Lionel Shriver: 'I had to get to grips with death'

The latest novel from the author of We Need To Talk About Kevin was inspired by the terminal illness of a friend who refused to accept that she was dying

I almost can't see Lionel Shriver among the large cardboard boxes occupying the front room and open-plan kitchen of her new Bermondsey house. She's just moved in, the first home she has ever owned, and I briefly, inelegantly wonder why an award-winning, best-selling novelist might choose to live on this unlovely stretch of south London. She seems rather dazed – uncertain of this new, "overwhelming" possession she is responsible for, and in the grey, dribbling morning light, this tiny, compact woman looks tired, reduced, and a bit irritated. She is also sniffling. "I just have a cold," she says in her deep, iron-hewn voice. "It's not anything else. In case you were wondering."

As well you might wonder, after reading Shriver's new novel So Much For That. The main character, Glynis, has mesothelioma, a rare and incurable form of cancer. A secondary character, a young teenage girl called Flicka, has familial dysautonomia, also rare, also incurable. Glynis's father-in-law is eking out his last days (and the family bank account) in a private nursing home, while Flicka's father, Jackson, is in near intolerable pain following a botched penile enlargement (in Shriver's novels, disaster and farce are rarely far from each other).

She wrote the book, her ninth, following the death of a close friend, Terri Gelenian-Wood, from mesothelioma; a few months before publication, Shriver's elder brother died from complications arising from diabetes and obesity; while Shriver herself has Raynaud's phenomenon, a disease that affects her circulation and requires her to wear gloves indoors. So illness and mortality feel oppressively close in this cold south London house on this bleak spring morning, as Shriver sniffs and shivers and barks at her publicist as they finalise details for a forthcoming book tour, and throws me an occasional glowering glance.

So Much For That, which like most of her books is set in Shriver's native America, again demonstrates her uncanny, taboo-exploding knack for skewering timely social phenomena. Just as her 2005 Orange-prize-winning We Need To Talk About Kevin cracked open hitherto seemingly unspeakable issues surrounding teenage high-school killings, so So Much For That is a raging, unflinching attack on our inability to talk about death, and the iniquities of America's health-care system. "This book may be misconceived as me jumping on the health-care bandwagon but I began it in 2007, way before Obama was a serious candidate," she says, a bit combatively.

"Then, there was no debate. When I go back to the US [she has lived in the UK for nearly 23 years, 12 in Belfast] the only health insurance I've got will basically fly me back to Britain to be taken care of by the NHS. Even if I were to become resident again, now that I've crossed 50, it would be very expensive for me to get private health insurance... it makes me feel angry. Resentful. Vulnerable."

Vulnerability is not something readily associated with Shriver, who in print and person can come across as spiky and steadfast. So far her novelistic gaze has zoned in on teenage killers and a mother who despises her own child (We Need To Talk About Kevin was partly Shriver's personal inquiry into whether she wanted children; she decided she didn't), an excoriating portrait of a marriage (her excellent 1997 Double Fault) and somewhat daringly, romantic love (2007's The Post-Birthday World). She is 52 and with her hard, sinewy body and scraped-back hair, can look as severe as a 19th-century governess. Then without warning, a huge smile and a bolt of laughter will transform that face into the joyous countenance of a 10-year-old girl.

So Much For That feels like Shriver's most personal book to date: it kicks and bucks with the voltage of deeply felt anger and grief. At times it resembles an exhaustive primer to the intricacies of the insurance company policies that dominate America's healthcare system. At others it's an uncompromising inquiry into the awkward question of how much an individual life should cost. Fundamentally it looks at what it means to die, the monotony, indignity and pain of a terminal illness, and the cowardice and terror of friends and family (including her own) in the face of someone else's drawn-out death.

"I guess I began it after Terri died," says Shriver. "I wasn't that crass... while my friend was ill, and I was on the phone with her, I wasn't taking notes. But at a certain point I cut my cell-phone. After she died I ended up doing all this research on mesothelioma. And I became this little expert on the illness after the point at which on a personal level it would have done me [or her] any good. That really filled me with chagrin. Even after writing it I don't think I've completely confronted the idea of death," she adds. "I don't think you confront these things until you really have to."

Lionel Shriver grew up in North Carolina to deeply religious parents – her father was a Presbyterian minister. She did a degree in English and Russian at Columbia University while also dabbling in metalwork (she still sculpts) and, after spending several peripatetic years living in Kenya and Thailand, among other places, published her first novel at the age of 30. Her books, invariably unblinking studies of relationships, often feature strong women, who, as Shriver puts it, all "share shards of my world view," by which you can assume no bullshitting, no sentimentality, a refusal to be orthodox, and a willingness to ask hard questions.

