My Sister's Keeper

“My parents tried to make things normal, but that’s a relative term. The truth is, I was never really a kid. To be honest, neither were Kate and Jesse. I guess maybe my brother had his moment in the sun for the four years he was alive before Kate got diagnosed, but ever since then, we’ve been too busy looking over our shoulders to run headlong into growing up. You know how most little kids think they’re like cartoon characters—if an anvil drops on their heads they can peel themselves off the sidewalk and keep going? Well, I never once believed that. How could I, when we practically set a place for Death at the dinner table?”

One of the novel’s themes is Bodily Autonomy and Choosing a Life. Anna is a mature girl who recognizes how Kate’s illness has altered their family, especially the possibility of her death. At the same time, all three Fitzgerald children struggle as a result of their parents’ hyperfocus on Kate—with Anna being denied a proper childhood and Jesse being denied attention at all. While Sara and Brian suffer from their hyperfocus as well, Kate’s suffering more so explains their actions than excuses them.

“‘Just so you know,’ I say, more loudly than I’ve intended, ‘I’m not going to let Kate die.’

There is an awful sound beside me—an animal wounded, a drowning gasp. Then Brian presses his face against my shoulder, sobs into my skin. He wraps his arms around me and holds on as if he’s losing his balance. ‘I’m not,’ I repeat, but even to myself, it sounds like I am trying too hard.”

The shock of Kate’s diagnosis overwhelms Sara and Brian. Yet, Sara takes responsibility for Kate’s life. Brian is a fireman whose job is to rescue people—but in this moment, Sara takes on the burden of Kate’s illness and becomes determined to try any treatment to save her. In fact, Sara ends up unintentionally pushing Anna to petition for medical emancipation. Sara’s hyperfocus also causes a great deal of discord in the family, causing her three children to feel invisible. Questions of morality and ethics aside, Sara’s determination does pay off—with Kate making a recovery after her kidney transplant.

“There are always sides. There is always a winner, and a loser. For every person who gets, there’s someone who must give.”

Anna once again reveals her level of maturity, or at least her grasp of adult issues, with this statement. There is a give and take in life that Anna recognizes. She understands that she is the one who gives Kate the things she needs to survive, and is attempting to stop the cycle. She also understands that it is her parents who put her in this situation, and it is her parents whom she must fight to get out of it. Anna’s mature understanding of her situation suggest her motives are not as simple as Sara wants to think they are.

“Anna is the only proof I have that I was born into this family, instead of dropped off on the doorstep by some Bonnie and Clyde couple that ran off into the night. On the surface, we’re polar opposites. Under the skin, though, we’re the same: people think they know what they’re getting, and they’re always wrong.”

Jesse expresses multiple thoughts on his position in his family. Like Anna, he feels like he doesn’t belong, and that he isn’t what his parents thought he should be. In suggesting a “Bonnie and Clyde” couple left him at the door, he compares himself to criminals. It is clear that Jesse not only feels like an outsider, but like his behavior is equal to that of a criminal. This foreshadows the moment Jesse reveals that he is the arsonist his father’s fire department has been investigating for weeks. However, Jesse’s insight on his own behavior suggests there is more to his actions than a desire to create chaos and destroy empty buildings. There is irony to this, as Sara assumes Anna’s petition is a cry for attention, but fails to notice her son is using fire to get his father’s attention.

“‘We didn’t ask for a baby with blue eyes, or one that would grow to be six feet tall, or one that would have an IQ of two hundred. Sure, we asked for specific characteristics—but they’re not anything anyone would ever consider to be model human traits. They’re just Kate’s traits. We don’t want a superbaby; we just want to save our daughter’s life.’”

Brian explains to a reporter why he and Sara turned to a geneticist to control Anna’s birth. Designer babies, the term used to describe children like Anna, is highly controversial. In the face of criticism, Brian owns up to his and Sara’s actions, as they ended up saving Kate. He falters in his support of Sara later in the novel, only to support Sara over Anna in the courtroom—which is foreshadowed by this moment.

“‘This is a service dog.’ When that doesn’t seem to ring a bell, I spell it out for him. ‘You know. Like Seeing Eye.’

‘You don’t look blind.’

‘I’m a recovering alcoholic,’ I tell him. ‘The dog gets between me and a beer.’”

