same way in similar cases: that is, to formalize a program with the help of the high-ranking Reich leader Philip Bouhler, chief of Hitler’s Chancellery. This “test case” was pivotal for the two killing programs—of children and of adults....

  It seemed easier—perhaps more “natural” and at least less “unnatural”—to begin with the very young: first, newborns; then, children up to three and four; then older ones. Similarly, the authorization—at first, oral and secret and to be “kept in a very narrow scope, and cover only the most serious cases”—was later to become loose, extensive, and increasingly known. A small group of doctors and Chancellery officials held discussions in which they laid out some of the ground rules for the project. Then a group of medical consultants known to have a “positive” attitude to the project was assembled, including administrators, pediatricians, and psychiatrists.6. . .

  Falsification, then was in the service of medical claim. Everyone proceeded as if these children were to receive the blessings of medical science, were to be healed rather than killed. The falsification was clearly intended to deceive—the children’s families, the children themselves when old enough, and the general public. But it also served psychological needs of the killers in literally expressing the Nazi reversal of healing and killing. For example, a doctor could tell a parent that “it might be necessary to perform a surgical operation that could possibly have an unfavorable result,” or explain that “the ordinary therapy employed until now could no longer help their child so that extraordinary therapeutic measures have to be taken.” Dr. Heinze, who used such phrases with parents, explained in court testimony that there had been truth to what he said: “A very excitable child . . . completely idiotic . . . could not be kept quiet with the normal dose of sedatives,” so that “an overdose . . . had to be used in order to . . . avoid endangering itself through its own restlessness.” At the same time, “we physicians know that such an overdose of a sedative, for children usually luminal . . . could cause pneumonia, ... and that this is virtually incurable.”7 It is quite possible that Dr. Heinze not only was consciously lying, but was enabled by the medicalization of the murders partly to deceive himself: to come to believe, at least at moments, that the children were being given some form of therapy, and that their deaths were due to their own abnormality.

  In the same spirit, the policy was to gain “consent” from the parents for the transfer. Those who showed reluctance to give that consent received letters emphasizing the seriousness and permanence of their child’s disability, telling them that they “should be grateful” that there were available for children thus affected by fate facilities where “the best and most efficacious treatment is available,” and then declaring that “neither a delay nor a cancellation of the transfer is possible.” Should the parents continue to oppose it, “further steps, such as withdrawal of your guardianship, will have to be taken.”8 This threat to take away legal guardianship usually sufficed, but if it did not there could be the further threat of calling a parent up for special labor duty. The coercion here was in the service not only of the killing policy itself but also of maintaining its medical structure.

  That structure served to diffuse individual responsibility. In the entire sequence—from the reporting of cases by midwives or doctors, to the supervision of such reporting by institutional heads, to expert opinions rendered by central consultants, to coordination of the marked forms by Health Ministry officials, to the appearance of the child at the Reich Committee institution for killing—there was at no point a sense of personal responsibility for, or even involvement in, the murder of another human being. Each participant could feel like no more than a small cog in a vast, officially sanctioned, medical machine.

  Before being killed, children were generally kept for a few weeks in the institution in order to convey the impression that they were being given some form of medical therapy. The killing was usually arranged by the director of the institution or by the another doctor working under him, frequently by innuendo rather than specific order. It was generally done by means of luminal tables dissolved in liquid, such as tea, given to the child to drink. This sedative was given repeatedly—often in the morning and at night—over two or three days, until the child lapsed into continuous sleep. The luminal dose could be increased until the child went into coma and died. For children who had difficulty drinking, luminal was sometimes injected. If the luminal did not kill the child quickly enough—as happened with excitable children who developed considerable tolerance for the drug because of having been given so much of it—a fatal morphine-scopolamine injection was given. The cause of death was listed as a more or less ordinary disease such as pneumonia, which could even have the kind of kernel of truth we have noted.9

  The institutional doctor, then, was at the killing edge of the medical structure, whatever the regime’s assurance that the state took full responsibility. Yet he developed—in fact, cultivated—the sense that, as an agent of the state, he was powerless: from his vantage point, as one such doctor reported, “these children were already marked for killing on their transfer reports,” so that “I did not even bother to examine them.” Indeed, whatever examination he performed was no more than a formality, since he did not have the authority to question the definitive judgment of the three-man panel of experts.

  Yet later, program administrators countered with the insistence that “the if, when, and how of carrying out a mercy death is up to the judgment of the doctor in charge, who voluntarily and out of conviction agrees to euthanasia and its implementation. It is a ‘can’ and not a ‘must’ order.”10 They even claimed that, in some situations, there were no expert opinions at all and the decision about whether to kill a child was left to the discretion of the institutional doctor. To be sure, this kind of later legal testimony was put forward by the program’s organizers in order to deny or minimize their own responsibility. But that evasion of responsibility from the top can be said to have been built into the project: the institutional doctor’s role as triggerman was a way of investing the actual killing with a “medical responsibility” that was at least partially his. And the contradictory legal status of the “euthanasia” program—a de facto law that was not a law—added to the confusion and contradiction surrounding the question of anyone’s responsibility.

