Norman Autton 3rd Lecture

A Conference on Spirituality, Faith and Health - NHS Perspective
University of Wolverhampton: 15^th September 2004

On 2^nd September 1965 I bought a book. It was in the very first weeks of my theological college training; I was brand new and had only just arrived at Wells Theological College in Somerset, after reading for my first degree at the University College of Wales, Lampeter. The book that I bought, in which I noted the date so carefully, was written by Norman Autton and was entitled The Pastoral Care of the Mentally Ill [1] . When his other books were published, for example The Pastoral Care of the Dying [2] and The Pastoral Care of the Bereaved [3] , I bought them as well. On a tight budget, choices have to be made, but I chose Norman's work because I sensed, even as a very young and enthusiastic ordinand, that I was in the presence of a wise and godly man, from whom I should and could learn much. Later, when I was a parish priest in Surrey, Norman Autton invited me to the University Hospital of Wales, Cardiff, to preach at one of his Lenten lectures. It was a great privilege to do so, and I accepted as a way of trying, inadequately, to do justice to my appreciation of him. You may imagine then, that the invitation to give this lecture is one which I consider a real joy and honour.

One of Norman's great gifts was somehow to bring shape to things; to take very complicated material and, through intellectual rigour and a profoundly loving heart, to so shape it that the rest of us could understand. I have none of Norman Autton's experience as a hospital chaplain. I belong to those dark ages where. as a curate and vicar, I was able to visit parishioners in hospital, checking the lists with the clerks and seeing who was on them. We had been given a simple pastoral rule; we were told that we should call every nurse 'Sister', and every sister, 'Matron', and that when we saw Matron, we should genuflect. The colder winds that surround the Data Protection Act had not begun to blow at that time, and the assumption of all of us - hospital staff, patients and clergy - was not that I had a right to visit (though that was assumed) but that I had a duty to do so. It was what vicars did - and if you didn't, you were admonished by parishioners ('I was in hospital for weeks and the vicar didn't come to see me'). The admonishment came not from those whom we would now describe as 'members' of 'faith communities' (the very words, themselves, are indicative of an urban, consumerist, choice-driven culture), but from people who simply lived in the parish, whether they went to church or not. Times have changed - but we should not forget that when we (rightly) talk about the 'professionalisation' of hospital chaplaincy, some of the gains may be at the cost of other less easily definable virtues and graces.

Let me return to Norman Autton's gifts, of giving shape to complicated material, for 'giving shape' is going to be my theme in this lecture. One of my major interests is in the field of art history, and over recent years I have made a study of the image of the Resurrection in fifteenth-century northern European painting. It's a fascinating field, not least because of the insights that can be gained from it. But trying to understand and enter in to the mind-set of another period of history is very, very difficult and to do so, you sometimes need skilled guides. I should like to offer you some of the examples of the way some guides express themselves.

In a very influential book, Ways of Seeing [4] , John Berger analysed this particular painting in economic terms. It was, he suggested, a portrait of ownership.

You will all know this painting by Carlo Crivelli (active 1457-1493), which hangs in the National Gallery. It has been described by Lisa Jardine, in her book Worldly Goods, in this way:

This virtuoso painting is every bit as much a visual celebration of consumption and trade as it is a tribute to the chastity of Christ's mother [5] .

In both of those paintings, Gainsborough's Mr and Mrs Joseph Andrews and Crivelli's Annunciation, John Berger and Lisa Jardine have used predominantly economic tools in their analysis of them. They are not alone in bringing the insights of economics to bear on art. There is a beautifully written book by Michael Baxandall, called Painting and Experience in Fifteenth-Century Italy, which opens like this:

A fifteenth-century painting is the deposit of a social relationship. On one side there was a painter who made the picture, or at least supervised its making. On the other side there was somebody who asked him to make it, reckoned on using it in some way or other … some of the economic practices of this period are quite concretely embodied in the paintings. Money is very important in the history of art [6] .