Throughout the novel, Campbell fabricates different stories about why he has his service dog, Judge. When the novel was released in 2004, service dogs were not as common as they are in more recent years. As a result, most people expect someone with a service dog to have an “obvious” disability like blindness (which is problematic in itself, as not all disabilities are “obvious”). Campbell makes a game of these stories, not only hiding his seizure disorder, but making each explanation more and more outrageous to show how some will believe almost anything. This reveals a whimsical side to Campbell’s personality, as well as his desire to make himself feel more in control (due to his unpredictable seizures and his childhood making him feel unimportant and unintelligent due to years of parental abuse).

“If you have a sister and she dies, do you stop saying you have one? Or are you always a sister, even when the other half of the equation is gone?”

The question Anna poses is timeless. She is in a situation that forces her to contemplate adult issues; she hasn’t been protected from the realities of illness and death because her sister is the sole focus of the family. This illustrates another theme of the novel, Hyperfocus Creating Neglect, once again showing how Kate’s illness has impacted interactions between the Fitzgerald siblings as well as interactions between the children and their parents. Still, despite years of medical procedures for Kate’s sake, Anna doesn’t seem to resent her—rather, she can’t imagine life without her older sister.

“It takes only thirty seconds to realize that you will be canceling all your plans, erasing whatever you had been cocky enough to schedule on your calendar. It takes sixty seconds to understand that even if you’d been fooled into thinking so, you do not have an ordinary life.”

Sara describes what it’s like living with a chronic illness or, in her daughter’s case, cancer. In this quote, she describes Kate’s recurrence of leukemia at the age of eight. While Picoult has already described how Kate’s health has impacted her siblings, she begins to unpack its impact on Sara as well. Having a child with cancer changes the way a parent views her child and the common scrapes and injuries that come with childhood.

“‘How do your parents decide when Anna will help Kate medically?’ she asks.

‘You make it sound like there’s some process involved. Like there’s actually a choice.’

She shifts her head. ‘Isn’t there?’

I ignore her, because that’s a rhetorical question if I’ve ever heard one…”

The main conflict of the novel is Anna’s attempt to have a voice in the decision of whether or not she should donate a kidney to Kate. Jesse sees the question of Anna donating or not as rhetorical, because donating blood, tissue, and organs to Kate is the reason she was born, providing some criticism of savior siblings. As Anna’s guardian ad litem, Julia is trying to establish whether or not the Fitzgeralds are exploiting Anna to benefit Kate, but Jesse sees her question as illogical because he believes Kate must be saved—even if his other sister gets hurt in the process.

“All this means is that I’m actually educated to think that morals and ethics do not necessarily go hand in hand.”

Campbell makes this statement in regard to the code he was tested on before being allowed to open a private practice. This statement foreshadows one of Campbell’s arguments during the hearing for Anna’s petition—whether or not the use of Anna’s blood, tissue, and organs to save Kate without either girl’s explicit approval is moral and ethical. Again, Picoult explores the controversy of savior siblings, not in a public way, but by exposing the difficult position the Fitzgerald family is in as they fight to save Kate’s life.

“An hour later, we walk through the mall holding hands, a trio of bald girls. We stay for hours. Everywhere we go, heads turn and voices whisper. We are beautiful, times three.”

After Kate’s bone marrow transplant, she is embarrassed by her bald head, so Sara shaves her and Anna’s heads too. This illustrates how even normal moments in the Fitzgerald family are colored by Kate’s illness—for better and for worse. Kate, Sara, and Anna stand out as they walk through the mall, just as they stood out during Sara’s pregnancy with Anna.

“We are not the first parents to lose a child. But we are the first parents to lose our child. And that makes all the difference.”

The reality that Kate could die at any moment is something the Fitzgerald family has had to live with for 14 years. This quote, four years earlier, captures one of many close calls with Kate’s health. This moment of solidarity foreshadows Brian’s decision to support Sara’s belief that a new kidney will save Kate’s life rather than side with Anna. This moment underscores everything the Fitzgeralds have to lose and why their situation is so difficult.

“There are two reasons to not tell the truth—because lying will get you what you want, and because lying will keep someone from getting hurt.”

