Estrategias e indicadores del plan de marketing

The Führer holds the cleansing of the medical profession far more important than, for example, that of the bureaucracy, since in his opinion the duty of .the physician is or should be one of racial leadership.

— MARTIN BORMANN

The völkisch state must see to it that only the healthy beget children .... Here the state must act as the guardian of a millennial future .... It must put the most modern medical means in the service of this knowledge. It must declare unfit for propagation all who are in any way visibly sick or who have inherited a disease and can

therefore pass it on.

— ADOLF HITLER

First Steps Policies and the Courts

Only in Nazi Germany was sterilization a forerunner of mass murder. Programs of coercive sterilization were not peculiar to Nazi Germany. They have existed in much of the Western world, including the United States, which has a history of coercive and sometimes illegal sterilization applied mostly to the underclass of our society. It was in the United States that a relatively simple form of vasectomy was developed at a penal institution around the turn of the century. This procedure together with a rising interest in eugenics, led, by 1920, to the enactment of laws in twenty-five states providing for compulsory sterilization of the criminally insane and other people considered genetically inferior.

No wonder that Fritz Lenz, a German physician-geneticist advocate of sterilization (later a leading ideologue in the Nazi program of “racial hygiene”), could, in 1923, berate his countrymen for their backwardness in the domain of sterilization as compared with the United States. Lenz complained that provisions in the Weimar Constitution (prohibiting the infliction of bodily alterations on human beings) prevented widespread use of vasectomy techniques; that Germany had nothing to match the eugenics research institutions in England and the United States (for instance, that at Cold Spring Harbor, New York, led by Charles B. Davenport and funded by the Carnegie Institution in Washington and, by Mary Harriman); and that Germany had no equivalent to the American laws prohibiting marriage both for people suffering from such conditions as epilepsy or mental retardation, and between people of different races. Lenz criticized America only for focusing too generally on preserving the “white race” instead of specifically on the “Nordic race” — yet was convinced that "the next round in the thousand year fight for

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the life of the Nordic race will probably be fought in America.”¹That single reservation suggests the early German focus on a specific racial entity, the “Nordic” or “Aryan race,” however unsupported by existing knowledge.

There had been plenty of racial-eugenic passion in the United States, impulses to sterilize large numbers of criminals and mental patients out of fear of “national degeneration” and of threat to the health of ”the civilized races,” who were seen to be “biologically plunging downward.” Associated with the American eugenics movement was a biomedical vision whose extent is suggested by the following quotation from a 1923 book by A. E. Wiggam: “The first warning which biology gives to statesmanship is that the advanced races of mankind are going backward; ... that civilization, as you have so far administered it, is self-destructive; that civilization always destroys the man that builds it; that your vast efforts to improve man’s lot, instead of improving man, are hastening the hour of his destruction.”²

(A clear distinction must be made between genetics and eugenics. Genetics was, and is, a legitimate science, though one with limited development at the time [it began as a science with the recognition of Mendel’s laws in 1900]; its principles were crudely, often falsely, applied by the Nazis. “Eugenics” is a term coined by Francis Galion in 1883 to denote the principle of strengthening a biological group on the basis of ostensible hereditary worth; despite its evolutionary claims and later reference to genetic laws, eugenics has no scientific standing.)

But the German version of eugenics had a characteristic tone of romantic excess, as in Lenz’s earlier (1917) declaration, in a thesis written for his professor, Alfred Ploetz (a social-Darwinist and the founder, in 1904, of the German Society for Racial Hygiene), that “race was the criterion of value” and “the State is not there to see that the individual gets his rights, but to serve the race.” Lenz understood his advocacy to be one of “organic socialism” and feared that, without a radical eugenics project, “our [Nordic] race is doomed to extinction.”

For Germans like Lenz in the 1920s, establishing widespread compulsory, sterilization became a sacred mission — a mission that led them to embrace National Socialism, with its similar commitment. While

1 Lenz did not at this point infer anti-Semitism from his belief in racial differences. Citing him, among others, George L. Mosse has argued that “there is no warrant for the claim to seem the ... doctrine of ‘racial biology and hygiene’ an immediate forerunner of the Nazi Policy against the Jews.”^² But once the Jews came to be viewed as a race, the connection was readily made.

