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Picoult opens with a short swatch of back story, but we do not know who is really the narrator here. Is is Anna or Kate Fitzgerald? While subsequent development will put this in context, it is interesting that Picoult leaves it ambiguous to begin her novel.
  • pg. 3. "In my first memory, I am three years old and I am trying to kill my sister."
Starting on page 5, Picoult inserts short poems to begin each section of the book (The other passages can be found on pages 47, 73, 139, 201, 241, 285, 341, 397 and 419). She quite deliberately uses the symbolic metaphor of fire. How does this relate to the central plot of the novel? Is it an effective contributor to the story Picoult is trying to tell? How does the symbol / metaphor of fire relate to Jesse's pyromania? Brian's job as a firefighter?

Picoult begins with a central theme of the book: is it ethical to have a child to save a child? Anna puts this front and forward when she discusses the circumstances of her own birth and her integral connection to her sister Kate.
  • pg. 7-8 ". . . if aliens landed on earth today and took a good hard look at why babies get born, they'd conclude that most people have children by accident, or because they drink too much on a certain night, or because birth control isn't one hundred percent, or for a thousand other reasons that aren't really flattering . . . I was born for a specific purpose . . . because I could save my sister, Kate . . . It made me wonder, though, what would have happened if Kate had been healthy . . . Certainly I would not be part of this family. See, unlike the rest of the free world, I didn't get here by accident. And if your parents have you for a reason, then that reason better exist. Because once it's gone, so are you." ANNA IS THINKING ONLY IN HERSELF/ TRYING TO FIND AN IDENTITY SHE DOESNT HAVE
Anna is selling the locket her mother gave her for helping Kate to raise money to hire a lawyer to emancipate herself from her parents. She has been a donor for her sister Kate, who was diagnosed with APL -- acute promyelocytic leukemia. Her parents want her to donate her kidney. She is not thrilled by the idea. She sees herself and her family as an oddity and fells acutely the impact that Kate's illness has had on her family.
  • pg. 9-10: "My parents tried to make thing 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?"
  • pg. 11: "Normal, in our house, is like a blanket too short for a bed -- sometimes it covers you just fine, and other times it leaves you cold and shaking; and worst of all, you never know which of the two it's going to be."
Next, we are introduced to the mother Sara, who is fanatically devoted to her sick child, Kate, but deals with her tension by buying dresses on-line and returning them. Anna explains:
  • pg. 10,12: "My mother could be beautiful if she was parachuted into someone else's life . . . she doesn't have much free time, since a calendar is something that can change drastically if my sister develops a bruise or a nosebleed, but what time she does have she spends at Bluefly.com, ordering ridiculously fancy evening dresses for places she is never going to go . . . this mail-order compulsion, for any other mother, would be a wake-up call for therapy; for my mom, it would probably be considered a healthy break. I wonder if it's putting on someone else's skin for a while that she likes so much, or if it's the option of being able to send back a circumstance that just doesn't suit you."
Sara tends to overreact, just like her response to Kate crying over the denouement of a soap opera, but this is illustrative of life in the Fitzgerald household.
  • pg. 13: A clue to the fire analogy -- "My father says that a fire will burn itself out, unless you open a window and give it fuel. I suppose that's what I'm doing, when you get right down to it; but then again, my dad also says that when flames are licking at your heels you've got to break a wall or two if you want to escape." SHE IS GOING AGAINST THE NORMS AND IS TAKING DECISION WITHOUT THINKIN/CARING ABOUT HER PARENT'S REACTION- EGO
Then, we are introduced to Jesse, the delinquent older brother. He lives separately from the Fitzgerald family in a room above the garage.
  • pg. 14: "When Jesse turned sixteen he moved into the attic over the garage . . . since he didn't wants my parents to see what he was doing and my parents didn't really want to see . . . Blocking the stars . . . Sometimes I think Jesse sets up these obstacles himself, just to make getting to him more of a challenge . . . Don't get me wrong -- it isn't that my parents don't care about Jesse or whatever trouble he's gotten himself mixed up in. It's just they don't really have time to care about it, because it's a problem somewhere lower on the totem pole."
Jesse is philosophical about the roles that each Fitzgerald child plays in the family
  • pg. 15: "'Don't mess with the system, Anna' he say bitterly. 'We've all got our scripts down pat. Kate plays the Martyr. I'm the Lose Cause. And you, you're the Peacekeeper.' He thinks he knows me, but that goes both ways -- and when it comes to friction Jesse is an addict. I look right at him. 'Says who?'"

