It is Not the Patient, It is the System: Commentary on "How Advanced Directives Help When Patients Refuse Life-saving Treatment Because of Their Substance Use"

Serious infections are common in patients with opioid use disorder who use injection drugs. Clinicians are often frustrated by the complexity and uncertainty involved in managing these patients, who also have a high rate of discharges against medical advice. The commentary addresses a proposal for a substance use advance directive that would bind the patient to involuntary future treatment, even over their contemporaneous objections. Although the problem is significant, this commentary challenges the legal and ethical justifications for the substance use advance directive and advances that instead, attention should focus on mitigating the harms of continued institutional and structural discrimination and advocating for evidence-based inpatient treatment.