The 11th International Congress of the World Psychiatric Association (WPA) was held in Hamburg during August 1999. The most memorable feature of the successful event was not the presence of 10 000 psychiatrists from 96 countries, nor their 6000 papers, nor the elegance of the rebuilt city, but a poignant exhibition prepared by the German Society for Psychiatry, Psychotherapy and Neurology. The presentation, titled ‘In Memoriam’, described the wartime extermination within Germany of 180 000 psychiatric patients. The killers were their psychiatrists.

The order authorising euthanasia was signed by Hitler on the commencement of the Second World War. The regime had prepared the slaughter by its previous sterilisation of 400 000 patients with mental and physical illnesses. The liquidation was not confined to German citizens. Slave labourers who had been transported to work in the Reich and who fell ill mentally were singled out for destruction. The patients at the psychiatric hospital in Kiev, numbering over 2000, were removed and shot. Within Germany children with learning disabilities were subjected to dangerous and sometimes lethal experiments, such as inoculation with tubercle bacilli.

The exhibition selected as a striking example a 15-year-old youth who lacked parents. He possessed a degree of conduct disorder yet was friendly, likeable and literate. The day before his death from a morphine injection he was described by a nurse as helpful and cooperative. The boy had noticed unnatural deaths and expected that he himself would die.

Visitors to the display were silent and thoughtful. Perhaps the most moving feature lay in letters from relatives to medical superintendents of hospitals regarding loved ones who had disappeared or died.

The legal authorisation of euthanasia was withdrawn after two years in the face of public outrage that was courageously led by Bishop Galen of Münster. Until then the deaths in Germany were produced by drugs or occasionally by vehicle exhaust fumes. Only half the killings had occurred by that time. The remaining 80 000 deaths took place furtively, although with official encouragement, the preferred method was starvation. A further and greater tragedy ensued. The efficiency of the euthanasia programme provided incitement and a model for the extermination of Jews and Gypsies.

The exposition did not aim to recount in detail the reasoning behind the euthanasia policy with its goal of racial purity. It is disconcerting to reflect that excessive nationalism had a major origin in the harmless and respectable Romanticism formulated by, among others, Goethe. This literary movement was associated with supposed mediaeval ideals of Teutonic chivalry, and became linked by the philosopher Fichte with cultural and political freedom from Napoleonic dominance (Reference RichieRichie, 1999). Subsequent events, notably the military and political successes effected by Bismarck, led through stages to the bizarre and wicked ideology of Nazi theorists. The killings were not discussed over subsequent decades by German psychiatrists. Only in recent years has the present generation been able to acknowledge the conduct of their predecessors and commemorate the victims.

Complacency or smugness are not appropriate in other countries. The start of the AIDS epidemic witnessed expressions of satisfaction that undesirable persons were dying. The concept of progressive degeneration of inherited stock through mental disorders originated in France, found favour in the UK and led to the desire by some UK doctors for sterilisation of psychiatric patients. Although euthanasia was far from the minds of British psychiatrists, their hospital records until the 1950s sometimes bore remarkable similarities to the contemptuous accounts of the German psychiatrists who embarked on euthanasia.

There are also less pessimistic aspects. As noted above, the German public was shocked by the extermination. Many psychiatrists refused to participate, often at the price of their careers. The chairman of the Heidelberg clinic (a successor to Kraepelin) complained that because of resignations he was left with too few experienced colleagues. Finally, there are the sincerity and frankness of the exhibition. During the initial ceremony of the WPA Congress the President of the professional society responsible for the display declared, in the presence of his national President and the media, that the slaughter amounted to a holocaust. Smaller in scale and less well known than the major Holocaust, the euthanasia programme provides sombre reflection and a warning. Its avowal by leading contemporary psychiatrists in Germany calls for respect and hope.