 |
 |
|
|
|
Richard von Krafft–Ebing (1840–1902), Emil Kraepelin (1856–1926), Sigmund Freud (1856–1939), Eugen Bleuler (1857-1939), Julius Wagner-Juaregg (1857–1940), Alois Alzheimer (1864–1915), Carl Jung (1875–1961), Karl Jaspers (1883–1969)—these names attest to the intellectual ferment in German, Swiss, and Austrian psychological circles during the late 19th century. The debt we owe to these pioneers makes it all the harder to understand how, before the new century was 30 years old, German psychiatrists were gassing children with mental handicaps and sterilizing adults with mental handicaps and mental illness or using them as subjects for scientific experimentation before putting them, often brutally, to death (1–10). Psychiatrists who once were much admired—Ernst Rüdin, Franz Kallman, Carl Schneider—were complicit in these activities. Devotees of preventive health approved of the practices. Social reformers participated. Disciples of humanism and followers of the holistic medicine movement colluded in the atrocities. Academicians and scientists were at the centre of them. Even well-meaning child and adolescent psychiatrists willingly took part. Physicians were among the first to support National Socialism in Germany. The National Socialist Physicians League was formed in 1929. By early 1933, almost 3000 physicians (6% of the entire medical profession) had joined the League. By late 1933, 11 000 physicians were members. Undoubtedly, some joined not out of conviction but out of occupational necessity. Eventually, 45% of German physicians belonged to the Nazi party, about 7 times the mean rate for the employed male population of Germany. Physicians moved with alacrity from looking after individuals to upholding an idiosyncratic ideal of national health (Volksgesundheit) (1). They seemed to easily accept a hierarchy of human worth that put the infirm, the disabled, and the genetically imperfect on the bottom rung (1). Contemporary evidence suggests that, of the medical specialties, psychiatry was the most involved (4). Science, statistics, and economics conspired to beget the notion that appropriate sterilization of the genetically disabled would improve the health of the nation. The belief that life needed to be “worthy” to merit government-supported health services caught on among the public. However, “euthanasia” was carried out whether the public consented or not. The otherwise laudable concept of holistic health (that is, biological integrity, social well-being, and spiritual right- mindedness) led first to the sterilization and ultimately to the “euthanization” of not only the handicapped but, eventually, of the socially and spiritually unworthy—persons with mental illness, the socially wayward, criminals, Gypsies, homosexuals, and Jews. Psychiatrists helped in the selection. Can this happen ever again? Can this happen today? In a one-payer government system, are Canadian physicians sufficiently independent of the ideology of the government in power? Can we, like German psychiatrists from 1920 to 1940, come to value the health of Canadian society sufficiently to remove from that society those who threaten its health? In one sense, we do it now when we impose involuntary hospitalization on those with mental illness; will our motives for doing so be questioned by history? We currently prescribe large amounts of tranquilizing drugs that sometimes inadvertently impair our patients’ health. Are we being hoodwinked into acquiescence by a profit-driven pharmaceutical industry? After all, this is the industry that supports our meetings, whose advertisements sustain our journals, whose backing partly pays for our continuing education, whose funding often assists our clinical projects, whose deep pockets sometimes reimburse individual psychiatrists for recruitment into drug studies. Pressed by internal and external demands of career advancement, do we straightjacket our patients into DSM-IV–defined diagnostic categories? Can we, in other words, resist the pressure to close ranks behind our ideological leaders? Since Nuremberg, we have developed tight legislation to place constraints on human experimentation, but no such safeguards exist against biases that may influence our clinical decisions. We cannot subject individuals to research against their will, but we can decide, for instance, that a woman with schizophrenia is not a good enough mother. We can decide whether to lend credence to sexual-abuse narratives. We can hold families responsible for mental illness and choose, under the mantle of confidentiality, not to speak to them. We can buy the rhetoric of the superiority of community treatment to the extent of depriving