In a recent editorial, Spence stated that the pharmacological interventions currently available in psychiatry also improve moral behaviour. ^{Reference Spence1} He subsequently argued that there is no fundamental difference with moral enhancement therapy, medication specifically developed to increase moral behaviour. Spence gave the example of a patient who continues to take antipsychotic medication because he knows he can be violent when unwell and he wants to prevent risks to others.

Spence asserted that whether an intervention assists in ‘moral enhancement’ or not crucially depends upon the goals of the patient concerned, i.e. the ‘ends’ he or she is pursuing. However, ‘the goals of the patient concerned’ can be problematic in the cognitive enhancement debate and this formulation can conceal important ethical issues.

Spence mentioned the concept of meta-responsibility, the fact that somebody can be responsible for becoming irresponsible, in the case of the example that somebody can be responsible for deciding not to take medication. ^{Reference Mitchell2} In a somewhat similar way as Mitchell, Frankfurt ^{Reference Frankfurt3} discussed the difference between first- and second-order desires. One can have a desire for smoking, which is a first-order desire. One can also have a second-order desire, namely the desire not to have the desire for smoking.

One could argue that in the future pharmacological interventions might be able to interfere with second-order desires. Second-order desires according to Frankfurt are the core aspect of personhood. Even if one does not want to go as far as Frankfurt in stating that the second-order desires determine personhood, moral enhancement treatment can be problematic if it could change second-order desires. In that case, people's goals would alter. Contrary to Spence's view, moral enhancement pharmacotherapy can be quite controversial if it interferes with second-order desires.