In Reply.\p=m-\We appreciate Dr Krause's comments. Variations in the hepatitis B vaccine worldwide, in both cost and dosing recommendations, prevented us from constructing a useful cost-effectiveness algorithm within the discussion section of the article. However, in view of the long-term costs associated with chronic hepatitis B-related disease, it would seem that prophylactic neonatal vaccination could be cost\x=req-\ beneficial. This view has also been espoused in the recent recommendation for widened hepatitis B vaccination from the ACIP.1 We agree with Waters and Cook that other risk factors may be predictive of maternal hepatitis B status. This study was designed to look at the lack of prenatal care as a possible risk factor in itself and showed unregistered status to be linked to maternal drug use. The existence of other associated risks in these women speaks even more strongly to a need for widened neonatal vaccination. Finally, this study was not designed to study pediatric vaccines longitudinally. We cited a study by others that dem¬ onstrate women at highest risk for hepatitis infection to be less likely to follow up with recommended care,2 and agree that the children of such women would warrant aggressive surveillance to ensure completion of the vaccination process. Neil Silverman, MD Ronald J. Wapner, MD Thomas Jefferson University Philadelphia, Pa 1. Centers for Disease Control. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood immunization: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR. 1991;40(No. RR13):1-25. 2. Jonas MM, Reddy RK, DeMedina M, Schiff ER. Hepatitis B infection in a large municipal obstetrical population: characterization and prevention of perinatal transmission. Am J Gastroenterol. 1990;85:277-280.

Advance Directives To the Editor.\p=m-\If a patient were to request a specific medication (perhaps having seen it in a television advertisement) that you thought was not only unnecessary but actually contraindicated, would you feel obliged to comply? What if the patient had written and signed a directive stating explicitly that in the event of an illness, that medication was to be given? Unfortunately, the present state of advance directives surrounding the question of termination of care raises just such issues. As pointed out by Emanuel et al,1 the use of advanced care directives has been increasing and expanding, and the results of the Cruzan decision2 and the Patient Self-determination Act of 19903 will probably ensure the continuation of these trends. The suggestion of the authors that these documents include "a section in which the patient's physician acknowledges that he or she has seen the document and has had an opportunity to discuss its content with the patient"1 is a useful and constructive one and is sure to contribute to fur¬ ther discussion of this important issue. Unfortunately, the issue is not that simple. Physicians should not be forced to take part in advanced care directives if they are contrary to their own moral beliefs. With the best interests of the patient at heart, a physician should (in fact, must) offer the alternative of termination of treatment to a patient. However, a physician should never be forced to bow to the will of a patient with whom he or she disagrees. Ob¬ stetricians are not mandated to perform abortions if they consider that to be the termination of a life; in a like manner, other physicians should not be mandated to participate in the termination of what they consider a life—no matter what the quality of life in either instance. The issue of termination of care is a critical one and is sure

to increase in importance as our society ages. However, this does not change the fact that a physician's expertise should contribute to a patient's decision making process; just as the patient's wishes must not be compromised, neither should the desires or morals of the physician. I am not advocating a return to paternalism, in which the patient's wishes are ef¬ fectively disregarded. Rather, I am encouraging the forma¬ tion of a mutually acceptable agreement in which the patient and physician reach a common ground, with no fears of either abandonment on the part of the physician or unnecessary suffering on the part of the patient. Emanuel et al would reduce the role of a physician to one who would "implement the preferences contained in this document."1 Ideally, how¬ ever, physicians should be chosen because of their wisdom and principles, not merely because of their access to lifeor their ability to stop the adminis¬ saving medications tration of them. Erol Onel Albert Einstein College of Medicine ...

Bronx, NY

1. Emanuel EJ, Emanuel LL, Orentlicher D. Advance directives. JAMA. 266:2563. 2. Cruzan v Director, Missouri Dept of Health, 110 S Ct 2841 (1990). 3. Omnibus Budget Reconciliation Act of 1990. Publication 101-508.