patients of the safety of a hospital bed. Autonomy can currently trump beneficence to such a degree that patients with mental illness are left untreated, abandoned. Sometimes they starve, though not to death, as they did in Nazi Germany. Fürsorge and VorsorgeThe concern of one individual for another (Sorge in German) ruled the practice of German medicine in the early years of the 20th century (9). As in Canadian medicine today, equal emphasis was placed on 2 main forms of health care: Fürsorge, or care for the ill individual, and Vorsorge, or prior care, that is, preventive medicine. Then, as now, a tension existed between health interventions to benefit society as a whole (the realm of preventive medicine, health promotion, and community and public health) and measures that addressed the immediate needs of individual patients (treatment, rehabilitation, and palliation). At all times, governments with limited resources must continually weigh spending on preventive health against spending on the alleviation of suffering. This tension is reflected in contemporary expositions of health care ethics (11). Smith and colleagues articulate this unresolvable dilemma: While the duty of individual health care workers is primarily to the individual patients whose care they assume, caregivers must be aware that the interrelationships inherent in a system make it impossible to separate actions taken on behalf of individual patients from the overall performance of the system and its impact on the health of society. Doctors and other clinicians should be advocates for their patients or the populations they serve but should refrain from manipulating the system to obtain benefits for them to the substantial disadvantage of others (11, p 250). Physicians also have a responsibility to themselves and their families; in other words, while caring for their patients and for society, they need to earn a living. The code of ethics of the American Psychiatric Association (APA) emphasizes the psychiatrist’s fiduciary responsibility to individual patients but does not help clinicians struggle constructively with the question of how it is possible to both “care about patients” and “care about money” (12). The dilemma in Germany was resolved in favour of Vorsorge. Three historic factors contributed to the shift from Fürsorge to Vorsorge (9). Germany had a prior record of public health that emphasized early detection of illness and the promotion of occupational health and safety. The country had adopted the doctrine of holistic medicine (Ganzheitslehre), which advocated not only the comprehensive (that is, body and spirit) needs of the whole person but also those of the whole society in which the person lived. Belief in holistic medicine was probably a response to what was widely regarded at the time as overspecialization, bureaucratization, and the dominance of medical reductionism. Concurrently Germany stood at the centre of a worldwide eugenics movement whose overarching aim was to weed out population weaknesses (just as today, in many parts of the world, science is used to prevent the birth of unwanted [girl] babies). The science of eugenics expanded after World War I in that population weaknesses were deemed to include not only biological infirmities but also social and economic conditions. In 1920, Karl Binding, a lawyer, and Alfred Hoche, a psychiatrist, published an influential text with an extraordinary title, Permitting the Destruction of Unworthy Life (13). In this book, Binding states:
Hoche, the psychiatrist, notes that physicians may sometimes need to destroy the life of “complete idiots . . . and the mentally ill who are empty human shells and whose existence weighs most heavily on the community . . . in the interest of a higher good” (cited in 14). What was this “higher good”?
The Binding and Hoche book was controversial, and the idea of destroying “worthless” lives did not at first gain wide support among German doctors (14). However, it might have influenced Erwin Liek, a Swiss German cancer specialist. Squarely in the preventive medicine camp, Liek promoted bans on pesticides, smoking, drinking, use of X-rays, and poor nutrition. He also railed against the state of medicine as mechanical and overly scientific (15). The first obligation of the medical profession, argued Liek, was the health of the nation, even if it meant sacrificing specific individual needs. The new social security medical insurance system, wrote Liek, had changed German physicians from “priests in the temple of the art of healing” into Kässenartze (those who were reimbursed directly by the government, literally “cashier physicians”), “lowly wage-earners” in