Ozempic: Reshaping Desire Since 2023

A DRUG INITIALLY approved for type 2 diabetes, and now widely used for weight loss, is forcing us to grapple with the age-old question of what it means to choose freely. Weight loss drugs that work by suppressing appetite are not new. Semaglutide, better known by its brand names Ozempic and Wegovy, just happens to be very good at it. So much so that the drug is single-handedly boosting the economy of Denmark, where its manufacturer Novo Nordisk is based.

This is likely just the beginning. Given the potential revenue streams, we should expect these drugs to rapidly become more potent and targeted. As they do, we will have to reconsider some of our long-held notions about autonomy and personal freedom. That’s because semaglutide is not just helping people shed pounds, but fundamentally reshaping their desires—for food, and apparently much else besides. The drug has shown effectiveness in reducing dependency symptoms related to alcohol, nicotine, cocaine, and opioids. Earlier this month, a new retrospective cohort study offered evidence that semaglutide also significantly reduced the incidence of cannabis use disorder, a condition which is thought to affect a third of cannabis users, and for which no approved treatment currently exists.

We still don’t fully understand the exact mechanism through which semaglutide works. What we do know is that in the gastrointestinal system, semaglutide mimics the action of the hormone GLP-1, which enhances insulin secretion and slows gastric emptying, and in so doing creates a sense of satiety. We also know that GLP-1 receptors are found not only in the gut but also in the hypothalamus, in that most evolutionarily ancient part of our “reptilian” brain, which is involved in the regulation of mood, appetite, stress responses, and the body’s reward system. This likely explains why people on semaglutide describe lifelong food cravings disappearing overnight. And it’s also where things get murky, raising thorny medical and philosophical questions.

The most intriguing effects of semaglutide won’t be documented in randomized control trials for years to come. That’s why for the past months I have been trawling the online forums where thousands of semaglutide users share their experiences with one another. Pharmacological research moves slowly, and for now, these anecdotal accounts may provide the best hint of what is to come. As someone who studies people’s preferences, which are notoriously difficult to change, these accounts verge on the mind-boggling. I’m not alone in my fascination for these discussion forums. Occasionally, I come across fellow observers with different motives: market researchers trying to figure what to do once the food and beverage industry is faced with grocery shoppers who are no longer as easy to hook with sugar, salt, and fat as they once were.

Some of these users obtained semaglutide through a doctor’s prescription; others resorted to more circuitous means. What they share is a sense of collective surprise at the effects this drug has had on them. They claim to have lost interest not only in their favorite foods—chocolate croissants, Cosmic Brownies, peanut butter cups, chili cheese dip—but also in their cravings for caffeine, alcohol, cigarettes, vaping, and online porn. One person mentions leaving an unfinished drink at a restaurant for the first time in their lives. Others describe suddenly ceasing, without noticing, a list of compulsive behaviors, from biting their nails and the insides of their cheeks to going on gambling and shopping binges. Several report their monthly credit card bills dropping as a result of these changed behaviors. What kind of drug improves people’s credit scores?

These are all anecdotal accounts, and they most likely reflect a biased selection: those with positive effects may be the most eager to share, which means that they are unlikely to be representative of the effects across the population. Nonetheless, these early reports from the trenches of chemical desire suppression are at least suggestive of the types of behaviors that could one day be treated with the next generation of drugs acting on the same neural pathways.

On the basis of these accounts, the initially improbable claim that we have stumbled on a drug against addiction seems increasingly believable. Some medical studies have begun to suggest as much. The more tantalizing possibility, however, is that we have stumbled on the precursor to a drug for … virtue. By suppressing our weak, temptation-ridden selves, might we end up not only thinner but also, somehow, better people? The question that remains is, Better according to whom?

The world is awash with convoluted schemes designed to suppress our short-term urges, help us fight procrastination, and delay instant gratification in favor of nobler, more distant ends. There are fridges with programmable time locks, and websites that will donate money you place in escrow to the neo-Nazi party if you fail to meet the work deadline you set for yourself. When these are the lengths to which people are willing to go in pursuit of their better selves, a drug that instantly quells temptation may prove hard to resist.

Philosophers love to use fanciful thought experiments to test their intuitions. Conscious brains in jars of formaldehyde pondering the mind-body problem, cats in sealed boxes that are at once alive and dead, fat people dropped from high platforms to block ill-fated trolleys. This one seems no less fanciful: imagine there’s a drug that will quash your love of online shopping. Should you take it?

According to philosophers who study decision-making, our ability to make that choice rationally depends on whether the change is “transformational”—that is, on how deeply it affects our underlying preferences. We are what we want; our preferences define who we are. When we deliberate over a choice, whether it’s between cereal boxes or life partners, we weigh our options against our current preferences, and we try to imagine which outcome will make us happiest. But when faced with decisions that have the potential to transform those very preferences, we’re necessarily at a loss. Which set of preferences should serve as the basis for making the choice?

The question becomes: Is the person who has taken the drug, and who has lost all interest in filling their shopping cart with things they no longer want, different from the shopaholic who was considering taking the drug in the first place? If so, how can the earlier self choose on behalf of the later self, who will be the one to live with the decision? After all, if their fundamental desires are different, it means they will evaluate their lives, and what makes them happy, from an entirely different basis. And since the earlier self cannot know what it is like to be that future self without first taking the drug, she cannot decide on her future self’s behalf whether the drug will make her happier.

