Book Review: Do No Harm

Synopsis:

Even good people get addicted to bad things.

Emma loves her life. She’s the mother to a precocious five-year-old kindergartener, Josh. She’s married to Nate, her soulmate — a loyal and loving detective who is deeply committed to his work — and enjoys a rewarding career as a primary care physician at the local hospital.

But everything comes crashing down when Josh is diagnosed with a rare and aggressive form of leukemia.

Determined to save Josh, Enna is desperate to pay for the life-saving treatment the insurance company will not cover. She makes the dangerous decision to sell opioids.

When someone ends up dead, a lethal game of cat and mouse ensues. And Nate is leading the chase to find the killer . . . and the drug dealers.

With her son’s life hanging in the balance, Emma is immersed in the dark world of drugs, lies, and murder. Will the truth catch up to her before she can save Josh and extricate herself?

Do No Harm is a timely exploration of a small town gripped by the opioid epidemic that challenges readers to ponder this question: Do the ends ever justify the means . . . even for a desperate mother whose child’s life is at stake?

Review:

Christina McDonald’s stunningly emotional debut novel, The Night Olivia Fell, focused on a mother living out a parent’s worst nightmare, determined to learn what really happened to her daughter on the night she fell from a bridge and was rendered brain dead. McDonald followed that engrossing and emotional mystery with Behind Every Lie in which a woman wakes in the hospital after being struck by lightning to discover that her mother has been murdered. When the police suspect her, she initially doubts herself, actually wondering if she was capable of such a violent, abhorrent act. Her search for answers provides a tense, atmospheric story told at a relentless pace.

Now McDonald has crafted yet another fast-moving thriller with a mother at the center of the story. She aptly describes Do No Harm as “intense, emotional, and thought-provoking.” This time, however, the female protagonist, Emma, is faced with a moral dilemma. How far will she go to save her child? What is she willing to do to ensure that her five-year-old Josh gets the treatment he needs when he is diagnosed with leukemia? The treatment most likely to cure him is CAR T-cell therapy, a form of immunotherapy in which T cells are collected from the patient and genetically altered in a laboratory before being returned to the patient’s body. They serve as fighter cells that attack cancer cells. The treatment is not covered by insurance and carries a $500,000 price tag. And the hospital will not deliver the treatment to Josh until one-fifth of the cost is paid in advance. So Emma is desperate. She and Nate simply do not have either that much cash or assets they can liquify to raise it. They don’t even own their home and Emma is still making student loan payments. There is a possibility that Nate will be promoted in the near future, but that advancement in his career is not assured and will not generate the amount of money needed.

Emma is all too familiar with the opioid crisis because she has encountered patients and would-be patients in search of prescriptions, some of whom have become addicted as a result of chronic, unrelenting pain. Others have been victimized by physicians who did not prescribe medication judiciously in order to prevent addiction. She explains, “One of the most important things you learn in medical school is ‘do no harm.’ But what should doctors do when our patients need something we know could potentially be harmful? It was a quandary for doctors: chronic pain versus addiction. If we prescribed the medicine that could help, our patients could become dependent. In trying to solve one problem, we simply created another.” So Emma knows there is a ready market for prescriptions for Oxycontin. “Drugs had ruined my brother’s life, but maybe they could save Josh’s,” she theorizes, and begins selling prescriptions issued on prescription pads stolen from the clinic where she works, upon which she forges her colleague’s names. Forgery is a talent she’s used before. In high school she forged absence notes for her brother and his best friend, Gabe.

I can’t bear the thought of Josh dying because I didn’t do enough to save him. ~~ Emma in Do No Harm

If the plot sounds preposterous, consider McDonald’s very personal inspiration for the book. Her own brother was addicted to Oxycontin and overdosed. The book is dedicated to him. McDonald notes that the medication to which he became hooked was prescribed to him by a physician and “perfectly legal.” For quite some time, she wanted to write a book set against the backdrop of the American opioid crisis, and her strong opinions and emotions are on display in her fictional narrative. One day McDonald happened upon a news story about a podiatrist involved in an opioid ring. “I wondered why he did it: was it money, power, status?” McDonald relates. “What would drive someone to do that? And I thought, what would make me sell opioids amidst a horrific epidemic? The only answer I had was love. My children. And that was the moment I first thought of the story for Do No Harm.”

