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Practices of responsibility and nurses during the euthanasia programs of Nazi Germany: A discussion paper
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International Journal of Nursing Studies 44 (2007) 845–854 www.elsevier.com/locate/ijnurstu
Practices of responsibility and nurses during the euthanasia programs of Nazi Germany: A discussion paper Maria Berghsa, Bernadette Dierckx de Casterle´b, Chris Gastmansa, a Centre for Biomedical Ethics and Law, Faculty of Medicine, Catholic University of Leuven, Belgium Centre for Health Services and Nursing Research, Faculty of Medicine, Catholic University of Leuven, Belgium
b
Received 9 March 2005; received in revised form 4 April 2006; accepted 9 May 2006
Abstract In this paper, we focus on the contexts of moral decision-making by nurses in the euthanasia programs of Nazi Germany between 1939 and 1945 using Urban Walker’s philosophical model. We use the second hypothesis of this model, that morality consists of practices of responsibility, to give an analysis of the understandings nurses had of their responsibilities in the euthanasia programs. The article starts with a brief introduction to the euthanasia programs of Nazi Germany from 1939 to 1945 and nurse participation, to illustrate how the responsibilities of nurses were manipulated. Secondly, nursing as moral practices are analysed in the context of the euthanasia programs that implement commonly shared understandings and practices of responsibility. Thirdly, the reasons that nurses gave for avoiding any responsibilities are examined. Fourthly, it is examined if nurses took any responsibility in the euthanasia programs. In conclusion, this paper discusses three points of relevance such a reflection on moral responsibility in the context of Nazi Germany has for nurses today who may be confronted with euthanasia. r 2006 Elsevier Ltd. All rights reserved. Keywords: Ethics; Euthanasia; Nazi Germany; Nursing
What is already known about the topic?
Nurses
were involved in all the differing phases (registration, selection, transfer, and secret killing) of the euthanasia programs of Nazi Germany. Nurses are substantially involved in current illegal euthanasia practices in Belgium.
What this paper adds
A historical-ethical reflection on the involvement of nurses in the euthanasia programs of Nazi Germany Corresponding author. Tel.: +32 0 16 33 69 51;
fax: +32 0 16 33 69 52. E-mail address: [email protected] (C. Gastmans).
using Margaret Urban Walker’s philosophical insights on practices of responsibility. Identification of three important issues—transparency of role and responsibility, communication and decision-making, empowerment of nurses—that could aid ethical practice concerning nurses involvement in caring for patients requesting euthanasia.
1. Introduction The beginning of the 20th century marked the emergence of eugenics, the improvement of the human race, as a popular scientific movement in many countries such as the United States, Great Britain and Germany (Kevles, 1985). While many eugenic principles were positive in the sense that they were public health
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.05.003
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campaigns which educated the general public about health, heredity, and procreation, negative eugenic policies argued that the genetically ‘defective’ or ‘deviant’ were a threat to the public’s health (Kevles, 1985). The worst abuses of negative eugenic policies took place during the euthanasia programs of Nazi Germany from 1939 to 1945. Healthcare professionals, such as nurses, were involved and actively carried out such policies thereby giving up their moral responsibilities to care (Aly and Roth, 1984; McFarland-Icke, 1999). To try to gain new insights into how and why some nurses in Nazi Germany gave up their moral responsibilities as well as to reflect on recent evolutions in euthanasia today, we implement the philosophical insights of Margaret Urban Walker (1998) against the historical background of the euthanasia programs of Nazi Germany. Walker (1998, p. 9–10) elucidates a method of moral inquiry that she calls ‘expressivecollaborative’, which, ‘‘y prescribes an investigation of morality as a socially embodied medium of mutual understanding and negotiation between people over their responsibility for things open to human care and response.’’ This means that morality is expressed in the interpersonal contexts, it is ‘‘y reproduced or modified in what goes on between and among people.’’ Walker model is also collaborative in the sense that, ‘‘we construct and sustain it together’’, although not always in chosen or equal terms. Walker’s ‘expressive collaborative’ method of moral inquiry consists of four hypotheses, and we focus on the second hypothesis that states that, ‘‘the practices characteristic of morality are practices of responsibility’’ (1998, p. 16). Walker argues that morality works according to interpersonal understandings of practices of responsibility, so any description of responsibility has to focus on what participants understand by such responsibilities. This paper gives a close and critical analysis of the understandings some nurses had of their practices in the euthanasia programs of Nazi Germany. Thereby, allowing us to track these nurses’ roles and responsibilities in euthanasia practices as well as expose their values and why nurses became involved in such practices. The article starts with a brief introduction to the euthanasia programs of Nazi Germany from 1939 to 1945 and nurse participation, to illustrate how the responsibilities of many nurses were manipulated. Secondly, we examine nursing as moral practices in the context of the euthanasia programs that implement commonly shared understandings and practices of responsibility. Thirdly, we examine the reasons that nurses gave for avoiding any responsibilities. Fourthly, we examine if nurses took any responsibility in the euthanasia programs. In conclusion, we discuss the relevance that a novel ethical reflection on moral
responsibility in the context of Nazi Germany has for nurses today who may be confronted with euthanasia. Walker’s philosophical model allows us to give an ethical interpretation of moral life that can function both descriptively and normatively. Descriptively, the aim is to give an interpretation and/or reveal what ‘morality’ was and now is. Normatively, the aim is to suggest some important things that morality is for and on which past and present practices it depends on—for better or worse. We thus hope that by undertaking such a reflection we can contribute both descriptively and normatively to nurses’ understandings of their attitudes towards as well as involvement in euthanasia practices both past and the present.
2. The euthanasia programs and the manipulation of responsibilities of nurses In order for nurses to understand their moral responsibilities, they have to be able to question the moral terms and contexts that are set for them by their community. Walker (1998) elucidates that this ‘demand of transparency’ to understand moral responsibilities in a community, is based on a shared social contract or belief in a covenant of trust, represented by the shared general values of a community, as well as its laws. We aim to investigate whether in Nazi Germany, the shared social contract and belief in a covenant of trust was manipulated in order to implement the euthanasia programs and gain the participation of healthcare professionals in these programs. 2.1. The euthanasia programs The euthanasia programs began in 1939 with children’s euthanasia (Kinderacktion) and from 1941 onwards also included adult euthanasia (Acktion T-4) (Aly and Roth, 1984; Burleigh, 1994, 1997). The euthanasia programs involved the registration, selection, transfer and secret killing of the aged, insane, incurably ill, deformed, Jews and all other people termed ‘defective’ (Aly and Roth, 1984; Burleigh, 1994, 1997; Friedlander, 1995). New evidence has indicated that the secret euthanasia programs involved over 296 mental and nursing as well as medical institutions in Germany, Austria, the Czech Republic, Poland and Russia, as well as healthcare professionals in those countries at all levels (Bundesarchivs, 2003). Nurses were involved in all the differing phases of the euthanasia programs (NMT 01. Medical Case- USA v. Karl Brandt et al., 1947; Bundesarchivs, 2003). In the children’s euthanasia programs they actively assisted in killing children through injections of morphine and scopolamine, by starvation, or overdoses of medications (Burleigh, 1994; Benedict and Kuhla, 1999). In the adult
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euthanasia programs, nurses assisted in the selection and the transportation of adults to the institutions in which they were to be killed by gassing. In the later stages of the adult euthanasia program, nurses assisted the physicians and also actively killed patients by giving them drugs or administering lethal injections (Burleigh, 1994, 1997). Some of the staff (including the nurses) of the early euthanasia programs served to select and help eliminate ill concentration camp prisoners in the later Operation 14 f 13 and implement the Final Solution (Aly and Roth, 1984; Friedlander, 1995).
patients and their families, as well as the healthcare institutions themselves. The accountability that nurses accepted, defined how they thought about the scope and limits of their moral agency, and revealed what they cared about and who had standing to judge and blame them. Examining nursing as practices of responsibility in this way, allows us to give detailed and situated descriptions of the expectations and negotiations surrounding assignments of responsibility (Walker, 1998).
2.2. The manipulation of responsibilities of nurses
In assigning responsibility, in German hospitals and psychiatric institutions of the time as well as in society, there existed a strong hierarchical structure (Burleigh, 1994, 1997). In the psychiatric institutions involved in the euthanasia programs, the order to allow euthanasia came directly from Hitler through differing bureaucracies designed to diffuse any individual responsibility. In these differing bureaucracies, often bearing false names, prominent psychiatrists decided which institutions would be involved in euthanasia and how many victims, supplied the questionnaires and paperwork, as well as counseled the killers (Dudley and Gale, 2002). Institutional professional medical and nursing routines were adhered to, to give the appearance of normality. Orders were given from physicians to the head nurses, who in turn would give the orders to the other nurses. The physician or head nurse, by giving an order, stood as a kind of guarantee of the medical quality and ethical correctness of that order (McFarland-Icke, 1999). Both the physicians and nurses understood their ethical responsibilities in terms of a strong commitment to obedience. The importance of obedience was further highlighted by the fact that nurses did not always have the medical knowledge that the physicians had, so it was vital for the well-being of a patient that nurses obey orders (Benedict and Kuhla, 1999). To be a responsible nurse was to be a nurse who would follow orders with an unquestioning obedience—concisely, objectively and devoid of any judgments (McFarland-Icke, 1999).
In the beginning of the euthanasia program in 1939, Hitler gave the secret order for a program of ‘mercy killing’ or euthanasia to begin that was never legally nor officially sanctioned. By doing this, according to Kottow (1988), he violated the moral demands of transparency necessary in a democratic community and transformed the concept of euthanasia from voluntary assisted death to involuntary, medically supervised killing (Ernst, 1996). Reich (2001) has termed this manipulation of moral responsibility ‘the betrayal of care’, in that Hitler’s order betrayed the caring goals of medicine and nursing, and the moral integrity of healthcare professionals. Walker (1998) explains that the manipulation of a moral agent begins through changes affecting who is more likely to enter a profession. In the Nazi era, the entire nursing profession was purged of all nurses who had been affiliated with other political parties, trade unions, voiced criticism, or were Jewish. The entire nursing profession and its organization lost its independence and became aimed at creating conditions and structures to support the policies of National Socialism (Walter, 2003; Steppe, 2000). Furthermore, many new untrained and inexperienced people entered the nursing profession to escape the dole queues (Burleigh, 1994; Walter, 2003). The new nurses were often ordinary men and women from working class or lower middle class backgrounds in rural areas, often with a rudimentary elementary school education and accepting their new responsibility in the euthanasia programs (McFarland-Icke, 1999).