L. A. Paul, a philosophy professor at Yale, has famously applied this paradox to the decision to have children. In her telling, choosing to become a parent is a paradigmatic case of a transformative experience—one that fundamentally alters an individual’s preferences in unforeseeable ways. Paul argues that such decisions are unique in that they radically change the set of preferences from which we evaluate our decisions. The lack of foreknowledge about who we will be after making the decision renders the typical cost-benefit analysis—balancing lost personal time against love for a child—inadequate for making that decision in the first place.

We are notoriously bad at imagining how our future preferences might be different from our current ones. I often encounter this kind of myopia in my own undergrads. I cannot count the number of students who have told me, upon graduation, that they plan to enter a lucrative career for just five years (it’s always five years), enough to pay off their student debt or earn a down payment on a house, and then, they tell me, they will quit and do what they actually want to do with their lives. They will become a teacher, work in an NGO, open a ceramics business. What invariably happens, as time passes, is that their preferences change. Under the influence of a novel environment, and new peers, they become different people. Once they reach that five-year mark, the decision to pursue their “true calling” is no longer as straightforward as they initially imagined. The wants from which they evaluate what makes them happy have changed. Which of their two selves is correct—the student who said that what they “truly” wanted was to be a teacher, or the later self who aspires to make partner at the firm? There is no straightforward answer.

Can a weight loss drug be as transformative as having children, or becoming an investment banker? Unlikely. On the other hand, these drugs have one aspect that makes them more worrisome from the standpoint of rational decision-making: their effect is instant. People report a change of desire overnight, after a single dose of semaglutide. “Is it supposed to work this fast?” one patient asks. Another recurrent comment on semaglutide discussion forums is that people don’t notice their changed behavior until someone else points it out. They had simply stopped thinking about food, online porn, or shopping. Their hankerings change without their becoming aware of it.

By contrast, the transformational experiences philosophers talk about are typically far more gradual. I discovered this myself when I became a parent. With L. A. Paul’s work in mind, I expected my ego to be biologically transformed from one day to the next. The reality, I learned, was quite different. One becomes a parent in stages. From expecting, to hearing a heartbeat, to seeing a blurry image on a screen, to meeting the misshapen little being that you helped create, each stage requires an active adjustment. Those small steps allow for an ongoing reconsideration of your changing self. Becoming a parent, I discovered, is a far more conscious process than Paul’s account of it had led me to believe.

For that reason, I have always preferred Paul’s other, more fanciful example of transformational change: imagine someone asks you whether you would like to become a vampire. You would shun sunlight, crave human blood, and have a thing for sleeping inside coffins. You might be perfectly happy, but it would be on entirely different grounds. Would you go for it? Here, too, Paul’s answer is that there is no rational means of deciding, because your human self and your vampire self would evaluate their happiness from a fundamentally different basis. They would have no common framework from which to choose. I used to think of the vampire analogy as illuminating, if not very applicable to our normal lives. But after a few months spent on semaglutide discussion forums, it no longer seems so far-fetched.

Patients’ testimonials speak to a similar sense of bewilderment: “Now I just don’t want anything,” one reports. “Is this what it feels like to be normal?” Or as another semaglutide user put it, “Who even am I?” That is the question. When our fundamental desires change, it becomes very difficult to say whether we are authoring our future improved self or betraying it by becoming someone we are not.

When it comes to wrestling with obesity, it seems reasonable to think that we can decide on the basis of objective medical advice. Even if I cannot currently conceive of what it would be like not to yearn for peanut butter cups, I can be pretty confident, given what we know about the health effects of those cravings, that I will be better off without. In this respect, scientists studying addiction make a helpful distinction between “wanting” and “liking.” The implication is that the desire for peanut butter cups is not really my own, and taking a drug that rids me of it can help me become who I “really” am. But the same reasoning becomes murkier as these drugs are increasingly sought out not as treatments for a medical condition but as a means of self-improvement.

In this regard, the most intriguing reports on semaglutide forums are those that mention regret. Many people report actively missing their former cravings. They yearn for their past yearnings: the way they ached for a spoon of ice cream, and then a whole pint of it. These confessions of regret have been singled out by some media reports as evidence of the dangers of this powerful new drug. But as far as I’m concerned, regret is reassuring. It suggests that there is sufficient continuity between the pre-semaglutide self and the post-semaglutide self to allow each to make judgments about the other and decide which self they ultimately want to be. People still remember what it was like to want pizza, and some of them identify with that past desire even while no longer feeling it, and miss the feeling of desire itself. By contrast, after becoming a vampire—or a parent, for that matter—it might be all but impossible to meaningfully recall what it was like not to be one. That’s why we may grow more concerned when regret disappears altogether and the taking of these drugs proves truly transformative.

Americans have a strong reflexive commitment to individual freedom. But freedom is more complicated than we often make it out to be. It doesn’t just mean doing what we want; in a modern economy where market actors—advertisers, algorithms, social media influencers—are constantly vying to change our wants, freedom requires knowing who we really are. As the philosopher Harry Frankfurt once put it, freedom is wanting what you want to want. The risk with semaglutide, and the wave of more potent drugs soon to come, is that they could leave us estranged from our own values. Our obsessions, passions, and fixations—these are integral to who we are. The risk in changing these aspects of ourselves by taking a new miracle drug is not only that they could turn us into different people. It’s also that they could do so without our being able to evaluate whether we are better or worse off as a result.

¤