  Inevitably, there was great slippage in whatever discipline originally prevailed—broadening the killing net and fulfilling the regime’s ultimate purposes. As the age limit of children included moved upward, it came to include a large of older children and adolescents and even at times overlapped with the adult killing projec
t. Conditions considered a basis for killing also expanded and came to include mongolism (not listed at the beginning) as well as various borderline or limited impairments in children of different ages, culminating in the killing of those designated as juvenile delinquents. Jewish children could be placed in the net primarily because they were Jewish; and at one of the institutions, a special department was set up for “minor Jewish-Aryan half-breeds (Mischlinge).

  After 1941, the year Hitler officially ordered the general “euthanasia” project terminated, the killing of children continued, indeed probably increased, and was conducted still more haphazardly. It is estimated that five thousand children were killed—but the total was probably much higher if we include the “wild euthanasia” period.11

  The resistance to children’s euthanasia came mostly from families of children killed or threatened with death, later from Catholic and Protestant clergy, and to a lesser extent from within certain medical circles. Certain forms of resistance from within the children’s project are worth mentioning here, if only because they were so limited. There were many attempts—it is hard to say how many—on the part of doctors either to avoid diagnoses on children that they knew would lead directly to death, or to arrange to release children from institutions before they were swallowed up by the killing machinery. A Dr. Möckel at Wiesloch is reported to have refused an appointment as chief of a children’s section because he claimed to be “too weak” for the implementation of the Reich Committee’s program. And there were other reports of high-ranking doctors in certain areas responsible for appointments to these institutions holding back on those appointments because of the claim that candidates were too young and inexperienced. One doctor who had been extremely active as an expert consultant in the adult program refused to kill nine of the twelve children sent to the children’s unit he became chief of because, as he put it, “a therapeutic and nursing institution is not the right place for such measures.” And there is a report of a nurse who refused to take part in killings of children because she felt herself becoming “hysterical” from the “mental strain.”12 In general, there was probably considerably less medical resistance to the killing of children than to the killing of adults.

  NOTES

  1 Testimony of Professor Böhm, 12 July 1961. Heyde Trial, pp. 41–42. Also named in the 1936 discussions were Dr. Walter Gross of the Office of Racial Politics and Minister-Director Walter Schultze.

  2 Testimony of Otto Mauthe, 20 December 1961, Heyde Trial, pp. 42–43.

  3 Brandt testimony, 4 February 1947, Nuremberg Medical Case, transcript, pp. 2409–10, and vol. I. p. 894; also in Heyde Trial, pp. 51–52. See also Lothar Gruchmann, “Euthanasie und Justiz im Dritten Reich,” Vierteljahrshefte für Zeitgeschichte 20 (1972): 238–39, on general euthanasia requests involving the incurably ill during 1938–39; in the absence of a law they were directed to Hitler’s Chancellery.

  4 Brandt testimony, Nuremberg Medical Case, transcript. See also Hans Hefelmann’s account, 31 August and 7–14 November 1960, Heyde Trial, pp. 48–51, 53–54; and Gruchmann, “Euthanasie und Justiz,” pp. 240–41.

  5 Brandt transcript, Nuremberg Medical Case, transcript, p. 2410.

  6 Heyde Trial pp. 53–54.

  7 Heinze testimony, 27 September 1961, Heyde Trial, pp. 150–51.

  8 Sample letter to parents, 30 September 1941, Heyde Trial, p. 111; see pp. 100–16.

  9 Testimony of Dr. Valentin Faltlhauser, 22–23 April 1948; and Nurse Mina Wörle, 7 May 1948 (Kaufbeuren asylum), Heyde Trial, pp. 143–47.

  10 Hefelmann testimony, 7–14 November 1960, Heyde Trial, p. 123.

  11 On the broadening of categories, see Heyde Trial, pp. 82–90, 131–34.

  12 Ibid., pp. 165–72.

  Lawrence Grouse

  THE LIE

  Today we are far removed from the days when doctors and families colluded to keep diagnoses from patients. Yet, in everyday practice, those in the health care professions are presented with numerous occasions to turn from the direct question, to keep doubts to oneself, or to ponder the odd lab result without mention to the patient. What does it mean to give patients or families information that might corrode hope when hope is all that they have? Are honesty and integrity absolutes? “The Lie” examines these questions and others, not offering answers but revealing the complexity involved in acting with honesty and integrity.