the “magnificent hall of social insurance” (cited in 9). Echoing the concerns of today, Liek also blamed the pharmaceutical industry for turning doctors into pill pushers. Medicine, he said, was becoming depersonalized, moving away from the bedside and toward subspecialization and diagnosis by laboratory results, rather than by clinical judgement (9). Care of the individual patient, he went on to argue, brought little satisfaction because, under the new system, there were so many people to be looked after. However, he found a plus side to large numbers. Physicians could now clearly see that not everyone was prone to illness to the same degree. Some, of good constitution and good habits, resisted illness easily while others could not, demonstrating the primal importance of constitution and heredity. “The physician understands that a higher task awaits him than the care of the individual human being . . . namely, the future of his people” (cited in 9). These conclusions by an eminent cancer specialist were probably derived from the textbook Human Heredity and Racial Hygiene, which went through 5 editions between 1921 and 1940. It received rave reviews in contemporary journals and was considered the standard textbook on racial hygiene (16). Liek himself died in 1935. Foremost among his followers was Karl Kötschau, a leader in the natural healing movement, who organized a “New German Therapy”(Neue deutsche Heilkunde), which synthesized scientific medicine, naturopathy, and homeopathy. This fusion promoted wholesome effects—consumption of whole grain bread, avoidance of alcohol and tobacco, plentiful exercise, and herbal remedies. Herbs, incidentally, were not necessarily wholesome in Nazi Germany. Fertility experiments were conducted with botanicals, and in 1941, Nazi SS Reichsführer Heinrich Himmler was told that extracts of the South American plant Dieffenbachia seguine could be used for the mass sterilization of racially undesirable war prisoners (17). Sterilization of the UnworthyOn January 30, 1933, Adolph Hitler became Chancellor of the Third Reich, and Vorsage became the justification for his eugenic sterilization programs. On July 14, 1933, the Law for the Prevention of Genetically Defective Progeny was passed, mandating the involuntary sterilization by vasectomy or tubal ligation of carriers of so-called hereditary disease: the “weak-minded,” schizophrenics, alcoholics, the insane, the blind, the deaf, and the deformed. At the same time, to encourage population growth among the Aryan race, the regime restricted access to contraception and outlawed voluntary sterilization as well as abortion, unless it was necessary to save the mother’s life (14). Upon passage of the law, Dr Ernst Rüdin, professor of psychiatry, director of the Kaiser Wilhelm Institute of Psychiatry of Munich, and the “father of psychiatric genetics,” celebrated the occasion with these words:
In the first year of the Sterilization Act, Germany’s genetic health courts received 84 525 physician-initiated applications and reached 64 499 decisions, 56 244 in favour.
Within 2 years, up to 1% of citizens aged 17 to 24 years had been sterilized. Within 4 years, about 300 000 patients had been sterilized—at least one-half for “feeble mindedness,” as evidenced by their failing scientifically designed intelligence tests (7). In 1939, sterilizations came to an end except for adolescents at “high risk of reproduction” (19). Rüdin’s monograph on the genetics of dementia praecox served as scientific validation for the forced sterilization (20). Euthanasia for Persons With Mental IllnessThe primacy of Vorsorge and Rüdin’s scientific discoveries were also used to justify the murder of large numbers of “unworthy” individuals. Preparing for war, Hitler decided that mental illness and physical disability were not sufficient grounds for occupying hospital beds needed for wounded soldiers. Most academic psychiatrists embraced the Nazi philosophy and seemed content to lead the way in the “final solution” for psychiatric patients (20,21). It was possible, though costly, to resist. Among others, Karl Jaspers warned colleagues of the dangers of racial hygiene. The National Socialists did not appreciate Jaspers’ opinions, and in 1933, he was relieved of most of his teaching duties. By 1937, he was ousted from the university (to which he returned after the War). No law authorizing medical killing was ever debated or passed by the Reichstag. It was authorized by “Führer decree” in October 1939. All state institutions were required to complete questionnaires and report patients who had been ill for at least 5 years and unable to work. Forty-eight doctors were appointed to review