3. Nursing as practice of responsibility Nursing as moral practice, implements commonly shared understandings and practices of responsibility, ‘‘of who gets to do what to whom and who is supposed to do what for whom’’ (Walker, 1998, p. 16). In the context of the euthanasia programs of Nazi Germany, examining responsibility reveals the accountability that nurses had towards other members of a healthcare team, their
3.1. Responsibility and obedience
3.2. Differing levels of responsibility The ethical responsibilities that nurses claimed to have for their roles in the euthanasia programs differed according to the kinds of moral contexts that they found themselves in. According to Walker (1998, p. 16), who does ‘‘what, where, and for whom’’ becomes very important in assigning responsibility. Likewise, the fact that one is excluded from certain responsibilities also forms a moral agent’s understanding of the accountability or non-accountability for particular practices. McFarland-Icke (1999) too has pointed out that responsibilities were understood in different ways
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between nurses at the peripheries or at the beginnings of the euthanasia programs and those nurses who actively killed in the later programs. Nurses, at the peripheries who had indirectly participated in the euthanasia programs, by for example assisting in the transport of patients to other institutions, argued they were excluded from responsibilities because they did not know what was going to happen to their patients (McFarland-Icke, 1999). Nurses argued there was a difference in assisting and direct participation. Nurses also evaded responsibility through their own interpretation of events arguing that although they heard rumors, as they could not officially be sure, euthanasia was not occurring (McFarland-Icke, 1999; Dudley and Gale, 2002). Still other nurses reasoned that volitionally, as they had not actively participated, it had nothing to do with them (Benedict and Kuhla, 1999; Dudley and Gale, 2002). 3.3. Forced and accepted participation Walker (1998, p. 16) notes that, ‘‘y it is in the nature of morality to work by means of interpersonal understandings, so that what is to be described includes participants’ grasp of what the understandings are.’’ An examination of nurses’ understandings of their responsibilities is important, to understand why some nurses felt that they had no responsibilities in certain nursing practices. Those nurses who actively killed in euthanasia practices, could not say that they did not know about euthanasia and could not easily evade responsibility for their action. They claimed that they had been forced, under threat of death, to accept such responsibilities and were asked to sign oaths of secrecy (District Court Berlin, 1947; NMT 01. Medical Case- USA v. Karl Brandt et al., 1947). Some nurses accepted participation not because they were threatened but because they could see no other options for employment (Willig, 1947). Other nurses readily accepted participation and became spontaneous practiced killers. When the religious affiliations of the nursing staff made it difficult for euthanasia to be carried out, nurses who had the right kind of ideological commitment were sent to the institution to rectify the situation (Burleigh, 1994).
and values.’’ This analysis allows us to describe what such nurses’ interpersonal understandings of morality are as well as what practices or beliefs sustain their morality. 4.1. Coercion Nurses who deflected their responsibilities for direct participation in the euthanasia programs argued that they were behaving under coercion, and appealed to obedience and the background of war, terror, and psychological influence of the group as mitigating factors that necessarily made them evade their responsibilities. 4.1.1. Appeal to obedience Many nurses appealed to the fact that they had only obeyed orders by participating in the euthanasia programs. They argued that they had behaved morally by doing their duty, which had required them to behave in a Kant-like manner without any thoughts to their own moral inclinations, beliefs or desires (Benedict and Kuhla, 1999). Arendt (1964) argues against the nurses’ Kantian appeal to obedience pointing out that Kant’s moral philosophy is closely bound up with our faculty of judgment—ruling out blind obedience. The military courts also argued that acting on the orders of superiors does not relieve someone of responsibility for a crime. 4.1.2. Background of war, terror and the psychological influence of the group Nurses also appealed to the fact that they were living in a totalitarian state during a war, where they worked under a regime of terror (District Court Berlin, 1947; Friedlander, 1995; McFarland-Icke, 1999). Various nurses reported on feelings of being divided from normality and under intense pressure to comply and do unethical things that they would normally never do to keep their jobs or to stay alive (McFarland-Icke, 1999). Nurses also claimed to be unable in a wartime situation to see the consequences of their actions in a future perspective. In this respect nurses also alluded to the psychological influence of the group and the huge psychological pressures that they were under to comply and to engage in acts that they would normally never do (Burleigh, 1994, 1997; McFarland-Icke, 1999).
4. Avoiding responsibility 4.2. Complicity In order to further understand why some nurses participated in euthanasia practices and yet argue they have no responsibilities we need to look at the reasons they give for evading that responsibility. Walker (1998, p. 16) elucidates that in the ways that we, ‘‘y assign, accept, or deflect responsibilities, we express our understandings of our own and other’s identities, relationships,
Walker (1998) notes that the justifications for redrawn responsibilities often lie in the social moral values and positions of the time that the moral agent is living in. This was also the case for the nurses’ justifications of complicity, they appealed to their belief in the moral correctness of the euthanasia killings, the importance of
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the Volk over the individual, and lastly to utilitarian economic motives. 4.2.1. Belief in the ‘moral correctness’ of the euthanasia killings Some nurses believed in the moral correctness of the euthanasia killings, arguing that for humanitarian reasons, it was better for the patients to be put out of their misery (Burleigh, 1994, 1997; McFarland-Icke, 1999). In these cases, thinking about euthanasia as ‘mercy-killing’ or ‘death as deliverance’ allowed nurses to combine their conventional morality with participation in euthanasia practices (McFarland-Icke, 1999). Burleigh (1994) points out that in one of the last major euthanasia trials in 1986, the fact that the nurses repeated that they had ‘killed out of love and pity’ indicated that nurses believed in the notion of ‘life unworthy of life’ before, during, and long after the euthanasia programs. Most nurses who actively participated in euthanasia practices also believed that euthanasia was legal and sanctioned by the state and Hitler, as the right and thus moral thing to do (District Court Berlin, 1947). Nurses as good citizens and as human beings, felt that obeying the law especially in cases where the patients was suffering or going to suffer was also to behave morally (Benedict and Kuhla, 1999; McFarland-Icke, 1999). 4.2.2. The importance of the ‘Volk’ A nurse’s attention was also gradually turned away from individual towards the caring responsibilities in terms of the German ‘Volk’ or people. Reich (2001) elucidates that under the Nazis there was a corruption of the concept of care (Sorge) in terms of caring for (Fu¨rsorge), towards preventive care (Vorsorge) instead. Many nurses believed that scientific progress had identified certain people as health hazards to the German race and they had a professional duty to separate those people from the healthy contributing so to a healthy and stronger Germany. Their ethics became linked to a strong but simplistic belief in technology and scientific progress and a utopia where disease and illness did not exist (Burleigh, 1994). 4.2.3. Utilitarian economic motives Linked to the shift in some nurses’ moral understandings of the importance of the German people, were the utilitarian economic motives used to justify that shift. Euthanasia became linked to another larger and more moral cause, that of saving the Germany by aiding economically in the war effort. The idea of economic utility had been set out by Alfred Hoche and Karl Binding in 1920. They argued that a solution for the economic burdens of the institutionalized during wartime would be merciful killing. This idea was put into practice in many institutions at the beginning of the
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euthanasia programs. The running of all healthcare institutions was also taken over by bureaucrats loyal to the Nazi party, marginalizing the medical and nursing control of healthcare institutions and implementing ‘economic efficiency’ as core value (Burleigh, 1997). There were nurses who during the difficult wartime conditions received bonus payments for participating in the euthanasia killings. This money was known as ‘Schmutzgeld’ or dirty money (Benedict and Kuhla, 1999). Other nurses were worried about the money that they would lose by quitting their jobs (Willig, 1947). 5. Taking responsibility Walker (1998, p. 202) states that, ‘‘It is precisely in understanding what we are apt be held accountable for, what sorts of account we will be expected to give, and to whom, that we demonstrate our competence in a particular form of moral life.’’ As news of the euthanasia programs began to get known, the biggest protest against the euthanasia programs did not come from the nurses themselves, but from the general population, patient’s families, and religious leaders in Germany (Stephenson, 1975; Burleigh, 1994, 1997; McFarland-Icke, 1999; Walter, 2003). Nurses’ responsibilities were stopped by limiting the role of conscience in making euthanasia more acceptable. Despite this, there were some nurses who refused participation in the euthanasia programs and understood that it was to the patients that they had to demonstrate a responsibility for their actions. 5.1. Small gestures and responsibility Many nurses felt unable to take any moral responsibilities for others even though they disagreed with the euthanasia programs. These nurses claimed that they had to think of the responsibilities to themselves and their families to survive while outwardly compiling with the euthanasia programs. Yet, they in such small gestures, such as a kind word, tried to save what humanity they felt that they could save and afford to show in a totalitarian system (McFarland-Icke, 1999). However, the fact that they could not save their patients and had to resort to such small gestures caused many nurses to feel a deep ambivalence about their compliance with the euthanasia programs (Burleigh, 1994, 1997; McFarland-Icke, 1999). Many nurses realized that they were betraying not only their nursing ideals but also the trust put into them by their patients. As one nurses’ testimony shows: ‘‘Then with tears in our eyes, we filled the syringes’’ (Reich, 2001, p. 69). 5.2. Limiting the role of conscience In order to make the situation tolerable for the nurses who participated directly in the euthanasia programs, it
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had to be acceptable to them and their consciences. The roles of conscience had to be limited by diffusing the individual responsibility that nurses could take for their actions. This was done in three ways. Firstly, by making sure that these nurses were not responsible for individual patients and could not build up strong relationships to their patients. This was done by dehumanizing and objectifying the relationship between patients and caregivers through language and administrative tasks. Nurse Willig’s (1947, p. 1786) testimony is indicative of this. Before the Poles and the Russians came to Hadamar for the first time, Klein called together all the male employees and told us that foreign workers with tuberculosis would come there and they were to be liquidatedyAs far as I can remember there were two loads of them. The Poles and Russians are ‘foreign workers’, that had to be dealt with, rather than human beings in need of care. In the terminology of euthanasia, nurse Willig’s use of the word ‘liquidation’ testifies to a total dehumanization and objectification of not only the patients but also himself as a nurse too. Other nurses described euthanasia as ‘disinfections’ or ‘special handling’ showing how a distance to their actions was invoked to escape knowledge of the reality of murder (Rogow, 1999). Secondly, euthanasia had to be a secretive collective endeavor with each individual following orders in doing very specialized administrative or technical tasks. This stopped not only an individual moral responsibility from being able to be taken but also stopped nurses understanding the whole moral picture in which they were participants (Steppe, 2000). An absorption with very specialized tasks meant that, for example, such nurses began to focus on performances of those tasks and measuring their responsibilities as a nurse in the narrow terms of efficiency, productivity, or competence (Milgram, 1974). Mckie (2004) too notes that a focus on the detached nature of a task, allows an emphasis to be shifted from victims (patients) to perpetrator (nurses) and the difficulties inherent in their responsibilities for tasks and not responsibilities towards patients. Thirdly, Blum (1947), an employee at Hadamar, has testified that the killing was never done alone, but in pairs. The responsibilities for killing had to be as diffuse as possible and for practical reasons there had to be more than one nurse present (Benedict and Kuhla, 1999). Often while it was the senior physicians who implemented the policies and the decisions in the institutions, it was the younger less experienced physicians and especially the nurses that had to carry out the actual euthanasia practices (Dudley and Gale, 2002). Despite the ways in which nursing practices were manipulated to try and make the situation more
tolerable, nurses testified that even if they wanted to avoid understanding and accepting what was truly happening, the patients or families of the patients would remind them. In such cases, it was the patients and their families who acted as the conscience of the nurses, through their protests (Burleigh, 1994, 1997; McFarland-Icke, 1999). 5.3. Saying no There is no way of knowing how many nurses silently resisted the euthanasia programs by subverting a patient’s diagnosis or emphasizing a patient’s working ability (Dudley and Gale, 2002). Nurses engaged in such actions of responsibility often worked in institutions where the direction and personnel were all complicit in euthanasia, and such actions were done at great personal risk and had to be secret. These nurses believed that the inconveniences that some patients caused in wartime economy, the fact that they were another race, handicapped, or mentally ill, or sick could never justify killing them (Dudley and Gale, 2002). One of the reasons why we know so little about the nurses who resisted euthanasia is because the Nazi regime dealt with such refusals as private administrative matters. Refusal was thus not seen as a moral gesture because it did not take place in public realm. This was part of strategy for preserving generalized consent (McFarland-Icke, 1999). Other ways of refusing to participate entailed nurses getting married, becoming pregnant, asking for transfers to other institutions or moving (Friedlander, 1995; Burleigh, 1994, 1997; McFarland-Icke, 1999). In this way nurses listened to their conscience and their private thoughts became silent public protests. The sight of other people defying an authority or disobeying orders was of great importance to resistance to euthanasia. In such cases, the strong institutional hierarchies and professional obedience of nurses acted as a positive force for nurses resisting euthanasia policies (McFarland-Icke, 1999). Often Christian institutions had physicians and head nurses unwilling to participate in euthanasia and were able to avoid becoming heavily involved in the euthanasia programs (McFarland-Icke, 1999). However, in an authoritarian system like in Nazi Germany, these hierarchies were not sustaining practices of responsibility but dissuading individual responsibility. For many nurses this meant a loss of individual conscience, and involvement in societal moral reflection and debate.
