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Karl Brandt, doctor to Hitler and Hans Lammers, the head of the Reich Chancellery, testified after the war that Hitler had told them as early as 1933—when the sterilisation law was passed—that he favoured the killing of the incurably ill but recognised that public opinion would not accept this. In 1935, Hitler told the Leader of Reich Doctors, Gerhard Wagner, that the question could not be taken up in peacetime; "Such a problem could be more smoothly and easily carried out in war". He wrote that he intended to "radically solve" the problem of the mental asylums in such an event. Aktion T4 began with a "trial" case in late 1938. Hitler received word about a severely handicapped newborn through the Kanzlei des Führers, a.k.a. the Chancellery of the Führer of the Nazi Party, or KdF, headed by Phillip Bouhler. Unlike the SS or the Nazi Party Chancellery, the KdF had no public face, and provided Hitler with the cover needed to move forward with the first killing.

Hitler instructed Brandt to evaluate a petition sent by two parents for the "mercy killing" of their son who was blind and had physical and developmental disabilities. The child, born near Leipzig and eventually identified as Gerhard Kretschmar, was killed in July 1939. Hitler instructed Brandt to proceed in the same manner in all similar cases.

On 18 August 1939, three weeks after the killing of the boy, the Reich Committee for the Scientific Registering of Hereditary and Congenital Illnesses was established to register sick children or newborns identified as defective. The secret killing of infants began in 1939 and increased after the war started; by 1941, more than 5,000 children had been killed. Hitler was in favour of killing those whom he judged to be lebensunwertes Leben (Life unworthy of life). A few months before the "euthanasia" decree, in a 1939 conference with Leonardo Conti, Reich Health Leader and State Secretary for Health in the Interior Ministry, and Hans Lammers, Chief of the Reich Chancellery, Hitler gave as examples the mentally ill who he said could only be "bedded on sawdust or sand" because they "perpetually dirtied themselves" and "put their own excrement into their mouths". This issue, according to the Nazi regime, assumed a new urgency in wartime.

After the invasion of Poland, Hermann Pfannmüller (Head of the State Hospital near Munich) said

Für mich ist die Vorstellung untragbar, dass beste, blühende Jugend an der Front ihr Leben lassen muss, damit verblichene Asoziale und unverantwortliche Antisoziale ein gesichertes Dasein haben. (It is unbearable to me that the flower of our youth must lose their lives at the front, while that feeble-minded and asocial element can have a secure existence in the asylum.)

Pfannmüller advocated killing by a gradual decrease of food, which he believed was more merciful than poison injections.

Karl Brandt, Hitler's personal doctor and organiser of Aktion T4

The German eugenics movement had an extreme wing even before the Nazis came to power. As early as 1920, Alfred Hoche and Karl Binding advocated killing people whose lives were "unworthy of life" (lebensunwertes Leben). Darwinism was interpreted by them as justification of the demand for "beneficial" genes and eradication of the "harmful" ones. Robert Lifton wrote, "The argument went that the best young men died in war, causing a loss to the Volk of the best genes. The genes of those who did not fight (the worst genes) then proliferated freely, accelerating biological and cultural degeneration". The advocacy of eugenics in Germany gained ground after 1930, when the Depression was used to excuse cuts in funding to state mental hospitals, creating squalor and overcrowding.

Many German eugenicists were nationalists and antisemites, who embraced the Nazi regime with enthusiasm. Many were appointed to positions in the Health Ministry and German research institutes. Their ideas were gradually adopted by the majority of the German medical profession, from which Jewish and communist doctors were soon purged. During the 1930s, the Nazi Party had carried out a campaign of propaganda in favour of euthanasia. The National Socialist Racial and Political Office (NSRPA) produced leaflets, posters and short films to be shown in cinemas, pointing out to Germans the cost of maintaining asylums for the incurably ill and insane. These films included The Inheritance (Das Erbe, 1935), The Victim of the Past (Opfer der Vergangenheit, 1937), which was given a major première in Berlin and was shown in all German cinemas, and I Accuse (Ich klage an, 1941) which was based on a novel by Hellmuth Unger, a consultant for "child euthanasia".