nearly 300 000 applications for euthanasia; of these, about 75 000 patients were selected for death. The decree was backdated to September 1, 1939, to cover the initial phases of the invasion of Poland, during which 4000 Polish psychiatric patients were shot (14). The entire process was named Aktion T4 after Tiergarten 4, the address of a confiscated Jewish home in Berlin that housed the administrative offices of this operation. In January 1940, Dr Karl Brandt, Hitler’s personal physician, tested a new means of mass killing—the administration of carbon monoxide in a gas chamber disguised as a shower. This experiment was conducted at the Brandenburg psychiatric hospital. It was then replicated at 5 other psychiatric hospitals throughout Germany, each of which was outfitted with a gas chamber. The alleged aim was to create 70 000 beds for casualties of war. False death certificates were issued with diagnoses appropriate for age and previous symptoms, and payment for “treatment and burial” was collected from surviving relatives. Between 1939 and 1945, 180 000 psychiatric patients were killed in Nazi Germany (14). Cost–benefit analyses were a prominent feature of Nazi medicine. Schoolchildren were sent home with mathematics problems that required balancing the cost of housing units for young couples against the costs of looking after “the crippled, the criminal and the insane.” The killing of 70 000 patients in the T4 program was calculated to save 245 955.50 Reichsmarks daily, which freed up “4,781,339.72 kg of bread, 19,754,325.27 kg of potatoes,” a total of “33,733,003.40 kg” of 17 categories of food, plus “2,124,568 eggs.” Projected over 10 years, these savings were predicted to amount to “400,244,520 kg” of 20 categories of food worth “141,775,573.80 Reichsmarks.” Removal of these patients from the wards saved estimated hospital expenses of “245,955.50 Reichsmarks per day,” or “88,543,980.00 Reichsmarks per year.” Further, the “State of Prussia invest[ed] annually 125 Reichsmarks for a normal pupil, 573 Reichsmarks for a slow learner, 950 Reichsmarks for an educable but mentally ill child, and 1500 Reichsmarks for a child born blind and deaf” (from documents examined and reported in 7). In the spring of 1940, several family members brought murder charges against the directors of 2 of the killing institutions, but the courts dropped charges when they learned that Hitler himself had authorized the operation (14). Some of the asylums from which patients with mental illness were selected for killing were church-run organizations, and church officials protested. The most famous public statement against Aktion T4 came from Catholic Bishop Clemens Graf von Galen in a sermon delivered on August 3, 1941:
Von Galen’s sermon was copied and circulated across Germany, provoking large-scale demonstrations. Not long thereafter, Hitler issued an order halting Aktion T4. It is uncertain whether this was done in response to the protests or because Aktion T4 had by then met its initial goals (22). However, the practice of killing the disabled continued. From 1941 onward, patients who suffered from mental illness were killed by neglect and starvation and, when this method proved too slow, by lethal injection. The selection process for this phase of “wild euthanasia,” as it is called in Nazi documents, was carried out by individual psychiatrists (23). Patients were selected to die not only because they were nonproductive but also because they were hard to manage or because they displayed homosexual behaviour. “Wild euthanasia” was extended to slave labourers who were ill, to residents of reform schools, and to the elderly, especially those in institutions for the poor. In 1990 previously unknown documents from the Nazi era, preserved in the central archives of the Ministry for State Security, were found in Berlin. Nearly 30 000 of the more than 70 000 psychiatric patient files surfaced. A sampling of 185 files indicated that most of the victims had been hospitalized over long periods and classified either as schizophrenic or feeble-minded. Five percent of the victims were not unproductive—they were employed (24). Euthanasia found its way to the concentration camps under the program code-named 14f13 (25). 