The journal Molecular Autism this week published an article about the links between Hans Asperger and the Nazis in world war 2 Vienna, Austria. Hans Asperger is the paediatric pscyhiatrist on whose work Asperger’s syndrome is based, and after whom the syndrome is known. Until recently Asperger was believed to have been an anti-Nazi, someone who resisted the Nazis and risked his own career to protect some of his developmentally delayed patients from the Nazi “euthanasia” program, which killed or sterilized people with certain developmental disabilities for eugenics reasons.

The article, entitled Hans Asperger, National Socialism, and “race hygiene” in Nazi-era Vienna, is a thorough, well-researched and extensively documented piece of work, which I think is based on several years of detailed examination of primary sources, often in their original German. It uses these sources – often previously untouched – to explore and rebut several claims Asperger made about himself, and also to examine the nature of his diagnostic work during the Nazi era to see whether he was resisting or aiding the Nazis in their racial hygiene goals. In this post I want to talk a little about the background of the paper, and ask a few questions about the implications of these findings for our understanding of autism, and also for our practice as public health workers in the modern era. I want to make clear that I do not know much if anything about Asperger’s syndrome or autism, so my questions are questions, not statements of opinion disguised as questions.

What was known about Asperger

Most of Asperger’s history under the Nazis was not known in the English language press, and when his name was attached to the condition of Asperger’s syndrome he was presented as a valiant defender of his patients against Nazi racial hygiene, and as a conscientious objector to Nazi ideology. This view of his life was based on some speeches and written articles translated into English during the post war years, in particular a 1974 interview in which he claims to have defended his patients and had to be saved from being arrested by the Gestapo twice by his boss, Dr. Hamburger. Although some German language publications were more critical, in general Asperger’s statements about his own life’s work were taken at face value, and seminal works in 1981 and 1991 that introduced him to the medical fraternity did not include any particular reference to his activities in the Nazi era.

What Asperger actually did

Investigation of the original documents shows a different picture, however. Before Anschluss (the German occupation of Austria in 1938), Asperger was a member of several far right Catholic political organizations that were known to be anti-semitic and anti-democratic. After Anschluss he joined several Nazi organizations affiliated with the Nazi party. His boss at the clinic where he worked was Dr. Hamburger, who he claimed saved him twice from the Gestapo. In fact Hamburger was an avowed neo-nazi, probably an entryist to these Catholic social movements during the period when Nazism was outlawed in Vienna, and a virulent anti-semite. He drove Jews out of the clinic even before Anschluss, and after 1938 all Jews were purged from the clinic, leaving openings that enabled Asperger to get promoted. It is almost impossible given the power structures at the time that Asperger could have been promoted if he disagreed strongly with Hamburger’s politics, but we have more than circumstantial evidence that they agreed: the author of the article, Herwig Czech, uncovered the annual political reports submitted concerning Asperger by the Gestapo, and they consistently agreed that he was either neutral or positive towards Nazism. Over time these reports became more positive and confident. Also during the war era Asperger gained new roles in organizations outside his clinic, taking on greater responsibility for public health in Vienna, which would have been impossible if he were politically suspect, and his 1944 PhD thesis was approved by the Nazis.

A review of Asperger’s notes also finds that he did send at least some of his patients to the “euthanasia” program, and in at least one case records a conversation with a parent in which the child’s fate is pretty much accepted by both of them. The head of the institution that did the “euthanasia” killings was a former colleague of Asperger’s, and the author presents pretty damning evidence that Asperger must have known what would happen to the children he referred to the clinic. It is clear from his speeches and writings in the Nazi era that Asperger was not a rabid killer of children with developmental disabilities: he believed in rehabilitating children and finding ways to make them productive members of society, only sending the most “ineducable” children to institutional care and not always to the institution that killed them. But it is also clear that he accepted the importance of “euthanasia” in some instances. In one particularly compelling situation, he was put in charge – along with a group of his peers – of deciding the fate of some 200 “ineducable” children in an institution for the severely mentally disabled, and 35 of those ended up being murdered. It seems unlikely that he did not participate in this process.