Next we are introduced to Campbell Alexander when Anna goes to retain him to emancipate herself from her parents. Several points became immediately clear about Campbell. First, he tells (bad) jokes to deflect tension. Second, he actively embraces publicity and takes Anna's case because of the spectacle value of the case, just like when he "sued God." (pg. 18). Third, he will provide a series of dishonest answers about his service dog and will not describe / acknowledge his real condition that necessitates the service dog. All three are telling about his personality
The other key element from this scene is how mature Anna is for her age. She does not seem emotional or phased. She comes into the lawyer's office quite prepared THIS IS DUE TO THE FACT THAT SHE GOES THROUGH LIFE CHANGING EXPERIENCE- BEEN THERE. NO THAT SHES HEARTLESS OR CRUEL BU THAT SHE IS MATURED. Does this seem like an accurate portrayal of the typical early adolescent? Is Anna too mature for her age? Perhaps, especially compared to all the childish behavior on the part of the adults in this book.
In her consultation with Campbell Alexander, Anna gives a good capsule summary of the procedures she is asked to undergo by her parents for Kate's sake:
  • pg. 21: "'No one can make you donate an organ if you don't want to.' 'Oh Really?' She leans forward, counting off on her fingers. 'The first time I gave something to my sister, it was cord blood, and I was a newborn. She has leukemia -- APL -- and my cells put her into remission. The next time she relapsed, I was five and I had lymphocytes drawn from me, three times over, because the doctors never seemed to get enough of them the first time around. When that stopped working, they took bone marrow for a transplant. When Kate got infections, I had to donate granulocytes. When she relapsed again, I had to donate peripheral blood stem cells.' This girl's medical vocabulary would put some of my paid experts to shame. . . 'Obviously, you've agreed to be a donor for your sister before.' . . . 'No one ever asked'"
Campbell speculates on the reasons for parents to have a child, somewhat justifying the Fitzgeralds decision (compare with Anna's monologue at the beginning of the book)
  • pg. 22: "An heir and a spare -- this was a custom that went back to my ancestors in England. It sounded callous -- have a subsequent child just in case the first one happens to die -- yet it had been eminently practical once. Being an afterthought might not sit well with this kid, but the truth is that chlidren are conceived for less than admirable reasons every single day: to glue a bad marriage together, to keep the family name alive; to mold in a parent's own image."
Anna also gives her first take on her actions' impact on her sister.
  • pg. 22 "'What happens if you don't give your sister a kidney?' 'She'll die.' 'And you are okay with that?' . . . 'I'm here, aren't I?' 'Yes, you are. I'm just trying to figure out what made you want to put your foot down, after all this time.' 'Because . . . it never stops.'"

SARA, 1990
This section provides a baseline for evaluating the changes in the Fitzgerald family before Kate's illness. I think it also illustrates how, while doing ordinary things, a small discovery of a lump or a bruise hearkens an illness that will change all of their lives.
  • pg. 26-7: "The bruise is the size and shape of a four-leaf clover and sits square between Kate's shoulder blades. Jesse is the one to find it, while they are both in the bathtub. 'Mommy,' he asks, 'does that mean she's lucky?' I try to rub it off first, assuming it's dirt, without success. Kate, two, the subject of scrutiny, stares up at me with her china blue eyes. 'Does it hurt?' I ask her, and she shakes her head . . . every holocaust starts with an ember. You just have to know what to look for."
  • pg. 30-1: ". . . there are crossroads in our lives when we make grand sweeping decisions without even realizing it. Like scanning the newspaper headline at a red light, and therefore missing the rogue van that jumps the line of traffic and causes an accident. Entering a coffee shop on a whim and meeting the man you will marry one day, while he's digging for change at the counter. Or this one: instructing your husband to meet you, when for hours you have been convincing yourself this is nothing important at all."
Sara is clearly a talented woman, but she also clearly identifies her personality with her role as a mother.
  • pg. 27: "the smile of a child is a tattoo: indelible art. Half the battle is figuring out what works for you, and I am much better at being a mother than I ever would have been as a lawyer. I sometimes wonder if it is just me, or if there are other women who figure out where they are supposed to be by going nowhere."
Another interesting scene is Sara's reaction to the medical personnel at the hospital, a combination of caring and crazy.
  • pg. 32: "'Do you think that it's easy for me to be sitting here with my child and not have any idea what's going on wor why you're doing all these tests? Do you think it's easy for her? Since when does anyone get the option to do what's easiest?' . . . One more moment and the woman storms away, her clogs striking the tile floor. The minute she is out of sight I wilt. 'Sara,' Brian says. 'What's the matter with you?' 'What's the matter with me? I don't know, Brian, because no one is coming to tell us what's wrong with--' . . . He tells me it's going to be all right, and for the first time in my life I don't believe him."
  • pg. 34: "This is a mistake. This is someone else's unfortunate vial of blood that the doctor had analyzed. Look at my child, at the shine of her flyaway curls and the butterfly flight of her smile--this is not the face of someone dying by degrees. I have only known her for two years. But if you took every memory, every moment, if you stretched them end to end--they'd reach forever."
  • pg.36:"This is happening to us because I yelled at Jesse last week, yesterday, moments ago. This is happening because I didn't buy Kate the M&Ms she wanted at the grocery store. This is happening because once, for a split second, I wondered what my life would have been like if I'd never had children. This is happening because I did not realize how good I have it."

  • pg. 37: "It is the biggest mistake rookies make: the assumption that fighting a fire means rushing in with a stream of water . . . A fire can't burn forever. Eventually, it consumes itself."
The family dinner scene further illustrates family dynamics. Jesse and Kate with their respective drama dominating the discussion; Sara being a mother telling them how they should behave and worrying about dinner. Anna quiet . . . and only her father notices.
  • pg. 39-40: "This is not Anna. I am used to struggling with Jesse, to lightening Kate's load; but Anna is our family's constant . . . [she] gives us a backbeat, and seeing her sitting there unresponsive makes me realize that silence has a sound . . . This is when I realize that Anna has already left the table, and more importantly, that nobody noticed."
Another fire reference:
  • pg. 41: "A fire's a beautiful thing, right? Something you can't take your eyes off, when it's burning. If you can keep it contained, it'll throw light and heat for you. It's only when it gets out of control that you have to go on the offensive."
Brian describes his love of astronomy, noting, "It is so easy to think that the world revolves around you, but all you have to do is stare up at the sky to realize it isn't that way at all." (pg. 43). He explains Anna's name and the Andromeda myth which could be an allegory for the Fitzgerald's situation. He also comments on his feelings about Kate's situation.
  • pg. 43: "When Kate was born, I used to imagine how beautiful she would be on her wedding day. Then she was diagnosed with APL, and instead, I'd imagine her walking across the stage to get her high school diploma. When she relapsed, all this went out the window; I pictured her making it to her fifth birthday party. Nowadays, I don't have expectations, and this way she beats them all. Kate is going to die. It took me a long time to be able to say that. We all are going to die, when you get down to it, but it's not supposed to be like this. Kate ought to be the one who has to say good-bye to me."