2 In a 1932 study of the sterilization movement in the United States, J. P. Landman spoke of “alarmist eugenics”

and of “overzealous and over ardent eugenicists” who “regard the socially inadequate persons, i.e., the feeble-minded, the epileptics, the mentally diseased, the blind, the deformed and the criminals as inimical to the human race ... [because] these peoples perpetuate their deficiencies and thus threaten the quality of the ensuing generations. It should be our aim to exterminate these undesirables, they contend, since a nation must defend itself against national degeneration as much as against the external foreign enemy.”

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American and British advocates of eugenics sometimes approached this German romantic excess, the political systems in the two countries allowed for open criticism and for legal redress. In Britain there was continual legal resistance to coercive sterilization; and in the United States, legal questions could be raised concerning individual rights and limited knowledge about heredity, which eventually led to the rescinding or inactivation of sterilization laws in the states where they had been passed.³ In Nazi Germany, on the other hand, the genetic romanticism of an extreme biomedical vision combined with a totalistic political structure to enable the nation to carry out relentlessly, and without legal interference, a more extensive program of compulsory sterilization than had ever previously been attempted. Indeed, the entire Nazi regime was built on a biomedical vision that required the kind of racial purification that would progress, from sterilization to extensive killing.⁴

As early as his publication of Mein Kampf between 1924 and 1926, Hitler had declared the sacred racial mission of the German people to be “assembling and preserving the most valuable stocks of basic racial elements [and] ... slowly and surely raising them to a dominant position.” He was specific about the necessity for sterilization (“the most modern medical means ”) on behalf of an immortalizing vision of the state-mediated race (“a millennial future”). And for him the stakes were absolute: “If the power to fight for one’s own health is no longer present, the right to live in this world of struggle ends.”

Once in power — Hitler took the oath of office as Chancellor of the Third Reich on 30 January 1933 — the Nazi regime made sterilization the first application of the biomedical imagination to this issue of collective life or death. On 22 June, Wilhelm Frick, the minister of the interior, introduced the early sterilization law with a declaration that Germany was in grave danger of Volkstod (“death of the people”

[or “nation” or “race"]) and that harsh and sweeping measures were therefore imperative. The law was implemented three weeks later, less than six months after Hitler had become chancellor, and was extended by amendation later that year. It became basic sterilization doctrine and set the tone for the regime's medicalized approach to “life unworthy of life.” Included among the “hereditarily sick” who were to be surgically sterilized were the categories of congenital feeblemindedness (now called mental deficiency), an estimated 200,000; schizophrenia, 80,000; manic depressive insanity, 20,000; epilepsy, 60,000; Huntington’s chorea (a hereditary brain disorder), 600; hereditary blindness, 4,000; hereditary deafness, 16,000; grave bodily malformation, 20,000; and hereditary alcoholism, 10,000. The projected total of 410,000 was considered only preliminary, drawn mostly from people already in institutions; it was assumed that much greater numbers of people would eventually be identified and sterilized.

Special “Hereditary Health Courts” were set up to make decisions on sterilization, their composition reflecting the desired combination of medicalization and Nazi Party influence. Of the three members, two were physicians — one an administrative health officer likely to have close Party ties and the other

3 In observing Nazi sterilization policies, the Journal of the American Medical Association did not so much express outrage as it contrasted America’s “more gradual evolution of practice and principles” regarding sterilization.

Ardent American sterilizers, such as Dr. Joseph S. De Jarnette of Virginia, could, even complain: “The Germans are beating us at our own game.”

4 Thus Daniel J. Kevles reports: “Within three years, German authorities had sterilized some two hundred and twenty-five thousand people, almost ten times the number so treated in the previous thirty years in America.”

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ostensibly knowledgeable about issues of hereditary health; the third was a district judge, also likely to be close to the regime, who served as chairman and coordinator. There were also appeals courts, which made final decisions in contested cases and on which some of the regime’s most recognized medical leaders served. All physicians were legally required to report to health officers anyone they encountered in their practice or elsewhere who fell into any of the preceding categories for sterilization, and also to give testimony on such matters unrestricted by the principle of patient-doctor confidentiality. Physicians also performed the surgical procedures. The entire process was backed up by law and police power.