The author also notes that in some cases Asperger’s prognoses for some children were more severe than those of the doctors at the institute that ran the “euthanasia” program, suggesting that he wasn’t just a fairweather friend of these racial hygiene ideals, and the author also makes the point that because Asperger remained in charge of the clinic in the post-war years he was in a very good position to sanitize his case notes of any connection with Nazis and especially with the murder of Jews. Certainly, the author does not credit Asperger’s claims that he was saved from the Gestapo by Hamburger, and suggests that these are straight-up fabrications intended to sanitize Asperger’s role in the wartime public health field.

Was Asperger’s treatment and research ethical in any way?

Reading the article, one question that occurred to me immediately was whether any of his treatments could be ethical, given the context, and also whether his research could possibly have been unbiased. The “euthanasia” program was actually well known in Austria at the time – so well known in fact that at one point allied bombers dropped leaflets about it on the town, and there were demonstrations against it at public buildings. So put yourself in the shoes of a parent of a child with a developmental disability, bringing your child to the clinic for an assessment. You know that if your child gets an unfavourable assessment there is a good chance that he or she will be sterilized or taken away and murdered. Asperger offers you a treatment that may rehabilitate the child. Obviously, with the threat of “euthanasia” hanging over your child, you will say yes to this treatment. But in modern medicine there is no way that we could consider that to be willing consent. The parent might actually not care about “rehabilitating” their child, and is perfectly happy for the child to grow up and be loved within the bounds of what their developmental disability allows them; it may be that rehabilitation is difficult and challenging for the child, and not in the child’s best emotional interests. But faced with that threat of a racial hygiene-based intervention, as a parent you have to say yes. Which means that in a great many cases I suspect that Asperger’s treatments were not ethical from any post-war perspective.

In addition, I also suspect that the research he conducted for his 1944 PhD thesis, in addition to being unethical, was highly biased, because the parents of these children were lying through their teeth to him. Again, consider yourself as the parent of such a child, under threat of sterilization or murder. You “consent” to your child’s treatment regardless of what might be in the child’s best developmental and emotional interests, and also allow the child to be enrolled in Asperger’s study[1]. Then your child will be subjected to various rehabilitation strategies, what Asperger called pedagogical therapy. You will bring your child into the clinic every week or every day for assessments and tests. Presumably the doctor or his staff will ask you questions about the child’s progress: does he or she engage with strangers? How is his or her behavior in this or that situation? In every situation where you can, you will lie and tell them whatever you think is most likely to make them think that your child is progressing. Once you know what the tests at the clinic involve, you will coach your child to make sure he or she performs well in them. You will game every test, lie at every assessment, and scam your way into a rehabilitation even if your child is gaining nothing from the program. So all the results on rehabilitation and the nature of the condition that Asperger documents in his 1944 PhD thesis must be based on extremely dubious research data. You simply cannot believe that the research data you obtained from your subjects is accurate when some of them know that their responses decide whether their child lives or dies. Note that this problem with his research exists regardless of whether Asperger was an active Nazi – it’s a consequence of the times, not the doctor – but it is partially ameliorated if Asperger actually was an active resister to Nazi ideology, since it’s conceivable in that case that the first thing he did was give the parent an assurance that he wasn’t going to ship their kid off to die no matter what his diagnosis was. But since we now know he did ship kids off to die, that possibility is off the table. Asperger’s research subjects were consenting to a research study and providing subjective data on the assumption that the study investigator was a murderer with the power to kill their child. This means Asperger’s 1944 work probably needs to be ditched from the medical canon, simply on the basis of the poor quality of the data. It also has implications, I think, for some of his conclusions and their influence on how we view Asperger’s syndrome.

What does this mean for the concept of the autism spectrum?