This section begins with Kate' s dialysis session and the topic of Anna being her kidney donor comes up. While kidney transplants have become routine, it is an involved procedure as Anna describes:
  • pg. 50: "Kidney donation is considered relatively safe surgery, but if you ask me, the writer must have been comparing it to something like a heart-lung transplant, or some brain tumor removal. In my opinion, safe surgery is the kind where you go into the doctor's office and you're awake the whole time and the procedure is finished in five minutes--like when you have a wart removed or a cavity drilled. On the other hand, when you donate a kidney, you spend the night before the operation fasting and taking laxatives. You're given anesthesia, the risks of which can include stroke, heart attack, and lung problems. The four-hour surgery isn't a walk in the park either--you have a 1 in 3,000 chance of dying on the operating table. If you don't, you are hospitalized for four to seven days, although it takes four to six weeks to fully recover. And that doesn't even include the long-term effects: an increased chance of high blood pressure, a risk of complications with pregnancy, a recommendation to refrain from activities where your lone remaining kidney might be damaged." ITS GOING TO AFFECT HER PHYSICALLY
The sheriff serves Sara with the medical emancipation papers and fireworks . . . the key thing to notice is the dynamic between Anna, Brian, and Sara. Anna is clearly closer to her father and her father acts as the mediator between mother and daughter. However, Anna adds a memory of when her mother helped her when she had a fight with Kate, this deflates the building image of the mother Sara as the ogre in the story. Another tender moment to deflate the building family tension is the exchange between Anna and Kate and for the first real time, we hear Kate express a feeling about the situation.
  • pg. 56-7: "Kate wipes her eyes and looks up at me. 'You do realize, she says, 'that you're the only friend I've got?' "That's not true,' I immediately reply, but we both know I'm lying . . . 'I'm not your friend, I'm your sister' And doing a damn lousy job at that. 'That's what I wanted to talk about,' Kate says, 'If you don't want to be my sister anymore, that's one thing. But I don't think I could stand to lose you as a friend.'" ANNA IS ACTING ALUTRISM- SHE WANTS TO HELP AND BE A GOOD SISTER/ FRIEND
The tensions between the parents over the care of their children is a common phenomenon when a child becomes chronically sick
  • pg. 58: "'For God's sake, Brian . . . whose side are you on?' . . . 'Who said there were sides?' But I could answer that for him. There are always sides. There is always a winner, and a loser. For every person who gets, there' someone who must give."

SARA, 1990
Sara makes an interesting note about pediatric medicine and oncology. There is more of a sense of a "club" united by a common illness. Unlike some diseases that tend to divide people, cancer, an equal opportunity illness creates solidarity among patients, families and survivors. Why is that?
  • pg. 59: "there is an unexpected comfort to being at the oncology wing of the hospital, a sense that I am a member of the club . . . these people have all been here before us, and there's safety in numbers."
Note how Dr. Chance uses humor to defuse a tense situation. We are introduced to Sara's older sister Zanne (Suzanne). There is tension in that relationship as well. How does Sara and Zanne's relationship compare with Anna and Kate's? How does Zanne's overachiever persona create feelings of inadequacy in Sara? Does this explain her fanatical care of Kate?
  • pg. 60: "My first strike was marrying a guy without a college degree. My second and third were getting pregnant. I suppose that when I didn't go on to become the next Gloria Allred, she was justified in counting me a failure. And I suppose that until now, I was justified in thinking that I wasn't one.:
  • pg. 61: "She is the person I ran to when I got my period; the one who helped me knit back together my first broken heart; the hand I would reach for in the middle of the night when I could no longer remember which side our father parted his hair on, or what it sounded like when our mother laughed. No matter what she is now, before all that, she was my built-in best friend."
Why is having an ill child considered a failure by Sara?
There is an interesting comparison of doctors and nurses and the roles they play on the medical team and how they relate to patients. Think about this and wonder if you agree or not.
  • pg. 61: "The nurses, I have already learned, are the ones who give us the answers we're desperate for. Unlike the doctors, who fidget like they need to be somewhere else, the nurses patiently answer us as if we are the first set of parents to ever have this kind of meeting with them, instead of the thousandth."
The next few pages of narration describe Kate's illness in detail, the treatment and therapies. Do not get lost in the jargon and pay attention to how the doctor handles the parents and how the disease is explained.
  • pg. 66: "He is talking about my little girl as if she were some kind of machine: a car with a faulty carburetor, a plane whose landing gear is stuck. Rather than face this, I turn away just in time to see one of the misbegotten leaves on the plant . . ."

  • pg. 75: "We are all, I suppose, beholden to our parents--the question is, how much? . . . I wish for siblings--if only so that I would receive sunrise phone calls like this only once or twice a week, instead of seven . . . 'Reason number 106 why dogs are smarter than humans,' I say. 'Once you leave the litter, you sever contact with your mothers."
pg. 77-81. We get Campbell's second evasive answer about his need for Judge, his service dog. Does Campbell's behavior suggest denial? We get a little more of Campbell's backstory, particularly his relationship with his father through the vignette of the boat race. Campbell comes from an affluent background, but a demanding father, who he does not seem able to please.
For those counting at home, Campbell gives his third evasive answer about the dog (pg. 81).

