Authors' reply

The varied correspondence precipitated by my editorial has invoked a great many issues. However, the sole aim of my original piece was to examine whether a current concern with the putative cognitive-enhancing effects of certain medications might be redirected towards the possible enhancement of other human attributes such as moral behaviour. ¹ Should this be of interest to psychiatrists? Well, I believe that there is something worth scrutinising within the medical consultation when a patient (a moral agent) considers the likely impact of their future conduct upon others, and the various means via which such conduct might be modulated. Drugs are not the only means by which such modulation might occur but they do provide an interesting example. Nevertheless, as I acknowledged in the editorial, such a juxtaposition of pharmacology with morality risks provoking reflexive responses: strong opinions unencumbered by reflection.

Clearly, the situation in the consulting room with an antisocial or aggressive man is rather different from that outlined by Al-Adwani. We are not talking about the social consumption of stimulants and intoxicants or the enforced ingestion of medicines by combatants in order for them to fight for longer. We are talking about what individual patients might choose to do about their own future behaviours, sometimes under very difficult circumstances; indeed, an antisocial male may not even enjoy a community of peers with whom to consume coca, kratom or qat. I apologise if this was not sufficiently obvious.

With respect to Frankfurt's conjecture that we might all harbour first- and second-order desires, Hubbeling's point is well taken: that if we posit such a hierarchy of desiring processes, then an individual's second-order (pro-social) desire to control an aberrant first-order desire (to react aggressively, to assault someone) might utilise a pharmaceutical agent only, to discover (later on) that the latter had modulated not only the first-order construct but the second-order one as well. The questions arising, here, are: (a) whether such first-order and second-order desires enjoy any empirical demonstration of their existence; and (b) whether, if second-order desires really exist, we are currently managing to avoid affecting them when we prescribe psychotropic medications or engage in any form of dynamic psychotherapy. To my mind, this makes the central question of even greater interest and one deserving of further empirical exploration.