German Eugenics in Practice
Eugenics Review, 27, 1936; pp. 285-95
According to figures quoted from Deutsche Justiz in the July 1935 issueof the Eugenics Review (page 90), some 56,000 people were sterilized in Germany in the first twelve months after the introduction of the sterilization law. If this figure may be taken as correct, it does not follow that the first year of sterilization will be typical of the following ones, or that this rate of sterilization will be kept up. The operation of the law is likely with time to improve in efficiency, leading one to expect an increased number of sterilizations per year. On the other 'hand, in the first year the standing population of defectives, schizophrenics, etc., will be attacked, the operations of subsequent years being more confined to the yearly increment. Could, however, this figure of 56,000 be taken as a probable yearly average, it would imply about two per thousand of the fertile population being sterilized every year, with a total expectation of sterilization for the average individual in the neighbourhood of 4 per cent.
Public Reaction to Sterilization Law
It is not easy to discover the reaction of the population to this very definite attack on their personal and physical liberty. My information, from a well-informed source, is that there is much resentment throughout Germany among the common people, particularly directed against its compulsory nature. Compulsion itself is not liked, and as a police affair is doubly objectionable. The nature of the operation does not improve matters. An attack on the sexual organs is calculated to arouse more resentment than any operation of corresponding severity on another part. Among women there is a definite mortality, not entirely to be eliminated in any double laparotomy, and this mortality tends to be exaggerated and associated with both sexes. Lastly, the nature of the operation is still misunderstood and thought to have a castrating effect. Some of these grounds for objection will disappear in the course of time; others will always be felt.
Patients to be sterilized seldom protest; they know that if they did it would have no effect. Physical resistance must be extremely rare. The law provides for the use of direct force, but this has not yet been necessary. Resistance to sterilization by appeal is statutory and frequent. There have indeed been attempts to organize this resistance. In Bavaria pamphlets were printed and found in Catholic hands recommending all patients to appeal in every case. This was, of course, an attempt to make the law unworkable. The pamphlet was seized and destroyed. The frequency of appeal has varied much from time to time and from place to place, in some areas being as low as 1%, in others as high as two-thirds of all cases where the order was made.
In many scientific and more liberal circles there is a strong objection to the compulsory aspect of the law, partly as a matter of principle, partly based on reasoned argument. In support of this view are quoted the calculations of Haldane and others, which go to show that sterilization operates extremely slowly towards the removal of characteristics dependent on infrequent recessive genes, and the findings of one scientific worker, that practically all the children of schizophrenics are born before the manifestation of the disease. One authority, with whom I discussed the matter, was of the opinion that the law would operate at least as well if sterilization were made voluntary-that in fact one would get as good results by propaganda as by compulsion. Against this one must put the opinion of such a well-informed authority as Sjögren of Sweden, who told me that in his opinion the reverse would be the case. Apparently the experience in Sweden with voluntary sterilization has been very disappointing, only a few hundreds having been sterilized since the introduction of the law a few years ago.
Practising doctors in general are inclined to object to the law, and to the increase in their duties, and to the increasedly police nature of these duties which the law entails. The doctor must notify all cases of the hereditary disorders named in the law, as far as these become known to him through the practice of his profession. For instance, were he, on a professional visit, to see the patient's brother have an epileptic fit, he would not be bound to notify him, though he could do so if he wished. If the patient himself were to have the fit, and it could not be referred to definite exogenous causes, then he must notify. If, on the other hand, the doctor passing casually along the street were to see a patient of his having a fit, he would not be bound to report him. Presumably, however, if he were to proceed to his assistance, the duty to notify would reappear.
The keenness with which doctors carry out their duties varies greatly from place to place. In small country villages, with only one doctor, he generally does it satisfactorily, because he neither loses nor gains by it. In places with two or more doctors they usually notify only where it is obviously unavoidable. The doctor slackest in notifying will tend to profit at the expense of the others. On the other hand in Thuringia and Baden these duties were carried out with the greatest enthusiasm. In the latter place, the doctors seemed possessed of the notion that the more cases they notified, the better pleased would they be in high quarters. At length a circular had to be sent round, telling them that they were only to notify cases properly capable of reproduction.
In clinics, the duty of notification is carried out conscientiously, and proceeds for the most part automatically. The chief difficulties are those of diagnosis. The diagnosis should be of such a degree of certainty that the clinician would be prepared to back it in a court of law, or alternatively for the Professor to be able to demonstrate the case as such to a class of students. Many authorities find difficulty in fitting their cases into the official scheme of classification - particularly, for instance, Kleist. According to Kleist's classification there are a number of separate syndromes, for instance-motility and confusion psychoses, which would by most clinicians be considered schizophrenic, but which he treats as separate entities. As in these cases his researches into the heredity have shown no connection with schizophrenia, he does not hold them to be schizophrenic, nor covered by the law, nor in his clinic are they notified.
Difficulties of diagnosis must necessarily occur, and may have unfortunate effects. The following is such a case.
The daughter of a doctor had had in childhood an obscure febrile complaint, accompanied by some minor neurological signs. At puberty she developed periodical but rare and slight " absences "; but with the years these increased in frequency and severity until they were major epileptic fits. In the course of treatment her father was informed she would have to be notified for sterilization. He objected very much, and took her from doctor to doctor in the vain attempt to get her recognized as a case of fits of exogenous origin. At last she was seen by one of the best-known neurological surgeons of the country, who after an encephalography operated on her and removed a large cyst from the brain, with complete recovery and cessation of the fits.