Asperger introduced the idea of a spectrum of autism, with some of the children he called “autistic psychopaths” being high functioning, and some being low functioning, with a spectrum of disorder. This idea seems to be an important part of modern discussion of autism as well. But from my reading of the paper [again I stress I am not an expert] it seems that this definition was at least partly informed by the child’s response to therapy. That is, if a child responded to therapy and was able to be “rehabilitated”, they were deemed high functioning, while those who did not were considered low functioning. We have seen that it is likely that some of the parents of these children were lying about their children’s functional level, so probably his research results on this topic are unreliable, but there is a deeper problem with this definition, I think. The author implies that Asperger was quite an arrogant and overbearing character, and it seems possible to me that his assumption that he is deeply flawed in assuming his therapy would always work and that if it failed the problem was with the child’s level of function. What if his treatment only worked 50% of the time, randomly? Then the 50% of children who failed are not “low-functioning”, they’re just unlucky. If we compare with a pharmaceutical treatment, it simply is not the case that when your drugs fail your doctor deems this to be because you are “low functioning”, and ships you off to the “euthanasia” clinic. They assume the drugs didn’t work and give you better, stronger, or more experimental drugs. Only when all the possible treatments have failed do they finally deem your condition to be incurable. But there is no evidence that Asperger considered the possibility that his treatment was the problem, and because the treatment was entirely subjective – the parameters decided on a case-by-case basis – there is no way to know whether the problem was the children or the treatment. So to the extent that this concept of a spectrum is determined by Asperger’s judgment of how the child responded to his entirely subjective treatment, maybe the spectrum doesn’t exist?

This is particularly a problem because the concept of “functioning” was deeply important to the Nazis and had a large connection to who got selected for murder. In the Nazi era, to quote Negan, “people were a resource”, and everyone was expected to be functioning. Asperger’s interest in this spectrum and the diagnosis of children along it wasn’t just or even driven by a desire to understand the condition of “autistic psychopathy”, it was integral to his racial hygiene conception of what to do with these children. In determining where on the spectrum they lay he was providing a social and public health diagnosis, not a personal diagnosis. His concern here was not with the child’s health or wellbeing or even an accurate assessment of the depth and nature of their disability – he and his colleagues were interested in deciding whether to kill them or not. Given the likely biases in his research, the dubious link between the definition of the spectrum and his own highly subjective treatment strategy, and the real reasons for defining this spectrum, is it a good idea to keep it as a concept in the handling of autism in the modern medical world? Should we revisit this concept, if not to throw it away at least to reconsider how we define the spectrum and why we define it? Is it in the best interests of the child and/or their family to apply this concept?

How much did Asperger’s racial hygiene influence ideas about autism’s heritability?

Again, I want to stress that I know little about autism and it is not my goal here to dissect the details of this disease. However, from what I have seen of the autism advocacy movement, there does seem to be a strong desire to find some deep biological cause of the condition. I think parents want – rightly – to believe that it is not their fault that their child is autistic, and that the condition is not caused by environmental factors that might somehow be associated with their pre- or post-natal behaviors. Although the causes of autism are not clear, there seems to be a strong desire of some in the autism community to see it as biological or inherited. I think this is part of the reason that Andrew Wakefield’s scam linking autism to MMR vaccines remains successful despite his disbarment in the UK and exile to America. Parents want to think that they did not cause this condition, and blaming a pharmaceutical company is an easy alternative to this possibility. Heritability is another alternative explanation to behavioral or environmental causes. Asperger of course thought that autism was entirely inherited, blaming it – and its severity – on the child’s “constitution”, which was his phrase for their genetic inheritance. This is natural for a Nazi, of course – Nazis believe everything is inherited. Asperger also believed that sexual abuse was due to genetic causes (some children had a genetic property that led them to “seduce” adults!) Given Asperger’s influence on the definition of autism, I think it would be a good idea to assess how much his ideas also influence the idea that autism is inherited or biologically determined, and to question the extent to which this is just received knowledge from the original researcher. On a broader level, I wonder how many conditions identified during the war era and immediately afterwards were influenced by racial hygiene ideals, and how much the Nazi medical establishment left a taint on European medical research generally.

What lessons can we learn about public health practice from this case?

It seems pretty clear that some mistakes were made in the decision to assign Asperger’s name to this condition, given what we now know about his past. It also seems clear that Asperger was able to whitewash his reputation and bury his responsibilities for many years, including potentially avoiding being held accountable as an accessory to murder. How many other medical doctors, social scientists and public health workers from this time were also able to launder their history and reinvent themselves in the post-war era as good Germans who resisted the Nazis, rather than active accomplices of a murderous and cruel regime? What is the impact of their rehabilitation on the ethics and practice of medicine or public health in the post-war era? If someone was a Nazi, who believed that murdering the sick, disabled and certain races for the good of the race was a good thing, then when they launder their history there is no reason to think they actually laundered their beliefs as well. Instead they carried these beliefs into the post war era, and presumably quietly continued acting on them in the institutions they now occupied and corrupted. How much of European public health practice still bears the taint of these people? It’s worth bearing in mind that in the post war era many European countries continued to run a variety of programs that we now consider to have been rife with human rights abuse, in particular the way institutions for the mentally ill were run, the treatment of the Roma people (which often maintained racial-hygiene elements even decades after the war), treatment of “promiscuous” women and single mothers, and management of orphanages. How much of this is due to the ideas of people like Asperger, propagating slyly through the post-war public health institutional framework and carefully hidden from view by people like Asperger, who were assiduously purging past evidence of their criminal actions and building a public reputation for purity and good ethics? I hope that medical historians like Czech will in future investigate these questions.