As the story opens, Emma and Nate are happy, still deeply in love after several years of marriage, and fully committed to each other, their marriage, and their son. But Emma is a woman with secrets she has kept from Nate because, for her, it had proven “easy to hide the darker side of yourself from others, even those you loved. To hide fear and sadness, anger and hostility. The mask was easy. It was honesty, openness, and trust that were truly difficult in marriage.” Both Emma and Nate have successful, satisfying careers in the small fictional town of Skamania, Washington, which McDonald fashioned after Snoqualmie. McDonald says it was very important to her that the town be named Skamania because in Cascades Chinook it means “swift waters” and she knows all too well that “circumstances can change very fast once a person becomes addicted.” Indeed, she immediately places her characters in some very deep, swiftly running, dramatic waters. Nate is assigned to investigate the homicide of a local informant who was heavily involved in drug trafficking, but warned that he will be removed from the case if the evidence leads back to Emma’s brother from whom she has been estranged for years. He has a criminal history and is suspected of being the leader of a drug ring. Only in a little town with a small police force would such a potential conflict of interest be disregarded. But it’s the plot device needed to set in motion the series of developments that frenetically propel the story forward.

Because of her own complicated past, Emma knows just who to go to in order to sell the prescriptions. She turns to Gabe, her old boyfriend she has kept a secret from Nate, confident that he will be able to sell the prescriptions quickly so that she can get the cash she needs to ensure that Josh receives the first treatment before his condition worsens. After she negotiates the deal, money begins rolling in. But her behavior takes an immediate toll on her and her relationships with her family. Nate begins to suspect that something other than Josh’s illness is amiss, and they start drifting apart because Emma knows she will not be able to hid the truth from him indefinitely. Emma is on high alert, edgy, and sneaking around in fear of the severe, life-altering consequences she will endure if she is caught. Each count of unlawful distribution of OxyContin by a medical professional could net her a twenty-year prison sentence, and cause her to lose the career she loves and her family. McDonald credibly and compassionately portrays her singular focus on seeing to it that Josh is provided the best possible chance to survive. Her internal struggle is heartbreakingly believable, especially when she lapses into moments of believing that she is actually providing a service to those who suffering from intractable pain who cannot obtain medication via legitimate means. Emma justifies her behavior, arguing that “sometimes we have to do the wrong thing for the right reason. Maybe it was wrong to sign those prescriptions . . . The ends justify the means. Everything I’ve done is for the right reason.”

Do No Harm is a thoroughly riveting thriller, replete with surprising, intricately-constructed plot developments and revelations. There is no imaginable character more empathetic than a mother driven to save her deathly-ill child, no matter the cost to herself, and McDonald capably portrays not just Emma’s anguish, but that of Nate and Nate’s mother, as well. Josh is a charming little boy who asks questions that no child should ever have to pose to his parents, and the unscrupulous characters with whom Emma becomes entangled are equally believable. McDonald does not shy away from developments in the story that are logical, but heartbreaking, and keeps accelerating the pace right up to a shocking and controversial conclusion. At numerous junctures, she offers readers the opportunity to ponder what they would do should they find themselves in similar circumstances, making Do No Harm an excellent choice for book clubs. McDonald acknowledges that her goal was to “get people talking about the opioid epidemic, discussing the driving factors behind it and what we as a society can do to help those who struggle.” She has succeeded: the issues she examines provide plenty of material to discuss and debate.

With Do No Harm, McDonald again demonstrates why she is one of today’s strongest female novelists, penning breathlessly engrossing thrillers that balance action with emotionally-rich character studies. Do No Harm is sure to be recognized as one of the best thrillers of the year.

Excerpt from Do No Harm

Prologue

The knife burrowed into my side with a moist thwump.

I looked down, confused. The blade was buried so deep that the hand holding it was pressed almost flat against my stomach. My pulse hammered against the steel.

And then I felt the fire. My mouth dropped open. The blood was rushing out of me too fast, I knew, soaking my shirt, turning it from white to red in seconds. It was too late. Too late to save myself.

I looked into those familiar eyes, mouthed a single word.

You.

The knife slid out of me, a sickening, wet sound. Blood pooled at the bottom of my throat. And then I fell, an abrupt, uninterrupted drop.

