The Fine Line: Balancing Pragmatism and Ethics in the Management of Acute Mania

Ethical decision-making within the realm of mental health care represents an evolving challenge.¹ Psychiatrists frequently contend with conflicting ethical principles, particularly when confronted with patients exhibiting acute psychiatric symptoms.² Considerations of respect for autonomy, beneficence, nonmaleficence, and justice must be meticulously evaluated in each case to arrive at a normative ethical conclusion concerning a therapeutic intervention.³ This report scrutinizes a scenario in which a psychiatrist strategically used a patient’s internalized fear of extremism to redirect behavior during a manic episode. While such interventions may facilitate immediate behavioral modification, they simultaneously engender a plethora of ethical dilemmas, which were thoroughly deliberated.

Case Report

Mr A, a 50-year-old man with a history of depression, experienced a manic switch triggered by antidepressant medication. During this episode, he developed intense religious fervor, disseminating his views through YouTube videos and WhatsApp speeches. He formed a group called Pure Islam, which led to conflict within his local community. Mr A challenged established religious leaders and argued with fellow Muslims, asserting that they were misguided. In light of his problematic behaviors, he was admitted to a psychiatric facility; however, he subsequently discharged himself against medical advice and adamantly refused to adhere to prescribed medications.

Despite his reluctance to engage in pharmacologic treatment, Mr A consented to attend sessions with his psychiatrist, with whom he had previously cultivated a positive rapport during his depressive episodes. The psychiatrist, also a practicing Muslim, listened to Mr A’s beliefs, including those questioning the psychiatrist’s own faith. Instead of directly confronting the patient’s beliefs, the psychiatrist gently educated Mr A about the potential consequences of using language like “Pure Islam,” explaining that such terms are often associated with extremist groups and could attract the attention of security agencies. This approach resonated with Mr A, who subsequently became more receptive to treatment and medication. He also expressed his gratitude to the psychiatrist for safeguarding him from potential legal predicaments by furnishing him with judicious counsel.

Discussion

This clinical scenario engenders a multitude of intricate ethical dilemmas regarding the manner in which the attending psychiatrist influenced alterations in the patient’s behavior. The approach adopted by the psychiatrist involved leveraging the prevailing anxieties associated with extremism and security concerns to persuade the patient to cease his excessive religious proclamations, which were precipitating numerous issues both within the family and the broader community. The psychiatrist’s awareness that Muslims frequently contend with the apprehension of being unjustly categorized as extremists—a legitimate concern in an atmosphere increasingly characterized by Islamophobia and discriminatory discourse—shaped his therapeutic methodology.⁴ Furthermore, his elucidation that extremist factions within Islam often manipulate the notion of pure Islam to rationalize their actions and ideologies, predicated on a selective interpretation of Islamic texts and historical narratives, resonated profoundly with the patient.⁵ Consequently, he acquiesced to cease his public religious proclamations and conveyed his gratitude to the psychiatrist.

Herein lies the question: Was the psychiatrist’s conduct ethical? From the principle of beneficence, one can contend that the paramount ethical obligation of the psychiatrist in this scenario was to act in the best interests of the patient. Mr A’s behaviors were inflicting considerable distress upon both his family and the broader community, while simultaneously exposing him to the risk of involuntary treatment and potential legal repercussions. By meticulously weighing these factors, the psychiatrist succeeded in persuading Mr A to modify his conduct and embrace treatment, thereby potentially averting harm to himself and others. The established rapport with the patient may have facilitated this persuasive intervention.

However, one might contend that this approach was manipulative. By exploiting the internal fears that stem from societal biases and prejudices, the psychiatrist undermined the autonomy of the patient, who possesses the right to express his beliefs as he sees fit. Moreover, such therapeutic interventions during manic episodes may precipitate or exacerbate paranoia, leading to further behavioral complications. If such a scenario arises, it could be construed as an act of maleficence. One could also argue that in these circumstances, rather than capitalizing on the patient’s internal fears for therapeutic gain, the psychiatrist should endeavor to delve more profoundly into the religious convictions of the patient, fostering a better understanding of the underlying psychosociospiritual factors that drive such behaviors. Furthermore, the psychiatrist might communicate the potential social and legal ramifications of his actions without explicitly invoking the fear of being labeled an extremist.

Nevertheless, one must also acknowledge that mania, as a severe psychiatric condition, significantly impairs the patient’s judgment and impulse control. In this context, the patient’s capacity to comprehend such communication and to engage in genuinely autonomous decision making is questionable. The psychiatrist’s intervention may have been successful precisely because it tapped into a preexisting fear, a fear that persisted even amid the manic excitement.

Conclusion

Therapeutic interventions in acute mania necessitate a nuanced equilibrium between upholding ethical principles and addressing the immediate needs of the patient. While capitalizing on a patient’s preexisting fears can be a pragmatic and efficacious strategy, conducted with a spirit of beneficence, it also requires meticulous consideration, as it may contravene the principles of autonomy and nonmaleficence. Mental health professionals should remain acutely aware of these ethical quandaries while seeking therapeutic solutions in analogous circumstances.

Article Information

Published Online: December 16, 2025. https://doi.org/10.4088/PCC.25cr04034
© 2025 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2025;27(6):25cr04034
Submitted: June 27, 2025; accepted September 12, 2025.
To Cite: Uvais NA. The fine line: balancing pragmatism and ethics in the management of acute mania. Prim Care Companion CNS Disord 2025;27(6):25cr04034.
Author Affiliation: Department of Psychiatry, Iqraa International Hospital and Research Centre, Calicut, India.
Corresponding Author: N. A. Uvais, MBBS, DPM, FRSPH, FRSB, Department of Psychiatry, Iqraa International Hospital and Research Centre, Calicut, India ([email protected]).
Relevant Financial Relationships: None.
Funding/Support: None.
Additional Information: Patient information has been de-identified to protect anonymity.