FICTION: Lionel Shriver turns her often controversial pen to the American health system in her latest novel, writes Catherine Heaney

So Much For That, by Lionel Shriver, Harper Collins, 436pp, £15

LIONEL SHRIVER has never shied away from controversy – take the media flurry that greeted 2005's We Need to Talk About Kevin. The novel's violent, all-too-familiar centre-piece of a high-school massacre made it a shoo-in for newspaper column inches, and Shriver's own contributions to the debate marked her out as a media-savvy commentator who was never afraid to voice a controversial opinion. She brings that same provocative, prickly sensibility to bear in her ninth novel, So Much For That, and this time the issue taking centre stage is the US healthcare system – its injustices and punishing expense – and the cold question of how much a life is worth.

Decent, hard-working Shepherd Knacker has devoted his life to building up his handyman business, eventually selling it so that he and his family can escape New York and retire to a simpler existence in a developing country. The novel opens as Shep prepares to tell his reluctant wife, Glynis, that he is leaving for the African island of Pemba and “The Afterlife”, with or without her, in a week. Glynis, however, has news of her own: she has been diagnosed with a rare and virulent form of cancer – so much for that indeed. Abandoning his life-long plan, to the bitter smugness of his wife and derision of his colleagues, Shep must now spend his every minute and life’s savings on fighting Glynis’s illness, something he does with an unquestioning self-sacrifice and a Job-like stoicism. Glynis, meanwhile, is anything but the haloed victim: a brilliantly shrewish character, she has harboured resentment all her life – resentment that the metalwork she once created didn’t bring her success as an artist, resentment towards her do-the-right-thing husband and her role as suburban mom. As Shriver puts it: “Glynis not only worked with metal (or used to); she was metal. Stiff, uncooperative, and inflexible. Hard, refractive, and shiny with defiance. And as the cancer ravages her body, its malign effects insidiously spread to the couple’s relationship.

While the human drama unfolds, so too does the bureaucratic nightmare of the labyrinthine US health insurance system: Shep must stay in a job he now loathes so that he can keep the health insurance policy that will pay for his wife’s treatment (only partially, as it turns out), and the crippling medical bills devour their nest egg. The reality of survival soon becomes clear: “They would buy Glynis’s life, day by costly day, and in the end you would be able to affix a price tag to every one.”

Added to this, Shep must also pay for the care of his sick father. Sympathising with him throughout these trials is his best friend, Jackson, himself the father of a terminally ill child – 16-year-old Flicka, who suffers from a debilitating degenerative disease. A likeable, mouthy, self-taught proselytiser who believes the world is divided into “Mooches and Mugs”, Jackson is endlessly exercised by the evils of the federal government, from Medicare to taxes to parking violations. His caustic rants allow Shriver to go into detail on the larcenous cost of medical care and the loopholes that let health insurers off the hook, but while eye-opening on one level, these tirades become ever-more bilious, eventually alienating Jackson from his wife and friends – and the reader. It’s at such moments that one feels the heart of the novel is in danger of being sacrificed on the altar of political statement (the dialogue is often burdened by chunks of fact-delivering information), and in a fairly heavy-handed way.

But then, Shriver's books arehard-hitting – a quality many of her readers admire her for. So Much For Thatis no exception, with its graphic cataloguing of the humiliations that Glynis and Flicka must endure at the hands of doctors, and their own failing bodies. Nor is the author afraid to confront the uglier emotions that accompany serious illness – rage at the platitudes offered by friends, jealousy of others' good health, cruelty to the very people who care the most – and it's when she examines these that she's at her flinty best.

A clear-eyed observer of human behaviour, Shriver describes Glynis’s fear, isolation and regret for a life that she herself sabotaged in a chapter towards the end of the book, which manages to be both unsentimental and deeply moving – a hard combination to pull off. (By contrast, however, another subplot about a botched “cosmetic” surgery is both grotesque and unnecessary: even for a writer known for using shock value to maximum effect, it seems gratuitous.)

Other items on the book's roll call of issues are children on anti-depressants, withdrawn teens (shades of Kevinhere) and euthanasia – Flicka repeatedly threatens to end her own suffering as soon as she comes of age, and Shriver weaves in the story of Terri Schiavo, a young woman whose life support was withdrawn, to public outcry, in 2005, the year in which the novel is set.

Well-paced, and written in Shriver's accomplished, sinewy prose, So Much For Thatis bound to generate the same level of debate as her previous novels. Yet for such an unrelentingly grim book, it is softened by an unexpectedly sweet, redemptive ending: the closing chapter brings things full circle, back to idyllic Pemba, and back to The Afterlife. Meanwhile, in real life, Shriver was lambasted for name-checking the island's Fundu Lagoon resort and accused of using her novel for product placement – an accusation she hotly denied in a subsequent newspaper article. Let the controversy begin . . .

Catherine Heaney is a contributing editor to

The Gloss

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