To the Editor. \p=m-\Werisk caring more for paper than patients if we too literally interpret advance directives. It is important, then, if unfortunate, that the article by Sehgal et al1 asks how strictly patients wish to have advance directives followed. On the one hand, such questions advocate the importance of the physician-patient relationship. The article encourages physicians to ask patients "what factors they want considered in making decisions for them," demonstrating the importance of ongoing, honest conversation. On the other hand, asking patients "how strictly they want their advance directive followed" forces the patient to cover all bases and address an almost infinite number of possible variations. The compassionate and open discussion of the patient's values, beliefs, attitudes, and outlook would be more effective. Patients, reassured that their perspective, comfort, and prognosis will be considered, can allow the physician and surrogate to direct their care when necessary. In this ideal scenario, an advance directive could be simpler and clearer: "My family and my physician know my wishes, values, and goals. I trust them to make decisions for me should I become unable." Additional specifications could be added for clarification and emphasis. Unfortunately, I have not seen an advance directive include a physician. Have phy¬ sicians' time and temperament become so short that we have stopped knowing our patients? Are physicians unable to avoid projecting personal values into such decisions? Have physi¬ cians' practices been so constrained that a checklist is re¬ quired to guide care? Physicians must not rely only on papers as a guide. Literal interpretation of an advance directive is potentially unfair to everyone. It is impossible to account for all possible scenar¬ ios. There is no guarantee that the values of the patient will be understood or respected in unforeseen circumstances. Like¬ wise, putting the decision making solely on an unguided fam¬ ily may be unfair—they will be insecure in their medical knowledge no matter how thorough a discussion and will have hesitant thoughts, if not guilt, when forced to decide. Physicians must not abdicate responsibility to care for their patients and to assist surrogate decision makers. Phy¬ sicians must work to know their patients, encourage patients to express their wishes, turn to the family (or surrogate) for guidance, information, and support, and continue to care for

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patient. Advance directives are an important means for patients to share their wishes. We must not give them more (or less) weight than they possess. Physicians must still par¬ ticipate in patient care and decision making. Let's not lose sight of the patient for the paper before us. the

James G. Adams, MD Lackland (Tex) Air Force Base 1. do

Sehgal A, Galbraith A, Chesney M, Schoenfeld P, Charles G, Lo B. How strictly dialysis patients want their advance directives followed? JAMA. 1992;267:59-63. This letter


shown to the authors, who declined to




by Specialty, 1986 Through 1990 «$40000,



Specialty»_No. (%)_No. (%)_No. (%)_Total

Surgery_30(17.5)_34(14.7)_48(14.3)_112 Medicine_62 (36.3)_82(35.5) 128(38.3)_272 Ophthalmology_8 (4.7)_8 (3.5)_11 (3.3)_27_ Ob/gyn_7 (4.0)_15(6.5)_17(5.1)_39_ Family practice_8 (4.7)_9 (3.9)_20 (6.0)_37_ Ortho/urol/ENT_5 (2.9)_12(5.2)_13(3.9)_30_ Radiology_9 (5.3)_9 (3.9)_17(5.1)_35_ Anesthesiology_5 (2.9)_5 (2.2)_10(3.0)_20_ Pediatrics_21 (12.3)_22 (9.5)_33 (9.9)_76_ All otherst_ 16(9.4)_35(15.1)_37(11.1)_88_ Total





*Ob/gyn indicates obstetrics and gynecology, and ortho/urol/ENT, orthopedics, urology, and otorhinolaryngology. tlncludes psychiatry, rehabilitation medicine, emergency medicine, pathology, and neurology.

1. Geertsma

RH, Romano J. Relationship between expected indebtedness and cachoice of medical students. J Med Educ. 1986;61:555-559. students, 1981\x=req-\