6. Relevance for nursing today On September 23, 2002, the Belgian Act on Euthanasia came into force, legally allowing euthanasia under
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certain strict conditions. This made Belgium the second country in the world, after the Netherlands, to allow euthanasia. Euthanasia is defined as intentionally terminating life by someone other than the person concerned, at the latter’s request (The Belgian Statute, 2002). Before the Belgian Act on Euthanasia came into force, nurses were involved in illegal euthanasia practices (Bilsen et al., 2004; De Beer et al., 2004; Verpoort et al., 2004). Bilsen et al.’s (2004) empirical study indicated that although nurses in Belgium had a limited involvement in the decision-making process, they had a high involvement in illegally administering lethal drugs to patients, mostly without attendance of the prescribing physician. While euthanasia in Belgium today, can in no way be compared to the euthanasia programs of Nazi Germany that occurred from 1939 to 1945, an understanding of the past is important towards critical reflection in the present. The link between the past, the present and the future lies within the perceived status of nurses and their relationship with the medical profession, as well as the responsibility of professional nurses to individual patients (Hoskins, 2005). More specifically, we note three points of relevance that we feel could aid critical reflection: (1) greater transparency of role and responsibilities, (2) better communication and decision-making, and (3) the empowerment of nurses within the political and societal context of euthanasia. 6.1. Greater transparency of role and responsibilities We have illustrated how in Nazi Germany, there was a gradual erosion of the moral responsibilities of healthcare workers such as nurses based on the manipulation of the societal ‘demands of transparency’. The illegal and unregulated character of euthanasia combined with a too rigid focus on caregiving responsibilities defined in hierarchical, administrative and technical tasks led to a dangerous conformism (Steppe, 2000). In the present, we note that internationally nurses are involved in illegal euthanasia practices (De Beer et al., 2004). In a nationwide study in 1998, it was found that nurses administered lethal drugs in 58,8% of euthanasia cases in healthcare institutions in Belgium, mostly without attendance of the prescribing physician. The nurses while hardly involved in the actual decisionmaking surrounding euthanasia were involved in administering the lethal drugs, despite the fact that it was illegal and furthermore against their own professional guidelines (Bilsen et al., 2004). This practice places nurses in a very precarious legal position as they are not allowed to administer lethal drugs to patients (The Belgian Statute, 2002). It cannot be excluded that, in some cases, nurses feel adverse towards administering
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lethal drugs, but feel obliged to do so because of their subordinate position to the physician. Moreover nurses who care for patients where euthanasia is regulated and guidelines exists, indicated that euthanasia is seen as technical, and unnatural due to legal fears of not following the guidelines correctly (Pool, 1996; The´, 1997). In such guidelines, the precise role of a nurse and what procedures and practices they could engage was not always clearly defined (Pool, 1996; The´, 1997). This finding shows that even though there is currently a legal regulation of euthanasia in Belgium, and the Netherlands, very little is know about how this legal regulation could be translated into care for patients requesting euthanasia. Learning from the past to aid in critical reflection in the present, we recommend that nurses be able to understand the professional and legal responsibilities set by their communities and institutions in an as transparent manner as possible. For instance, healthcare institutions have to guarantee legal security for healthcare workers involved and give explicit attention to nurses’ conscientious objections (De Beer et al., 2004). Nurses themselves have also reported the need for adequate support from managers when caring for patients who request euthanasia (van de Scheur and van der Arend, 1998; De Beer et al., 2004). In this respect, well defined institutional ethics policies on euthanasia might give helpful support and direction for their nurse and physician employees. The development of an ethics policy on euthanasia can be the beginning of a well thought out procedure for clinical practice, which can stop certain unwanted practices (such as the administration of lethal drugs by nurses) as well as clarify the responsibilities of all those involved (i.e. physicians and nurses) (Miles and Ryder, 1985; Haverkate, 1999). A recent nationwide study in Belgium revealed that 79% of the Catholic hospitals and 30% of the Catholic nursing homes had a written ethics policy on euthanasia (Gastmans et al., 2006a–c). Nursing as an independent profession, should have a greater involvement in contributing to defining their roles and responsibilities. This also means indicating when things go wrong, illegal acts occur or when illegal practices take place in a regulated euthanasia process (McKie, 2004). Nurses and physicians should work together on such issues and a good example with regards to such practices are the Dutch guidelines on euthanasia for physicians and nurses that are formulated by the two biggest professional medical (KNMG) and nursing (NU’91) organizations (KNMG & NU’91, 1997). 6.2. Better communication and decision-making processes Many nurses in Nazi Germany worked under a strict hierarchy, where the head nurses or physician stood as a guarantee of the ethical correctness of an order; nurses’
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responsibilities were limited to following orders. Responsibilities were also made as diffuse as possible with nurses arguing that if they were indirectly involved in euthanasia, they could not be held accountable for it. We also noted that while the senior physicians implemented euthanasia policies and the decisions in the institutions, it was the younger less experienced physicians and especially the nurses that had to carry out the actual euthanasia practices (Dudley and Gale, 2002). In the present nurses involved in euthanasia decisions are critical of the way decisions are made, felt their opinions were overlooked, and also indicated their vulnerable legal position (Verpoort et al., 2004). De Beer et al. (2004) revealed that internationally nurses had little say in decision-making processes. Their participation was limited to being consulted and involvement in discussions. Bilsen et al. (2004) have also shown that in general the consultation of nurses by physicians before performing euthanasia was limited in Belgium. This result contrasts with that of the due care conditions stated by the Belgian Law on euthanasia that the patient’s request must be discussed with the nursing team having regular contact with the patient (Art. 3 Section 2,41). In clinical practice, nurses should not have a limited function in the decision-making process (Bilsen et al., 2004) but should become key team players. However, nurses need to be empowered before they can take on this role. In this respect, perhaps practical guidelines need to be created with regards to physician-nurse communication (Garity, 2004). De Bal et al. (2006) have also noted that there are no formal guidelines that outline the content of this communication and that these are desperately needed by nurses. Nurses who are confronted with euthanasia in a legal sphere note how important a just attentiveness is to everyone who participates in the euthanasia process and how nurses can facilitate the relationship between physician and patient (Pool, 1996; The´, 1997). Nurses taking responsibility for ensuring the dignity of their patient in the euthanasia process have stated that communication and decision-making cannot be facilitated if the healthcare team, and in particular the heads of the teams, do not recognize nurses’ roles and responsibilities. A greater involvement of nurses in decision-making could help ensure that the patient and his family never feel either professionally nor emotionally abandoned at the end of life as well as empower nurses in euthanasia practices (Pool, 1996; The´, 1997; Aranda, 2004). This needs to go hand in hand with the development of skills to aid the nurse in exploring a patient’s wish to die, as well as empowering the entire team in addressing their feelings of powerlessness when it comes to dealing with euthanasia requests and end-oflife care (Verpoort et al., 2004; De Bal et al., 2006).
Lastly, we argue that an atmosphere of truth is important for all those involved in euthanasia practices. Not only patients, but also caregivers, such as the nurses, should be able to be true to themselves when they are having morally difficult moments and be able to listen to their conscience. A purely objective, scientific and rational approach to euthanasia practices does not do justice to respecting the dignity and humanity of the patients or nurses and is not condusive to a supportive environment for all involved (Aranda, 2004). Nurses have indicated that they need to be able to work in an atmosphere where they can give a voice to their emotions and frustrations in a supportive team, and it is this that allows them to best care and offer support to not only their patients but also the patients’ families (De Bal et al., 2006). Aranda (2004) has pointed out that it is precisely this inclusive process of support and reflection for all that stops the ending of life from becoming simply a technical task. 6.3. Empowerment of nurses within the political and societal context of euthanasia We noted that in an authoritarian system like in Nazi Germany, nurses’ manipulation into giving up individual responsibility, led to a loss of individual conscience, and societal moral reflection for nurses. Both Walker (1998) and Steppe (2000) have argued that moral responsibility precisely because it is socially modular and morally contextual in nature can collapse under the weight of politically, economically, or ideologically motivated values, as was the case in Nazi Germany. McFarland-Icke (1999) has also pointed out that moral reflection and action was relegated to a private sphere, and how important it is for nurses to see it take place in a public sphere. Today likewise, an emphasis on the governmental, institutional, or economic management of care, entails a real danger that the individual responsibility in nursing practices can be lost. Nurses’ responsibilities for patients are seen in narrow terms, such as efficiently undertaking technical tasks (Bilsen et al., 2004). Nurses in Belgium, when confronted with ethical dilemmas, mainly conform to environmental requirements such as rules, norms, and duties (Dierckx de Casterle´ et al., 1997). Belgian nurses have also reported that an ideal nursing practice requires effective teamwork, supportive management, societal recognition, and sufficient time to perform their duties— all environmental factors which they felt were absent in daily practice (Siebens et al., 2006). There is also an absence of the voices of nurses in societal debate with regards to euthanasia (Garity, 2004; Bilsen et al., 2004). When nurses in Belgium did develop a position paper on euthanasia in the years before the euthanasia law was enacted, it did not get any attention in a public forum (WVVV, 2002).