If you want further evidence of the relationship between art and money, I commend to you a book by Bram Kempers, entitled Painting, Power and Patronage. He, himself, began life as a painter and illustrator, and later moved into the study of sociology. He became particularly interested in the Italian Renaissance, and in his introduction to his book, he wrote this:

What particularly intrigued me was the question of how it was possible that for a period spanning more than three hundred years, painters in Italy had produced innovative and high quality work when working for clients who saw art primarily as a means of glorifying themselves and the power they possessed [7] .

I should like you to bear in mind those largely sociological and economic critiques of art when I show you this next painting.

It's by Roger van der Weyden, a fifteenth-century Netherlandish artist. It was commissioned by Nicholas Rolin, the Chancellor of the Duchy of Burgundy, for the hospice at Beaune.

Let me attempt to describe Roger van der Weyden's painting of The Last Judgment to you. It shows the Risen Christ as Judge, seated on a rainbow; to one side of him is the lily of mercy and, to the other, the sword of justice. He is surrounded by apostles and saints, and some of the 'great and good' of the Burgundian court. Sinners are being consigned to hell, and saints are being welcomed to heaven.

But now, let me put it in its original physical context. This painting was in a chapel, behind the altar, and the chapel, itself, was the central focus of the ward in which people lay dying. If they were well enough, they were confronted, in their last days, by this powerful image.

It can be 'read', therefore, not simply as a masterpiece (which it is) of fifteenth-century Netherlandish art, it can also be seen as a carrier of profound theological meaning. I used to think of it as a terrifying image - but I have begun to change my mind, because of its context. A priest was paid to say Mass; that priest was able to give the dying patients the last rites. In short, if you turned to God through the Church, even at the last minute, it was believed that you would enter Paradise. This painting, then, may be 'read' as a theological and spiritual treatise, as much about promise, as threat.

It cannot be denied (if you 'read' the painting in a purely economic way), that it was commissioned by one of the wealthiest men in northern Europe - and, if you look at the painting carefully, you will see that in the heavenly court 'above', as it were, all the trials and tribulations, sit some of the wealthiest people of the day: a bishop, the Pope, a king - and possibly even Nicholas Rolin himself?

Yet I would argue that to 'read' this painting only in financial terms, or only in terms of politics and power, is to miss some of its richness. I want to remind you of its physical context again, because at the opposite end of the ward from the chapel, above the door through which all patients entered, there was this figure - a bound figure of Christ.

I do not know whether the juxtaposition of the suffering Christ with the redeeming Christ was a conscious one; nor do I know whether the bound Christ was, as it were, understood by the patients as representing their own suffering - but it does seem likely that this might have been the case. If you acknowledge the original context, a hospice ward, enclosed by a figure of Christ suffering at one end, and a figure of Christ the just and merciful at the other, you have to recognise that to adopt an economic reading of this painting as though that told you everything you needed to know about it, is to adopt an impoverished and mechanistic view of humanity and art, and life itself.

Now this may seem a long way from the central thrust of this lecture, which is about giving shape to things, but I think not. What I am arguing, is that for many paintings of the fifteenth century to be understood, we must not only give attention to their political and economic milieu, but we must take their theological and spiritual context with equal seriousness. What art historians are engaged in is giving shape to what might otherwise be an inchoate and difficult field - and to give shape they (we) have to choose their (our) boundaries. Some art historians choose largely economic boundaries - they certainly give shape - but, in my view, the shape is too constricting, too driven by an underlying ideology.

It seems to me to be not a million miles from the world of art history to the world of the National Health Service - the same human processes are at work (trying to give shape to things) and the same temptation also arises, that is, to take only one context seriously and omit the rest. I believe that the context of healthcare is not only economic (the finite resources; the infinite demand), not only political (the rhetoric of patient choice), but it is also spiritual and theological as well.

When I visited hospitals as a curate and as an incumbent in the 1960s, 70s and 80s, the religious and social context was essentially that of 'Christendom', that is, the assumptions, largely unexplored and unexplained, which we all shared, were those of Christendom. There was an overarching series of values within the NHS, derived from the Judaeo-Christian faith, involving compassion and care. It is not a bit surprising, therefore, that much of the imagery of hospital chapels or, indeed, the very names of hospitals - St Peter's or St Luke's, for example, were based on the Christendom model. You will know, better than many, that in the past decade or two the Christendom model has undergone enormous pressure. I am not prepared to say it has gone entirely because I believe that many of the values deeply embedded in the Judaeo-Christian tradition are still deeply embedded in the NHS. And yet what is also clear, is that a new and explicit language has now entered the vocabulary of the NHS and is influencing us all - the language, and therefore the thought-world, of Human Rights.