This section begins with Anna describing her funeral and comparing it with Kate. It is clear that Anna feels alone and isolated, while Kate would get all the attention. Most of this section is the narration of the legal procedures surrounding medical emancipation. Anna reiterates her desire to carry through with the suit, but also expresses her reluctance. She would prefer not to have a trial, but seems to think there is no other way. We get another snapshot description of Sara through the eyes of Anna:
  • pg. 88-9: "She looks like someone I do not recognize. I have seen her before be a tiger, fighting a medical system that isn't moving fast enough for her. I have seen her be a rock, giving the rest of us something to cling to. I have seen her be a boxer, coming up swinging before the next punch can be thrown by Fate. But I have never seen her be a lawyer before."
Up until now, Kate has been isolated form the intra-family war going on between Sara and Anna, but she enters the loop on page 91.
  • "'I have one child who's just signed her sister's death sentence, and I'm supposed to cool off?' . . . 'Kate, I shouldn't have said that. It's not what I meant.' In my family we seem to have a tortured history of not saying what we ought to and not meaning what we do. Kate covers her mouth with her hand . . . So I do what I do best. I move in the opposite direction."

Finally, we hear Jesse in his own voice. The first insight he provides is his closeness to Anna, he says:
  • pg. 93: "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."
Obviously Jesse has a lot of anger, but it is also paired with a considerable amount of self-loathing. While his behavior is sociopathic, he does seem to care about others. A true sociopath would not want to give his organs away to help others.
    • pg. 94: "It would solve a thousand problems if I rolled the Jeep over an embankment. It's not like I haven't thought about it, you know, On my license, it says I'm an organ donor, but the truth is I'd consider being an organ martyr. I'm sure I'm worth a lot more dead than alive--the sum of the parts equals more than the whole. I wonder who might wind up walking around with my liver, my lungs, even my eyeballs. I wonder what poor ahole would get stuck with whatever it is in me that passes for a heart."
    • pg. 95: "I look for places like me: big, hollow, forgotten by most everyone."
    • pg. 98: "What made me believe I was worth something, even now? What made me think I could save my sister, when I can't even save myself?"

SARA, 1990-1991
Sara states for the first time her motivations about have Anna and it seems more stark that has been already suggested.
  • pg. 100: "'You have any names picked?' It strikes me that I don't. Although I am nine months pregnant, although I have had plenty of time to dream, I have not really considered the specifics of this child. I have thought of this daughter only in terms of what she will be able to do for the daughter I already have. I haven't admitted this even to Brian."
This section raises the ethical debate over designer babies, where parents pick the traits of their child before birth. People often have strong views on this issue. Some think it is okay if the reason is medical/biological, but not so much if it is cosmetic. Is it a problem of "playing God" or does the rationale matter when choosing the genetic traits for a human?
  • pg.102: "'People seem to think that we're trying to make a designer baby.' 'Aren't you?' '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 consider to be model human traits. They're just Kate's traits. We don't want a super baby; we just want to save our daughter's life.'"
No pain, no gain -- the Murphy's law of oncology:
  • pg. 105: "There's a Murphy's Law to oncology, one which is not written anywhere but held in widespread belief: if you don't get sick, you won't get well. Therefore, if you chemo makes you violently ill, if radiation sears your skin--it's all good. On the other hand, if you sail through therapy quickly with only negligible nausea or pain, chances are the drugs have somehow been excreted by your body and aren't doing their job."

Julia is the Guardian ad Litem for Anna. I think developing this character is one of the big mistakes of the book. In my view, she should have been a background character like Dr. Chance and her backstory does not contribute to the whole story. Agree? Disagree?
My guess is that Picoult is trying to establish a sister-sister parallel between Anna-Kate and Julia-Isobel and present an "objective" perspective by an outsider to the Fitzgerald family, but I just don't see any valued-added after reading the book multiple times.
  • pg.111: "'Are you sure you're ready to face what's going to happen if you stop being a donor?' 'I know what's going to happen . . . I never said I liked it .'PROVES SHE ISNT BEING EGO BC DOESNT WAN TO THE IDEA IS BAD TO HER She raises her face to mine, challenging me to find fault with her . . . What would I do, if I found out that Izzy needed a kidney, or part of my liver; or marrow? The answer isn't even questionable--I would ask how quickly we could go to the hospital and have it done. But then, it would have been my choice, my decision."

The opening scene of Campbell Alexander arguing about an intramural team called the "Whiteys" is potentially an analogy to the Fitzgerald family situation. Legally, we have individual "rights" that are often interpreted as being able to do what one wants without the interference of others, even if it offends them. Perhaps no individual right is stronger than control over one's own body. Anna's decision to stop being a donor is a right, but, we may ask, is it the right thing to do? If it is not, how do we reconcile the common good with the ability of individuals to withhold participation? Many legal scholars have argued that when issues devolve into clashes of competing rights, no one wins and it becomes more difficult for individuals to reach a resolution. Others, such as Nobel Prize winning economist Ronald Coase, has argued that clearly specifying everyone's rights helps resolve disputes. An example of the situation is inserted in Campbell's reminiscences
  • pg. 122. "You come across a horrible four-car accident. There are people moaning in pain, and the bodies strewn all over the place. do you have an obligation to stop? 'Why should I help?' she said. 'Well, legally, you shouldn't. If you pull someone out and hurt them more, you could get sued.' . . . '. . . even if the law says that no one is responsible for anyone else, helping some one who needs it is the right thing to do."
How does this play out in the medical field? For example, should patients be seen on a first-come, first-serve basis (their right), or the seriousness of their injury? Could someone insist on having a splinter removed before a trauma patient? Can hospitals/clinics refuse treatment to certain individuals or can they be compelled to perform procedures they find ethically problematic? Does someone have the right to die?