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We recommend an awareness of the links between euthanasia today and politically, economically, or ideologically motivated values. This is needed in light of the fact that the medical and nursing profession, generally, is unaware or ignores, the connections between clinical practice, social norms and values, state purposes and economics (Steppe, 2000). To encourage and ensure that the nursing profession voices their concerns, and understandings of euthanasia practices, open spaces must be created where nurses can independently raise their concerns both as individuals and as an independent profession (Steppe, 2000). Moreover the individual ethical responsibility of each nurse needs to be situated within a wider framework both private and public that supports and aids critical reflective ‘imaginative capacity’ and conscience rather than curtailing it (Arendt, 1964). A part of supporting that wider framework consists in increasing the research and perspectives that one can take on euthanasia both in a legal and illegal sphere to facilitate and aid further critical development in nurses to best optimize the care for themselves and their patients when faced with such a difficult ethical issue. Especially with respect to euthanasia, nurses need to be able to voice their moral concerns and policy needs whether it affects them, their patients or their family, caregivers, and even a whole society (Garity, 2004).
7. Conclusion In this paper, we have focused on the contexts of moral decision-making by nurses in the euthanasia programs of Nazi Germany using Walker’s (1998) philosophical model. We used the second hypothesis of this model, that morality consists of practices of responsibility, to give an ethical analysis of the understandings nurses had of their responsibilities in the euthanasia programs. Nurses involved in both legal and illegal euthanasia practices have much to learn from an investigation of their past as well as present euthanasia practices. Nurses also have the potential to play a pivotal role in moral reflection on euthanasia. However they need to be aided to understand that the responsibilities for raising issues in connection to euthanasia are part of the tasks of nursing practice and part of what it means to be a nurse. Nursing perspectives and moral insights, both past and present, have been largely ignored, while they can only contribute to a richer, inclusive, and more critical public debate on the issue of euthanasia
References Aly, G., Roth, K.H., 1984. The legalization of mercy killings in medical and nursing institutions in Nazi Germany from
853
1938 Until 1941. Commented Documentation. International Journal of Law and Psychiatry 7, 145–163. Aranda, S., 2004. Commentary: euthanasia—A clincial and professional issue for nurses. Journal of Advanced Nursing 47 (6), 601–604. Arendt, H., 1964. A Report on the Banality of Evil. Eichmann in Jerusalem. Penguin Books, Harmondsworth. Benedict, S., Kuhla, J., 1999. Nurses participation in the ‘Euthanasia’ programs of Nazi Germany. Western Journal of Nursing Research 21 (2), 246–263. Bilsen, J.R., Vander Stichele, R.H., Mortier, F., Deliens, L., 2004. Involvement of nurses in physician-assisted dying. Journal of Advanced Nursing 47 (6), 583–591. Blum, P., 1947. Affidavit concerning Euthanasia program at Hadamar, Germany. NMT 01. Medical Case—USA v. Karl Brandt, et al., English Transcript, p. 1783 (16 January 1947). Bundesarchivs, 2003. Inventar der Quellen zur Geschichte der ‘Euthanasie’—Verbrechen 1939–1945. Im Auftrag des Bundesarchivs, Germany. Burleigh, M., 1994. Death and Deliverance. ‘Euthanasia’ in Germany 1900–1945. Cambridge University Press, Cambridge. Burleigh, M., 1997. Ethics and Extermination. Reflections on Nazi Genocide. Cambridge University Press, Cambridge. De Bal, N., Dierckx de Casterle´, B., Gastmans, C., 2006. Involvement of nurses in caring for patients requesting euthanasia in flanders (Belgium): a qualitative study. International Journal of Nursing Studies 43, 589–599. De Beer, T., Gastmans, C., Dierckx de Casterle´, B., 2004. Involvement of nurses in Euthanasia: a review of the literature. Journal of Medical Ethics 30, 494–498. Dierckx de Casterle´, B., Grypdonck, M., Vuylsteke-Wauters, M., Janssen, P.J., 1997. Nursing students’ responses to ethical dilemmas in nursing practice. Nursing Ethics 4 (1), 12–28. District Court (Court of Assizes), Berlin. 1947. In the Name of the People! NMT 01. Medical Case—USA v. Karl Brandt, et al., English Transcript, p. 1690 (14 January 1947). Dudley, M., Gale, F., 2002. Psychiatrists as a moral community? Psychiatry under the Nazis and its contemporary relevance. Australian and New Zealand Journal of Psychiatry 36, 585–594. Ernst, E., 1996. Killing in the name of healing: the active role of the German medical profession during the Third Reich. The American Journal of Medicine 100, 579–581. Friedlander, H., 1995. The Origins of Nazi Genocide: From Euthanasia to Final Solution. The University of North Carolina Press, Chapel Hill. Garity, J., 2004. Commentary: Euthanasia—nursing education and research implications. Journal of Advanced Nursing 47 (6), 601–604. Gastmans, C., Lemiengre, J., Schotsmans, P., van der Wal, G., Dierckx de Casterle´, B., 2006a. Prevalence and content of written ethics policies on Euthanasia in catholic healthcare institutions in Belgium (Flanders). Health Policy 76, 169–178. Gastmans, C., Lemiengre, J., Dierckx de Casterle´, B., 2006b. Role of nurses in institutional ethics policies on Euthanasia in Belgium (Flanders). Journal of Advanced Nursing 54, 53–61.
ARTICLE IN PRESS 854
M. Berghs et al. / International Journal of Nursing Studies 44 (2007) 845–854
Gastmans, C., Lemiengre, J., Dierckx de Casterle´, B., 2006c. Development and communication of written ethics policies on Euthanasia in catholic hospitals and nursing homes (Flanders). Patient Education and Counseling, (in press). Haverkate, I., 1999. Policies and Guidelines on Medical Decisions Concerning the End of Life in Dutch Health Care. Thela-Thesis, Amsterdam. Hoskins, S.A., 2005. Nurses and national socialism—a moral dilemma: one historical example of a route to Euthanasia. Nursing Ethics 12 (1), 79–91. Kevles, D.J., 1985. In the Name of Eugenics. Genetics and the Uses of Human Heredity. Penguin Books, New York. KNMG & NU’91, 1997. Euthanasierichtlijnen arts-verpleegkundigen. Richtlijnen samenwerking en taakafbakening arts en verpleegkundige bij de procedure rond euthanasie. [Physician-Nurse Euthanasia guidelines. Guidelines for physician and nurse teamwork and task delegation in the procedure around Euthanasia] Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG) en Nieuwe Unie’ 91, beroepsorganistatie van de verpleging, Utrecht. Kottow, M.H., 1988. Euthanasia after the holocaust—is it possible? A report from the federal republic of Germany. Bioethics 2 (1), 58–69. McFarland-Icke, B.R., 1999. Nurses in Nazi Germany. Moral Choice in History. Princeton University Press, Princeton. Mckie, A., 2004. ‘The demolition of a man’: lessons from holocaust literature for the teaching of nursing ethics. Nursing Ethics 11 (2), 138–149. Miles, S.H., Ryder, M.B., 1985. Limited-treatment policies in long-term care facilities? Journal of American Geriatric Society. 33, 707–711. Milgram, S., 1974. Obedience to Authority. An Experimental View. Harper & Row, N.Y, Hagerstown, San Francisco, & London. NMT 01. Medical Case—USA v. Karl Brandt, et al., 1947. English Transcript, p. 1551 (13 January 1947).
Pool, R., 1996. Vragen om te sterven—Euthanasie in een Nederlands ziekenhuis. WYT Uitgeefgroep, Rotterdam. Reich, W.T., 2001. The care-based ethic of Nazi medicine and the moral importance of what we care about. American Journal of Bioethics 1 (1), 64–74. Rogow, S.M., 1999. Child victims in Nazi Germany. The Journal of Holocaust Education 8 (3), 71–86. Siebens, K., Dierckx de Casterle´, B., Abraham, I., Dierckx, K., Braes, T., Darras, E., Bubois, Y., Milisen, K., 2006. The professional self-image of nurses in Belgian Hospitals. Meaning for the future of the professional. International Journal of Nursing Studies 43, 71–82. Stephenson, J., 1975. Women in Nazi Society. Croom Helm, London. Steppe, H., 2000. Das Selbstversta¨ndnis der Krankenpflege in ihrer historischen Entwicklung. Pflege 13, 77–78. The´, B.A.M., 1997. ‘Vanavond om 8 uury’ Verpleegkundige dilemma’s bij euthanasie en andere beslissingen rond het levenseinde. Bohn Stafleu Van Loghum, Houten/Diegem. The Belgian Statue Book (Belgisch Staatsblad), 2002. The Belgian Act on Euthanasia of 28 May 2002. Van de Scheur, A., van der Arend, A., 1998. The role of nurses in Euthanasia: a Dutch study. Nursing Ethics 5, 497–508. Verpoort, C., Gastmans, C., De Bal, N., Dierckx de Casterle´, B., 2004. Nurses’ attitudes to Euthanasia: a review of the literature. Nursing Ethics 11 (4), 349–365. Walker, M.U., 1998. Moral Understandings. A Feminist Study in Ethics. Routledge, New York and London. Walter, I., 2003. Auswirkung des ‘‘Anschlusses’’ auf die o¨sterreichische Krankenpflege. Pflege 16, 6–16. Willig, K., 1947. Statement of Karl Willig. NMT 01. Medical Case—USA v. Karl Brandt, et al., English Transcript, p. 1786 (16 January 1947). WVVV (Wetenschappelijke Vereniging voor Verpleegkunde en Vroedkunde) [Scientific Union for Nursing and Midwifery], 2002. Standpunt over euthanasie [Position on euthanasia]. Available at: http://allserv.rug.ac.be/lefloor/artikel8.htm
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Practices of responsibility and nurses during the euthanasia programs of Nazi Germany: A discussion paper Maria Berghsa, Bernadette Dierckx de Casterle´b, Chris Gastmansa, a Centre for Biomedical Ethics and Law, Faculty of Medicine, Catholic University of Leuven, Belgium Centre for Health Services and Nursing Research, Faculty of Medicine, Catholic University of Leuven, Belgium
b
Received 9 March 2005; received in revised form 4 April 2006; accepted 9 May 2006
Abstract In this paper, we focus on the contexts of moral decision-making by nurses in the euthanasia programs of Nazi Germany between 1939 and 1945 using Urban Walker’s philosophical model. We use the second hypothesis of this model, that morality consists of practices of responsibility, to give an analysis of the understandings nurses had of their responsibilities in the euthanasia programs. The article starts with a brief introduction to the euthanasia programs of Nazi Germany from 1939 to 1945 and nurse participation, to illustrate how the responsibilities of nurses were manipulated. Secondly, nursing as moral practices are analysed in the context of the euthanasia programs that implement commonly shared understandings and practices of responsibility. Thirdly, the reasons that nurses gave for avoiding any responsibilities are examined. Fourthly, it is examined if nurses took any responsibility in the euthanasia programs. In conclusion, this paper discusses three points of relevance such a reflection on moral responsibility in the context of Nazi Germany has for nurses today who may be confronted with euthanasia. r 2006 Elsevier Ltd. All rights reserved. Keywords: Ethics; Euthanasia; Nazi Germany; Nursing
What is already known about the topic?