14f referred to the code number for the Inspectorate of Concentration Camps, and 13 referred to the “special treatment of sick and frail prisoners.” The program was devised by Himmler to rid the camps of sick prisoners (14). In the Auschwitz concentration camp alone, thousands of disabled and mentally ill people were murdered in gas chambers. ChildrenIn 1935, a young protégé of Ernst Rüdin’s, Dr Franz J Kallman, presented a paper at the Berlin International Congress for Population Science, in which he argued for the sterilization of even the apparently healthy relatives of those with schizophrenia, along with the patients themselves, to eliminate defective genes. Kallmann’s genetic studies were used partly to justify the murder of patients, many of them children (26). The killing of children with mental and physical disabilities was carried out in so-called Specialized Children’s Departments (27). Information on these children was sent to Berlin, where it was reviewed by a panel of 3 medical experts who decided whether a particular child was to be killed. The decision was made without the expert examining the child and without the consent of parents. The children selected for death were transported to one of the designated killing centres in Germany, while the parents were told that the transfers would allow for “the best and most efficacious treatment available.” After the children arrived, the process of euthanasia was delayed for several weeks to give the impression that treatments were being tried. The actual murder was by barbiturate injection. Some doctors did not waste medications on their “patients,” preferring to starve them to death. The parents of the deceased child were informed via form letter that the infant had died of pneumonia or another made-up cause (14). Although the children’s program was initially restricted to children under age 3 years, this age limit was soon extended. The German Association of Child and Adolescent Psychiatry and Allied Professions was founded in 1940 in Vienna. At the first conference, speakers found a solution for the problem of “asocial” minors: They were separated from their families and given special education. The object of this effort was to indoctrinate them into the ideology of National Socialism. Physicians then determined the value of each child’s life according to economic criteria. Children with negative ratings (for example, those deemed unlikely to be able to work or showing a low IQ test score) were killed by fasting “cures” or by barbiturates. Some 6000 children were killed by the end of the war. In addition, children were used as research subjects, because German scientists were very interested in brain research (19). Julius Deussen (1906–1970), head of the Department for Hereditary Psychology at the Deutsche Forschungsanstalt and a close coworker of Carl Schneider (1891–1946) at the University of Heidelberg, coordinated studies on children with the aim of correlating clinical and laboratory findings with brain histopathology. Ernst Rüdin supported the activities of Deussen in Heidelberg and repeatedly noted that they were important for the health and population policy of the Nazi regime (28). Carl Schneider, head of the famous Department of Psychiatry at Heidelberg until 1945, was known for advocating intensive therapy for patients to reintegrate them into society. At the same time, he suffered no apparent compunction about killing those he considered beyond the reach of active therapy. There were 52 children with mental handicap in the research program that he headed, and the historical record shows that 20 were killed in the asylum of Eichberg so that their brains could be examined in Heidelberg (29). Professor Schneider committed suicide in 1946. Dr Elizabeth Hecker, a pioneer of child and adolescent psychiatry in Germany, was director of a clinic for adolescent psychiatry in Silesia. This clinic was one of the first to be dedicated solely to adolescent psychiatry. Any child in this clinic who did not pass intelligence and behaviour tests was reported to the Reich Committee for the Scientific Registration of Severe Genetically and Constitutionally Determined Diseases in Berlin and was then transferred to a local “special department.” Despite this, in 1979 the German Association of Child and Adolescent Psychiatry appointed Hecker an honorary member because of her postwar commitment to the cause (30). What Does This Teach Us?One lesson for contemporary psychiatry is that Vorsorge—preventive health—must never be prized above treatment for those who are ill. Preventive health saves money. Treating the ill is costly. The design of public health measures is a white- collar activity. The care of the ill is bloody, back-breaking, grimy, unglamorous, and often unrewarding. The physician’s core values are healing, relief of suffering, and compassion. Responding to human suffering is the primary responsibility of psychiatry. To quote Barondess,