Does Campbell's and Julia's previous relationship present a conflict of interest in their representation of Anna? (pg. 118) Also, does Campbell's desire to win the case for his client, Anna, compete with what is best for the Fitzgerald family, including Anna?
  • pg. 119. "'Campbell, that's her mother!' 'This week, she's opposing counsel, and if she's prejudicing my client in any way she needs to be ordered not to do so.' 'Your client has a name, and an age, and a world that's falling apart -- the last thing she needs is more instability in her life. have you even bothered to get to know here?' . . . '. . . my job is to protect Anna's legal rights and win the case, and that's exactly what I'm going to do.' 'Of course you are. Not necessarily because it's in Anna's best interests . . .but because it's yours.'"
In his reminiscence about Julia, Campbell makes a telling observation in his inner monologue:
  • pg. 121. "I wonder what it would be like to not give a damn about what people thought about you."
What does this tell us about Campbell's personality? Could these words be put in the mouths of any other characters in the novel?
  • pg. 125. "'Well this is new to me, too," Anna confesses. 'What is?" She twists a strand of hair around her pinky. 'Hoping,' she says."
pg. 125. Campbell's fourth evasive answer about his dog.
pg. 127. Reference to Smilla's Sense of Snow a pot-boiler novel and Julia Ormond movie.

Anna reflects on her family's photo collection and how each of the children is represented. She notes
  • pg. 130. "There are pictures of me, too, but not many. I go from infant to about ten years old in one fell swoop. Maybe it's because I was the third child, and they were sick and tired of keeping a catalog of life. Maybe it's because they forgot. It's nobody's fault, and it's not a big deal, but it's a little depressing all the same NO PIC OF HER NO LOVE FEELS MENTALLY AFFECTED. A photo says, You were happy, and I wanted to catch that. A photo says, You were so important to me that I put down everything else to come watch."
Being sick changes how people treat you. Anna gives us an anecdote:
  • pg. 131 "There was this kid in my school . . . who used to be a total loser . . . then one summer he was diagnosed with MS. After that, no one was mean to Jimmy anymore. If you passed him in the hall, you smiled. If he sat next to you at the lunch table, you nodded hello. It was as if being a walking tragedy canceled out ever having been a geek. From the moment I was born, I have been the girl with the sick sister. All my life bank tellers have given me extra lollipops; principals have known me by name. No one is ever outright mean to me. It makes me wonders how I'd be treated if I were like everyone else."
  • pg. 133. "'Seeing Kate isn't going to make you feel better.' There's really no way to explain why I need to know that she's okay, at least now, even though I have taken steps that will put an end to that."
The little vignette of two sisters doing handstands add a layer to the relationship between Anna and Kate. It would be a different novel if Anna and Kate did not like each other personally or resented each other. This scene suggests the opposite. Once again, a brief digression on what's the best way to die. Everyone would like to "die with dignity" but we do not generally get to choose the circumstances. However, the conversation brings up the notion of a "life not worth living" and the idea in Stoic philosophy that how one dies defines how one lived.
  • pg. 134-5. "'What do you think is the best way to die?' . . . I'm dying. You're dying . . . I just happen to be more gifted at it than you are . . . Maybe an airplane crash . . . It would suck, you know, when you realized you were going down . . . but then it happens and you're just powder . . . There's just sleeping through it as you croak, but that's kind of boring.' 'You know, normal people don't sit around thinking about dying.' 'Liar. Everyone thinks about dying.' 'Everyone thinks about you dying," I said. 'Well, . . . At least now you're telling the truth."
This passage is also a good example of the Kubler-Ross stages of denial and bargaining (over how one will die) in dealing with sickness or death.
The scene of the family football game on Thanksgiving is true Americana -- ordinary, but it is an extraordinary experience for the Fitzgeralds. It is also the reminder that one of the greatest desires of people who are sick is to be normal, just like everyone else. Often, by giving them care, family, friends, and medical professionals do not allow patients to experience that.
I think the scene setting of the hospital ward is apt:
  • pg. 138. "Hospital rooms never get completely dark; there is always some glowing panel behind the bed in the case of catastrophe, a runway strip so that nurses and doctors can find their way. I have seen Kate a hundred times in beds like this one, although the tubes and wires change. She always looks smaller than I remember."
Poignant closing note to this section.
  • pg. 138. "Jesse is wrong -- I didn't come to see Kate because it would make me feel better, I came because without her, it's hard to remember who I am." NEEDS HER SO NOT EGO

It only took 140 pages, but we finally get to hear from Brian, the father. The opening scene of responding to a fire call made me think of the parallels between firefighters and trauma/emergency room teams. This scene could be an emergency surgeon responding to a case coming through the doors. The closing note might be interpreted as a statement of the relative value of Anna and Kate:
  • pg. 142. "The safety of the rescuer is of a higher priority than the safety of the victim. Always."
The contrast between his work life and his home life also makes a key point, providing a window into his personality.
  • pg. 142. "I'm a coward. There are times when my shift is over that I'll stay and roll hose, or put on a fresh pot of coffee for the crew coming in, instead of heading straight to my house. I have often wondered why I get more rest in a place where, for the most part, I'm roused out of bed two or three times a night. I think it is because in a firehouse, I don't have to worry about emergencies happening-they're supposed to. The minute I walk through the door at home, I'm worrying about what might come next."
However, Brian does make a parallel between his home life and fighting fires (think of the opening quotes to each major section)
  • pg. 143. "There is a moment during a structure fire when you now you are either going to get the upper hand, or that it's going to get the upper hand on you . . . The sum of the parts overwhelms, and that's when you back out and force yourself to remember that every fire will burn itself out, even without your help. These days I'm fighting fires on six sides. I look in front of me and see Kate sick. I look behind me and see Anna with her lawyer. The only time Jesse isn't drinking like a fish, he's strung out on drugs; Sara's grasping at straws. And me, I've got my gear on, safe. I'm holding dozens of hooks and irons and poles--all tools that are meant to destroy, when what I need is something to rope us together."
Brian concludes:
  • pg. 147. "I became a firefighter because I wanted to save people. But I should have been more specific. I should have named names."