Nurses
were involved in all the differing phases (registration, selection, transfer, and secret killing) of the euthanasia programs of Nazi Germany. Nurses are substantially involved in current illegal euthanasia practices in Belgium.
What this paper adds
A historical-ethical reflection on the involvement of nurses in the euthanasia programs of Nazi Germany Corresponding author. Tel.: +32 0 16 33 69 51;
fax: +32 0 16 33 69 52. E-mail address: [email protected] (C. Gastmans).
using Margaret Urban Walker’s philosophical insights on practices of responsibility. Identification of three important issues—transparency of role and responsibility, communication and decision-making, empowerment of nurses—that could aid ethical practice concerning nurses involvement in caring for patients requesting euthanasia.
1. Introduction The beginning of the 20th century marked the emergence of eugenics, the improvement of the human race, as a popular scientific movement in many countries such as the United States, Great Britain and Germany (Kevles, 1985). While many eugenic principles were positive in the sense that they were public health
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.05.003
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campaigns which educated the general public about health, heredity, and procreation, negative eugenic policies argued that the genetically ‘defective’ or ‘deviant’ were a threat to the public’s health (Kevles, 1985). The worst abuses of negative eugenic policies took place during the euthanasia programs of Nazi Germany from 1939 to 1945. Healthcare professionals, such as nurses, were involved and actively carried out such policies thereby giving up their moral responsibilities to care (Aly and Roth, 1984; McFarland-Icke, 1999). To try to gain new insights into how and why some nurses in Nazi Germany gave up their moral responsibilities as well as to reflect on recent evolutions in euthanasia today, we implement the philosophical insights of Margaret Urban Walker (1998) against the historical background of the euthanasia programs of Nazi Germany. Walker (1998, p. 9–10) elucidates a method of moral inquiry that she calls ‘expressivecollaborative’, which, ‘‘y prescribes an investigation of morality as a socially embodied medium of mutual understanding and negotiation between people over their responsibility for things open to human care and response.’’ This means that morality is expressed in the interpersonal contexts, it is ‘‘y reproduced or modified in what goes on between and among people.’’ Walker model is also collaborative in the sense that, ‘‘we construct and sustain it together’’, although not always in chosen or equal terms. Walker’s ‘expressive collaborative’ method of moral inquiry consists of four hypotheses, and we focus on the second hypothesis that states that, ‘‘the practices characteristic of morality are practices of responsibility’’ (1998, p. 16). Walker argues that morality works according to interpersonal understandings of practices of responsibility, so any description of responsibility has to focus on what participants understand by such responsibilities. This paper gives a close and critical analysis of the understandings some nurses had of their practices in the euthanasia programs of Nazi Germany. Thereby, allowing us to track these nurses’ roles and responsibilities in euthanasia practices as well as expose their values and why nurses became involved in such practices. The article starts with a brief introduction to the euthanasia programs of Nazi Germany from 1939 to 1945 and nurse participation, to illustrate how the responsibilities of many nurses were manipulated. Secondly, we examine nursing as moral practices in the context of the euthanasia programs that implement commonly shared understandings and practices of responsibility. Thirdly, we examine the reasons that nurses gave for avoiding any responsibilities. Fourthly, we examine if nurses took any responsibility in the euthanasia programs. In conclusion, we discuss the relevance that a novel ethical reflection on moral
responsibility in the context of Nazi Germany has for nurses today who may be confronted with euthanasia. Walker’s philosophical model allows us to give an ethical interpretation of moral life that can function both descriptively and normatively. Descriptively, the aim is to give an interpretation and/or reveal what ‘morality’ was and now is. Normatively, the aim is to suggest some important things that morality is for and on which past and present practices it depends on—for better or worse. We thus hope that by undertaking such a reflection we can contribute both descriptively and normatively to nurses’ understandings of their attitudes towards as well as involvement in euthanasia practices both past and the present.
2. The euthanasia programs and the manipulation of responsibilities of nurses In order for nurses to understand their moral responsibilities, they have to be able to question the moral terms and contexts that are set for them by their community. Walker (1998) elucidates that this ‘demand of transparency’ to understand moral responsibilities in a community, is based on a shared social contract or belief in a covenant of trust, represented by the shared general values of a community, as well as its laws. We aim to investigate whether in Nazi Germany, the shared social contract and belief in a covenant of trust was manipulated in order to implement the euthanasia programs and gain the participation of healthcare professionals in these programs. 2.1. The euthanasia programs The euthanasia programs began in 1939 with children’s euthanasia (Kinderacktion) and from 1941 onwards also included adult euthanasia (Acktion T-4) (Aly and Roth, 1984; Burleigh, 1994, 1997). The euthanasia programs involved the registration, selection, transfer and secret killing of the aged, insane, incurably ill, deformed, Jews and all other people termed ‘defective’ (Aly and Roth, 1984; Burleigh, 1994, 1997; Friedlander, 1995). New evidence has indicated that the secret euthanasia programs involved over 296 mental and nursing as well as medical institutions in Germany, Austria, the Czech Republic, Poland and Russia, as well as healthcare professionals in those countries at all levels (Bundesarchivs, 2003). Nurses were involved in all the differing phases of the euthanasia programs (NMT 01. Medical Case- USA v. Karl Brandt et al., 1947; Bundesarchivs, 2003). In the children’s euthanasia programs they actively assisted in killing children through injections of morphine and scopolamine, by starvation, or overdoses of medications (Burleigh, 1994; Benedict and Kuhla, 1999). In the adult
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euthanasia programs, nurses assisted in the selection and the transportation of adults to the institutions in which they were to be killed by gassing. In the later stages of the adult euthanasia program, nurses assisted the physicians and also actively killed patients by giving them drugs or administering lethal injections (Burleigh, 1994, 1997). Some of the staff (including the nurses) of the early euthanasia programs served to select and help eliminate ill concentration camp prisoners in the later Operation 14 f 13 and implement the Final Solution (Aly and Roth, 1984; Friedlander, 1995).
patients and their families, as well as the healthcare institutions themselves. The accountability that nurses accepted, defined how they thought about the scope and limits of their moral agency, and revealed what they cared about and who had standing to judge and blame them. Examining nursing as practices of responsibility in this way, allows us to give detailed and situated descriptions of the expectations and negotiations surrounding assignments of responsibility (Walker, 1998).
2.2. The manipulation of responsibilities of nurses
In assigning responsibility, in German hospitals and psychiatric institutions of the time as well as in society, there existed a strong hierarchical structure (Burleigh, 1994, 1997). In the psychiatric institutions involved in the euthanasia programs, the order to allow euthanasia came directly from Hitler through differing bureaucracies designed to diffuse any individual responsibility. In these differing bureaucracies, often bearing false names, prominent psychiatrists decided which institutions would be involved in euthanasia and how many victims, supplied the questionnaires and paperwork, as well as counseled the killers (Dudley and Gale, 2002). Institutional professional medical and nursing routines were adhered to, to give the appearance of normality. Orders were given from physicians to the head nurses, who in turn would give the orders to the other nurses. The physician or head nurse, by giving an order, stood as a kind of guarantee of the medical quality and ethical correctness of that order (McFarland-Icke, 1999). Both the physicians and nurses understood their ethical responsibilities in terms of a strong commitment to obedience. The importance of obedience was further highlighted by the fact that nurses did not always have the medical knowledge that the physicians had, so it was vital for the well-being of a patient that nurses obey orders (Benedict and Kuhla, 1999). To be a responsible nurse was to be a nurse who would follow orders with an unquestioning obedience—concisely, objectively and devoid of any judgments (McFarland-Icke, 1999).
In the beginning of the euthanasia program in 1939, Hitler gave the secret order for a program of ‘mercy killing’ or euthanasia to begin that was never legally nor officially sanctioned. By doing this, according to Kottow (1988), he violated the moral demands of transparency necessary in a democratic community and transformed the concept of euthanasia from voluntary assisted death to involuntary, medically supervised killing (Ernst, 1996). Reich (2001) has termed this manipulation of moral responsibility ‘the betrayal of care’, in that Hitler’s order betrayed the caring goals of medicine and nursing, and the moral integrity of healthcare professionals. Walker (1998) explains that the manipulation of a moral agent begins through changes affecting who is more likely to enter a profession. In the Nazi era, the entire nursing profession was purged of all nurses who had been affiliated with other political parties, trade unions, voiced criticism, or were Jewish. The entire nursing profession and its organization lost its independence and became aimed at creating conditions and structures to support the policies of National Socialism (Walter, 2003; Steppe, 2000). Furthermore, many new untrained and inexperienced people entered the nursing profession to escape the dole queues (Burleigh, 1994; Walter, 2003). The new nurses were often ordinary men and women from working class or lower middle class backgrounds in rural areas, often with a rudimentary elementary school education and accepting their new responsibility in the euthanasia programs (McFarland-Icke, 1999).