2. Tudor C. Career plans and debt levels of graduating US medical 1986. J Med Educ. 1988;63:271-275.

Medical Student Indebtedness and Choice of Specialty To the Editor. \p=m-\Thecosts of medical education rise yearly and a large proportion of these costs are met by borrowing. Nationwide, the average debt incurred during medical school in 1989 was $40 636 with only 24% of graduates having no reported debt. Conventional wisdom suggests that students select higher\x=req-\ paying medical specialties in order to repay the debt.1-2 Boston University School of Medicine is a private school with a high tuition ($23 900 for the calendar year 1990-1991) as compared with state schools. The average indebtedness ofthose who borrowed to complete their medical education at the school was $64 500 for the 1990 graduating class. Approximately 23% of the graduating classes at Boston University School of Medicine incur no reported debt, although it is possible that their family members lend them money (or assume the financial obligation for tuition) to complete their education. But I do not believe our data indicate that the choice of specialty is dictated by heavy indebtedness, based on our study of the 736 students in the graduating classes at Boston University School of Medicine from 1986 through 1990. Data were accumulated concerning sex, marital status, minority designation, total money borrowed, and specialty choice. For those 5 years, the composite data (Table) show no significant association between debt and specialty choice ( 2 10.3, df= 18). It is noteworthy that the practice choices of the Boston University School of Medicine students are slightly greater than the national average in the area of internal medicine. In the past 5 years there have been fewer medical school applicants, presumably owing to the increased costs of a medical education. This trend has been reversed in 1991. The Association of American Medical Colleges Graduation Ques¬ tionnaire for 1989 has listed "good income" as a low incentive factor in specialty selection.3 This study corroborates the questionnaire and finds no relation between indebtedness and specialty choice.

No Debt,

Daniel S. Bernstein, MD Boston University School of Medicine reer

Distribution of Debt,

The chance for most practicing physicians to earn large of money is no longer present. While the debts incurred for medical education are large and growing, it is reassuring that they do not appear to be a major determinant for career choices. It may be that students choose medical careers based on their altruism, compassion, and enlightened self-interest. sums

3. 1989 Graduation Questionnaire Results. ican Medical Colleges; 1989.

Washington, DC: Association of Amer-

Radiation Therapy in Patients With AIDS-Related Central Nervous System Lymphomas To the Editor.\p=m-\Recently, there were three reports in JAMA1-3 regarding central nervous system prophylaxis of patients with acquired immunodeficiency syndrome (AIDS)\p=m-\related non-Hodgkin's lymphoma (NHL). This has prompted us to report our experience in the treatment of similar patients. From June 1987 to December 1991, the Radiation Oncology Center at The New York Hospital\p=m-\CornellMedical Center has used brain irradiation to treat 25 men with AIDS-related central nervous system NHL. Ages ranged from 27 to 57 years (median, 37.8 years). All patients except one had a history of opportunistic infections. Virtually all were receiving antiretroviral therapy. Twenty-one had primary brain lymphoma, four had central nervous system relapse of NHL, and three of them had received combination chemotherapy. Two patients had associated Kaposi's sarcoma. All patients had clinical neurological deficits, and computed transverse tomography (CT) and/or magnetic resonance imaging (MRI) were highly suggestive of lymphoma. Six had positive brain biopsy results, and in four, cerebrospinal fluid cytology was consistent with NHL. Two patients had CTguided needle biopsy performed, with tissue insufficient for diagnosis. The rest either refused biopsy or had medical contraindications for the procedure. All had negative toxoplasmosis serological results and/or failed a therapeutic an¬ tibiotic trial. They were then referred for radiation therapy. The whole brain was treated with a total dose ranging from 30 to 40 Gy over 3 to 4 weeks. If response was obtained, a "boost" to the tumor bed was delivered (in general, 14 Gy was given in about 1 week). Twenty-four patients were évaluable, and 19 of 24 exhibited improvement in their neurological manifestations (79.2%). No subject who responded to treat¬ ment had recurrence of the neurological dysfunction. Eight patients had CT or MRI after radiation therapy, and seven of eight showed marked tumor regression, while one showed disease progression. Side effects were minimal and tempo¬ rary and were limited to skin erythema and alopecia. Blood cell counts were unaffected. No subjects required interrup¬ tion of the antiretroviral therapy. Forty percent of patients with AIDS will develop central nervous system symptoms sometime in the course of their disease.4 Differential diagnosis should include opportunistic infections and neoplasms. Magnetic resonance imaging is the most valuable and sensitive imaging study for diagnosis, along with treatment planning.5 If brain biopsy cannot be performed and patients have failed empirical trials for toxoplasmosis, radiation therapy should be seriously consid¬ ered. Failure to achieve clinical response after radiation ther¬ apy determines the need for further evaluation. The mean survival in patients with untreated AIDS-re¬ lated central nervous system NHL is less than 2 months. Our

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Advance directives.

In Reply.\p=m-\We appreciate Dr Krause's comments. Variations in the hepatitis B vaccine worldwide, in both cost and dosing recommendations, prevented...
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