Perhaps I can put it, with much sadness, in this way: the assumptions which Norman Autton worked with when he wrote his books on pastoral care, and the assumptions with which I read them in the 1960s and 1970s, are now under very considerable stress and strain, maybe even at breaking point. What I want to suggest is that part of the function of a chaplain is to explore, express and critique the assumptions on which healthcare is now based.

I return to John Berger. In 1967 he published, with a photographer, Jean Mohr, a study of a country doctor, John Sassall, who had chosen to work in what the author claimed was 'a remote and impoverished English rural community'. As it was the area of the Welsh borders where I grew up, I take serious issue with this description of it as 'remote' and 'impoverished'. It is, however, an interesting account and in it Berger refers to John Sassall, the GP, as the 'clerk' of the community:

He does more than treat them when they are ill; he is the objective witness of their lives. They seldom refer to him as a witness …He is in no way a final arbiter …He is not the representative of an all-knowing, all-powerful being. He is their own representative … He keeps the records so that, from time to time, they can consult themselves [8] .

Well, I venture to suggest that John Berger has both hit the nail on the head - and entirely missed the point. He painted a moving portrait of a GP who entered deeply into the lives of his patients and the community and who, from time to time, clerked for them - but he failed to see that the community literally had its own language and its own ways of clerking itself, whether or not a GP was there. It is a highly romantic picture that he has created but, in spite of that, it is a picture which those in chaplaincy need to take very, very seriously.

Norman Autton 'clerked' the world of the NHS for me and my generation. He gave voice to it, gave shape to it, enabled me to understand it - but it was a world, back then, where, as I have said, Christendom assumptions were part of the very fabric of the service.

And what now? I can only raise some questions: Who 'clerks' the NHS community? A further question: Is it accurate, in any sense, to talk of a 'community' or is the NHS now a myriad of communities? Further, if one of the functions of a chaplain is to 'give shape' to things, how can the chaplain do that, when all the attention is now focussed on individuals - and when any sense that the hospital itself needs to have a meta-narrative, is unexplored and unspoken? Put another way, is there a correlation between the language of Human Rights and the fact that in Accident and Emergency departments there are now those all-too-obvious notices about patients not using abusive or threatening behaviour towards staff? It would seem (note the language) that nurses have gone from being regarded as angels to those who are paid to meet the rights of others.

One of the privileges of my rôle as Chairman of HCC is that I visit a number of hospitals across the country. Invariably I meet the CEO and senior Board members, and conversations with them are fascinating. I have little doubt that if I asked them who clerked their hospital, many of them would reply that they do. I do not dispute the claim; they have an overview, they have to try to see the big picture. They have to balance priorities, they have to make very difficult choices - and they are under the most colossal pressure from all sides. And they do try, whether consciously or not, to give shape, to give voice to the hospital. The turnover of senior staff, however, means that their clerking rôle is frequently curtailed; by the time they have listened, it's time to move on - and what happens then is a jostling for position amongst those who carry the story of the institution until the next CEO arrives.

The kind of language that CEOs use is, naturally and properly, what might be called NHS-speak - all those acronyms that pour out of the Government - but then, if you listen carefully, there is also a fairly specialised way of constructing sentences in NHS-speak, which involves frequent use of special words like 'issues' and the word 'around'. They are often combined, as in 'there are a number of issues around …', and you then fill in the gaps with your favourite buzzword. I don't know where and when 'benchmarking' became the vogue - perhaps it no longer is, but it is possible to construct entire sentences in NHS-speak, using 'benchmarking' as the hooray word, for example: 'there are a number of issues around benchmarking which are high on our agenda at this moment in time.' I only tease; the Church of England also has its own language games, as, for example, in our particular use of the word 'share'. 'I'd just like to share this with you,' means, in translation, 'I am going to tell you what I think,' with the implication that I know and you do not.