3. Nursing as practice of responsibility Nursing as moral practice, implements commonly shared understandings and practices of responsibility, ‘‘of who gets to do what to whom and who is supposed to do what for whom’’ (Walker, 1998, p. 16). In the context of the euthanasia programs of Nazi Germany, examining responsibility reveals the accountability that nurses had towards other members of a healthcare team, their
3.1. Responsibility and obedience
3.2. Differing levels of responsibility The ethical responsibilities that nurses claimed to have for their roles in the euthanasia programs differed according to the kinds of moral contexts that they found themselves in. According to Walker (1998, p. 16), who does ‘‘what, where, and for whom’’ becomes very important in assigning responsibility. Likewise, the fact that one is excluded from certain responsibilities also forms a moral agent’s understanding of the accountability or non-accountability for particular practices. McFarland-Icke (1999) too has pointed out that responsibilities were understood in different ways
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between nurses at the peripheries or at the beginnings of the euthanasia programs and those nurses who actively killed in the later programs. Nurses, at the peripheries who had indirectly participated in the euthanasia programs, by for example assisting in the transport of patients to other institutions, argued they were excluded from responsibilities because they did not know what was going to happen to their patients (McFarland-Icke, 1999). Nurses argued there was a difference in assisting and direct participation. Nurses also evaded responsibility through their own interpretation of events arguing that although they heard rumors, as they could not officially be sure, euthanasia was not occurring (McFarland-Icke, 1999; Dudley and Gale, 2002). Still other nurses reasoned that volitionally, as they had not actively participated, it had nothing to do with them (Benedict and Kuhla, 1999; Dudley and Gale, 2002). 3.3. Forced and accepted participation Walker (1998, p. 16) notes that, ‘‘y it is in the nature of morality to work by means of interpersonal understandings, so that what is to be described includes participants’ grasp of what the understandings are.’’ An examination of nurses’ understandings of their responsibilities is important, to understand why some nurses felt that they had no responsibilities in certain nursing practices. Those nurses who actively killed in euthanasia practices, could not say that they did not know about euthanasia and could not easily evade responsibility for their action. They claimed that they had been forced, under threat of death, to accept such responsibilities and were asked to sign oaths of secrecy (District Court Berlin, 1947; NMT 01. Medical Case- USA v. Karl Brandt et al., 1947). Some nurses accepted participation not because they were threatened but because they could see no other options for employment (Willig, 1947). Other nurses readily accepted participation and became spontaneous practiced killers. When the religious affiliations of the nursing staff made it difficult for euthanasia to be carried out, nurses who had the right kind of ideological commitment were sent to the institution to rectify the situation (Burleigh, 1994).
and values.’’ This analysis allows us to describe what such nurses’ interpersonal understandings of morality are as well as what practices or beliefs sustain their morality. 4.1. Coercion Nurses who deflected their responsibilities for direct participation in the euthanasia programs argued that they were behaving under coercion, and appealed to obedience and the background of war, terror, and psychological influence of the group as mitigating factors that necessarily made them evade their responsibilities. 4.1.1. Appeal to obedience Many nurses appealed to the fact that they had only obeyed orders by participating in the euthanasia programs. They argued that they had behaved morally by doing their duty, which had required them to behave in a Kant-like manner without any thoughts to their own moral inclinations, beliefs or desires (Benedict and Kuhla, 1999). Arendt (1964) argues against the nurses’ Kantian appeal to obedience pointing out that Kant’s moral philosophy is closely bound up with our faculty of judgment—ruling out blind obedience. The military courts also argued that acting on the orders of superiors does not relieve someone of responsibility for a crime. 4.1.2. Background of war, terror and the psychological influence of the group Nurses also appealed to the fact that they were living in a totalitarian state during a war, where they worked under a regime of terror (District Court Berlin, 1947; Friedlander, 1995; McFarland-Icke, 1999). Various nurses reported on feelings of being divided from normality and under intense pressure to comply and do unethical things that they would normally never do to keep their jobs or to stay alive (McFarland-Icke, 1999). Nurses also claimed to be unable in a wartime situation to see the consequences of their actions in a future perspective. In this respect nurses also alluded to the psychological influence of the group and the huge psychological pressures that they were under to comply and to engage in acts that they would normally never do (Burleigh, 1994, 1997; McFarland-Icke, 1999).
4. Avoiding responsibility 4.2. Complicity In order to further understand why some nurses participated in euthanasia practices and yet argue they have no responsibilities we need to look at the reasons they give for evading that responsibility. Walker (1998, p. 16) elucidates that in the ways that we, ‘‘y assign, accept, or deflect responsibilities, we express our understandings of our own and other’s identities, relationships,
Walker (1998) notes that the justifications for redrawn responsibilities often lie in the social moral values and positions of the time that the moral agent is living in. This was also the case for the nurses’ justifications of complicity, they appealed to their belief in the moral correctness of the euthanasia killings, the importance of
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the Volk over the individual, and lastly to utilitarian economic motives. 4.2.1. Belief in the ‘moral correctness’ of the euthanasia killings Some nurses believed in the moral correctness of the euthanasia killings, arguing that for humanitarian reasons, it was better for the patients to be put out of their misery (Burleigh, 1994, 1997; McFarland-Icke, 1999). In these cases, thinking about euthanasia as ‘mercy-killing’ or ‘death as deliverance’ allowed nurses to combine their conventional morality with participation in euthanasia practices (McFarland-Icke, 1999). Burleigh (1994) points out that in one of the last major euthanasia trials in 1986, the fact that the nurses repeated that they had ‘killed out of love and pity’ indicated that nurses believed in the notion of ‘life unworthy of life’ before, during, and long after the euthanasia programs. Most nurses who actively participated in euthanasia practices also believed that euthanasia was legal and sanctioned by the state and Hitler, as the right and thus moral thing to do (District Court Berlin, 1947). Nurses as good citizens and as human beings, felt that obeying the law especially in cases where the patients was suffering or going to suffer was also to behave morally (Benedict and Kuhla, 1999; McFarland-Icke, 1999). 4.2.2. The importance of the ‘Volk’ A nurse’s attention was also gradually turned away from individual towards the caring responsibilities in terms of the German ‘Volk’ or people. Reich (2001) elucidates that under the Nazis there was a corruption of the concept of care (Sorge) in terms of caring for (Fu¨rsorge), towards preventive care (Vorsorge) instead. Many nurses believed that scientific progress had identified certain people as health hazards to the German race and they had a professional duty to separate those people from the healthy contributing so to a healthy and stronger Germany. Their ethics became linked to a strong but simplistic belief in technology and scientific progress and a utopia where disease and illness did not exist (Burleigh, 1994). 4.2.3. Utilitarian economic motives Linked to the shift in some nurses’ moral understandings of the importance of the German people, were the utilitarian economic motives used to justify that shift. Euthanasia became linked to another larger and more moral cause, that of saving the Germany by aiding economically in the war effort. The idea of economic utility had been set out by Alfred Hoche and Karl Binding in 1920. They argued that a solution for the economic burdens of the institutionalized during wartime would be merciful killing. This idea was put into practice in many institutions at the beginning of the
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euthanasia programs. The running of all healthcare institutions was also taken over by bureaucrats loyal to the Nazi party, marginalizing the medical and nursing control of healthcare institutions and implementing ‘economic efficiency’ as core value (Burleigh, 1997). There were nurses who during the difficult wartime conditions received bonus payments for participating in the euthanasia killings. This money was known as ‘Schmutzgeld’ or dirty money (Benedict and Kuhla, 1999). Other nurses were worried about the money that they would lose by quitting their jobs (Willig, 1947). 5. Taking responsibility Walker (1998, p. 202) states that, ‘‘It is precisely in understanding what we are apt be held accountable for, what sorts of account we will be expected to give, and to whom, that we demonstrate our competence in a particular form of moral life.’’ As news of the euthanasia programs began to get known, the biggest protest against the euthanasia programs did not come from the nurses themselves, but from the general population, patient’s families, and religious leaders in Germany (Stephenson, 1975; Burleigh, 1994, 1997; McFarland-Icke, 1999; Walter, 2003). Nurses’ responsibilities were stopped by limiting the role of conscience in making euthanasia more acceptable. Despite this, there were some nurses who refused participation in the euthanasia programs and understood that it was to the patients that they had to demonstrate a responsibility for their actions. 5.1. Small gestures and responsibility Many nurses felt unable to take any moral responsibilities for others even though they disagreed with the euthanasia programs. These nurses claimed that they had to think of the responsibilities to themselves and their families to survive while outwardly compiling with the euthanasia programs. Yet, they in such small gestures, such as a kind word, tried to save what humanity they felt that they could save and afford to show in a totalitarian system (McFarland-Icke, 1999). However, the fact that they could not save their patients and had to resort to such small gestures caused many nurses to feel a deep ambivalence about their compliance with the euthanasia programs (Burleigh, 1994, 1997; McFarland-Icke, 1999). Many nurses realized that they were betraying not only their nursing ideals but also the trust put into them by their patients. As one nurses’ testimony shows: ‘‘Then with tears in our eyes, we filled the syringes’’ (Reich, 2001, p. 69). 5.2. Limiting the role of conscience In order to make the situation tolerable for the nurses who participated directly in the euthanasia programs, it
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had to be acceptable to them and their consciences. The roles of conscience had to be limited by diffusing the individual responsibility that nurses could take for their actions. This was done in three ways. Firstly, by making sure that these nurses were not responsible for individual patients and could not build up strong relationships to their patients. This was done by dehumanizing and objectifying the relationship between patients and caregivers through language and administrative tasks. Nurse Willig’s (1947, p. 1786) testimony is indicative of this. Before the Poles and the Russians came to Hadamar for the first time, Klein called together all the male employees and told us that foreign workers with tuberculosis would come there and they were to be liquidatedyAs far as I can remember there were two loads of them. The Poles and Russians are ‘foreign workers’, that had to be dealt with, rather than human beings in need of care. In the terminology of euthanasia, nurse Willig’s use of the word ‘liquidation’ testifies to a total dehumanization and objectification of not only the patients but also himself as a nurse too. Other nurses described euthanasia as ‘disinfections’ or ‘special handling’ showing how a distance to their actions was invoked to escape knowledge of the reality of murder (Rogow, 1999). Secondly, euthanasia had to be a secretive collective endeavor with each individual following orders in doing very specialized administrative or technical tasks. This stopped not only an individual moral responsibility from being able to be taken but also stopped nurses understanding the whole moral picture in which they were participants (Steppe, 2000). An absorption with very specialized tasks meant that, for example, such nurses began to focus on performances of those tasks and measuring their responsibilities as a nurse in the narrow terms of efficiency, productivity, or competence (Milgram, 1974). Mckie (2004) too notes that a focus on the detached nature of a task, allows an emphasis to be shifted from victims (patients) to perpetrator (nurses) and the difficulties inherent in their responsibilities for tasks and not responsibilities towards patients. Thirdly, Blum (1947), an employee at Hadamar, has testified that the killing was never done alone, but in pairs. The responsibilities for killing had to be as diffuse as possible and for practical reasons there had to be more than one nurse present (Benedict and Kuhla, 1999). Often while it was the senior physicians who implemented the policies and the decisions in the institutions, it was the younger less experienced physicians and especially the nurses that had to carry out the actual euthanasia practices (Dudley and Gale, 2002). Despite the ways in which nursing practices were manipulated to try and make the situation more
tolerable, nurses testified that even if they wanted to avoid understanding and accepting what was truly happening, the patients or families of the patients would remind them. In such cases, it was the patients and their families who acted as the conscience of the nurses, through their protests (Burleigh, 1994, 1997; McFarland-Icke, 1999). 5.3. Saying no There is no way of knowing how many nurses silently resisted the euthanasia programs by subverting a patient’s diagnosis or emphasizing a patient’s working ability (Dudley and Gale, 2002). Nurses engaged in such actions of responsibility often worked in institutions where the direction and personnel were all complicit in euthanasia, and such actions were done at great personal risk and had to be secret. These nurses believed that the inconveniences that some patients caused in wartime economy, the fact that they were another race, handicapped, or mentally ill, or sick could never justify killing them (Dudley and Gale, 2002). One of the reasons why we know so little about the nurses who resisted euthanasia is because the Nazi regime dealt with such refusals as private administrative matters. Refusal was thus not seen as a moral gesture because it did not take place in public realm. This was part of strategy for preserving generalized consent (McFarland-Icke, 1999). Other ways of refusing to participate entailed nurses getting married, becoming pregnant, asking for transfers to other institutions or moving (Friedlander, 1995; Burleigh, 1994, 1997; McFarland-Icke, 1999). In this way nurses listened to their conscience and their private thoughts became silent public protests. The sight of other people defying an authority or disobeying orders was of great importance to resistance to euthanasia. In such cases, the strong institutional hierarchies and professional obedience of nurses acted as a positive force for nurses resisting euthanasia policies (McFarland-Icke, 1999). Often Christian institutions had physicians and head nurses unwilling to participate in euthanasia and were able to avoid becoming heavily involved in the euthanasia programs (McFarland-Icke, 1999). However, in an authoritarian system like in Nazi Germany, these hierarchies were not sustaining practices of responsibility but dissuading individual responsibility. For many nurses this meant a loss of individual conscience, and involvement in societal moral reflection and debate.