The analogy between dark matter in the universe and the plot of the novel is telling.
  • pg. 149. "'. . . ninety percent of the universe is made of stuff we can't even see.' 'Then how do you know it's there?' . . . 'Dark matter has a gravitational effect on other objects. You can't see it, you can't feel it, but you can watch something being pulled in its direction."
What is the "dark matter" of My Sister's Keeper?
There is a lot of relationship fluff here. Cliche, as Seven notes. No comment, however, Julia closes with how some people try to get attention: have an artificial crisis:
  • pg. 157-8. "'You,' Seven pronounced, 'are a train wreck of sexual history.' But this inaccurate. A runaway train is an accident. Me, I'll jump in front of the tracks. I'll even tie myself down in front of the speeding engine. There's some illogical part of me that still believes if you want Superman to show up, first there's got to be someone worth saving."
Another analogy for not getting noticed: squirrel in the elephant cage.

SARA, 1996
This section deals with the Kate's relapse and the many signs and symptoms a parent should watch for that might indicate something is wrong. Sometimes it is over reaction, but sometimes it is the worst:
  • pg. 164-5. "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. A routine bone marrow aspiration-one we'd scheduled long before I ever saw that bruise-has come back with some abnormal promyelocytes floating around. Then a polymerase chain reaction test-one that allows the study of DNA-showed that in Kate, the 15 and 17 chromosomes were translocated. All of this means that Kate is in molecular relapse now, and clinical symptoms can't be that far behind. Maybe she won't present with blasts for a month. Maybe we won't find blood in her urine or stools for a year. But inevitably, it will happen."
  • pg. 165. "Dr. Chance has explained that this is one of the great debates for oncologists-do you fix a wheel that isn't broken, or do you wait until the cart collapses?"
The following illustrates the physical and mental exhaustion having a child with cancer can be on parents and the impact this has on other children in the family.
  • pg. 166. "'Your sister,' I say evenly, 'is incredibly sick. I'm sorry if that interferes with your dentist's appointment or your plan to go buy a pair of cleats. But those don't rate quite as high in the grand scheme of things right now. I'd think that since you're ten, you might be able to grow up enough to realize that the whole world doesn't always revolve around you.' . . . 'Yea, right, she's sick,' he says. 'Why don't you grow up? Why don't you figure out that the world doesn't revolve around her?"
The next few pages detail Kate's relapse and the need for Anna to become a donor again; this time, it is white blood cells, but as the nurse notes, "Kids and phlebotomy never mix well." (p. 170).
There is another parallel between Sara's efforts to save Kate's goldfish and how she reacts to her daughter's illness. (p.170-1)
This section is mostly about illustrating the many stresses Sara undergoes in caring for Kate and the irritations for other family members created by Anna's illness and how they cope with the illness through humor, distractions, and denial (drinking pinot noir and trips to Boston, etc.). There is also the distinct sense of victimhood: other people have "small" problems and they do not understand "real" problems like we have.
  • pg. 174-5. "'You are allowed to take a break, you know. No one has to be a martyr twenty-four/seven.' But I hear her wrong. 'I think once you sign on to be a mother, that's the only shift they offer.' 'I said martyr ' Zanne laughs. 'Not mother.' I smile a little. 'Is there a difference?'"
  • pg. 175. "'You are not living, Sara. You're waiting for Kate to die.' . . . '. . . Kate is not going to die sooner because you have one more glass of wine, or because you stay overnight in a hotel, or because you let yourself crack up at a bad joke. So sit your ass back down and turn up the volume and act like you're a normal person.'"

  • pg. 178. "Thanks to a little bout of insomnia and way too many doses of Tony Robbins, I decided one day to force myself into imagining what it would be like after Kate died. That way, or so Tony vowed, when it really happened, I'd be ready . . . But then, there were times when I let the veil life a little, and other ideas would pop up . . . I am convinced that there is a censor sitting on my brain with a red stamp, reminding me what I am not supposed to even think about, no matter how seductive it might be. It's probably a good thing. I have a feeling that if I really try to figure out who I am without Kate in the equation, I'm not going to like who I see."
The following interchange between Anna and Sara about dropping the lawsuit is a good example of a combination "denial" and "bargaining" in the sense of Kubler-Ross. Once again, a vignette of "normal" is provided. Anna has her first date, sisters fight, gossip, etc. As they approach the courthouse, Anna's status as a "designer baby" is brought up, Anna's thoughts:
  • pg. 182. ". . . one guy asks if I'm aware that I am Rhode Island's first designer baby . . . I've known since I was seven how I was conceived, and it wasn't that huge a deal. First off, my parents told me when the thought of them having sex was far more disgusting than the thought of creation in a petri dish. Second, by then tons of people were having fertility drugs and septulets and my story wasn't really all that original anymore. But a designer baby? yah, right. If my parents were going to go to all that trouble, you'd think they'd have made sure to implant the genes for obedience, humility, and gratitude."
Then, the curveball: Anna changes her mind about wanting her mother to move out, but her father provides another solution, namely, staying with him at the fire station.

This section just goes through the motions of the legal motions, etc, to keep the plot moving along. Campbell reflects on the soul-lessness of lawyers. It may be interesting to contrast how lawyers and how doctors are perceived by society. Lawyers are usually portrayed in a negative light, ceteris paribus, while doctors are often put in a favorable one. Is this fair and accurate?
Another issue that is raised is the influence parents can have over their children in their legal and medical choices. Children can be influenced to say and do things that are not in their own best interests and often counter to their genuine feelings. This comes out in the interchange between Julia and Campbell.
We get the first hint of what Campbell's dog, Judge, is for and how the dog is trying to warn Campbell to get to an isolated place.

