The eugenicist roots of assisted dying

In a letter dated 1 October 1940, Helene M wrote to her father from an asylum in the southern German town of Stetten (1). An epileptic, Helene had been chosen for ‘transport to another facility’. But, in the context of Nazi Germany, she knew what that really meant.

‘Today I must write these words of farewell as I leave this earthly life for an eternal home’, she wrote. ‘I do not want to part from you without asking you and all my dear brothers and sisters once more for forgiveness, for all that I have failed you in throughout my whole life. May the dear Lord God accept my illness and this sacrifice as a penance for this.’

In a further note, dated 2 October 1940, Helene addressed her father again: ‘Please pray a lot for the peace of my soul. See you again, good father, in heaven.’

It is unclear how old Helene was at the time, but it was likely she was in her late teens or early twenties. Her father wrote to the authorities requesting a halt to her ‘transfer’. This was granted, but by then it was too late. She had already been moved to the facility, where she was gassed to death and her body burned. He later received another letter stating that she died of ‘breathing difficulties’.

The order for Helene’s death was issued from an anonymous office located at No4 Tiergartenstrasse (shortened to T4) in Berlin’s Charlottenburg district. Under the name Reich Cooperative for State Hospitals and Nursing Homes (RAG), the Aktion T4 programme chose candidates for death after a two-tier review by medical experts. They sent complex registration forms to mental hospitals and other institutions to gather details on potential candidates. Once returned, two expert panels reviewed the documents. In Helene’s registration form, the panels marked a ‘plus’ sign in red, which meant she was to be killed – a ‘minus’ sign in blue signified that a patient should be spared.

One of the experts who decided Helene’s fate was a psychiatric doctor called Josef Schreck. He completed over 15,000 such forms between April 1940 and January 1941, sometimes processing up to 400 a week in addition to his other hospital duties. He could not have spent more than a few seconds on any of the forms (2).

After experts like Schreck had completed their evaluations, the T4 transport authority would receive a list of ‘eligible’ patients with ‘plus’ signs. A few days before the appointed date, the mental hospitals would be sent a form requiring them to log the patient’s medical records as well as personal possessions. Sometimes institutional directors objected that some of the chosen patients did useful work. The transport authority, however, worked to a quota and required other patients to be substituted if some were to be spared.

Large, grey buses would pick up the patients, many of whom, like Helene, had already guessed their fate. Forced aboard, they were transported to killing centres disguised as mental institutions. Nearly 20 patients at a time were herded into a sealed room and ordered to remove their clothes. An X was painted on to the backs of those with gold teeth that could be removed after death. Canisters of carbon monoxide were then released by a physician opening a valve. After 20 minutes all patients were dead and the corpses sorted according to whether or not they had an X on their back.

Relatives were then informed that their loved ones had died of natural causes and their bodies cremated because of the threat of disease. They were offered an urn containing the ashes.

This campaign of involuntary euthanasia, known as Aktion T4, cost tens of thousands of lives. According to the Nazis’ own record, at least 70,000 disabled people were put to death, although some sources suggest that the figure could be as high as 200,000.

It is tempting to believe that the eugenic ethos that informed this methodical, murderous campaign died with the defeat of the Nazis. But that is wishful thinking. The eugenicist approach, which measures the worth of all according to whether or not they are a net ‘benefit’ or ‘burden’ to society – indeed, whether they add to or subtract from the nation / community / race – has proven stubbornly persistent. And it is now enjoying a resurgence with the worldwide push for assisted-dying laws.

The term ‘eugenics’ was originally coined in 1883 by the British scientist, Francis Galton. He argued for what is sometimes seen as positive eugenics – an attempt to improve humanity through selective breeding. To this end, he advocated promoting the marriage of the ‘fittest’ individuals using monetary incentives. Yet, so-called negative eugenics – the desire to cull the number of people from ‘inferior stock’ – was always implicit in the idea of selective breeding. As Galton himself stated in Inquiries into Human Faculty and its Development (1883), eugenics ‘is by no means confined to questions of judicious mating’; it also takes ‘cognisance of all influences that tend… to give the more suitable races or strains of blood a better chance of prevailing speedily over the less suitable than they otherwise would have had’ (3). If positive eugenics was expressed in terms of birth control, its dark flipside was expressed in terms of sterilisation programmes and euthanasia.

Indeed, it is no coincidence that the idea of euthanasia emerged at the same time as eugenics. The two were always conceptually and politically entwined. From the start, the implications of euthanasia were always eugenic. Samuel D Williams, a member of the Birmingham Speculative Club, first raised the prospect of euthanasia in an 1870 pamphlet of the same name. Williams made the case for taking a life away ‘that has ceased to be useful to others, and has become an unbearable infliction to its possessor’. In her 1885 book, My Path to Atheism, socialist and euthanasia advocate Annie Besant argued for ‘relieving [society] from a useless burden’ (4).

