When many people see euthanasia as bad — for example, as a denial of the right to life or simply as murder — then it is to be expected that perpetrators will take steps to reduce adverse reactions.
Consider first the notorious Nazi T4 programme, commonly called the euthanasia programme, seen as so outrageous that it stigmatised all forms of euthanasia for decades. The Nazi programme of killing people with disabilities was authorised by Hitler in 1939 and officially halted in 1941. Unknown to most, the children’s killing programme was exempted from the halt decree; furthermore, killings continued locally until the end of World War II.
Some might say that to refer to the T4 programme as euthanasia is completely inappropriate: there was no compassionate intention as the Nazis tried to suggest by using the euphemisms “euthanasia” and “mercy death” (Friedlander1995, p. xxi), but simply a programme of killing given a deceptive patina of legitimacy. Whatever one’s assessment of the Nazi programme, it can be analysed in terms of tactics used by the perpetrators to reduce outrage. It is worthwhile to learn from the tactics in the Nazi case in order to set up and assess responsible euthanasia processes, namely ones that do not rely on the same sorts of tactics.
Cover-up
The Nazi programme was not publicly announced or explained. Quite the contrary: “Immense pains were taken to keep T–4’s operations covert” (Burleigh1994, p. 162). To run the programme, the obscure agency KdF (Chancellery of the Führer) was chosen because of its small size and low visibility (Friedlander1995, p. 40).
Though the programme was classified top secret, many knew about it, notably doctors involved. They were perpetrators and aided in the cover-up. They hid their actions from those most likely to be disturbed by and protest against the killings, including relatives, members of the Catholic Church, and foreign populations (Aly1994, pp. 29–32). After public protest led to the closing of two killing centres, transit institutions were created to add greater secrecy to the process (Friedlander1995, p. 108).
Devaluation
Under Nazi rule, people with disabilities were commonly labelled “idiots,” “crazies” and “cripples.” Perpetrators used the expression “life unworthy of life” (Friedlander1995, p. xxii). The eugenics movement, strong in Germany as well as some other countries, devalued anyone deemed to have defective genes (Proctor1988). The Nazis produced propaganda films devaluing people with disabilities (Burleigh1994, pp. 183–219). For example, the 1936 film Erbkrank was intended “to criminalise, degrade and dehumanise the mentally and physically handicapped so as to justify compulsorily sterilising them” (Burleigh1994, p. 183). Devaluation, at a psychological level (Bandura1986, pp. 375–389), also helped enable the killings.
Reinterpretation
Language is the most obvious part of reinterpretation: as noted, the Nazis used the terms “euthanasia” and “mercy death” to describe the killings, which otherwise would be called murder. Another reinterpretation technique was to rationalise killings by saying that people in institutions were expensive drains on the Nazi state when facilities were needed for injured soldiers.
Outright lying was another standard reinterpretation technique. For example, patients from institutions were transferred to other centres for killing, with guards in white coats in attendance to make it seem like a medically supervised process. Parents were told that their children were being sent to special centres where they would receive better treatment. Relatives were sent death certificates with false information about the cause of death (Burleigh1994;Friedlander1995, pp. 85, 98–106). To disguise the central direction of the programme, physicians and administrators used pseudonyms (Friedlander1995, p. 103). Lying can serve as a form of cover-up; it fits within the category of reinterpretation when relatives knew that something had happened — death of a loved one — but were deceived about how and when it occurred.
Official channels
The programme was never given legal approval; Hitler refused this because the German people would not support it (Friedlander1995, p. 154). Instead, Hitler wrote a letter privately authorising the programme and this letter was used to win over some participants (Burleigh1994;pp. 112–113; Friedlander , pp. 112–113; Friedlander pp. 112–113; Friedlander1995, pp. 67, 154). A formal meeting served to win over sceptical legal professionals (Burleigh1994;pp. 172–173; Friedlander , pp. 172–173; Friedlander pp. 172–173; Friedlander1995, p. 122).
In August 1941, Hitler halted the programme, but this official response to protest was deceptive. The “halt” only applied to killing centres and did not apply to children. T4 continued, with physicians killing adults using starvation and injections (Burleigh1994;Friedlander p. 180; Friedlander1995, p. 154).