Killing of children

Main article: Child euthanasia in Nazi Germany Schönbrunn Psychiatric Hospital, 1934 (Photo by SS photographer Friedrich Franz Bauer)

In mid-1939, Hitler authorised the creation of the Reich Committee for the Scientific Registering of Serious Hereditary and Congenital Illnesses (Reichsausschuss zur wissenschaftlichen Erfassung erb- und anlagebedingter schwerer Leiden) led by his physician, Karl Brandt, administered by Herbert Linden of the Interior Ministry, leader of German Red Cross Reichsarzt SS und Polizei Ernst-Robert Grawitz and SS-Oberführer Viktor Brack. Brandt and Bouhler were authorised to approve applications to kill children in relevant circumstances, though Bouhler left the details to subordinates such as Brack and SA-Oberführer Werner Blankenburg.

Extermination centres were established at six existing psychiatric hospitals: Bernburg, Brandenburg, Grafeneck, Hadamar, Hartheim, and Sonnenstein. One thousand children under the age of 17 were killed at the institutions Am Spiegelgrund and Gugging in Austria. They played a crucial role in developments leading to the Holocaust. As a related aspect of the "medical" and scientific basis of this programme, the Nazi doctors took thousands of brains from 'euthanasia' victims for research. Viktor Brack, organiser of the T4 Programme From August 1939, the Interior Ministry registered children with disabilities, requiring doctors and midwives to report all cases of newborns with severe disabilities; the 'guardian' consent element soon disappeared. Those to be killed were identified as "all children under three years of age in whom any of the following 'serious hereditary diseases' were 'suspected': idiocy and Down syndrome (especially when associated with blindness and deafness); microcephaly; hydrocephaly; malformations of all kinds, especially of limbs, head, and spinal column; and paralysis, including spastic conditions". The reports were assessed by a panel of medical experts, of whom three were required to give their approval before a child could be killed.

The Ministry used deceit when dealing with parents or guardians, particularly in Catholic areas, where parents were generally uncooperative. Parents were told that their children were being sent to "Special Sections", where they would receive improved treatment. The children sent to these centres were kept for "assessment" for a few weeks and then killed by injection of toxic chemicals, typically phenol; their deaths were recorded as "pneumonia". Autopsies were usually performed and brain samples were taken to be used for "medical research". Post mortem examinations apparently helped to ease the consciences of many of those involved, giving them the feeling that there was a genuine medical purpose to the killings. The most notorious of these institutions in Austria was Am Spiegelgrund, where from 1940 to 1945, 789 children were killed by lethal injection, gas poisoning and physical abuse. Children's brains were preserved in jars of formaldehyde and stored in the basement of the clinic and in the private collection of Heinrich Gross, one of the institution's directors, until 2001.

When the Second World War began in September 1939, less rigorous standards of assessment and a quicker approval process were adopted. Older children and adolescents were included and the conditions covered came to include

... various borderline or limited impairments in children of different ages, culminating in the killing of those designated as juvenile delinquents. Jewish children could be placed in the net primarily because they were Jewish; and at one of the institutions, a special department was set up for 'minor Jewish-Aryan half-breeds'. — 

More pressure was placed on parents to agree to their children being sent away. Many parents suspected what was happening and refused consent, especially when it became apparent that institutions for children with disabilities were being systematically cleared of their charges. The parents were warned that they could lose custody of all their children and if that did not suffice, the parents could be threatened with call-up for 'labour duty'. By 1941, more than 5,000 children had been killed. The last child to be killed under Aktion T4 was Richard Jenne on 29 May 1945, in the children's ward of the Kaufbeuren-Irsee state hospital in Bavaria, Germany, more than three weeks after U.S. Army troops had occupied the town. Copied from Aktion T4