Today, the callous justification for voluntary euthanasia, assisted suicide or assisted dying tends to be hidden behind appeals to compassion. Euthanasia is presented as a way to end the unbearable suffering of desperate individuals. But prior to the 1930s, few hid the true intentions of euthanasia – to improve society by ridding it of burdensome lives.

In America, in a widely syndicated 1905 article, Dr Ella K Dearborn cheerfully called for ‘euthanasia for the incurably ill, insane, criminals and degenerates’. She even thought it was entirely reasonable that all persons should pass an examination allowing them to continue living. Using the example of cancer sufferers, she asked readers whether they would prefer ‘euthanasia by the chloroform route, that ends all suffering for the individual, or a loathsome burden for weary months or years for those you love?’. In 1906, sociologist L Graham Crozier went further: ‘I would personally rather administer chloroform to the poor, starving children of New York, Philadelphia, Chicago and other American cities, than to see them living as they must in squalor and misery.’ This was ‘mercy killing’, she argued (5).

There was of course resistance to euthanasia. The so-called chloroform acts, for example, were defeated in 1906 in Ohio and Iowa. But in 1907, Indiana enacted the first eugenic sterilisation law, with state programmes targeting institutionalised, mentally disabled women. By the start of the Second World War, the US authorities had sterilised approximately 60,000 persons.

During the interwar years, the eugenicist focus shifted from good breeding to the elimination of supposedly undesirable human stock. In Germany in 1920, jurist Karl Binding and psychiatrist Alfred Hoche published a pamphlet entitled Permitting the Destruction of Life Unworthy of Life. As historian Henry Friedlander has pointed out, Binding and Hoche ‘wanted to “destroy” the “unworthy life” of healthy but “degenerate” individuals’.

In Britain, euthanasia advocates ran up against significant legal and cultural obstacles. It was during this period, the 1930s, that Charles Killick Millard, former vice-president of the Malthusian League and founder of the first birth-control clinic in Leicester, coined the expression ‘voluntary euthanasia’. As president of the Society of Medical Officers of Health, Millard proposed a Voluntary Euthanasia (Legislation) Bill for the incurably disabled in 1931. After the bill was rejected by parliament, Millard made a telling admission, complaining that ‘only the “right to die” – not the “right to kill”… has any chance of being legalised at present’. As historian Ian Dowbiggin noted, Millard’s opposition to ‘involuntary euthanasia’ stemmed less from principle than a pragmatic acceptance that it stood no chance of ‘becoming law in the foreseeable future’.

In the US, the idea of voluntary euthanasia was also picking up steam. Prominent humanist and Unitarian minister Dr Charles Potter and several others formed the Voluntary Euthanasia Society of America in 1938. Potter, however, made it clear that euthanasia was not driven by the needs of the individual but by the needs of society: ‘I think mercy killing is justified in certain instances… One of the conditions should be severe pain.’ It was clear, however, that Potter also had ‘burdensome’ others in his sights. ‘The incurable insane also should be euthanised’, he wrote, ‘because there are 500,000 people in insane asylums, most of whom are incurable’ (6).

The German euthanasia programme, despite its attempts to disguise itself, was well understood both inside and outside of Germany (7). Clemens August Count von Galen, the Catholic bishop of Münster, Germany, is now famous for his opposition to Nazism. Much of this reputation rests on his public opposition to euthanasia. On 3 August 1940, he rightly protested that euthanasia opened the way to the murder of all ‘unproductive people’, like old horses or cows. He asked rhetorically: ‘Who can trust his doctor anymore?’ (8)

In response to Galen’s high-profile criticisms, German’s leader, Adolf Hitler, made a great show of halting the T4 programme in 1941. Behind closed doors, however, it continued unabated. At the same time, Nazi propaganda advocating euthanasia changed tack. In the 1930s, the Nazis bluntly complained about the cost of keeping mental patients alive. But, as a 1941 film, Ich klage an (‘I accuse’), shows, the emphasis was now on ending suffering. Ich klage an featured an attractive young woman, struck down by multiple sclerosis, who expressed a wish to die and was helped by her husband and another friend.

When the crimes of the Nazis were exposed at Nuremburg, Karl Brandt – the doctor in overall control of the regime’s euthanasia programme – was careful to dismiss the idea that he killed Helene M and 200,000 others for ‘reasons of utility’. He insisted: ‘For me the decisive motive was compassion.’ No one believed Hitler’s chief eugenicist, and he was hanged at Nuremburg in 1948.

After the war, the framing of euthanasia changed completely. Its intimate connection with eugenics, breeding the fit and culling the unfit, was downplayed. The emphasis was now on the voluntary aspect of any euthanasia programme. Indeed, the term ‘assisted suicide’ emerged after the war as a replacement for ‘euthanasia’ and ‘mercy killings’, tainted as they were by their Nazi-era associations: A New Statesman article at the time argued that, ‘If we call these situations “assisted suicide” rather than “mercy killing”, the moral content would be considerably changed…’ (9).