It was only after the war that official channels, namely courts, were used against the perpetrators. After 1947, the German Federal Republic judiciary mostly made decisions that allowed T4 participants to rejoin German professions, for example by terminating trials, acquitting defendants or giving lenient sentences (Bryant2005, p. 218).
Intimidation
Speaking out against Nazi policies was always risky. Parents who refused permission for their children with disabilities to be sent away were threatened with being sent to work camps or having all their children taken into state custody (Burleigh1994;Friedlander p. 166; Friedlander1995, pp. 59–60). After Bishop Galen’s sermon condemning the T4 programme (discussed later), ordinary Germans found to possess, circulate or discuss the sermon were subject to reprisals including losing jobs, being sent to concentration camps or execution (Burleigh1994, pp. 178–180).
The perpetrators of the Nazi T4 programme thus relied on all five types of tactics to reduce outrage — a very strong indication of the potential for popular outrage about the programme. This is exactly what is to be expected using this analysis of tactics: when powerful perpetrators anticipate resistance, they are likely to use a range of tactics that reduce outrage.
What then about challenging the programme? Methods of doing this can be categorised into five types of counter-tactics to the five types of outrage-reduction tactics.
Exposure
The key to challenging cover-up is to get information to receptive audiences. Information about the T4 programme gradually leaked out via observations and inferences by relatives and local people (Burleigh1994;pp. 162–164; Friedlander , pp. 162–164; Friedlander pp. 162–164; Friedlander1995, p. 111). The breakthrough event was a 1941 pastoral letter by Clemens August von Galen, bishop of Münster, which was reprinted and widely distributed throughout Germany (Burleigh1994;Friedlander p. 178; Friedlander1995, p. 115).
Validation
To challenge devaluation, the victims needed to be conceived as humans with lives worth living. Von Galen (1941), referring to the targets of the T4 programme, said “we are dealing with human beings, with our neighbours, brothers and sisters,” describing them positively in terms of vital relationships. (Incidentally, von Galen was far less vocal about the value of Jewish lives [Griech-Polelle2001).
Reframing
To counter techniques of lying, minimising, blaming and framing, the programme had to be named as an injustice, namely killing pure and simple. One asylum director, Heinrich Hermann, used the word “killing” in criticising T4 to visiting euthanasia planners, who were disconcerted by the direct language: “These institutional murderers with civil servant status were not equal to a confrontation with the naked word ‘killing’” (Aly1994, p. 34).
Mobilisation
There are two ways to respond to official channels used to give a deceptive appearance of justice. One is to avoid or discredit the official channels. In the long term, discrediting the Nazi regime accomplished this, so much so that virtually any Nazi policy was discredited by association. The other response is to not rely on official channels for redress but instead to mobilise support among the public, for example by talking to individuals, publicising the issues, holding private or public meetings, forming networks and groups, and making public protests.
For many months prior to von Galen’s pastoral letter, various individual opponents of T4 — especially church people — wrote letters to or had meetings with government officials, such as the Ministry of Justice, but this insider approach achieved little (Burleigh1994;pp. 166–176; Friedlander , pp. 166–176; Friedlander pp. 166–176; Friedlander1995, pp. 113–114, 121–122). These were significant signs of opposition but they were not so effective as mobilising public support: they essentially relied on an official channel, namely appealing to government officials, that gave only the appearance of offering a solution.
Resistance
The counter to intimidation is to continue taking action against the injustice and to expose evidence of intimidation in order to create greater outrage. Those who opposed the euthanasia programme at the time, in word or deed, displayed incredible courage (Gallagher1995, pp. 137–146, 186–203).
In summary, the Nazi T4 programme is an ideal illustration of an injustice in which all the methods of reducing and fostering outrage can be observed.
In the current debate over euthanasia, the issues are not as clear-cut as in the Nazi case. Nevertheless, the same sorts of methods are involved. As a typical example, consider the case of a patient, with a terminal illness, whose doctor believes is suffering unnecessarily and would be better off dead. Suppose the doctor, without informing or obtaining permission from anyone, gives this patient a lethal drug dose. This can occur whether or not active euthanasia is legal (Kuhse et al.1996;Magnusson2002).
The primary means of preventing outrage is cover-up: the doctor tells no one about intentionally hastening death. Other doctors or perhaps relatives might suspect what the doctor has done, but not have sufficient evidence or incentive to expose it. If there is a suspicion of foul play, then the doctor may use reinterpretation, saying the person was going down quickly or claiming not to have been involved. In such situations, devaluation may or may not be used. The doctor seldom has access to official channels to reduce outrage, nor has any means of intimidating critics.