This is not just a historical matter, either. I have colleagues and collaborators who work in countries experiencing various degrees of authoritarianism and/or racism – countries like China, Vietnam, Singapore, the USA – who are presumably vulnerable to the same kinds of institutional pressures at work in Nazi Germany. There have been cases, for example, of studies published from China that were likely done using organs harvested from prisoners. Presumably the authors of those studies thought this practice was okay? If China goes down a racial hygiene path, will public health workers who are currently doing good, solid work on improving the public health of the population start shifting their ideals towards murderous extermination? Again, this is not an academic question: After 9/11, the USA’s despicable regime of torture was developed by two psychologists, who presumably were well aware of the ethical standards their discipline is supposed to maintain, and just ignored them. The American Psychological Association had to amend its code in 2016 to include an explicit statement about avoiding harm, but I can’t find any evidence of any disciplinary proceedings by either the APA or the psychologists’ graduating universities to take action for the psychologists’ involvement in this shocking scheme. So it is not just in dictatorships that public policy pressure can lead to doctors taking on highly unethical standards. Medical, pscyhological and public health communities need to take much stronger action to make sure that our members aren’t allowed to give into their worst impulses when political and social pressure comes to bear on them.

These ideas are still with us

As a final point, I want to note that the ideas that motivated Asperger are not all dead, and the battle against the pernicious influence of racial hygiene was not won in 1945. Here is Asperger in 1952, talking about “feeblemindedness”:

Multiple studies, above all in Germany, have shown that these families procreate in numbers clearly above the average, especially in the cities. [They] live without inhibitions, and rely without scruples on public welfare to raise or help raise their children. It is clear that this fact presents a very serious eugenic problem, a solution to which is far off—all the more, since the eugenic policies of the recent past have turned out to be unacceptable from a human standpoint

And here is Charles Murray in 1994:

We are silent partly because we are as apprehensive as most other people about what might happen when a government decides to social-engineer who has babies and who doesn’t. We can imagine no recommendation for using the government to manipulate fertility that does not have dangers. But this highlights the problem: The United States already has policies that inadvertently social-engineer who has babies, and it is encouraging the wrong women. If the United States did as much to encourage high-IQ women to have babies as it now does to encourage low-IQ women, it would rightly be described as engaging in aggressive manipulation of fertility. The technically precise description of America’s fertility policy is that it subsidizes births among poor women, who are also disproportionately at the low end of the intelligence distribution. We urge generally that these policies, represented by the extensive network of cash and services for low-income women who have babies, be ended. [Emphasis in the Vox original]

There is an effort in Trump’s America to rehabilitate Murray’s reputation, long after his policy prescriptions were enacted during the 1990s. There isn’t any real difference between Murray in 1994, Murray’s defenders in 2018, or Asperger in 1952. We now know what the basis for Asperger’s beliefs were. Sixty years later they’re still there in polite society, almost getting to broadcast themselves through the opinion pages of a major centrist magazine. Racial hygiene didn’t die with the Nazis, and we need to redouble our efforts now to get this pernicious ideology out of public health, medicine, and public policy. I expect that in the next few months this will include some uncomfortable discussions about Asperger’s legacy, and I hope a reassessment of the entire definition of autism, Asperger’s syndrome and its management. But we should all be aware that in these troubled times, the ideals that motivated Asperger did not die with him, and our fields are still vulnerable to their evil influence.

 


fn1: Note that you consent to this study regardless of your actual views on its merits, whether it will cause harm to your child, etc. because this doctor is going to decide whether your child “rehabilitates” or slides out of view and into the T4 program where they will die of “pneumonia” within 6 months, and so you are going to do everything this doctor asks. This is not consent.

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