Life, Death and the Meaning of Cancer?

The leading cancer specialist, Dr Karol Sikora, and the author and Standpoint columnist, Lionel Shriver, discuss healthcare in Britain and America with the Editor, Daniel Johnson

Dialogue Economy Health Literature

Daniel Johnson: What is a life worth? Why is cancer the one illness that provokes these deep moral issues in a way that nothing else quite does? Lionel, what made you angry enough to write your latest novel So Much For That?

Lionel Shriver: Part of it is that I went through the death of a close friend from peritoneal mesothelioma. Obviously, cancer is very emotive and very expensive.

Karol Sikora: The nice thing about the book is that you have four different illnesses in there and the problems are really the same in all of them — even with the girl with familial dysautonomia, which I’d never really heard about since I was a medical student. I had to look it up. The same can be said for your character, Jackson, with his complex psyche and his penis problem, asking for cowboy surgery and then going for expensive corrective surgery. Then there’s his tragic end — cheap in terms of healthcare. We also have the father who fractures his femur, then ends up with a care problem and not a medical one. Who’s going to look after this old boy who can’t look after himself?  

LS: I tried to cover the bases. 

KS: It’s been written with the US system in mind, and at a time when there’s been a lot of interest in the healthcare debate there. But over here we have the same problem.

LS: The issue of costs and what you’re willing to pay for a certain amount of life which may not even be very high-quality life, maybe even miserable, is huge. There’s that cliché in the US: you can’t put a dollar value on human life. That’s exactly what we’ve got to do. It’s not feasible to spend an infinite amount of money on each citizen. Yet you get these articles such as the one in today’s Daily Mail which seem so scandalous. Here’s this mother of twins with a rare disease and the mean NHS won’t fund the expensive treatment of an off-label drug. 

KS: It’s so topical. The Conservatives are promising to put £1 billion into cancer drugs because it’s so easily understandable by the voter. But, talking as an oncologist, the effect of these drugs is not great. Is cancer worth £1 billion? Probably not. That’s what I really like about the book. One thing I’d like to ask you: Goldman is the fictional oncologist. He doesn’t have his character developed in any way. He’s sort of aloof and patronising and yet we don’t really hear about him. Only maybe a little towards the end…

LS: There is a section where I try to give him a character. 

KS: But much less than the other people.

LS: Are you insulted that the oncologist isn’t the star of the show? You’ll have to write that book then.

DJ: In popular mythology, the doctors often are the stars.

LS: We see them on TV, but this book is looking at the patients. Dr Goldman is off-camera most of the time. What he’s doing is certainly the star of the show: treatment is the star of the show. I hope that my characterisation of him wasn’t too cursory. I like the idea of somebody whose real relationship is with the illness and not the patient. It’s not that he’s cruel to Glynis, his cancer patient, or that he doesn’t care at all about her, but most of all what he cares about is beating the disease because he conflates its defeat with his own personal triumph. He’s driven. He’s ambitious. As Glynis’s husband Shep points out, while there’s something a little disturbing about this on a personal level, it’s in their interests that Goldman is primarily motivated to succeed personally because that translates into Glynis’s survival.

KS: The last consultation between Shep and the doctor is about a drug that’s not licensed so it’s almost like the Daily Mail story, about the same cost. It’s a made-up drug — you haven’t used a real one. Nice title for it, “peritoxamil”, just like a real cancer drug these days. The problem is all about money. The doctor turns to the patient — and this is something I’d never do, but I’m British and not American, and American doctors do do this — and he’s almost pressurising the poor guy: “Surely, your wife is worth $100,000?”

LS: Of course she is. Or $150,000? $200,000? $5 million?

The remainder of this piece is available in the magazine, out on newsstands now