Another lesson is that the care of the sick must never be subverted to an ideology, whether imposed by the state, by the church, by science, or by commercial interests. Professional relations with governments require our constant vigilance. We must forever be wary of political and economic pressures that impinge on our decisions about the delivery of health services, the distribution of resources, and the support for some kinds of educational endeavours above others or for some kinds of research pursuits at the exclusion of others (10). An editorial in the British Medical Journal alerts us to the fact that today’s physicians are not immune to political pressures:
The same editorial also issues a warning about science:
Medical science must always concern itself with the human implications of its discoveries, must recognize that its conclusions are at best tentative (1), and must not permit the requirements of a research agenda to trump individual well-being. In answer to the British Medical Journal’s Nuremburg issue that this editorial prefaced, readers pointed out that the policy of compulsory sterilization of “defective” people was first implemented not in Germany but in the US in 1907; by 1913 sterilization was legal in 12 states. More than 60 000 people were sterilized in the US between 1907 and the 1970s. These laws were drafted by doctors, upheld by the US Supreme Court in 1927, and in 1985, were still valid in 19 states (32). In 1928 Alberta passed similar laws, under which 3500 Native women were sterilized. After British Columbia passed a sterilization law in 1933, The United Church of Canada established 2 major centres on the West Coast, and missionary doctors sterilized thousands of Native men and women. This practice continued until the 1980s (33,34). In what ways do such practices differ from assisted suicide and mercy killing of the profoundly disabled (motivated not by an ideological or personal agenda but by the wish to stop unbearable suffering—as in Robert Latimer’s 1993 asphyxiation of his daughter, Tracy)? This issue has preoccupied Canadian bioethicists in recent years (35). We must be humble in what we think we know. Diagnostic and motivational uncertainties are everywhere in psychiatry, and our ability to prognosticate is very poor. Treatment response is variable and often unpredictable. We have done little about the large numbers of individuals who have limited access to mental health services and about the inequalities in the calibre of psychiatric care that exist between privileged and disadvantaged groups of people. This implies the existence of hierarchies of human worth, a disturbing echo of the Nazi era (1). We have done little for those who seek help and are stigmatized for it. We have done little to collectively endorse and publicize the fact that there is no single universally right method to treat mental illnesses, that many valid approaches coexist. We must be careful about the commercial exploitation of our research findings, especially the eventual discovery of susceptibility genes for psychiatric disorders (36). When these genes are found, we must apply all our collective wisdom to prevent a new biological determinism from sweeping our profession. Current pressures in the health care system make it imperative that we protect the traditional values of caring for the sick. Short hospitalizations that help the bottom line of institutions pose as reflecting the best interests of patients. Do they? Recent reforms of the mental health system seem to be based mainly on considerations of cost. The Nazi era has taught us that medical values are malleable and can all too easily be shaped by priorities of the state, personal agendas, careerism, the profit motive, and deep biases in society and in ourselves (1). References1. Barondess JA. Care of the medical ethos: reflections on social Darwinism, racial hygiene, and the Holocaust. Ann Intern Med 1998;129:891–8. 2. Birley JL. Political abuse of psychiatry. Acta Psychiatr Scand Suppl 2000;399:13–5. 3. Blasius D. [Psychiatry in the era of national socialism]. Sudhoffs Arch Z Wissenschaftsgesch 1991;75:90–105. 4. Dudley M, Gale F. Psychiatrists as a moral community? Psychiatry under the Nazis and its contemporary relevance. Aust N Z J Psychiatry 2002;36:585–94. 5. Geiderman JM. Ethics seminars: physician complicity in the Holocaust: historical review and reflections on emergency medicine in the 21st century, part I. Acad Emerg Med 2002;9:223–31. 6. Geiderman JM. Ethics seminars: physician complicity in the Holocaust: historical review and reflections on emergency medicine in the 21st century, part II. Acad Emerg Med 2002;9:232–40. 7. Hanauske-Abel HM. Not a slippery slope or sudden subversion: German medicine and National Socialism in 1933. BMJ 1996;131:1453–63. 