Campbell makes an observation about lying after Anna tells him that she “wanted it to be about me instead of Kate” (291)—framing her decision as her wanting attention. He realizes Anna has been lying about her reason for petitioning for medical emancipation, and considers two possibilities—that lying will get what Anna wants, or lying will prevent someone else from being hurt. This foreshadows the moment Campbell places Anna on the stand, and she confesses to filing the petition to fulfill Kate’s desire to die. However, Campbell’s observation doesn’t just apply to Anna. This observation also foreshadows Julia learning the truth about why Campbell broke up with her after his high school graduation. It seems Campbell is able to analyze Anna’s lying because he, too, had similar reasons for lying.

“I wonder if all mothers feel like this the moment they realize their daughters are growing up—as if it is impossible to believe that the laundry I once folded for her was doll-sized; as if I can still see her dancing in lazy pirouettes along the lip of the sandbox. Wasn’t it yesterday that her hand was only as big as the sand dollar she found on the beach? That same hand, the one that’s held a boy’s; wasn’t it just holding mine, tugging so that I might stop and see the spiderweb, the milkweed pod, any of a thousand moments she wanted me to freeze? Time is an optical illusion—never quite as solid or strong as we think it is.”

Sara observes Kate with a boy—her first love—and suddenly feels the passing of time. It is a nostalgic moment made more so in light of Kate’s illness. This moment shows Sara’s deep love for her elder daughter. However, what makes this moment tragic is the fact that Anna had a similar experience with a classmate, but Sara was so focused on Kate that she never noticed. Again, the theme of Hyperfocus Creating Neglect is present here, as Sara’s hyperfocus causes her to miss formative moments in her other daughter’s life.

“So I do what I know will destroy him: I pull Jesse into my arms as he sobs. His back is broader than mine. He stands a half-head taller than me. I don’t remember seeing him go from that five-year-old, who wants a genetic match, to the man he is now, and I guess this is the problem. How does someone go from thinking that if he cannot rescue, he must destroy? And do you blame him, or do you blame the folks who should have told him otherwise?”

As she often does, Picoult contrasts one character’s thoughts or experiences with those of another. Earlier, Picoult presented a flashback in which Sara marveled at the passage of time, as Kate entered her first romantic relationship. In contrast, she presents Brian’s thoughts as he discovers Jesse is the serial arsonist he and his crew have been investigating. While Sara was overwhelmed with love and pride, Brian looks back on his son’s life and sees the burden he unwittingly placed on him (as Jesse is not a genetic match to Kate). Throughout the fight over Anna’s petition for medical emancipation, Sara insists that Anna only wants attention, even suggesting she take her to “a movie, or shopping, so she doesn’t feel left out” (57). Ironically, it was never Anna who was looking for attention: It was Jesse, seeking his father’s attention.

“It is a curious thing, watching a strong man fall to pieces. ‘Can you tell me what the right answer is here?’ Brian asks, his voice raw. ‘Because I don’t know where to look for it. I know what’s right. I know what’s fair. But neither of those apply here. I can sit, and I can think about it, and I can tell you what should be and what ought to be. I can even tell you there’s got to be a better solution. But it’s been thirteen years, Mr. Alexander, and I still haven’t found it.’”

The Fitzgerald family is in an impossible situation. Like any other parents, Sara and Brian want Kate to survive. At the same time, they don’t want Anna to suffer the consequences of donating a major organ. However, if they protect Anna, Kate will likely die of kidney failure. If they force Anna to agree to the kidney transplant, she will never be able to play hockey again, and there is a chance she will have complications as an adult. Brian expresses his frustration with this situation in his testimony, ultimately pushing Anna to donate. While complicit in Anna’s fate, he breaks down in a way that illustrates the complicated nature of the situation.

“It’s harder to come up with a solution, though—because although it may not be in Anna’s best interests to be a donor for her sister, her own family is incapable of making informed decisions about that. If Kate’s illness is a runaway train, then everyone reacts from crisis to crisis without figuring out the best way to bring this into the station. And using the same analogy, her parents’ pressure is a switch on the track—Anna isn’t mentally or physically strong enough to guide her own decisions, knowing what their wishes are.”

Even as the Fitzgeralds struggle to decide what is best for their two daughters, so do the professionals testifying at Anna’s hearing. Julia, Anna’s guardian ad litem, tells Judge DeSalvo that she doesn’t believe anyone in the Fitzgerald family is capable of making an unbiased decision regarding Kate’s health, including Anna and her parents. This once again illustrates how impossible the situation is and echoes some of the concerns bioethicists have in regard to designer babies or savior siblings. It is impossible to be unbiased when a child is dying, even if saving this child requires potentially injuring another, as illustrated by the theme of Bodily Autonomy and Choosing a Life.

