Explainer

Comment

Community

Mental Health

10 October 2023

6 min read

The rough sleeper: an icon of injustice

Each rough sleeper is a raw illustration of injustice. On an awareness day for both homelessness and mental health, Jon Kuhrt reflects on the root causes and yet sees hope.

Jon Kuhrt

Jon Kuhrt is CEO of Hope into Action, a homelessness charity. He is a former government adviser on how faith groups address rough sleeping.

A black and white close up of the weather-beaten and wrinkled face and beard of a homeless man.

Portrait of a homeless man in Prague.

Ales Dusa on Unsplash.

In 2016, five-year Brooke Blair became an internet sensation after a video of her berating Prime Minister Theresa May went viral. As she put it, she was ‘very angry’:

“Yesterday night, I was out on the streets, and saw a hundred and a million of homeless people. I saw one with floppy ears, I saw loads. You should be out there, Theresa May. You should be, biscuits! Hot chocolate, sandwiches, you should be building houses. Look, I'm only five-years-old. There's nothing I can do about it. I'm saving up money but there'll never be enough. You've got the pot of money, spend some and help people.”

The video struck a chord because a young girl was passionately expressing the distress, anger, sympathy and bewilderment that so many feel when seeing people sleep rough in such a wealthy country.

The image of a rough sleeper is an icon of poverty. And just as religious icons represent the sacred, so does each person sleeping rough.

Each rough sleeper is a raw illustration of injustice and social breakdown.  The structural issues of poverty and inequality crystalize in the plight of a vulnerable person huddling in a doorway. In them we see an amalgam of both political failure and personal tragedy.

It's personal because we know that each person has a different story about what led them onto the streets. We will always be moved far more by a person than any statistic.

The image of a rough sleeper is an icon of poverty. And just as religious icons represent the sacred, so does each person sleeping rough. A precious human of infinite worth, imprinted with the divine, living in destitution. And just as restoring fragile religious icons is a specialist job, so the task of restoring those who have been homeless is often complex and intricate work.

Today, 10 October, is both World Homeless Day and World Mental Health Day. The two are closely intertwined. It’s a good day to reflect on the nature of homelessness and what we can do in the work of restoration.

We cannot simply remove the tip of the iceberg without addressing the deeper issues ... The water is getting colder and the iceberg is growing.

Rough sleeping is just the tip of a far bigger homelessness iceberg. It receives the most attention because it’s visible and visceral. But it is just a small fraction of the total number of people who have no settled home who exist underneath the waterline: those sleeping in temporary shelters, hostels and squats, sofa-surfing or placed in B&Bs.

It’s the visibility of rough sleeping that gives it political capital. Whilst in power, Margaret Thatcher, Tony Blair, Theresa May and Boris Johnson all launched high profile initiatives with ambitious targets to reduce or end rough sleeping.

In 2018, I was seconded from the Christian charity I was working for into the Civil Service as a specialist adviser on rough sleeping. In the four years I spent in this role I worked under four different Prime Ministers and six different homelessness ministers. Despite some significant progress made before and during the pandemic, the numbers of people sleeping rough and those in temporary accommodation are starting to rise again.

We cannot simply remove the tip of the iceberg without addressing the deeper issues of poverty that it is connected to. The reality is that we have a deep housing crisis in this country. The water is getting colder and the iceberg is growing.

But the challenge is that rough sleeping and homelessness are genuinely complex problems. Politics and economics provide some of the answers but not all. After thirty years of working with people who are homeless, these are the key issues which lie behind homelessness.

Poverty of resources

The most obvious cause of homelessness is the lack of affordable housing. Housing is a resource which is not distributed fairly, and this inequity creates intense pressure and vulnerability. All of this is compounded by austerity, funding cuts and benefit sanctions which have withdrawn support services for vulnerable groups.

As London has become an international playground for the uber rich, many new housing developments are simply investment opportunities. Often people sleep rough outside accommodation no one lives in. It is a stark picture of the failure of the housing market.

This aspect of homelessness is the one that government can do most about. Brooke Blair was fundamentally right – Prime Ministers need to build more houses for those who need them.

A poverty of relationships

But homelessness is more than house-lessness. Homes are more than bricks and mortar: they are places of relationships.

And if you talk with anyone sleeping rough, you are likely to hear of relationships that have gone wrong with partners or with their wider family. Some are fleeing abuse or domestic violence; some have been perpetrators. Relational problems are often a key source of regret and shame; where people carry their deepest scars.

In our concern for people’s rights to the resources they deserve, we should not lose sight of where humans find true meaning and fulfilment. We all have a deep need to know and be known, to love and to be loved.  We cannot get away from the importance of relationships and a sense of belonging.

A poverty of identity

Finally, and most deeply, is the issue of people’s inner identity. The essential relationship that everyone has with themselves.  

The rise in mental health problems are symptoms of a vulnerability of our inner well-being.  For people affected by homelessness, their experiences of exclusion and trauma are both a root cause and an on-going reason for their mental fragility.