8. Meyer JE.The fate of the mentally ill in Germany during the Third Reich. Psychol Med 1988;18:575–81. 9. Reich WT. The care-based ethic of Nazi medicine and the moral importance of what we care about. Am J Bioethics 2001;1:64–74. 10. Seidelman WE. Nuremberg lamentation: for the forgotten members of medical science. BMJ 1996;313:1463–7. 11. Smith R, Hiatt H, Berwick D. Shared ethical principles for everybody in health care: a working draft from the Tavistock Group. BMJ 1999;318(7178):248–51. 12. Sabin JE. Caring about patients and caring about money: the American Psychiatric Association Code of Ethics meets managed care. Behav Sci Law 1994;12:317–30. 13. Binding K, Hoche A. Permitting the destruction of unworthy life. Wright WE, translator. Issues Law Med 1994;8:231–65. 14. Gardella JE. The cost-effectiveness of killing: an overview of Nazi “euthanasia.” Medical Sentinel 1999;4:132–5. 15. Proctor R. The Nazi war on tobacco: ideology, evidence, and possible cancer consequences. Bull Hist Med 1997;71:435–88. 16. Fangerau H, Muller I. [The standard textbook on racial hygiene by Erwin Baur, Eugen Fischer, and Fritz Lenz as viewed by the psychiatric and neurological communities from 1921 to 1940]. Nervenarzt 2002;73:1039–46. 17. Kenny MG. A darker shade of green: medical botany, homeopathy, and cultural politics in interwar Germany. Soc Hist Med 2002;15:481–504. 18. Burleigh M. Psychiatry, German society, and the Nazi ‘euthanasia’ programme. Soc Hist Med 1994;7:213–28. 19. Dahl M. [Selection and destruction—treatment of “unworthy-to-live” children in the Third Reich and the role of child and adolescent psychiatry]. Prax Kinderpsychol Kinderpsychiatr 2001;50:170–91. 20. Peters UH. [Ernst Rüdin—a Swiss psychiatrist as the leader of Nazi psychiatry—the final solution as a goal]. Fortschr Neurol Psychiatr 1996;64:327–43. 21. Hassenfeld IN. Doctor–patient relations in Nazi Germany and the fate of psychiatric patients. Psychiatr Q 2002;73:183–94. 22. Izumi H. [“Euthanasia” operation by Nazis on patients with psychiatric or hereditary diseases, and Bishop von Galen of Munster]. Nippon Ishigaku Zasshi 2003;49:277–319. 23. von Cranach M. [The killing of psychiatric patients in Nazi Germany between 1939–1945]. Isr J Psychiatry Relat Sci 2003;40:8–18. Discussion 19–28. 24. Hohendorf G, Rotzoll M, Richter P, Eckart W, Mundt C. [Victims of Nazi euthanasia, the so-called T4 action. First results of a project at the German Federal Archives to disclose records of killed patients]. Nervenarzt 2002;73:1065–74. 25. Kucharski J. [Euthanasia as a form of extermination applied by Germans in concentration camps during the World War II]. Arch Hist Filoz Med 1998;61:335–44. 26. Mildenberger F. [On the track of “scientific pursuit”. Franz Josef Kallmann (1897–1965) and genetic racial research]. Medizinhist J 2002;37:183–200. 27. Bernhardt H. [“Never useful even for the most primitive accomplishments.” Murder of handicapped and sick children 1939 to 1945 in the Ueckermunde district hospital] Prax Kinderpsychol Kinderpsychiatr 1993;42:240–8. 28. Roelcke V, Hohendorf G, Rotzoll M. [Hereditary psychological research in the context of “euthanasia”: new documents and aspects on Carl Schneider, Julius Deussen and Ernst Rüdin] Fortschr Neurol Psychiatr 1998;66:331–6. 29. Hohendorf G, Roelcke V, Rotzoll M. [Innovation and extermination— psychiatric research and “euthanasia” at the Heidelberg Psychiatric Clinic 1939–1945] Nervenarzt 1996;67:935–46. 30. Dahl M. [Dr Elisabeth Hecker (1895–1986): career in child and adolescent psychiatry on the one hand—involvement in elimination of the handicapped on the other hand] Prax Kinderpsychol Kinderpsychiatr 2003;52:98–108. 31. Leaning J.War crimes and medical science. BMJ 1996;313:1413–5. 32. Baron JH. The BMJ’s Nuremberg issue. Compulsory sterilisation of defective people was legal in several countries besides Germany. BMJ 1997;314:440. 33. Reilly PR. The surgical solution: a history of involuntary sterilization in the USA. Baltimore (MD): Johns Hopkins University Press; 1991. 34. McLaren A. Our own master race: eugenics in Canada, 1885–1945. Toronto (ON): McClelland & Stewart; 1990. 35. Lavery JV, Dickens BM, Boyle JM, Singer PA. Bioethics for clinicians: 11. Euthanasia and assisted suicide. CMAJ 1997;156:1405–8. 36. Jones I, Kent L, Paul M, Craddock N. Clinical implications of psychiatric genetics in the new millennium—nightmare or nirvana? Psychiatr Bull 2001;25:129–31. Author(s)Manuscript received March 2004 and accepted July 2004. 1. Staff Psychiatrist, Centre for Addiction and Mental Health, Toronto, Ontario. Address for correspondence: Dr MV Seeman, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8 e-mail: mary.seeman@utoronto.ca
1 | 2
|
||||||