By the 1970s, the terminology had altered almost beyond recognition. The Euthanasia Society of America changed its name in 1974 to the Society for the Right to Die (SRD). A prominent member of the SRD, newspaper columnist Abigail ‘Dear Abby’ Van Buren, noted in 1974 that ‘a bill with the word “euthanasia” in it will never get passed’ (10). As historian Ian Dowbiggin notes, ‘euthanasia ceased being defined as active mercy killing, with its disturbing overtones of coercion and social usefulness, and increasingly became viewed as personal freedom from unwanted interference in one’s own life’.

Indeed, it was only from the late 1970s onwards, that euthanasia advocates found popular support for their cause. Framed in the language of individual rights and compassion, it now appeared progressive.

Yet appearances can be deceptive. Wherever euthanasia is legalised, it remains open to the very same medical and social categories of people eugenicists once dismissed as ‘human ballast’ – the sick, the disabled and the old. After all, no one is calling for healthy, productive individuals to be given the right to die. It is right restricted to the most vulnerable, those living on the margins of society. Those whose lives are deemed not useful to themselves or others, as euthanasia’s first advocate, Samuel D Williams, put it.

Supporters of the right to die will claim that the eugenicist culture, which led to the mass killing of the disabled and elderly, is long gone. But is it? In the Netherlands, campaigners continue to call for those aged 75 and older, who are simply ‘tired of life’, to be given access to assisted-suicide programmes. And in the UK and elsewhere, people with learning difficulties hospitalised with Covid during the pandemic were issued with ‘do not artificially resuscitate’ orders (DNARs).

And there’s more than a hint of the old eugenicist ethos in the Terminally Ill Adults (End of Life) Bill currently wending its way through parliament. Like euthanasia’s historical advocates, the bill’s supporters use the language of compassion, and talk about allowing people suffering unbearably to end their lives. But buried deep in the bill’s impact-assessment reports, published just a few weeks ago, it was possible to see the eugenicist logic still at work. The first report said that the NHS could save up to £10million in ‘unutilised healthcare’ within the first year of the law coming into effect, and £59million over the next decade. Even more chillingly, the Equality Impact Assessment report insisted that, if the bill becomes law, it must protect equal opportunities, and allow those suffering from disabilities such as Down’s syndrome to access assisted suicide. The report even states that when mobility issues start to create more and more problems for disabled people, doctor-delivered euthanasia might be an appropriate course of action.

Today, Helene M would not be forcibly transported by Nazi officials to a room where she would be gassed to death. But if the assisted-dying lobby gets its way, her fate would be no less grim. She would be encouraged to follow her inclinations to die and deliver her father of her burdensome existence. She would be counselled to overcome the barriers people with disabilities face in arranging their assisted death. And all the while, euthanasia’s eugenicist cheerleaders would be shouting ‘you go, girl’ and celebrating her death as an expression of empowerment.

Assisted dying may have been dressed up as a liberal cause supported by good, compassionate people. But its roots in the eugenicist movement tell a different story. It remains what it always was – cruel and deeply anti-human.

Kevin Yuill is emeritus professor of history at the University of Sunderland and CEO of Humanists Against Assisted Suicide.

(1) See Death and Deliverance: ‘Euthanasia’ in Germany, 1900-1945, by Michael Burleigh, Cambridge University Press, 1994, pp142-43

(2) The Third Reich at War, by Richard J Evans, Penguin, 2009, p86

(3) Cited in ‘Eugenic Thinking and the Cognitive Sciences’, by Robert A Wilson, Open Encyclopedia of Cognitive Science

(4) Cited in ‘Suicide versus Euthanasia in the American Press in the 1890s and 1900s: “A Man Should be Permitted to Go Out of This World Whenever He Sees Fit”’, by Kevin Yuill, Journal of Policy History, Vol 34, No2, 2022, pp213-244 & 226

(5) Cited in ‘Suicide versus Euthanasia in the American Press in the 1890s and 1900s: “A Man Should be Permitted to Go Out of This World Whenever He Sees Fit”’, by Kevin Yuill, Journal of Policy History, Vol 34, No2, 2022, p233

(6) ‘Moves to legalize “mercy-killings” sponsored’, Times-News, 17 January 1938

(7) See ‘Hitler Kills Germans, Too’, by Pat Frank, Southern Jewish Weekly, 16 May 1941

(8) The Third Reich at War, by Richard J Evans, Penguin, 2009, p98

(9) Cited in Assisted Suicide: The Liberal, Humanist Case Against Legalisation, by Kevin Yuill, Palgrave, 2013), p12

(10) Cited in Assisted Suicide: The Liberal, Humanist Case Against Legalisation, by Kevin Yuill, Palgrave, 2013), p14