And the addictions to alcohol or drugs which are common to many rough sleepers are deeply connected to these psychological vulnerabilities. Drugs become a form of self-medication to ameliorate pain. And however negative, the lifestyle required to maintain addictions can be relatively exciting and can provide each give a day a clear goal. It can be hard to leave such an identity and embark on a demanding journey of recovery.

Homelessness doesn’t just end in a flat. It truly ends in community and connection.

So, in short, homelessness is far more than house-lessness. Houses are a key resource but homes are primarily places of relationships and identity. And the restoration of these cannot be just done by the government. It requires a whole community.

Thirteen years ago, a Christian couple in Peterborough, Ed and Rachel Walker chose to invest their own inheritance into a house for people who were homeless. The idea inspired others: it was simple and innovative: encourage people with wealth to invest in homes for those who are poor. And each home was attached to a local church which provides friendship and support and a critical sense of community.

This is the roots of Hope into Action where I now work. We are now a national charity with 106 homes across the country and last year we housed over 400 people. Our model is a holistic response to the types of poverty I have described.

Our tenants are provided with the resource of a great house where they feel safe and secure. And this is combined with relationships with housemates and the support of local church volunteers. And our whole focus is to empower our tenants to find a more positive identity: whether through purposeful work, on-going recovery or through exploring faith. Last year, fifty percent of our tenants chose to engage in church activities and six took the step to be baptised.

Homelessness doesn’t just end in a flat. It truly ends in community and connection. In our work we see justice and generosity in how resources are shared, compassion in the relationships that are formed, and hope on which people can rebuild a positive identity. Just as a lone rough sleeper is an icon of poverty, each of our tenants is a symbol of hope.

Article

Assisted dying

Comment

Politics

25 November 2024

7 min read

Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

Markus Zimmerman

Markus is Professor of Moral Theology and Ethics at the University of Fribourg, Switzerland.

A single bed, wiith an unmade colourful duvet stands in the corner of a room. A hoist reaches over it from the corner.

The dying room, Dignitas Clinic, Zurich.

Dignitas.

While countries such as Germany, France or the UK are currently struggling to find a suitable regulation for assisted suicide, their peers in the Netherlands, Canada and Switzerland have years of experience with the controversial medical practice. Even if each state must explore its own ways of dealing with these ethically controversial issues, it is obvious that international experience should not be ignored as they try to find a way forward.

In Switzerland the discussions and challenges surrounding assisted suicide are increasing rather than decreasing. Contrary to the idea that a liberalisation of assisted suicide would lead to fewer debate, tensions and difficulties are increasing. My observation, and thesis, indicates that practices such as assisted suicide cannot be “normalised”, even in the medium and long term.

Developments

In recent years, one to two per cent of all deaths in Switzerland were due to assisted suicide. From an overall perspective, this practice is therefore still a marginal phenomenon. However, a look at the total number of assisted suicides per year gives a different impression, as this has increased more than fivefold in the years between 2008 and 2020, from an initial 253 to 1,251 deaths per year, a rising trend. The cause of death statistics for Switzerland only include those cases of assisted suicide in which persons resident in Switzerland were involved and the death was reported to the authorities. According to the Swiss Federal Statistical Office, in 2020, it was mainly people over the age of 64 who made use of assisted suicide. Detailed information on the underlying illnesses of the people affected in 2018 shows that about 40 per cent were affected by cancer, just under 12 per cent by diseases of the nervous system, a further 12 per cent by cardiovascular diseases and just over a third by other illnesses, including dementia and depression. There are currently seven right-to-die organisations in Switzerland which play a leading role in a typical assisted suicide procedure. They work closely with doctors who are prepared to prescribe a lethal drug, generally Pentobarbital. The data reflects an ambivalent picture: on the one hand, the proportion of assisted suicide cases is relatively low in relation to all deaths and, for example, in comparison to the large number of people who die in Switzerland in a state of deep sedation until death; on the other hand, the number of assisted suicides in Switzerland has risen sharply in recent years.

Perceptions and assessments

Since the 1990s, the public perception and assessment of assisted suicide in Swiss society has changed from an initially cautious and sceptical attitude towards broad acceptance. While the debates in other countries are characterised by relatively sharp controversies between those in favour and those against, public discourse in Switzerland has been less polarised. There are indications of a certain normalisation of the situation, the strongest sign is that Switzerland has so far refrained from regulating assisted suicide in a separate law. The results of a recently-published study on the opinions of Swiss people over the age of 55 regarding assisted suicide confirm these impressions.: The survey showed that over four-fifths of respondents support legal assisted suicide, almost two-thirds can imagine asking for assisted suicide themselves at some point, and that almost one-third are considering becoming members of an right-to-die organisation in the near future, with one-twentieth of respondents already being members at the time of the survey in 2015. Among people with a higher level of education and older people aged between 65 and 74, approval of assisted suicide and corresponding practices was higher than among less educated, younger and very old people; approval was also significantly lower among religious practitioners.

