All Commentary
Friday, August 1, 1997

From Small Beginnings: The Road to Genocide

The German Medical Profession Could Have Resisted Medical Extermination

Mr. Maccaro is an attorney in New York state.

Dr. Leo Alexander, a prominent American psychiatrist, was the chief U.S. medical consultant at the Nuremberg War Crimes Trials that judged Nazi leaders following World War II. One question in particular perplexed him: Why was the German medical profession unable to effectively resist the Nazis?

As he searched in German archives, Dr. Alexander was puzzled by the lack of documentation of resistance by doctors. He assumed that German physicians, as scientists devoted to relieving human suffering, were appalled by the Nazis. He knew of the high regard the German public had for doctors, who were typically among the leading citizens of their communities, and expected to find many examples of doctors who used their prestige to resist the Nazis. Yet he found no such evidence. In shocking contrast, Dr. Alexander discovered that the German medical profession fully cooperated with the Nazis and, indeed, was responsible for some of the most disturbing outrages of the Nazi regime.

Dr. Alexander was forced by the facts to change the focus of his research to an examination of the process by which the German medical profession came under the total domination of Hitler’s government. He set forth his findings in the July 14, 1949, issue of The New England Journal of Medicine. In this remarkable study, Medical Science Under Dictatorship, Dr. Alexander described how the German medical profession, in the words of Malcolm Muggeridge, sleepwalked to the collectivist-authoritarian way of life.

Dr. Alexander discovered that the Nazi Holocaust began with a subtle shift . . . in attitude that accepted a philosophy of government that judged people based upon their perceived costs and benefits to the state. The first manifestation of this was the open discussion during the time of the Weimar republic, prior to Hitler’s takeover of Germany, of government schemes for the sterilization and euthanasia of people with severe psychiatric illnesses. By 1936, medical extermination was widely and openly practiced, and the category of those deemed to be a burden to the state and therefore socially unfit to live had expanded to encompass all people with chronic illness.

On September 1, 1939, euthanasia was officially recognized as state policy and two government agencies were established to carry out the killings in an efficient manner. They were cynically named the Reich’s Work Committee of Institutions for Cure and Care, which dealt with adults, and the Reich’s Committee for Scientific Approach to Severe Illness Due to Heredity and Constitution, for children. Separate organizations were created to transport patients to killing centers and to collect the cost of the killing from the next of kin, who were told that the victim had died of natural causes.

Doctors were required to report on all patients who had been sick for five years or more or who were medically unable to work and unlikely to recover. The decision about whether someone should be put to death was generally made by psychiatrists who taught at leading universities. These consultants never examined or even saw the patient and based their decisions on brief questionnaires, which contained information about race, ethnic origin, marital status, next of kin, financial resources, and whether and by whom the patient was visited.

What began as a slow acceptance of mercy killings in rare cases of extreme mental illness soon expanded to mass extermination on an unprecedented scale. Among those killed were people with epilepsy, infantile paralysis, Parkinson’s disease, depression, multiple sclerosis, and various infirmities of old age. In short, all people who were unable to work and not considered rehabilitable were killed. One physician later admitted: [The victims] were selected from the various wards of the institutions according to an excessively simple and quick method. Most institutions did not have enough physicians, and what physicians there were were either too busy or did not care, and they delegated the selection to the nurses and attendants. Whoever looked sick or was otherwise a problem was put on a list and was transported to the killing center. The worst thing about this business was it produced a certain brutalization of the nursing personnel. They got to simply picking out those whom they did not like, and the doctors had so many patients that they did not even know them, and put their names on the list.

It is estimated that 275,000 Germans were exterminated in the killing centers; this provided extensive opportunities to perfect the methods that were later used in the concentration camps.

The next step taken by the German medical profession was the accumulation and use of human material obtained from the exterminated for medical research. For instance, one physician obtained 500 brains for use in his neurological research. This was soon followed by the use of live people for terminal human experiments, a practice that was openly accepted by the German medical profession.

“A Life Not Worthy to Be Lived”

Dr. Alexander demonstrated in Medical Science Under Dictatorship that by the early 1940s, the German medical profession had become fully implicated with the Nazi regime and its death camps. Moreover, he outlined how this monstrous outcome originated from small beginnings. It started with acceptance of the progressive and rational idea that some people had a life not worthy to be lived and were a burden to society and to the state. Once this idea was acted upon, and physicians became accustomed to it, the extermination system expanded to include all people considered for any reason to be a financial burden to the state, followed by all those considered to be disloyal or a threat to the government and, ultimately, anyone considered undesirable by the government. Once the first German mental patient was put to death, a chain of events was begun that only ended with destruction on a nearly unfathomable scale, including the murder of the majority of European Jews.

Dr. Alexander contrasted the actions of the German medical profession with those of doctors in the Netherlands under German occupation, who refused to take the first small step to genocide.

In December 1944, an order was issued by the Nazi authorities to all Dutch physicians: It is the duty of the doctor, through advice and effort, conscientiously and to his best ability, to assist as helper the person entrusted to his care in the maintenance, improvement and re-establishment of his vitality, physical efficiency and health. The accomplishment of this duty is a public task.

This statement might appear on first reading to be unobjectionable and innocuous. However, the Dutch medical profession, which was aware of the extermination system in place on the other side of the Dutch-German border, recognized that this order would serve as a basis for the promulgation of a new standard of care that would place first priority upon the return of patients to productivity for the state, rather than the relief of suffering. Physicians would consequently be subordinated to the state and its interest to maximize utility.

Dutch physicians unanimously refused to comply. When the Nazis threatened to revoke uncooperating doctors’ licenses to practice, all doctors returned their licenses and closed their offices, but continued to see patients in private. The Nazis then arrested 100 Dutch doctors and sent them to concentration camps, but the medical profession refused to back down. The result was that no Dutch doctor participated in a killing and the Nazi plans for medical exterminations in the Netherlands were not carried out.

Dr. Alexander concluded:

It is obvious that if the medical profession of a small nation under the conqueror’s heel could resist so effectively, the German medical profession could likewise have resisted had they not taken the fatal first step. It is the first seemingly innocent step away from principle that frequently decides a life of crime. Corrosion begins in microscopic proportions.


  1. Leo Alexander, Medical Science Under Dictatorship (Flushing, N.Y.: Bibliographic Press, 1996), p. 9.
  2. Ibid., p. 10.
  3. Ibid., pp. 17-21.
  4. Ibid., p. 24.
  5. Ibid., p. 25.