ABANDONMENT DRESSED UP IN AUTONOMY
Dr. Katherine Warburton and Father Alberto Carrara
Philippe Pinel at the Salpêtrière, painted by Tony Robert-Fleury in 1876
I’ve been thinking about myths—not in the modern sense of the word, which often implies an untrue rumor, but in the ancient, Greek sense. Mythology as storytelling: a way of explaining, warning, and seeking to be understood. Mythology as a mirror for society, where we tell stories about ourselves to reveal truths about who we are as a people. The stories I tell about the work I do are born from bearing witness to some of the most profound human suffering in our culture today. They are stories about human beings subjected to conditions worse than animals because of a particular neurological condition. People who are denied the right to dignity and denied the right to medical care. These human beings live on the streets. They live in cages. They live in chains.
Here is one of my stories, which I think will someday become one of my myths.
In May of 2025, I was standing in a jail mental health unit with a friend—a Vatican priest who is also a noted neuroethicist. I was there on my vacation time with a group of psychiatrists and lawyers, part of a global effort we’ve created to share the burden of witnessing and addressing such suffering. The patients on the unit were naked or wearing safety smocks. They were chained to tables. Like animals. As I watched my friend watch this, he began to pray. ‘See, I told you’, I thought. I’ve been telling him about this for years. Things aren’t like this in Italy, so I was never sure if he totally believed me.
Even though I am always telling people about what I see through my stories, only when I was watching my friend pray did I make a connection. I realized that I’ve been referencing a painting featuring Phillippe Pinel unshackling a mental patient from chains in 1876, but weirdly this was the first time I asked, “isn’t this the same mythology”? We’d have to ask Freud why I repressed this parallel. Maybe because it is just too much to bear-the fact that mental health wards 150 years later are worse- so it has never really consciously occurred to me.
Today is even more cruel because we have treatment that significantly reduces the worst symptoms of that neurological condition. Treatment that is proven to prevent people from ending up in those chains. As a society, we have decided that we won’t give the treatment. Instead, we have decided to withhold it and allow people to end up back in chains. This is just very hard to bear. That’s why my friends and I have connected from around the world to form our college- so that we have others with whom to share this burden. And that is why we were all standing in that jail together.
Here is what my friend, Father Alberto Carrara, Dean of Neuroethics at the Pontifical Academy for Life, said that day:
As we gather here today under the theme of optimizing interventions for schizophrenia to avoid dire outcomes, I invite you to zoom out—not to lose focus, but to gain depth. The failure to treat people with schizophrenia, the persistence of homelessness, untreated psychosis, and premature death are not simply lapses in clinical delivery. They are signs of a deeper ethical misalignment. As a neuroethicist and member of ICONN—the International College of Neuroethics and Neuroscience—I believe we need a new lens, one that reframes our approach to human persons with schizophrenia from within the interior logic of the human person.
Neuroethics, at its core, is not merely ethics applied to brain data. It is a systematic and informed reflection on both neuroscientific findings and their interpretations—especially the models we construct of the brain, the mind, and the person. These models matter. They shape how we diagnose, treat, and legislate. They determine whether our interventions liberate or limit, whether they dignify or dehumanize.
Let us be clear: schizophrenia, especially in its most severe forms, impairs not only perception and reasoning—it fractures the very unity of consciousness, disrupting the person’s capacity for coherent self-representation and deliberate freedom.
To illuminate this, I propose a bio-systemic model—a stratified understanding of human consciousness and free will—that allows us to locate, with precision, where and how schizophrenia erodes freedom, and therefore where ethics and policy must respond.
Stratifying consciousness, calibrating freedom
Human consciousness is not a monolith. It is a dynamic, bottom-up system structured across at least six dimensions: interoception, exteroception, integrative perception, awareness, proprioception, and phenomenal self-awareness. Each layer is not only a level of conscious experience—it is the foundation of a corresponding form of freedom:
Intero-freedom: The ability to respond to internal bodily states.
Extero-freedom: The capacity to react meaningfully to external stimuli.
Integrative-freedom: The power to synthesize sensory input into coherent perception.
Aware-freedom: Reflective insight into one’s own condition and choices.
Proprio-freedom: Control over bodily movement and spatial agency.
Self-freedom: The highest tier—phenomenal consciousness and the capacity for self-directed, value-based choice.
Now consider what happens in schizophrenia.
The disease does not destroy the nervous system like ALS (Amyotrophic Lateral Sclerosis) or Parkinson’s. Rather, it scrambles the layered architecture of consciousness. Delusions distort integrative-freedom. Hallucinations override extero-freedom. Anosognosia erases aware-freedom. And in its most severe forms, self-freedom—the freedom that makes us fully human—is silenced.
This is not mere impairment. This is a disintegration of freedom from within. And yet, tragically, our policies too often wait until the patient can ‘choose’ help—assuming a level of freedom that the condition has already dismantled.
What neuroethics demands
Neuroethics demands that we stop asking the wrong questions. We should not be asking, ‘Is this person refusing care?’ but rather: ‘At what level of consciousness—and thus freedom—is this person operating?’
If the answer is that self-freedom is compromised, then our ethical responsibility is not inaction, but intervention.
This is where we must distinguish between paternalism—which seeks control—and parens patriae—which recognizes responsibility for those who cannot exercise full autonomy. People with schizophrenia, especially those with anosognosia, are not merely resistant. They are structurally incapable—at least temporarily—of self-rescuing from a collapsing conscious order.
And so, we must speak clearly: treatment is not coercion. It is restoration. The stratification of freedom tells us where intervention is not only justified, but ethically imperative. To withhold care until ‘consent’ re-emerges is to abandon the patient to disintegration. That is not ethics. That is abandonment dressed up in autonomy.
Policy implications: restoring autonomy, not violating it
From this perspective, early and assertive treatment is not a violation of rights, but a precondition for their recovery. The person with schizophrenia is not a problem to manage. They are a subject whose freedom must be scaffolded—reconstructed—from within.
When we apply this layered model of consciousness, we can:
Target interventions where integration breaks down (e.g., perceptual therapies for hallucinations, cognitive remediation for integrative deficits).
Justify legal mechanisms for urgent care based not on subjective distress, but on measurable collapse in freedom.
Redefine psychiatric recovery not merely as symptom reduction, but as the restoration of layered autonomy.
This is a profound shift: from compliance to dignity. From documentation to discernment.
A neuroethical call to action
Let me end where I began: with dignity.
Schizophrenia is not just a clinical challenge. It is a mirror held up to our ethical systems. Neuroethics, as I understand it, is the discipline that forces us to look into that mirror—not to despair, but to reconstruct the moral architecture of care.
Let us no longer be complicit in a system that calls neglect autonomy and calls abandonment compassion. Let us instead build neuroethically informed pathways of care—where neuroscience guides us not only toward what is possible, but toward what is just.
In the layered ruins of disintegrated consciousness, we must place not blame, but bridges—bridges back to autonomy, to relationality, to dignity.
Because every person with schizophrenia is not a broken machine. They are a stratified, wounded freedom calling out—quietly, incoherently, perhaps even violently—for a chance to be restored.
That is our task. That is our responsibility. That is our human obligation.