I want to ration your health care. Well, I don’t want to do it personally, and not to you specifically. And that’s the problem. Policies on the individual and societal levels feel very different. We are not culturally prepared for “rational” rationing. We’re happy to do it irrationally; if you don’t have insurance, you’re probably not going to get proton beam therapy for your prostate cancer. Someone might be willing to chemically or surgically castrate you, though.

Even if you do have insurance, should you be able to get, for example, proton beam therapy? Therapies new and old are often available and used independent of how good they actually work and how cost-effective they actually are. What if (and I’m making up the numbers here) proton beam therapy, which costs gazillions of dollars, decreases cancer recurrence by a few percentage points, and decreases impotence by a few more? Is it worth it? For you? For us?

I’m not beating up on proton beams; never pick a fight with ionizing radiation unless you’re sure you will win. The wider point stands though. In the U.S. we practice medicine with complete irrationality. There are thousands of lives that can be saved by simple practices that so many of us ignore. There are thousands more that can be saved by the proper use of medications.

And yet we continue to pour money into a fantasy. We believe that a 95 year old with cancer just might be the one to survive the ICU, with just one more day on the ventilator, just one more round of dialysis. We believe that our own patient with pancreatic cancer might be the one who feels better on Gemzar. We believe we can cure our obesity-related disorders without exercise, without medicine, and without society-level interventions (it worked with smoking).

The American medical system is an irrational fantasy, one in which we swoop down and cure one person’s problem at a time, forgetting that the system as a whole is making us all sick and broke.

“PalMD” is an internal medicine physician who blogs at White Coat Underground.