I find it easier to pose the question than to answer it. I guess that if an NHS anaesthetist from Truro was at a conference with an NHS anaesthetist from Durham, the language they would use would be the same. There would be no need for any clerking; the professional skills, the problems, the insights, would all be in a common language. But what I am fairly clear about, however, is that in the NHS there is far too much talking and not enough listening. And one of the gifts of a clerk is to listen; you cannot give voice, you cannot give shape, unless you listen - and listen very deeply.

I have recently returned from leading a retreat in the Apennines. We stayed in a monastery which has been in existence for over one thousand years. It is situated high up on the edge of a mountain, forests tumbling around it and silence so sweet, so refreshing, you could drink it. There seems to me to be a kind of spiritual law of the universe which is that if you do not create silence or enter silence, all that you do is babble. Information can only become wisdom if those who use it are willing and able to enter a profound silence. And there is another spiritual law of the universe which is that silence begets creativity, creativity begets beauty and beauty begets silence. If we fail to enter that cycle, then creativity dries up and beauty withers.

Ask yourself a question, then, about the NHS: Where is beauty to be found? And if your answer is a perplexed, 'I don't know,' then it may be that the NHS needs to go, as it were, on a corporate Retreat. It certainly seems to me that the forces for disintegration are now very, very powerful - and that is partly, I suggest, because at the very heart of the NHS there is no stillness and no silence. Shops in the entrance halls of hospitals tell their own sad story of the spiritual impoverishment of our society, in which the purchasing of a newspaper has the same moral equivalence as the purchasing of healthcare.

To answer my original question, then ('is the NHS one community or many?'), I suspect that the answer is rapidly becoming 'many'; and if silence and wisdom and beauty (and the possibility of God) are not built into the system, the system will become self-defeatingly complex and mechanistic.

Following the Hatfield rail crash I spent time with one of the chaplains in one of our hospitals. He took me, on my arrival, straight to the mortuary to meet one of the attendants there; only later did I meet the Chief Executive. As the chaplain (like all good chaplains), he literally walked through every level of the hospital on a daily basis and, as a result, he had the knowledge (and, in his case, the capacity) to help clerk that particular tragedy.

Following the Potters Bar rail crash I went to meet with all the clergy of the town on the evening of the accident. It was a very, very moving experience - because they, unlike many others involved, had been clerking the entire community, giving shape to what had been a chaotic and meaning-less event. It wasn't that they were at the trackside all the time; but they helped everyone in the town to give shape to the dreadful event. At both Hatfield and Potters Bar there was an act of worship within one week of the tragedies, and I was asked to preach at both. Then, one year later, there was an act of worship and remembrance at St Albans Abbey. In both cases, at Hatfield and at Potters Bar, the language of Christendom, the architecture of Christendom and the liturgies of Christendom provided a meta-narrative, an overall shape.

I use these examples as a parable of the clerking process; first, there was the clerking of individuals (those in the accident and those who survived), then there was the clerking of the local community, and then there was a county level act of clerking. The parallels of clerking as a chaplain, as the CEO, and the clerking of the hospital are obvious - but suppose the rail disasters I have mentioned had happened in other parts of Hertfordshire or Bedfordshire, where there are large non-Christian populations, and large numbers of local people had been injured or killed, the clerking of the situation would have been much more complex. Could we have found a common language, a common architecture and a common metanarrative? I am saying nothing that hospital chaplains haven't been struggling with for a long time.

But I suspect that the drive for professionalisation, the arrival of documents such as Care for the Spirit, the emergence of 'spiritual caregivers', and phrases such as 'spiritual caregiver interventions', are, in themselves, signs that we are entering a new and confusing moment in chaplaincy history. It is not confusing because no-one has seen it coming or thought about it – but because the reality is confusing, and narratives are frequently compiled during or after the events, rather than ahead of them.

The people who clerk the Hospital Trust's community in these changed religious and social circumstances are, of course, the Chief Executive and the Board, plus the chaplains, plus all the other members of staff and the local community. But who is it who deeply reflects on the community – and tries to create the narrative? I venture to suggest that that must fall to the chaplain as one who, at least in principle, has the time to reflect; as one who, in principle, has some experience of clerking individual joys, suffering and bereavement; and as one who, by the nature of the task, can move between a wide range of settings. And if my analysis is correct, then the literary skills required by chaplains are high (narratives are 'stories') and the spiritual wisdom required is immense.