Jesse's demonstrated machismo in this section contrasts with his obvious insecurities. Jesse provides another anecdote of how Kate' s illness upsets family life for the Fitzgeralds, this time their Christmas celebration. When describing how the parents treat Anna, Jesse notes:
  • pg. 192. "'No. Anna's on their radar, because she plays into their grand plan for Kate.' "How do our parents decide when Anna will help Kate medically?' 'You make it sound like there's some process involved. Like there's actually a choice."
  • pg. 192. "No one in this family ever covers up their mistakes."
  • pg. 193. "Darkness, you know, is relative."

Brian, the father, is finally taking some active steps at keeping his family together, but he is clearly out of his comfort zone.
  • pg. 195. "I am more comfortable rushing into a building that is going to pieces around me than I am trying to make her feel at ease . . . Maybe I can convince myself that this move will ultimately keep my family together, even though the first step involves breaking it apart."
  • pg. 196. "It seems remarkable that while one of our daughters is leading us into a legal crisis, the other is in the throes of a medical one-but then again, we have known for quite some time that Kate's at the end stages of reanl failure. It is is Anna, this time, who's thrown us for a loop. And yet-like always-you figure it out; you manage to deal with both. The human capacity for burden is like bamboo-far more flexible than you'd ever believe at first glance."
What is clear is that Brian and Sara differ considerably in their assessment of Anna's lawsuit. Sara sees it as a "tantrum" while Brian is much more understanding. Is this realistic?
pg. 197-99 is a good description of the situations that first responders often face getting individuals to hospitals for acute care.

pg. 203. Campbell's fifth evasive answer about his dog to the security guard, but he decides to forego giving a response to Dr. Bergen's secretary.
Campbell finally seems personally involved in this case, and not just for publicity reasons. What might be changing his mind?
Campbell visit and inquiry about the hospital ethics committee is interesting. Does the scope of the ethics committee only cover the treatment of patients? Or, does it cover donors like Anna, too?
  • pg. 204. "'As I was saying -- Anna Fitzgerald? Do you have any notes from the ethics committee about her?' 'The ethics committee has never convened on Anna Fitzgerald's behalf. It's her sister who's the patient.' . . . ''Do you have any idea how many times Anna's been both an outpatient and an inpatient in this hospital?' 'No,' Bergen says. 'I'm counting eight.' 'But those procedures wouldn't necessarily come before the ethics committee. When the physicians agree with what the patients want, and vice versa, there's no conflict. No reason for us to even hear about it . . . We all have full-time jobs, Mr. Alexander. We're psychiatrists and nurses and doctors and scientists and chaplains. We don't go looking for problems."
I do not find Dr. Bergen's explanation satisfactory, what about you?
Another wrinkle is that the kidney transplant may not save Kate's life as Julia and Campbell discuss.
  • pg. 207. "'[Dr.] Chance told me that there's nothing left to do for Kate,' Julia tells me. 'You mean other than the kidney transplant.' 'No. Here's the incredible thing . . . [He] doesn't think Kate's strong enough THIS MEANS SHE WILL BE AFFECTED BY IT EGO BC WON'T EVEN WORK 100%.' 'And Sara Fitzgerald is pushing for it,' I say. 'When you think about it, Campbell, you can't blame her logic. If Kate's going to die without the transplant anyway, why not go for it?' . . . 'Because the transplant involves major surgery for her other daughter,' I point out. 'And putting Anna's health at risk for a procedure that's not necessary for her seems a little cavalier.'"
pg. 208. Campbell's sixth evasive response about his dog, this time to Julia's Uncle Luigi.
Julia and Campbell speculate about Anna's ability to make a decision on her own.
  • pg. 208. "'I know what's right for Anna,' Julia tells me, 'but I'm not sure she's mature enough to make her own decisions . . . every time Anna's mom confronts her, she backs off. Every time something happens to Kate, she backs off. And in spite of what she thinks she's capable of, she hasn't made a decision of this magnitude before -- considering what the consequences are going to be to her sister.'"
pg. 209. Evasive answer # 7.
pg. 210. Rhode Island = no feng shui, relations without referents.
Jesse gets in trouble (again).
Campbell's stance on morality and ethics:
  • pg. 214. "What is ethical to a lawyer differs from what's ethical to the rest of the world . . . All this means is that I'm actually educated to think that morals and ethics do not necessarily go hand in hand . . . I wonder how much of the general population of this country knows that the legal system has far more to do with playing a good hand of poker than it does with justice."
Could the same be said about doctors? Nurses? Medical Professionals?
Anna finally gets angry:
  • pg. 218. "'You know to know what I want? I'm sick of being a guinea pig. I'm sick of nobody asking me how I fell about all this. I'm sick, but I'm never fucking sick enough for this family.'"

Brian makes a literary connection between "fire" and "hope" by using the Greek myths of Prometheus and Pandora. Fire may be destructive and ephemeral, as many of the short poems that lead off each chapter suggest, but they are also what gives us the power to deal with all of our other problems. This seemed close to another famous quotation by the (St.) Augustine that went, "hope has two beautiful daughters: anger and courage."
  • pg. 219. "Fire and hope are connected, just so you know . . . Pandora's curiosity got the best of her, and one day she opened that box . . . She managed to shut the lid tight before hope escaped. It's the only weapon we have left to fight the others."
When dealing with fatal or chronic diseases, there is often the tension between giving someone "false hope" and the healing power of belief and optimism. What side would you come down on for this?
pg. 219: Evasive answer # 8
pg. 220-1. Another good scene of a first responder and the types of situations they face. It also becomes clear that the stress is getting to Brian, too, and it is affecting his work. However, work is his escape from the stressful situation at home:]
  • pg. 221. "'You know, if it's too much, we can cover for you,' he offered. 'The chief'll give you as much time off as you want.' 'I need to work . . . When I'm not here,' I explained, 'I have to be there.'"