Sensitive topics

The fact that assisted suicide enjoys broad support in Swiss society as a whole does not mean that there are not difficult and controversial aspects relating to its practice. Relevant topics include, in particular, places of death, authorisation criteria and procedures.

Places of death: Assisted suicide is permitted also for mentally ill persons in psychiatric clinics, but the federal court recommends great caution here and requires two psychiatric expert opinions to ensure that the person willing to die is capable of judgement with regard to the desire to commit suicide. Although assisted suicide for children and adolescents has hardly been an issue in Switzerland to date, the corresponding debates are currently being held in Canada and elsewhere. The question of whether people in prison also have a right to make use of assisted suicide, has been the subject of intense debate in Switzerland for years, with a generally positive response. The question of whether right-to-die organisations should be given access to acute hospitals and nursing homes is still the subject of controversial debate, with regulations varying from hospital to hospital, nursing home to nursing home

Authorisation criteria: With regard to the admission criteria for persons willing to die, the capacity for judgement is at the centre of attention: while the importance of the criterion is undisputed in itself, there is a struggle for reliable standards and procedures to reliably test this criterion. Since the publication of the SAMS ethical guidelines Management of Dying and Death in 2018, the criterion for end of life and, depending on this, that of unbearable suffering have received new attention due to an objection by the Swiss Medical AssociationFMH. While the guidelines are based on the criterion of unbearable suffering, the FMH wants to stick to the near end of life. It is certainly difficult to diagnose the existence of unbearable suffering, as the international debate on the significance and assessment of existential (neither physical nor psychological) suffering shows. This difficulty is illustrated by the debate that has been going on for several years in Switzerland about so-called old-age suicide and the inherent criterion of tiredness of life. At the centre of the dispute is the legally difficult question of whether a doctor is also allowed to prescribe a lethal drug to a healthy person.

Procedures: Here the role of the medical profession and right to die organisations is by far the most important issue. In contrast to the physician-centred models in Belgium, Canada and the Netherlands, the Swiss model of assisted suicide is based on the idea that every person has the right to end their life and may call on the help of any other person to do so. Although the medical profession is usually involved in the process, the management of the procedure is normally the responsibility of a right-to-die organisation. This division of responsibilities is always up for debate when legal regulations are being considered, in which doctors should tend to take the lead in the process due to their professional background. There is also a debate about how and by whom compliance with the authorisation criteria should or could be monitored, whereby it remains to be decided whether this should be carried out before or after the death. At present, a certain amount of monitoring takes place following a suicide, insofar as the authorities investigate the cases afterwards. There is also debate as to whether Pentobarbital is a suitable means of suicide, especially if this barbiturate is not administered intravenously but taken orally; there is no knowledge of how many cases are currently administered intravenously and by whom an infusion is then set up. Last but not least, consideration has already been given to the use of lethal drugs, such as helium gas, which can be obtained over the counter.

Attempts at regulation

Political efforts to regulate assisted suicide in Switzerland in a more nuanced way than today have been made since the 1990s but have remain largely without consequences to date. In relevant judgements by the Federal Supreme Court or in statements by the Federal Department of Justice and Police, reference is regularly made to the ethical guidelines of the SAMS. These are classified as soft law and are therefore not legally binding, even though their content has become the subject of dispute. The National Advisory Commission on Biomedical Ethics (NCE) had already recommended more far-reaching legal regulation in 2005 as part of a detailed opinion on the subject; in the opinion of the NCE at the time, the review of authorisation criteria, a justifiable regulation of assisted suicide for the mentally ill, children and adolescents and state supervision of right-to-die organisations, should be ensured by law. The question is what form a legal regulation can take that grants the medical profession far-reaching powers but at the same time prevents medical paternalism (in favour of or against assisted suicide). From the perspective of Swiss experience, this is “a square circle”: either the doctors retain the final decision on who receives the barbiturate, or official access rules are established, the review of which does not generally require medical expertise.

The outlook

In the short and medium term, it can be assumed that the number of assisted suicides in Switzerland will continue to rise. The coronavirus pandemic and the particular difficulties faced by nursing homes during this time are likely to exacerbate this increase. In view of these expectations and the legislative processes in other European countries, pressure is likely to increase in Switzerland to create a legal regulation. Overall, I think politically it will be important to create a legal regulation, in order to ensure legal equality and legal certainty on the one hand and prevention of abuse and expansion on the other. At the centre of social-ethical reflection is the challenge of learning to deal with the pluralism of different ideas of a good death and to develop and establish alternative models to medically assisted dying. The thesis I mentioned at the beginning is confirmed today: assisted suicide in Switzerland can hardly be normalised; new problems, challenges and demands are constantly arising. Suicide, whether with or without the help of another person, always means an existential transgression that defies normalisation.