6. Relevance for nursing today On September 23, 2002, the Belgian Act on Euthanasia came into force, legally allowing euthanasia under
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certain strict conditions. This made Belgium the second country in the world, after the Netherlands, to allow euthanasia. Euthanasia is defined as intentionally terminating life by someone other than the person concerned, at the latter’s request (The Belgian Statute, 2002). Before the Belgian Act on Euthanasia came into force, nurses were involved in illegal euthanasia practices (Bilsen et al., 2004; De Beer et al., 2004; Verpoort et al., 2004). Bilsen et al.’s (2004) empirical study indicated that although nurses in Belgium had a limited involvement in the decision-making process, they had a high involvement in illegally administering lethal drugs to patients, mostly without attendance of the prescribing physician. While euthanasia in Belgium today, can in no way be compared to the euthanasia programs of Nazi Germany that occurred from 1939 to 1945, an understanding of the past is important towards critical reflection in the present. The link between the past, the present and the future lies within the perceived status of nurses and their relationship with the medical profession, as well as the responsibility of professional nurses to individual patients (Hoskins, 2005). More specifically, we note three points of relevance that we feel could aid critical reflection: (1) greater transparency of role and responsibilities, (2) better communication and decision-making, and (3) the empowerment of nurses within the political and societal context of euthanasia. 6.1. Greater transparency of role and responsibilities We have illustrated how in Nazi Germany, there was a gradual erosion of the moral responsibilities of healthcare workers such as nurses based on the manipulation of the societal ‘demands of transparency’. The illegal and unregulated character of euthanasia combined with a too rigid focus on caregiving responsibilities defined in hierarchical, administrative and technical tasks led to a dangerous conformism (Steppe, 2000). In the present, we note that internationally nurses are involved in illegal euthanasia practices (De Beer et al., 2004). In a nationwide study in 1998, it was found that nurses administered lethal drugs in 58,8% of euthanasia cases in healthcare institutions in Belgium, mostly without attendance of the prescribing physician. The nurses while hardly involved in the actual decisionmaking surrounding euthanasia were involved in administering the lethal drugs, despite the fact that it was illegal and furthermore against their own professional guidelines (Bilsen et al., 2004). This practice places nurses in a very precarious legal position as they are not allowed to administer lethal drugs to patients (The Belgian Statute, 2002). It cannot be excluded that, in some cases, nurses feel adverse towards administering
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lethal drugs, but feel obliged to do so because of their subordinate position to the physician. Moreover nurses who care for patients where euthanasia is regulated and guidelines exists, indicated that euthanasia is seen as technical, and unnatural due to legal fears of not following the guidelines correctly (Pool, 1996; The´, 1997). In such guidelines, the precise role of a nurse and what procedures and practices they could engage was not always clearly defined (Pool, 1996; The´, 1997). This finding shows that even though there is currently a legal regulation of euthanasia in Belgium, and the Netherlands, very little is know about how this legal regulation could be translated into care for patients requesting euthanasia. Learning from the past to aid in critical reflection in the present, we recommend that nurses be able to understand the professional and legal responsibilities set by their communities and institutions in an as transparent manner as possible. For instance, healthcare institutions have to guarantee legal security for healthcare workers involved and give explicit attention to nurses’ conscientious objections (De Beer et al., 2004). Nurses themselves have also reported the need for adequate support from managers when caring for patients who request euthanasia (van de Scheur and van der Arend, 1998; De Beer et al., 2004). In this respect, well defined institutional ethics policies on euthanasia might give helpful support and direction for their nurse and physician employees. The development of an ethics policy on euthanasia can be the beginning of a well thought out procedure for clinical practice, which can stop certain unwanted practices (such as the administration of lethal drugs by nurses) as well as clarify the responsibilities of all those involved (i.e. physicians and nurses) (Miles and Ryder, 1985; Haverkate, 1999). A recent nationwide study in Belgium revealed that 79% of the Catholic hospitals and 30% of the Catholic nursing homes had a written ethics policy on euthanasia (Gastmans et al., 2006a–c). Nursing as an independent profession, should have a greater involvement in contributing to defining their roles and responsibilities. This also means indicating when things go wrong, illegal acts occur or when illegal practices take place in a regulated euthanasia process (McKie, 2004). Nurses and physicians should work together on such issues and a good example with regards to such practices are the Dutch guidelines on euthanasia for physicians and nurses that are formulated by the two biggest professional medical (KNMG) and nursing (NU’91) organizations (KNMG & NU’91, 1997). 6.2. Better communication and decision-making processes Many nurses in Nazi Germany worked under a strict hierarchy, where the head nurses or physician stood as a guarantee of the ethical correctness of an order; nurses’
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responsibilities were limited to following orders. Responsibilities were also made as diffuse as possible with nurses arguing that if they were indirectly involved in euthanasia, they could not be held accountable for it. We also noted that while the senior physicians implemented euthanasia policies and the decisions in the institutions, it was the younger less experienced physicians and especially the nurses that had to carry out the actual euthanasia practices (Dudley and Gale, 2002). In the present nurses involved in euthanasia decisions are critical of the way decisions are made, felt their opinions were overlooked, and also indicated their vulnerable legal position (Verpoort et al., 2004). De Beer et al. (2004) revealed that internationally nurses had little say in decision-making processes. Their participation was limited to being consulted and involvement in discussions. Bilsen et al. (2004) have also shown that in general the consultation of nurses by physicians before performing euthanasia was limited in Belgium. This result contrasts with that of the due care conditions stated by the Belgian Law on euthanasia that the patient’s request must be discussed with the nursing team having regular contact with the patient (Art. 3 Section 2,41). In clinical practice, nurses should not have a limited function in the decision-making process (Bilsen et al., 2004) but should become key team players. However, nurses need to be empowered before they can take on this role. In this respect, perhaps practical guidelines need to be created with regards to physician-nurse communication (Garity, 2004). De Bal et al. (2006) have also noted that there are no formal guidelines that outline the content of this communication and that these are desperately needed by nurses. Nurses who are confronted with euthanasia in a legal sphere note how important a just attentiveness is to everyone who participates in the euthanasia process and how nurses can facilitate the relationship between physician and patient (Pool, 1996; The´, 1997). Nurses taking responsibility for ensuring the dignity of their patient in the euthanasia process have stated that communication and decision-making cannot be facilitated if the healthcare team, and in particular the heads of the teams, do not recognize nurses’ roles and responsibilities. A greater involvement of nurses in decision-making could help ensure that the patient and his family never feel either professionally nor emotionally abandoned at the end of life as well as empower nurses in euthanasia practices (Pool, 1996; The´, 1997; Aranda, 2004). This needs to go hand in hand with the development of skills to aid the nurse in exploring a patient’s wish to die, as well as empowering the entire team in addressing their feelings of powerlessness when it comes to dealing with euthanasia requests and end-oflife care (Verpoort et al., 2004; De Bal et al., 2006).
Lastly, we argue that an atmosphere of truth is important for all those involved in euthanasia practices. Not only patients, but also caregivers, such as the nurses, should be able to be true to themselves when they are having morally difficult moments and be able to listen to their conscience. A purely objective, scientific and rational approach to euthanasia practices does not do justice to respecting the dignity and humanity of the patients or nurses and is not condusive to a supportive environment for all involved (Aranda, 2004). Nurses have indicated that they need to be able to work in an atmosphere where they can give a voice to their emotions and frustrations in a supportive team, and it is this that allows them to best care and offer support to not only their patients but also the patients’ families (De Bal et al., 2006). Aranda (2004) has pointed out that it is precisely this inclusive process of support and reflection for all that stops the ending of life from becoming simply a technical task. 6.3. Empowerment of nurses within the political and societal context of euthanasia We noted that in an authoritarian system like in Nazi Germany, nurses’ manipulation into giving up individual responsibility, led to a loss of individual conscience, and societal moral reflection for nurses. Both Walker (1998) and Steppe (2000) have argued that moral responsibility precisely because it is socially modular and morally contextual in nature can collapse under the weight of politically, economically, or ideologically motivated values, as was the case in Nazi Germany. McFarland-Icke (1999) has also pointed out that moral reflection and action was relegated to a private sphere, and how important it is for nurses to see it take place in a public sphere. Today likewise, an emphasis on the governmental, institutional, or economic management of care, entails a real danger that the individual responsibility in nursing practices can be lost. Nurses’ responsibilities for patients are seen in narrow terms, such as efficiently undertaking technical tasks (Bilsen et al., 2004). Nurses in Belgium, when confronted with ethical dilemmas, mainly conform to environmental requirements such as rules, norms, and duties (Dierckx de Casterle´ et al., 1997). Belgian nurses have also reported that an ideal nursing practice requires effective teamwork, supportive management, societal recognition, and sufficient time to perform their duties— all environmental factors which they felt were absent in daily practice (Siebens et al., 2006). There is also an absence of the voices of nurses in societal debate with regards to euthanasia (Garity, 2004; Bilsen et al., 2004). When nurses in Belgium did develop a position paper on euthanasia in the years before the euthanasia law was enacted, it did not get any attention in a public forum (WVVV, 2002).