Such cases cannot be published, owing to the disrepute into which they might bring the law, if they were at all frequent.
In the first few months after the law was passed, there was a considerable amount of overcrowding in clinics and hospitals, because cases of recovery from schizophrenia and manic-depressive psychosis had to be held pending decision on the matter of sterilization. This is the case no longer. Once the case is notified, he may be discharged and wait at home for the notice of reception into a surgical clinic, or altematively conduct his appeal before the court from home. Only cases where the danger of procreation is really serious, e.g. men in a mild hypomanic state with much sexual desire-should be held till the question of sterilization is finally settled and they can be directly transferred to the surgical clinic. In all other cases it suffices for the law to have been set in motion, and patients are subjected to a minimum of delay and inconvenience.
Cases for sterilization are notified to the "Bezirksarzt." He would correspond to some degree to the English local medical officer of health, though his activities are being more and more confined to the operation of the eugenic laws. He draws up a document, the "Antrag," which summarizes all available data to enable a decision to be reached as to sterilization or not. To obtain sufficient information he is entitled to order the patient's admission to a psychiatric clinic for a period not longer than six weeks for examination and report. The "Antrag" is laid before the local eugenic court ("Erbgesundheitsgericht"), which consists of a jurist as president, a "Bezirksarzt," and a specialist in medical genetics, and they reach the decision on sterilization. If the patient is dissatisfied with the decision he may appeal to a higher court, the "Erbgesundheitsobergericht."
If the " Bezirksarzt" is a Catholic, difficulties of conscience are likely to appear. Catholic general practitioners are allowed by their Church to make the notification, because it does not necessarily follow that the patient will be sterilized. Also such notifications have an unrelated statistical significance. The actual order to sterilize is another matter, and a Catholic "Bezirksarzt" is forbidden by his Church, and compelled by the State, to make such sterilization orders. In districts where there are two such doctors, one of whom is a Catholic, it has sometimes been arranged that the Catholic hands over the whole of these duties to his colleague. Presumably the whole matter could be settled by an agreement between Church and State. The order for admission to a psychiatric clinic for examination and report is made in quite a fair proportion of cases where the original notification has not been made from such a clinic. The senior assistants at the clinics make a very reasonable addition to their small salaries out of the fees for these reports. The admission to a clinic for this purpose is specially likely to happen where the patient has appealed against the order for sterilization. The reports in these cases are long, exhaustive and reasoned documents. For instance, I saw a report on a case of congenital syphilis and mental deficiency.
The family history, personal history, physical, psychiatric, and psychological examinations were given in detail. The difficult point of whether the patient was mentally defective because of the syphilis, or because of hereditary defect and only happened concurrently to be syphilitic, was discussed in full on general grounds and in the particular circumstances of the case; and finally judgment was given, in this case that the mental deficiency was to be referred to exogenous rather than endogenous causes.
Interesting here is the fact that a certainty of congenital syphilis is not taken legally as ipso facto precluding a diagnosis of hereditary mental defect. The patient is assured of a full and unbiased consideration of his case in any reputable clinic. Where the doctor does not prefer to write out the report in full, special forms are provided, which if properly filled in ensure a thoroughgoing anamnesis and examination from every point of view.
Before the introduction of the sterilization laws, Germany had no special laws for mental defectives, and practically no special institutions. Hospitalization was much less frequent than in England, and largely confined to idiots and the severer grades of defect. Mental defectives, apart from such special cases as the above, are judged principally on social grounds, to a less degree on school record and least of all on psychological tests. A special form is given for the latter, which few English or I suppose American psychologists would consider satisfactory. It consists of questions on orientation of the usual kind, on "school knowledge" of the most elementary kind (Who was Bismarck? When is Christmas?), mathematical problems (simple interest on 300 marks at 3 per cent. for 3 years), general questions of an almost philosophical kind (Why do we have day and night? Why are houses built higher in towns than in the country? Why do children go to school?), differences (between " mistake " and " lie," between " Rechtsanwalt " and " Staatsanwalt"), composition of sentences (e.g. out of "soldier," "war," "fatherland"), the repetition of a story, the explanation of proverbs "general moral ideas" (Why does one learn? save money? What is truth ?), memory and attention tests, and notes on the behaviour during the testing.
It is no wonder that the German does not place much reliance on such tests, considered as tests of intelligence. The requirement on which most importance is laid for a diagnosis of mental defect is a persistent failure of the person concerned to maintain any sort of a position in life for himself and his family; if this is backed by an unsatisfactory school record-e.g. twice having to stay on in the same class instead of being promoted at the end of the year, or attendance at a special school ("Hilfsschule")- the diagnosis of mental defect may be made almost regardless of the results of the"intelligence test."
One of the special problems of mental deficiency is its ascertainment. Psychiatric cases are got hold of largely through the psychiatric clinics. A few mental defectives will be discovered in the same way, if they come into the clinics in a state of excitement, or complaining of the depressive or hypochondriacal symptoms not infrequent in defectives; but these must be few. The majority are discovered in other ways. In the country the local "Bezirksarzt" is supposed to, and generally does, know every single family that lives in his district. He is accordingly able to put his hands on the local defectives, persistent low-grade misfits and failures at any time. In the towns the matter is more difficult, and the defectives are got hold of largely accidentally, as they come to doctors or hospitals for advice on entirely unrelated subjects-e.g.for appendicitis - or as they appear as candidates for financial or social assistance at the offices of charity organizations, church missions, public assistance offices, etc. With the development of the marriage-advice centres and related scientific and social institutions, there will be still further ways of ascertainment, until this should become in the end fairly complete.