I blinked, my brain softening, dulling. Images clicked by, one by one.

Polished black shoes.

The blur of snow as it tumbled past the open door.

The two-by-fours standing against the wall.

My body felt like it was composed of nothing but air. I had failed.

Chapter 3

Tuesday dawned gray and damp. A soft fall rain had settled outside, making the clinic look tired and dirty. Sagging chairs leaned against murky beige walls. A garbage can overflowed with empty paper cups. Wet jackets were hung on the coatrack, dripping onto the grimy linoleum. Reception was a crush of damp bodies that smelled of urine and feet and unwashed hair.

Some of my patients were from the eastern side of Skamania, where the yards were cut into neat squares of green, the bushes professionally trimmed. But most were poverty-stricken, immigrants, homeless, addicts, or all of the above. They had little or no access to health insurance, suffering agonizing pain instead of seeing a doctor because they couldn’t afford it. These were the people I’d gone to medical school to help.

The more cynical accused us at the clinic of having a savior complex, but I knew we were making a difference in these people’s lives. We were helping.

I yawned as I walked toward the shared medical staff office. It had been a busy morning examining patients, doing wellness checkups, checking X-rays and lab results. And all on very little sleep. Josh had come into our bedroom too many times to count last night. When we’d first woken this morning, his fever had been too high to send him to school, so I’d called Nate’s mother and she’d agreed to stay with him. Fortunately, I was good on very little sleep. It was sort of a prerequisite to being a doctor.

I dug my cell phone out of the closet where I stashed my purse. Nate had texted me an X. I smiled and shot an X back to him, loving that he thought about me during his day. I then dialed Moira before my next appointment.

“Hello, Emma.” Moira’s voice was brisk, the tone she always used with me. I could hear the pursed-mouth exhale of the cigarette she thought nobody knew about. I imagined her draped in her cashmere and pearls, slate-gray hair smoothed perfectly into place, a cigarette dangling out the window in secret. I gritted my teeth but kept quiet. It wasn’t like we had a lot of choice of babysitters.

“Hi, Moira. How’s Josh?”

“He’s sleeping now. I gave him some ibuprofen.”

“If he wakes up—”

“I’ve raised four children, and I stayed home with all of them.

I know how to take care of a sick child.”

I swallowed a sharp retort, resenting the insinuation that I was a lesser mother than her because I worked. I tried hard to be grateful for my mother-in-law. She was a wonderful grandma to Josh, and she and Nate were very close. I just didn’t understand why she didn’t like me.

“Sure, of course. Sorry, um . . .”

Julia, a nurse practitioner I’d become friends with, tapped me on the shoulder. “Sorry!” she whispered when she saw I was on the phone. She held a cup of black coffee out to me. “Your four o’clock is in room four.”

Thank you! I mouthed. “Sorry, Moira, I’ve gotta run. Tell Josh I love him.”

I grabbed the coffee and swallowed a giant gulp before hurrying to the exam room. I scanned the patient’s chart as I walked. She was a new patient. Fifty-four years old. Normal temperature. Slightly elevated BP. I rapped gently on the exam room door and entered.

“Mrs. Jones?”

“Yes.” Alice Jones was small and frail. Her pale hair was threaded with gray and tied into a messy ponytail. Spiderweb wrinkles framed the corners of brown eyes clouded with pain. Her clothes were threadbare, a faded sweatshirt over ripped jeans, scuffed canvas tennis shoes with no socks.

Her husband, or who I assumed was her husband, sat next to her, a short, burly-chested man with shiny red cheeks, oily dark gray hair, and a pair of round glasses on a bulbous nose.

“Her back’s hurting,” he said, his voice too loud in the small space. “It’s been going on a long time now. It’s from all that damned gardening.”

I sat at my desk and turned to Alice. “I’m so sorry to hear that. I like gardening too. I have a whole freezer of vegetables I grew this summer. It’s pretty tough on our back and knees, though, isn’t it?”

I opened Alice’s patient file on my computer and typed notes as her husband explained her symptoms.

“I need to examine you now, Alice. Can you show me where the pain is?”

Alice struggled to stand, her husband holding her elbow firmly. She bent forward at the hips and touched a hand to her lower back.

“Sometimes my legs go a little numb,” she whispered.