But this then raises another profound question. By definition, the Christian chaplain is representative of an institution which has a metanarrative; in Christian terms the institution is the Church and the Christian Faith, and the metanarrative of the Church involves claims and doctrines about the very nature of God and Christ; it involves theological doctrines about the Incarnation, the Atonement, forgiveness, eternal life and salvation. These are subjects which involve the making of universal claims and that is precisely what the Church has done over the centuries. Perhaps I can put it this way: the Church has not said that the death of Jesus of Nazareth was like any other death – rather it has said that in and of itself, that death had and has universal eternal meaning and significance. To claim, as Christians do, that God was in Christ, is to make a remarkable and a universal claim. We have, as Christians, inherited a metanarrative which shapes our doctrines of humankind, of human purpose and of human destiny.

In making these statements about the Christian faith and its metanarrative, I am not implying for one moment that other faiths do not have metanarratives themselves, of course, they do; and it is in the nature of metanarratives that they often differ significantly and profoundly from each other, but also have areas in which there is common ground. The fact that we talk so confidently about the spiritual needs of individuals, and use words such as 'faith communities' is, in some sense, I suggest, a sign that we are not yet able to come to grips with the differences between metanarratives. Or it may be that a new metanarrative is emerging in the UK and in the NHS, which is that individuals matter profoundly … but we are struggling to find or create a metanarrative language that has, within it, commonly accepted assumptions. However, it may be that words such as 'tolerance', 'respect', and 'diversity' are the beginnings of that. It seems to me that no one is really asking the question: What is the purpose of society? – though we have come a long way along the route towards an answer to the question: What is the worth of an individual? And here, I suggest, is the place precisely where the chaplain stands: between the mini narrative of each individual and the confusion, the Babel, which is now the characteristic of society. If society does not have any metanarrative, how can a hospital have one? It is even more complex and rich and paradoxical than that, however. Is it only and precisely because the chaplain (of whatever faith) has, and lives within, a religious metanarrative that that chaplain can then meet, with integrity, with the patient or the member of staff who may not share the chaplain's own metanarrative? And, as if that weren't enough, for the Christian chaplain, the Christian metanarrative may also come to be entered in the same kind of self-emptying way in which it is claimed that God became incarnate. Metanarrative does not imply certainty – though, I believe, it does imply mystery.

We are at a point in the history of our country, and therefore in the history of the NHS, in which the metanarratives of religion jostle against each other, and in which the NHS and the country are trying to form some kind of secularist but quasi-religious metanarrative in which, as I have said, words such as tolerance, diversity and respect are the common currency – a kind of Euro-speak. Chaplaincy is caught at the place where those language worlds collide.

One of the most significant tasks of chaplaincy, therefore, is to try to give some shape to the confusion, to try to discern where genuine wholeness is being revealed or being created, without losing sight of those truths of our faith which, we believe, have been revealed by the Almighty. It is a very difficult place to be – but if we can bring to it the same kind of patience, integrity and wisdom which Norman Autton had, then we shall have much to contribute to the wellbeing, not only of our hospital trusts, but of our nation. It is a huge challenge.

[1] N Autton: The Pastoral Care of the Mentally Ill, SPCK, 1963.

[2] N Autton: The Pastoral Care of the Dying, SPCK, 1966.

[3] N Autton: The Pastoral Care of the Bereaved, SPCK, 1967.

[4] J Berger and others: Ways of Seeing: Based on the BBC Television Series with John Berger, London, British Broadcasting Corporation and Penguin, 1972.

[5] L Jardine: Worldly Goods: a New History of the Renaissance, Macmillan, 1996, pagination needed.

[6] M Baxandall: Painting and Experience in Fifteenth-Century Italy, 2^nd edn, Oxford University Press, 1988, p.1.

[7] B Kempers: Painting, Power and Patronage, Penguin, 1987, p.1.

[8] J Berger (text) and J Mohr (illus.): A Fortunate Man: the Story of a Country Doctor, Penguin, 1969, p.109.