So Much for That [Hardcover]

The inadequacy of the US health insurance system; the complex, shifting emotions within a relationship in which the wife is struck by possibly terminal cancer; the dynamics of a family in which one child has a degenerative disease: these themes could combine to make a moving and opinion-changing masterpiece, but call for a subtlety and lightness of touch to make so much pain bearable. For the first half of the book I felt oppressed by the opposite, that is, the tsunami of words, the detailed, by turns pettifogging or unsavoury descriptions, lengthy digressions and rambling rants, always three or more examples where one would do. There are also some very original or telling comments, although they are at risk of getting lost in all the verbiage.

The story begins with Shep Knacker packing a bag to present his wife with an ultimatum: the time has come for him to travel to the idyllic African island where he has decided to settle, and he plans to take off whether she accompanies him or not. This could serve to reveal a good deal about our "hero" but instead becomes a pretty negative description of his wife. I would much rather have discovered what Glynis is like through situations and dialogues than be told what to think. Admittedly, some descriptions are very striking:

"..in art school, Glynis had not chosen her medium by accident. She naturally identified with any material that so fiercely refused to do what you wanted it to, whose form was resistant to change and responded only to violent manhandling. Metal was obstreperous. Were it ever mistreated, its dents and scratches caught the light like grudges." It's the last sentence that stands out for me.

Then the story moves on to Shep's "best friend" Jackson, whose exaggerated diatribes I admit to finding amusing and telling. It took me a while to realise that his sparky but odd daughter is in fact disabled with an obscure physical condition that blights not only her life, but that of the entire family. I felt very discouraged at this stage. Was so much suffering really necessary?

Also, in the midst of the wealth of unpleasant detail about bodily malfunctions, the opportunity is missed to enact, rather than report second-hand , some dramatic scenes, such as the point at which Glynis tells Shep she has cancer, and his initial reactions as his chance to escape evaporates, or to explore his feelings towards a woman he is prepared to leave until he hears of her need for his health insurance. This would not only have made the story more emotionally engaging, but also shown a clearer progression of the character's thoughts. Yet Shriver is capable of being very incisive, as when she closes a chapter with Shep's admission to himself that he only has enough money to realise his dreams if Glynis "dies soon".

As it is, the links between stages in both dialogue and scenes are at times clunky and contrived, and major new developments may seem to occur too abruptly, such as the degree to which Jackson has "reached his limit", when you might have expected Shep to be in this state.

Another limitation is that none of the characters seems to be afflicted by the sense of anguish based on deep love, or the fear of loss of a companion. This may be acceptable for Shep because he is ultra practical and pragmatic, but makes for a less moving story, in which you care too little for in many ways unlikeable people.

Perhaps I became inured to all this suffering, but the book improved for me as I persevered, and the last hundred pages or so seem the best: well-paced, plot strands coming together well, an ending which was remarkably positive, and avoided sentimentality, mawkishness or the cop out of not knowing how to finish the dilemma one has created. However, even here there is a superficiality in the personal relationships, a kind of "cold heart" and skimming round the depths of real grief.

I acknowledge Lionel Shriver's undoubted talent, but wish she had made the book shorter, checked her narrative for overkill (no pun intended), and toned down some of the cynical wisecracking humour, perhaps the product of an attempt to write like an American male.

As one of the main characters lives in the United States and develops incurable inoperable cancer, she receives several courses of treatment all of which have to be funded by and adequate health insurance plan, and so therefore in large part by the patients family, depleting their life savings. Most reviews of the book therefore focus on criticism of the American Healthcare system, but as an oncologist I saw it as a fascinating insight into the dilemmas of cancer patients and their families when they are undergoing palliative chemotherapy, whether it be with traditional or novel treatments.

In the United States, the cost of these treatments is borne by patients, usually via medical insurance policies, whilst in the United Kingdom it will be taken on by the NHS provided the drugs were NICE approved and would only be paid for by individuals if they were not.

Reader of Shriver's novel witness a patient going through ultimately futile treatment with significant toxicity, whilst her hopes are inappropriately raised by her oncologist and her colluding family and friends, at least initially however after the cancer and chemotherapy have taken an increasing toll, her husband asked the doctor how must he estimates the treatment has cost. "About two and a half million," replies the oncologist. "What do we get for that," enquires the husband. "I think it gave her a good 3 months extra," says the doctor. "It may have been extra," says the husband, "but none of it was good". This sentiment rings true. Patients expectations of palliative chemotherapy, and particularly the much publicised new drugs, are inappropriately raised by their own hopes, the media, and sadly often by their treating physician.

We do not always detail the precise benefits of these treatments, and indeed many cancer patients think their treatment might extend their life by a number of years whereas in reality, if successful the benefit is measured in terms of weeks or months. This book is a useful and salutary reminder of just what cancer treatments really `cost'.

I first experienced Lionel Shriver's writings in her tour de force of a book We Need to Talk About Kevin: a book that left me drained by the powerful feelings and events. In 'So much for that' the author again stirs a tremendous emotional response in me by her heart-rending story of the destruction of Shep Knacker's dreams for his future caused mainly by having to pay huge amounts of money to try and save his wife's life after she's diagnosed with an aggressive form of cancer. Shep is also put upon by members of his extended family and by life in general. This all sounds like a dreary and depressing story, but it isn't. OK, it makes me feel angry at the unfairness of the American health 'service', about which the author is excoriating in her dissection of it's inadequacies, but Shriver's writing is so acerbic, witty and often funny that I am captivated to keep on reading.

The author delves into taboo areas of human feeling and behaviour and makes one wonder at how one would react under similar stressful situations both as the patient or as a bystander to others suffering. There's some grim, and accurate, sections relating Shep's wife's extreme side-effects from her chemotherapy: so not a book, perhaps, for those undergoing similar treatment. Nevertheless, I think it's a terrific book that makes me even more grateful that the NHS exists.

This is one of those books that stays with you long after you've finished reading it. Not only is it an engrossing story, but it is also a thought-provoking analysis of the value of life, beliefs, and how to deal with the approach of death.