Rewriting the will: Autonomy and pharmacological desire modification in semaglutide use.

Abstract

This article responds to Ryan's and Savulescu's claim that semaglutide enhances autonomy by reducing problematic desires. Drawing on Frankfurt's hierarchical model of autonomy, this article argues that pharmacological alignment between first-order and higher-order desires can only be autonomy-enhancing if individuals also endorse the process by which their desires are reshaped. Further, it contends that socially influenced motivations, including those shaped by fatphobic norms, need not undermine autonomy so long as agents critically reflect on and endorse them. By reframing autonomy as a process of reconciling conflicting desires rather than a matter of outcomes, this analysis clarifies the ethical permissibility of pharmacological desire modification interventions. The broader implication is that respect for autonomy requires recognition of authentic authorship in contexts where medical and cultural forces shape desire, an approach that extends beyond weight-loss drugs to parallel debates about plastic surgery, gender-affirming care and addiction treatment.