I felt a heavy tug of pity in my stomach, the kind you’d feel for an injured bird. I examined her spine, assessed her ability to sit, stand, and walk. There was no redness or obvious swelling. The erector spinae muscles were smooth and strong, her reflexes normal. She wasn’t moving with enough pain to indicate a tear in the disc or enough restriction to indicate sciatica. But the numbness concerned me.

Doctors are scientists who work in an uncertain world. We use statistics, odds, and probability to diagnose and treat. Good or bad, we make the best-informed decisions we can.

“I’m going to order an MRI.” I typed more notes in her file.

“Can you give me something for the pain?” she asked. “I’ve heard OxyContin is good for back pain.”

I kept my face neutral. The opioid crisis had made it difficult for doctors to know where the line was, when to prescribe pain medicine and when not to. It was a doctor’s job to help people, to assuage their pain, and yet I’d watched other doctors’ patients succumb to addiction. I knew about addiction firsthand, from my brother. I refused to let my patients become another statistic.

“I’ll write a prescription for naproxen to help the pain.” I smiled gently at Alice. “Once we get the MRI results, we’ll know better how to treat it. In the meantime, ice it, and stay off your feet for the next few days, okay?”

I handed Alice a leaflet with advice on how to treat back pain, gave her arm a compassionate squeeze, and left to see my next patient.

After my last patient of the day had left, I went to find Julia. She was clearing up after a pelvic exam in one of the exam rooms. Tendrils of dark hair were falling out of her ponytail. Julia was conventionally pretty, with sea-glass eyes and a slight overbite that somehow made her look even more adorable. She smiled faintly, and I noticed her wrist was bandaged, her movements slow, a little delicate.

“You all right?” I nodded at her wrist.

“Oh, carpal tunnel syndrome. Lucky me.” She laughed wryly. Julia was lively and cheery, a nurse practitioner who somehow did more work than all the doctors combined.

I told her about Alice Jones, and she scowled, her freckled nose crinkling. “The husband was here last week. Said he’d sprained his wrist.”

“He wasn’t wearing a wrist wrap.”

“I think Dr. Watson saw him. She might’ve prescribed some OxyContin, although check his chart to be sure. Maybe he was back for more? I seem to remember he was pretty aggressive. She was glad to see the back of him, I know that.”

I’d come across my fair share of angry men in the ER during my residency at Harborview in Seattle. I could still remember stitching open wounds with shaking hands, dodging drunken fists, standing near the exit to make sure I had a quick escape route.

I pulled a fresh sheet of medical exam paper over the table while Julia swiped the edges with an antibacterial wipe. We headed down the hall to the staff office. The rectangular area was bisected by a long desk with multiple charging points; on one side was a wall of cupboard space, and on the other a coffee-making station. Dr. Wallington was writing reports into a file while two of the other doctors were speaking earnestly about a patient. I pulled my coat out of the closet and turned to Julia.

“I’m glad I didn’t prescribe any Oxy, then.”

I’d learned that what healed wasn’t always in a doctor’s drugs or a surgeon’s blade. Sometimes it was the quieter things, like compassion, being heard and shown you mattered. I was confident I’d made the right decision with Alice. We’d wait and see what her MRI said.

“It’s a tough call these days,” Julia agreed. She lowered her voice and glanced around. “Speaking of Oxy, watch out for Marjorie. She’s on the warpath right now.”

Marjorie was the medical administrator of the clinic, which was situated within the auspices of Cascade Regional Hospital. She’d worked here forever and was unnecessarily crotchety as a result. I’d only worked here for three years, after taking over for a doctor who’d decided to partially retire, so she basically scared the crap out of me.

“What’s wrong now?”

“People keep leaving the medical supply room unlocked. She keeps all the samples from our pharma reps in there.”

“Yikes. I’ll keep an eye out.”

“Hey, wanna grab a drink?” Julia slid her coat on. “It’s happy hour. We can get one of those derby thingies you like.”

I laughed. Sometimes I was still surprised by the collegial nature of my job. “It’s a Brown Derby. Wish I could, but Josh has been sick. Rain check?”

Her reply was cut off as our receptionist, Brittany, burst through the door, her eyes almost comically wide.

“Dr. Sweeney! You need to get downstairs! Josh’s been admitted to the ER!”