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Programmable drug delivery systems are emerging as a transformative class of therapeutic technologies because they can adjust drug release according to physiological signals, algorithmic rules, or external commands. Their appeal lies in the promise of more responsive, individualised, and continuous therapy than is possible with conventional dosage forms. Closed-loop insulin delivery, implantable programmable pumps, responsive antidote systems, and digitally mediated delivery platforms all illustrate this shift from passive administration to active therapeutic control. This shift also changes the ethical character of drug delivery. When a device senses, interprets, and acts on behalf of a patient, dosing becomes partly delegated to software, control architecture, and design assumptions. The ethical question is therefore not only whether the system works, but whether it preserves the patient’s agency while pursuing therapeutic optimisation. The core problem is that programmable delivery systems combine pharmacological intervention, medical device operation, data processing, and algorithmic decision-making in a single therapeutic object. This convergence creates tensions between efficiency and autonomy, adaptability and safety assurance, and automation and human oversight. Existing ethical and regulatory vocabularies do not fully capture these tensions because they often treat drugs, devices, software, and clinical decisions as separable domains. This critical perspective argues that programmable drug delivery requires an ethical design approach from the earliest stages of development. Autonomy must be translated into design features such as consent clarity, override capacity, patient-facing explanation, and withdrawal options. Safety must be treated as a lifecycle property rather than a static pre-market claim. The article proposes a critical framework for classifying programmable delivery systems according to autonomy level, identifying ethical pressure points, and linking them to design and governance requirements. It argues that trustworthy programmable delivery depends not merely on technical performance, but on the deliberate preservation of meaningful human control. Ethical foresight must therefore become part of the engineering logic of programmable drug delivery itself.