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We recommend an awareness of the links between euthanasia today and politically, economically, or ideologically motivated values. This is needed in light of the fact that the medical and nursing profession, generally, is unaware or ignores, the connections between clinical practice, social norms and values, state purposes and economics (Steppe, 2000). To encourage and ensure that the nursing profession voices their concerns, and understandings of euthanasia practices, open spaces must be created where nurses can independently raise their concerns both as individuals and as an independent profession (Steppe, 2000). Moreover the individual ethical responsibility of each nurse needs to be situated within a wider framework both private and public that supports and aids critical reflective ‘imaginative capacity’ and conscience rather than curtailing it (Arendt, 1964). A part of supporting that wider framework consists in increasing the research and perspectives that one can take on euthanasia both in a legal and illegal sphere to facilitate and aid further critical development in nurses to best optimize the care for themselves and their patients when faced with such a difficult ethical issue. Especially with respect to euthanasia, nurses need to be able to voice their moral concerns and policy needs whether it affects them, their patients or their family, caregivers, and even a whole society (Garity, 2004).
7. Conclusion In this paper, we have focused on the contexts of moral decision-making by nurses in the euthanasia programs of Nazi Germany using Walker’s (1998) philosophical model. We used the second hypothesis of this model, that morality consists of practices of responsibility, to give an ethical analysis of the understandings nurses had of their responsibilities in the euthanasia programs. Nurses involved in both legal and illegal euthanasia practices have much to learn from an investigation of their past as well as present euthanasia practices. Nurses also have the potential to play a pivotal role in moral reflection on euthanasia. However they need to be aided to understand that the responsibilities for raising issues in connection to euthanasia are part of the tasks of nursing practice and part of what it means to be a nurse. Nursing perspectives and moral insights, both past and present, have been largely ignored, while they can only contribute to a richer, inclusive, and more critical public debate on the issue of euthanasia
References Aly, G., Roth, K.H., 1984. The legalization of mercy killings in medical and nursing institutions in Nazi Germany from
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1938 Until 1941. Commented Documentation. International Journal of Law and Psychiatry 7, 145–163. Aranda, S., 2004. Commentary: euthanasia—A clincial and professional issue for nurses. Journal of Advanced Nursing 47 (6), 601–604. Arendt, H., 1964. A Report on the Banality of Evil. Eichmann in Jerusalem. Penguin Books, Harmondsworth. Benedict, S., Kuhla, J., 1999. Nurses participation in the ‘Euthanasia’ programs of Nazi Germany. Western Journal of Nursing Research 21 (2), 246–263. Bilsen, J.R., Vander Stichele, R.H., Mortier, F., Deliens, L., 2004. Involvement of nurses in physician-assisted dying. Journal of Advanced Nursing 47 (6), 583–591. Blum, P., 1947. Affidavit concerning Euthanasia program at Hadamar, Germany. NMT 01. Medical Case—USA v. Karl Brandt, et al., English Transcript, p. 1783 (16 January 1947). Bundesarchivs, 2003. Inventar der Quellen zur Geschichte der ‘Euthanasie’—Verbrechen 1939–1945. Im Auftrag des Bundesarchivs, Germany. Burleigh, M., 1994. Death and Deliverance. ‘Euthanasia’ in Germany 1900–1945. Cambridge University Press, Cambridge. Burleigh, M., 1997. Ethics and Extermination. Reflections on Nazi Genocide. Cambridge University Press, Cambridge. De Bal, N., Dierckx de Casterle´, B., Gastmans, C., 2006. Involvement of nurses in caring for patients requesting euthanasia in flanders (Belgium): a qualitative study. International Journal of Nursing Studies 43, 589–599. De Beer, T., Gastmans, C., Dierckx de Casterle´, B., 2004. Involvement of nurses in Euthanasia: a review of the literature. Journal of Medical Ethics 30, 494–498. Dierckx de Casterle´, B., Grypdonck, M., Vuylsteke-Wauters, M., Janssen, P.J., 1997. Nursing students’ responses to ethical dilemmas in nursing practice. Nursing Ethics 4 (1), 12–28. District Court (Court of Assizes), Berlin. 1947. In the Name of the People! NMT 01. Medical Case—USA v. Karl Brandt, et al., English Transcript, p. 1690 (14 January 1947). Dudley, M., Gale, F., 2002. Psychiatrists as a moral community? Psychiatry under the Nazis and its contemporary relevance. Australian and New Zealand Journal of Psychiatry 36, 585–594. Ernst, E., 1996. Killing in the name of healing: the active role of the German medical profession during the Third Reich. The American Journal of Medicine 100, 579–581. Friedlander, H., 1995. The Origins of Nazi Genocide: From Euthanasia to Final Solution. The University of North Carolina Press, Chapel Hill. Garity, J., 2004. Commentary: Euthanasia—nursing education and research implications. Journal of Advanced Nursing 47 (6), 601–604. Gastmans, C., Lemiengre, J., Schotsmans, P., van der Wal, G., Dierckx de Casterle´, B., 2006a. Prevalence and content of written ethics policies on Euthanasia in catholic healthcare institutions in Belgium (Flanders). Health Policy 76, 169–178. Gastmans, C., Lemiengre, J., Dierckx de Casterle´, B., 2006b. Role of nurses in institutional ethics policies on Euthanasia in Belgium (Flanders). Journal of Advanced Nursing 54, 53–61.
ARTICLE IN PRESS 854
M. Berghs et al. / International Journal of Nursing Studies 44 (2007) 845–854
Gastmans, C., Lemiengre, J., Dierckx de Casterle´, B., 2006c. Development and communication of written ethics policies on Euthanasia in catholic hospitals and nursing homes (Flanders). Patient Education and Counseling, (in press). Haverkate, I., 1999. Policies and Guidelines on Medical Decisions Concerning the End of Life in Dutch Health Care. Thela-Thesis, Amsterdam. Hoskins, S.A., 2005. Nurses and national socialism—a moral dilemma: one historical example of a route to Euthanasia. Nursing Ethics 12 (1), 79–91. Kevles, D.J., 1985. In the Name of Eugenics. Genetics and the Uses of Human Heredity. Penguin Books, New York. KNMG & NU’91, 1997. Euthanasierichtlijnen arts-verpleegkundigen. Richtlijnen samenwerking en taakafbakening arts en verpleegkundige bij de procedure rond euthanasie. [Physician-Nurse Euthanasia guidelines. Guidelines for physician and nurse teamwork and task delegation in the procedure around Euthanasia] Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG) en Nieuwe Unie’ 91, beroepsorganistatie van de verpleging, Utrecht. Kottow, M.H., 1988. Euthanasia after the holocaust—is it possible? A report from the federal republic of Germany. Bioethics 2 (1), 58–69. McFarland-Icke, B.R., 1999. Nurses in Nazi Germany. Moral Choice in History. Princeton University Press, Princeton. Mckie, A., 2004. ‘The demolition of a man’: lessons from holocaust literature for the teaching of nursing ethics. Nursing Ethics 11 (2), 138–149. Miles, S.H., Ryder, M.B., 1985. Limited-treatment policies in long-term care facilities? Journal of American Geriatric Society. 33, 707–711. Milgram, S., 1974. Obedience to Authority. An Experimental View. Harper & Row, N.Y, Hagerstown, San Francisco, & London. NMT 01. Medical Case—USA v. Karl Brandt, et al., 1947. English Transcript, p. 1551 (13 January 1947).
Pool, R., 1996. Vragen om te sterven—Euthanasie in een Nederlands ziekenhuis. WYT Uitgeefgroep, Rotterdam. Reich, W.T., 2001. The care-based ethic of Nazi medicine and the moral importance of what we care about. American Journal of Bioethics 1 (1), 64–74. Rogow, S.M., 1999. Child victims in Nazi Germany. The Journal of Holocaust Education 8 (3), 71–86. Siebens, K., Dierckx de Casterle´, B., Abraham, I., Dierckx, K., Braes, T., Darras, E., Bubois, Y., Milisen, K., 2006. The professional self-image of nurses in Belgian Hospitals. Meaning for the future of the professional. International Journal of Nursing Studies 43, 71–82. Stephenson, J., 1975. Women in Nazi Society. Croom Helm, London. Steppe, H., 2000. Das Selbstversta¨ndnis der Krankenpflege in ihrer historischen Entwicklung. Pflege 13, 77–78. The´, B.A.M., 1997. ‘Vanavond om 8 uury’ Verpleegkundige dilemma’s bij euthanasie en andere beslissingen rond het levenseinde. Bohn Stafleu Van Loghum, Houten/Diegem. The Belgian Statue Book (Belgisch Staatsblad), 2002. The Belgian Act on Euthanasia of 28 May 2002. Van de Scheur, A., van der Arend, A., 1998. The role of nurses in Euthanasia: a Dutch study. Nursing Ethics 5, 497–508. Verpoort, C., Gastmans, C., De Bal, N., Dierckx de Casterle´, B., 2004. Nurses’ attitudes to Euthanasia: a review of the literature. Nursing Ethics 11 (4), 349–365. Walker, M.U., 1998. Moral Understandings. A Feminist Study in Ethics. Routledge, New York and London. Walter, I., 2003. Auswirkung des ‘‘Anschlusses’’ auf die o¨sterreichische Krankenpflege. Pflege 16, 6–16. Willig, K., 1947. Statement of Karl Willig. NMT 01. Medical Case—USA v. Karl Brandt, et al., English Transcript, p. 1786 (16 January 1947). WVVV (Wetenschappelijke Vereniging voor Verpleegkunde en Vroedkunde) [Scientific Union for Nursing and Midwifery], 2002. Standpunt over euthanasie [Position on euthanasia]. Available at: http://allserv.rug.ac.be/lefloor/artikel8.htm