On 18 October 1935, a major ordinance regulating sterilization and the issuing of marriage licenses followed directly upon the notorious Nuremberg Laws (15 September), which prohibited marriage or any sexual contact between Jews and non-Jews. The Nuremberg lawmakers described themselves as

“permeated with the knowledge that the purity of the German blood is a precondition for the continued existence of the German people, and filled with the inflexible determination to make the German nation secure for all future time.”

There were revealing discussions of method. The favored surgical procedures were ligation of the vas deferens in men and of the ovarian tubes in women. Professor G. A. Wagner, director of the University of Berlin’s Women’s Clinic, advocated that the law provide an option for removing the entire uterus in mentally deficient women. His convoluted argument was based on the principle of “hereditary health”:

mentally deficient women, after being sterilized, were especially likely to attract the opposite sex (who need not worry about impregnating them) and therefore to develop gonorrhea, which is most resistant to treatment when it affects the uterine cervix; the men who would then contract gonorrhea from these women would, in turn, infect other women with desirable hereditary traits and render them sterile. Other medical commentators, making a less genetic and more specifically moralistic argument, favored removal of the uterus in those candidates for sterilization who showed tendencies to promiscuity.⁵ Still more foreboding was an official edict permitting sterilization by irradiation (X rays or radium) in certain specified cases “on the basis of scientific experiments.” These experiments, ostensibly in the service of improving medical procedures for specific cases, were a preliminary step toward later X-ray sterilization experiments conducted extensively, harmfully, and sometimes fatally on Jewish men and women in Auschwitz and elsewhere.

Directors of institutions of various kinds had a strong impulse to sterilize in order to eliminate the possible hereditary influence of a wide variety of conditions - blindness, deafness, congenital defects, and such “crippled” states as clubfoot, harelip, and cleft palate. The genetically dominated worldview demanded of physicians led to discussions of the advisability of sterilizing not only the weak and impaired, but their relatives, anyone who might be a “carrier” of these defects. Not surprisingly, Fritz Lenz carried the concept farthest in suggesting the advisability of sterilizing people with only slight signs

5 There was, indeed, concern that degenerate individuals might seek sterilization to pursue "unrestrained sexual gratification.

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of mental disease, though he recognized that a radical application of this principle would lead to the sterilization of 20 percent of the total German population — something on the order of twenty million people!

In that atmosphere, humane efforts were likely to take the form of pleas for restriction and exemption: for example, the recommendation by the distinguished anti-Nazi Berlin psychiatrist Karl Bonhoeffer that people who combined hereditary defects with unusual qualities or talents should not be sterilized; and the Munich psychiatrist Dr. Oswald Bumke’s recommendation against sterilizing people who were schizoid rather than schizophrenic, along with his cautionary statement that schizophrenia itself could not be eliminated by sterilization because of the complexity of hereditary influences. (The eugenics courts sometimes did make exceptions for the artistically gifted.)

But the regime discouraged qualifications and employed a rhetoric of medical emergency: “dangerous patients” and “urgent cases” were people with hereditary taints still in the prime of life. Among “urgent cases” were mentally deficient but physically healthy men and women between the ages of sixteen and forty, schizophrenic and manic-depressive patients in remission, epileptics and alcoholics under the age of fifty, etc. Once a petition was heard before a sterilization court, the die was pretty well cast. More than 90 percent of petitions taken before the special courts in 1934 resulted in sterilization (though a screening process eliminated some before they got to court); and fewer than 5 percent of appeals against sterilization, made to higher courts, were upheld. But the principle of legality was nonetheless extremely important, and the strict secrecy surrounding court deliberations lent power and mystery to this expression of medicalized authority.