  LAWRENCE GROUSE created the Journal of the American Medical Association’s (JAMA) column “A Piece of My Mind” in 1979, and originally wrote this piece for it. Today he is in the departments of medicine and neurology at the University of Washington School of Medicine.

  A nnie is from New Hampshire and came here to the foothills of the Blue Ridge Mountains for the horse show. The nurses and I carry her from the car into the emergency room and gently place her on the gurney. She was kicked in the abdomen by her horse and lay in a field for over an hour until friends found her and brought her to the hospital. Even though I am working in the emergency room of a small hospital, I am confident. The nurses know their jobs. Faced with a serious surgical problem, we work well together.

  Within a few minutes we have inserted two IV’s, one in a forearm vein, another in the external jugular; her blood pressure, however, remains marginal. The fluid from the abdominal tap is grossly bloody and so is her urine. Annie remains calm. Her serious eyes are piercing; I hold her hand to reassure her, but also to take her pulse. She is bleeding very rapidly into her abdomen. Nothing I do seems to help, and I am scared. She is in shock, yet she converses politely and inquires about her condition.

  “Thank you for helping me,” she says. “Really, it wasn’t the horse’s fault!”

  “We’re not worried about the horse, Annie,” I say. “The horse is fine.”

  “Is it a serious injury?” She pauses. “Will I live?”

  “Everything will work out, Annie,” I tell her. “It may be a little rough for a bit, but it will work out.”

  “Are you sure?” she asks, gazing steadily at me. “Please, tell me honestly.”

  I don’t answer for a moment. I look at her. I am already fond of her and I do not want to lie. I squeeze her hand and smile. I am unsure how she will do, but I say, “Yes, I’m sure.”

  After a third IV is in place, her blood pressure stabilizes. The general surgeon and the urologist arrive and plan their emergency workup and exploratory surgery. I breathe a sign of relief as they take charge of her care. Suddenly, we find that the door to the surgical suite in the emergency room has been inadvertently locked and the head nurse’s key won’t open it. Annie and a nurse are locked inside. There is a great deal of key rattling and doorknob shaking. The pitch of people’s voices starts to rise. I break into a sweat. The head nurse yells orders into the telephone and almost immediately three burly maintenance men with crowbars appear.

  “Get rid of that door! Now!” the head nurse bellows.

  The door is splintered in twenty seconds. Annie is laughing, tells us not to worry, tells us that she is fine. She thinks it is the funniest scene ever.

  At surgery, we find that Annie has a severely lacerated liver and a ruptured kidney. The liver is repaired; the kidney is removed, but when I wake up the next morning and look in on Annie, disseminated intravascular coagulation has developed and she is receiving heparin. Four nurses and two physicians have already given blood for her. The intensive care unit hosts a steady stream of staff who have helped Annie and who come by with a few encouraging words. Her parents have arrived. Annie’s father is a college professor: a tall, angular man, feeling frightened and out of place. Annie’s mother is a small woman with delicate features. The surgeon’s wife accompanies them. By the following day, when I leave the hospital after my weekend shift, several of the staff, including the head nurse, have each given two units of blood for Annie.

  Two weeks later—during my next shift—I am waylaid and hugged by a happy and ambulatory Annie.

  “Everyone here has been so good to me,” Annie beams.
/>
  As we sit over a cup of coffee, her parents timidly inquire whether Annie might have been close to death on her arrival at the hospital. I can’t help bragging about treating Annie in the emergency room. As I launch into the story, I find that Annie remembers it all, and she chimes in with an exact rendition of our entire conversation on the day of the accident. I am amazed! She was in shock, and still she remembers every word I said. I finish my story with a flourish. “When I found that you had abdominal bleeding and I still couldn’t bring up your blood pressure with two IV’s, I have to admit that I thought you were a goner.”

  Annie seems shocked to hear this. She looks at me angrily and says, “Don’t you remember? You said you were sure I would live. I remembered that promise all the time! I put a great deal of weight on what you said, and you . . .” Suddenly, for the first time since the accident, and to everyone’s surprise, tears are in her eyes and she is weeping; she is inconsolable because I lied to her.

  Walt Whitman

  THE WOUND DRESSER from Leaves of Grass

  At the outbreak of the Civil War, the distinguished American poet Walt Whitman was writing freelance journalism and visiting the wounded in New York–area hospitals. In December 1862 he traveled to Washington, D.C., to take care of his brother, who had been wounded in the war. In Washington, Whitman was overwhelmed by the suffering of so many young men; he decided to stay and attend the wounded and dying.

  Through he first brought out his collection of poems, titled Leaves of Grass, in 1855, Whitman continued to revise it, adding poems across a span of more than thirty years. This section, taken from the book’s final edition of 1891–92, describes the wounds Whitman dresses and the suffering he sees as he threads his way through the hospitals, trying to “pacify with soothing hand” the many men mortally wounded in the Civil War.