Saying they can no longer ignore the rising price of health care, some of the most influential groups in the nation are recommending that doctors weigh the costs, not just the effectiveness of treatments, as they make decisions about patients.
The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned about individual patients to exerting influence on how health care dollars are spent.
"We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room," said Dr. Lowell Schnipper, the chairman of a task force on the value of cancer care at the American Society of Clinical Oncology.
In practical terms, guidelines being developed by the medical groups could result in the selection of one drug over another or the decision that a particular treatment is too expensive. In the extreme, some critics have said that making treatment decisions based on cost is a form of rationing.
Traditionally, guidelines have heavily influenced the practice of medicine, and the latest ones are expected to make doctors more conscious of the economic consequences of their decisions - even though there is no obligation to follow them. Medical society guidelines are also used by insurance companies to help determine reimbursement policies.
The society of oncologists, alarmed by the escalating prices of cancer medicines, is developing a scorecard to evaluate drugs based on their cost and value, as well as their efficacy and side effects. It is expected to be ready by this fall.
And the American College of Cardiology and the American Heart Association recently announced that they would begin to use cost data to rate the value of treatments in their joint clinical practice guidelines and performance standards.
Some doctors see problems in trying to be both providers of patient care and financial overseers.
"There should be forces in society who should be concerned about the budget, about how many MRIs we do, but they shouldn't be functioning simultaneously as doctors," said Dr. Martin Samuels, the chairman of the neurology department at Brigham and Women's Hospital in Boston.
He said that doctors risk losing the trust of patients if they tell them, "I'm not going to do what I think is best for you because I think it's bad for the health care budget in the state of Massachusetts."
Doctors can face some stark trade-offs. Studies have shown, for example, that two drugs are about equally effective in treating an eye disease, macular degeneration. But one costs $50 a dose and the other close to $2,000. Medicare could save hundreds of millions of dollars a year if everyone used the cheaper drug, Avastin, instead of Lucentis.
But the Food and Drug Administration has not approved Avastin for use in the eye; and using it rather than the alternative, Lucentis, might carry an additional safety risk. Should doctors consider Medicare's budget in deciding what to use for their patients?
Some insurers and state Medicaid programs are saying that a highly effective new drug for hepatitis C, Sovaldi, from Gilead Sciences, could lead to an immense increase in spending because so many patients will want to use it, at a cost of $84,000 per course of treatment.
Some of them are hoping that, to save money, only more seriously ill patients will be treated. But Dr. Donald Jensen, director of the Center for Liver Disease at the University of Chicago, said some patients with earlier disease had symptoms such as fatigue and would benefit from the drug.
"I think ethically we are just worried about the patient in front of us and not trying to save money for the insurance industry per se, or society as a whole," he said.
Still, some analysts say that there is a role for doctors to play in cost analysis.
"In some ways, it represents a failure of wider society to take up the issue," said Dr. Daniel P. Sulmasy, professor of medicine and ethics at the University of Chicago.
Generally, Medicare is not supposed to consider cost effectiveness in coverage decisions, and other government attempts to do so are susceptible to criticism as rationing. Insurers do perform cost analyses, but they also risk ire from patients and doctors.
The cardiology societies say that the idea that doctors should ignore costs is unrealistic because they already have to consider the financial burden placed on the patient, if not society.
"Protecting patients from financial ruin is fundamental to the precept of 'do no harm,' " the societies wrote in their paper outlining new rules.
"We couldn't go on just ignoring costs," said Dr. Paul Heidenreich, a professor at Stanford and co-chairman of the policy panel.