The legal structure cloaked considerable chaos and arbitrariness in criteria for sterilization (especially concerning mental conditions, which resulted in the greatest number of sterilizations) and concerning alleged hereditary factors. Inevitably, too, political considerations affected diagnoses and decisions — as was made clear by a directive from Martin Bormann, Hitler's private secretary and close associate, instructing that the moral and political behavior of a person be considered in making a diagnosis of feeblemindedness. The clear implication was that one could be quick to label “feebleminded” a person seen as hostile to the Nazis, but that one should be cautious indeed about so labeling an ideologically enthusiastic Party member. Political currents and whims also affected the project in various ways; and, despite its high priority, there were undoubtedly periods of diminished enthusiasm for sterilization. No one really knows how many people were actually sterilized; reliable estimates are generally between 200,000 and 350,000.

In association with the sterilization laws, and as a further expression of racial policy, steps were taken to establish a national card index of people with hereditary taints. Special research institutes for hereditary biology and racial hygiene were set up at universities — for example, the institute established by Otmar von Verschuer, a professor at Frankfurt. These institutes sought genetic information about individuals

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extending back over several generations, and made use of hospitals, courts, and local and national health institutions. The physician, as genetic counselor and policeman, could be the vigilant “protector of the family that is free from hereditary defects.” In other words, sterilization was the medical fulcrum of the Nazi biocracy.

Fanatical Genetics

The Role of Ernst Rüdin The predominant medical presence in the Nazi sterilization program was Dr.

Ernst Rüdin, a Swiss-born psychiatrist of international renown. Originally a student of Emil Kraepelin, the great classical psychiatrist, Rüdin became a close associate of Alfred Plotz in establishing the German Society for Racial Hygiene. Rüdin was an indefatigable researcher and saw as his mission the application of Mendelian laws and eugenic principles to psychiatry. A former student and associate of his told me that “the aim of his life” was to establish the genetic basis for psychiatric conditions, and that “he was not so much a fanatical Nazi as a fanatical geneticist.”

But a Nazi Rüdin did become, joining the Party in 1937 at the age of sixty. From his prestigious position as director of the Research Institute for Psychiatry of the Kaiser Wilhelm Society in Munich, Rüdin worked closely with a regime whose commitment to genetic principles he applauded, and was one of the principle architects of the sterilization laws. He became a significant source of scientific legitimation for the regime’s racial policies (including consultations with Hans F. K. Günther, the leading Nazi anthropologist-publicist on racial matters, whose intellectual repute was generally held to be very low).

Rüdin was not involved in the direct medical killing of the “euthanasia” program; but a younger associate to whom I spoke had the impression that his teacher, though not without doubts about the program, could well have favored a version of it with careful medical control.

In a special 1943 issue of his journal, Archive für Rassen-und Gesellschaftsbiologie (Archive of Racial and Social Biology), celebrating ten years of National Socialist rule, Rüdin extolled Hitler and the movement for its “decisive … path-breaking step toward making racial hygiene a fact among the German people ... and inhibiting the propagation of the congenitally ill and inferior.” He praised both the Nuremberg Laws for “preventing the further penetration of the German gene pool by Jewish blood,” and the SS for “its ultimate goal, the creation of a special group of medically superior and healthy people of the German Nordic type.”

A close relative, also a physician, told me that Rüdin felt it “necessary” to write those things and, in response to my question whether he had meant them at the time, answered, ”Well, half and half.” While

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Rüdin apparently did eventually become disillusioned with the regime, he could never (according to a former colleague) bring himself to resign his positions but sought always to work from within.⁶

No one I spoke to thought Rüdin a cruel person; to the contrary, he was seen as decent and dedicated to his work. Yet he not only served the regime but, in his person and scientific reputation, did much to effect the medicalization of racial policies — not quite those of killing but of suppressing in specific groups the continuity of life. He also demonstrates, in extreme form, the attraction of the Nazi biomedical vision for a certain kind of biologically and genetically oriented scientist.

Opposition to Sterilization

There did not seem to be much opposition to sterilization. The Catholic Church disapproved of it, but avoided confronting the issue and did little more than press for the exemption of Catholic judges and doctors from enforcing the law. One judge on a Hereditary Health Appeals Court raised the interesting, question of the “burden of unusual responsibility” placed on doctors required to perform operations that

“serve no therapeutic purpose.” But Gerhard Wagner — then the leading Nazi medical authority and a

“serve no therapeutic purpose.” But Gerhard Wagner — then the leading Nazi medical authority and a