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Jodi Picoult built her reputation on picking at the knots most novelists leave alone, and My Sister's Keeper is the book where that instinct met its biggest subject and its largest audience. The premise is as uncomfortable as contemporary fiction gets: thirteen-year-old Anna Fitzgerald was engineered through preimplantation genetic diagnosis to be a donor match for her older sister Kate, who has battled acute promyelocytic leukaemia since toddlerhood. After a decade of blood draws, bone marrow harvests and surgeries, Anna is told she must now give up a kidney. She responds by hiring a lawyer and suing her parents for medical emancipation.

What makes the novel work is the unsentimental seriousness Picoult brings to the bioethics. This is not a thriller dressed up in hospital gowns. The designer-baby question, the limits of parental consent, the rights of a minor over her own body - these are dramatised through specific, credible family dynamics rather than op-ed grandstanding. The research shows. Kate's illness is drawn with a clinical authenticity that lends weight to every decision the Fitzgeralds make, and the domestic cost of chronic paediatric cancer - the marginalised older brother Jesse, the mother who has become a full-time advocate, the father retreating into his fire-chief work - is rendered with real feeling.

The alternating first-person structure is both the book's cleverest device and its most overused one. Hearing from Anna, her mother Sara, her father Brian, Jesse, her lawyer Campbell and his guardian ad litem Julia does give the moral argument genuine texture; each narrator changes the shape of whose side you think you're on. But the chapters given over to Campbell and Julia's rekindled college romance feel imported from a different, lesser novel. That subplot pads the middle and blunts the central dilemma, and the book would be sharper by fifty pages if it were cut back. Some characterisation thins under the distribution of attention too - Brian is a touch too saintly, Jesse a touch too symbolic, and Kate herself, who ought to be the gravitational centre, often feels glimpsed rather than known.

Then there is the ending, which has generated more argument than any other element of the book. Without spoiling the mechanics, the final twist has been called a cop-out by some and the only honest resolution by others, and both positions are defensible. The twist lands with real emotional force and gives the prologue a second meaning worth rereading, but it also arrives via a coincidence so abrupt that it can feel like the novel flinching from the philosophical question it has spent four hundred pages setting up. Picoult has defended the choice as thematically necessary, and on balance I think the rereading confirms her; the accusation of neatness is fair, though, and your mileage will depend on how much narrative convenience you are prepared to forgive.

For all its flaws, this is a novel that commits to its hard questions and trusts its readers with them. It earns its place on book-club shelves and classroom reading lists, and it still makes you think.