“…Kate spoke. ‘I’m not doing it again, all right? I’m sick of it. The hospitals and the chemo and the radiation and the whole freaking thing. Just leave me alone, will you?’

My mother’s face went white. ‘Fine, Kate. Go ahead and commit suicide!’

She put her headphones on again, turned the music up so loud that I could hear it. ‘It’s not suicide,’ she said, ‘if you’re already dying.’”

When Kate was first diagnosed with APL, Sara made a promise to keep her alive at all costs. However, Anna shares a moment in which Kate told their mother that she no longer wanted to fight for her life, but Sara callously dismissed her, denying her agency and illustrating the theme of Desire for Control. As Sara struggles to control Kate’s illness, she takes control away from both daughters by denying them the right to choose what happens to their own bodies—even to the point of forcing Anna’s hand.

“I jump over the gate of the gallery and have to fight the dog out of the way; he’s come to stand over Campbell Alexander’s twitching body like a sentry. The attorney enters the tonic phase with a cry, as air is forced out by the contraction of his breathing muscles. He lays rigid on the ground. Then the clonic phase starts, and his muscles fire randomly, repeatedly. I turn him on his side, in case he vomits, and start looking for something to stick between his jaws so that he won’t bite off his own tongue, when the most amazing thing happens—that dog knocks over Alexander’s briefcase and pulls out something that looks like a rubber bone but is actually a bite block, and drops it into my hand.”

Throughout the novel, Campbell has lied about the purpose of his service dog, Judge. However, after ignoring his dog’s alerting behavior, he has a grand mal seizure in the courtroom. It is at this moment that Judge’s purpose is revealed. Not only does Judge watch over Campbell, but he provides Brian with a bite block to help Campbell avoid injury. As per the theme of Desire for Control, this moment helps Anna and Julia understand why Campbell took Anna’s case—and in Julia’s case, it clarifies why Campbell broke up with her after his high school graduation (he did so out of shame over his lack of control).

“‘Do you think it would work?” I asked. ‘A kidney transplant?’

Kate looked at me. ‘It might.’ She leaned over, her hand on the light switch. ‘Don’t do it,’ she repeated, and it wasn’t until I heard her a second time that I understood what she was really saying.”

Anna recalls Kate asking her not to donate her kidney, making it clear she understands the consequences of not receiving treatment. As per the theme of Desire for Control, Kate is physically and mentally tired of medical procedures, but her mother refuses to listen to her plea. For this reason, Kate turns to Anna in an attempt to take control over her own fate. At the same time, Anna reveals the truth behind her desire for medical emancipation, showing the reader just how deep the psychological impact of being a savior sibling is (despite having some desire for bodily autonomy). As predicted by Campbell in an earlier chapter, Anna seeks to continue doing what she’s been doing—giving Kate what she needs.

“The truth is, as Anna once told me, nobody’s going to win. We are going to give our closing arguments and hear the judge’s opinion and even then, it won’t be over.”

Campbell acknowledges that even after Judge DeSalvo makes his decision, nothing will change. Even if Anna wins, she will still feel pressure from her parents to save Kate, and will continue to feel pressure from Kate not to save her. Either way, no one is truly in control of the outcome, touching once again on the theme of Desire for Control.

“Ask any kid who’s made it past fourth grade and they can tell you: water never stops moving. Rain falls, and runs down a mountain into a river. The river finds its way to the ocean. It evaporates, like a soul, into the clouds. And then, like everything else, it starts all over again.”

It rains on the morning Judge DeSalvo is to decide Anna’s case. Anna observes the rain, thinking of it as evaporating into the clouds like a soul—which foreshadows her death. There is optimism, however, in her thought that everything is a cycle, that there is something akin to life (and freedom) for Anna even after death.

“Only one thing’s a constant. ‘Ten years from now,’ I say, ‘I’d like to be Kate’s sister.’”

After winning medical emancipation, Anna voices wanting to be Kate’s sister 10 years in the future. This can be interpreted as Anna wanting to donate her kidney despite her victory. This is an important piece of foreshadowing because she will not be able to express her wishes after the car accident.