This assessment shows that covert euthanasia by individual doctors is quite different — in terms of available methods for reducing outrage — to the Nazi T4 programme. The primary techniques available to individual doctors are cover-up and reinterpretation. Without the backing of a powerful institution, such as the Nazi state, other methods of reducing outrage are unavailable or of limited assistance.
In practice, covert euthanasia of this sort ranges from sincere efforts to minimise suffering done on an ad hoc basis to regular killing that is more readily labelled criminal, as in the case of the British serial-killer doctor Harold Shipman (Whittle and Richie2004).
When euthanasia has been legalised, a different pattern emerges. Following a set of legal guidelines, physicians may assist a person to end their life (as in Oregon) or administer a lethal injection (as in the Netherlands). Consider an instance of legal euthanasia in which the patient has a terminal illness, is suffering, requests death and is provided with lethal drugs that can be self-administered.
Cover-up
There is no cover-up: the person dying knows quite well that the purpose of taking the drugs is to cause death. In some cases relatives and friends are present.
Devaluation
Whether devaluation is involved is a matter of debate. Critics of euthanasia might say the person’s life, by being shortened, has been devalued by that fact; supporters might say that euthanasia actually involves respect for a person’s autonomy and for their experience of life, which has become intolerable.
Reinterpretation
Those involved with legal euthanasia do not lie about what is happening: they are obliged to open about it. There is no evidence that they minimise the significance of what they are doing; many find it distressing (e.g., Kade2000). They cannot blame someone else for the death: they have to accept responsibility. The most important reinterpretation technique used is framing: they say that what occurs is voluntary and intended to reduce suffering — not an unfair termination of life and certainly not killing. For example, the Dutch government brochure Euthanasia: The Netherlands’ New Rules defines euthanasia as “the termination of life by a doctor at the patient’s request, with the aim of putting an end to unbearable suffering with no prospect of improvement” (Ministerie van Volksgezondheid, Welzijn en Sport, n.d.).
Some would say that the Oregon state model is less than fully open, in that deaths in which physicians provide assistance are officially called natural deaths. The Swiss model is more transparent: legal oversight is provided by the criminal justice system; police investigate every death for legal compliance; and some right-to-die societies film deaths and immediately provide videotapes to the police (Ziegler2009). This also allows research into euthanasia deaths (Ogden et al.2010) and thus greater understanding.
Official channels
When proper procedures are followed, official channels authorise the process of dying. Critics of euthanasia allege that consent sometimes has not been given or that cases are not reported as they are supposed to be (Jeffrey2009;pp. 63–73, 84; Smith , pp. 63–73, 84; Smith pp. 63–73, 84; Smith1997, pp. 90–114). However, it is very difficult for critics to use complaint procedures to challenge decisions, because the laws authorising euthanasia provide protection to doctors and others involved if formal procedures are followed.
Intimidation
There is little evidence that critics have been threatened or penalised. (See, for example, Thomasma et al.1998).
In summary, legal euthanasia involves few of the techniques typically used by powerful perpetrators to reduce outrage from injustice. There is little or no cover-up, little devaluation, reinterpretation only by framing, and little intimidation. The one exception is official channels: laws and judicial practice provide powerful protection for doctors and others involved in the process.
Note that this analysis does not by itself provide an endorsement of legal euthanasia. All it shows is an absence of most of the techniques commonly used by powerful perpetrators of actions potentially seen as unjust.
In this section, I have outlined the common tactics used by perpetrators to reduce outrage over euthanasia and some of the counter-tactics that can be used by those opposed to euthanasia. The Nazis, in killing hundreds of thousands of people with disabilities, used the full range of techniques for reducing outrage: cover-up, devaluation, reinterpretation, official channels and intimidation. On the other hand, individual doctors who practise euthanasia, where it is illegal, typically rely primarily on cover-up. When euthanasia is legal, the pattern is quite different: only official channels might be seen as tools to reduce outrage.
So far I have analysed euthanasia in terms of tactics used to reduce concern. A different analysis, to which I now turn, is of tactics used to reduce concern about the opposite injustice: refusal of euthanasia.