She is eccentric (she changed her name at 15 from Margaret Ann to the less girly Lionel) and, for all her balefulness, intoxicating company. For years she toiled away in absolute obscurity; 30 publishers rejected Kevin. And for all the ensuing success, book sales, journalism and, despite the disorder, seeming domestic contentment – she is married to a jazz drummer, Jeff Williams – a kernel of anger remains at the decade and more of hard slog she put in before she found recognition.

"Most of us work very hard for our money, right?" she says. (Her sentences become the verbal equivalent of whiplash whenever she is angry; and she bolts on additional "rights" not as question marks but as bullets). "What I have earned I have earned. Although I've been better paid in the last few years, I worked very hard for most of my life and got paid nothing. I'm reaping the benefits of a lifetime of getting up and sitting at the computer all day."

Hard-earned dough is also at the core of So Much For That, which shows the fiscal as well as physically eviscerating consequences of falling ill in the US, even if you have healthcare. When it begins, Shep, Glynis's husband, is a self-made man with $731,778.56 in his Merrill Lynch savings account, which he plans to use to take his family away, perhaps forever, to the African island of Pemba. Come the end, cancer having put paid to his dreams of retiring with his family to paradise, he is virtually bankrupt, having spent almost everything he owns on Glynis's healthcare. He has insurance, but not enough insurance, or quite the right insurance, and anyway, when faced with the opportunity to fork out a few more hundred thousand for a brand new drug that might just be the miracle worker, who isn't going to dig a bit deeper?

"And yet for what?" asks Shriver. "So that Glynis could have a few more months? Well, as Shep says, these were not good months. But are you going to refuse treatment because it's too expensive? Or are you going to say, 'I'm just not worth it'? In the abstract, and this is relevant in the UK, too, I'd like to think somebody could tell you, 'you could live three more months, but it's gonna cost $2m'. And I would say, 'those crappy three months are not worth $2m'. I'm gonna put it back on the shelf, right?" She lets loose a huge peal of laughter. "But I bet I'm not.'

Shriver's own attitude to money is a bit defensive: she rails against the taxes she has to pay in the US, and is furious at a recent newspaper article accusing her of product-placement for the upmarket African resort on Pemba (the highly favourable reference in the novel suggests that the journalist has a point but Shriver vigorously rejects it). She reportedly used to buy all her clothes from charity shops and still exudes a general air of utilitarian thrift.

"Although now I have more money than I used to, I'm more aware of money on a larger scale. Fiction writers don't write about money enough," she adds. "If they do write about it, it's often in a cheesy way in which everyone in the book is rich and they have all these expensive things."

She is also seemingly not that motivated by money, or if she is, she sometimes – like many a character in the novel – wonders whether the years spent working in pursuit of it are worth it. "Everyone is vulnerable to this, aren't they? OK, there is a certain kind of productivity that I pursue, but I could easily get on the other side of illness and wonder – why did I spend all that time doing all those dopey little journalistic assignments that don't really matter. Right? Why didn't I spend more time with my friends? Why didn't I spend more time doing figure sculpture [her figurative metal sculptures are the only things she appears to have unpacked]. Because that's what really made me happy. And why aren't there more of them. Right?"

Still, she enthusiastically promotes fiction "as the only form that matters" for discussing the big muscular questions of the day, as well as the small, petty, quotidian ones. "The only thing that makes healthcare interesting is that it has huge implications on all our lives," she argues. "But the secular mentality does not recognise death. We're all obsessed with our frenetic present tense and we don't keep an eye on the door. Well, who wants to?"

Certainly, much of the narrative tension in So Much For That comes from the fact Glynis won't accept that she is dying. "I took this from Terri – because I had to get to grips with it, I needed to understand that Terri refused to concede she was dying," Shriver says. "And I was interested on her behalf because I thought of her as someone who could confront difficulty and conflict. Her refusal to admit what was happening made it immensely difficult for other people. Her husband, primarily. Me, secondly. It created an artifice. So, the last time I saw her I knew it would be the last time. But we couldn't confront that. We couldn't say, 'Terri, we are probably never going to see each other again, is there something you would like to tell me?'" And she suddenly sounds terribly sad. "Instead we ended up talking about mashed potatoes."

'So Much for That' is published by HarperCollins at £15