SARA, 1997
  • pg. 213. "No matter how many times you drive to the emergency room, it never becomes routine."
The beginning of this section details Kate's clinical relapse, followed by a common description of how insurance companies that pay for the medical care interact with their clients. The second raises a common medical ethics dilemma: how much is a life worth and what steps and interventions should be taken? It is not everything and it is not nothing, but there is plenty of territory in between.
How one raises money for high-cost, high-risk, or experimental procedures can be ad hoc. Perhaps you have a rich aunt (Zanne) who can write a $100,000 check. Perhaps your parent works in an occupation with a strong sense of solidarity (Brian) like firefighters, police officers, or teachers. I once worked in a Catholic School where teachers have minimal benefits and have a salary that is about half of the median wage in the US. One of the teachers who had recently retired developed cancer and did not have the funds to cover the procedure. The school, located in a poor, blue-collar section of Buffalo, raised $30,000 in one week. American doctors earn, on average, approximately 3x the median wage in the US, while doctors in other developed countries make about 2x. Is there a better way to finance medical care?
  • pg. 236. "The mail is full of hospital bills. We have learned that the insurance company will not talk to the the hospital billing department, and vice versa, but neither one thinks that the charges are accurate--which leads them to charge us for procedures we shouldn't have to cover, in the hopes that we are stupid enough to pay them. Managing the monetary aspect of Kate's care is a full-time job that neither Brian nor I can do."
I thought how Kate cleans her room before going to the hospital is poignant. I know that once when I had a gall bladder procedure that I was told I had a 30% chance of not surviving, I did similar things. It may seem strange or irrational, but there is something about illness and dying that drives us to "put our affairs in order" -- perhaps this is a sign of Kubler-Ross' stage of acceptance, but it may seem irrational to do something like this when one has limited time.
Sara summarizes the fork in the road facing parents with sick children:
  • pg. 229. "It seems to me, now that this is more than just a hypothetical, that a parent falls one of two ways when told a child has a fatal disease. Either you dissolve into a puddle, or you take the blow on the cheek and force yourself to lift your face again for more. In this, we probably look a lot like patients."
A good description of the hierarchy and division of labor in a hospital between doctors and nurses.
  • pg. 229-30. "An oncology ward is a battlefield, and there are definite hierarchies of command. The patients, they're the ones doing the tour of duty. The doctors breeze in and out like conquering heroes, but they need to read your child's chart to remember where they've left off from the previous visit. It is the nurses who are the seasoned sergeants-the ones who are there when your baby is shaking with such a high fever she needs to be bathed in ice, the ones who can teach you how to flush a central venous catheter, or suggest which patient floor kitchens might still have Popsicles left to be stolen, or tell you which dry cleaners know how to remove the stains of blood and chemotherapies from clothing. The nurses know the name of your daughter's stuffed walrus and show her how to make tissue paper flowers to twine around her IV stand. The doctors may be mapping out the war games, but it is the nurses who make the conflict bearable."
  • pg. 230. "You get to know them as they know you, because they take the place of friends you once had in a previous life, the one before diagnosis. Donna's daughter, for example, is studying to be a vet. Ludmilla, on the graveyard shift, wears laminated pictures of Sanibel Island clipped like charms to her stethoscope, because it's where she wants to retire. Willie, the male nurse, has a weakness for chocolate and a wife expecting triplets."
Donna's vignette is an often repeated event in many hospitals.
Another example of how Sara's focus on Kate leads her to ignore or not hear what Anna is telling her.
There are family members who often think they know better about their relative's health than the medical professional, like Sara. You will run into these people all the time. Grin and bear it. We find the origin of the locket that Anna pawns in the opening scene of the book. It is from Brian as a reward for helping her sister.
A major reason that sickness can split families apart is that they lose the ability to talk about anything else, as illustrated by the dinner conversation between Sara and Brian
  • pg. 235. "'I was sort of hoping that we could come here to get away from all that. You know. Just talk.' 'I'd like to talk,' I admit. But when I look at Brian, the information that leaps to my lips is about Kate, not us. I have no call to ask him about his day-he has taken three weeks off from the station. We are connected by and through sickness. We fall back into silence . . . When the waiter arrives . . . we both turn eagerly, grateful for someone who keeps us from having to recognize the strangers we have become."
Having a sick child can be disempowering, as Brian's refusal to take Sara's sister's, Zanne's, money.
  • pg. 238. "'I won't let your sister take care of Kate,' Brian says. 'I'm supposed to take care of Kate.'"
The section closes with the aesthetic changes, which are often harder than the physical/biological/structure-functional indignities of sickness.
  • pg. 239. "'Don't say it. Don't tell me that nobody's going to stare at me, because they will. Don't tell me it doesn't matter, because it does. And don't tell me I look fine because that's a lie.' Her eyes, lash-bare, fill with tears. 'I'm a freak, Mom. Look at me.'"

Another example of how Kate's illness upends family plans and disrupts the other children's lives. Also, "guilt gifts." They are nice to have, but you never feel great about getting them, even when they are exactly you wanted, i.e. blood money. There are studies that show that when people earn money from criminal activity (or they feel they didn't "earn" it), they spend it differently than money they worked hard to acquire. Part of Jesse's self-destructiveness might be an emblem of this dynamic.
Jesse takes Dan to witness his latest arson event, and, partly to show Jesse is not fully destructive, he heroically goes in to save the homeless person who had been sleeping in the warehouse as their home.

  • pg. 250. "My family is famous for lying to ourselves by omission: if we don't talk about it, then-presto!- there's no more lawsuit, no more kidney failure, no worries at all . . . Maybe if you spend your life pretending you're on a movie set, you don't ever had to admit that the walls are made out of paper and the food is plastic and the world in your mouth aren't really yours."
Anna's story about how she would write the "creation myth" on pg. 256 is another insight into her character and can be used to interpret the whole thrust of the novel.

How Ms. Zegna's life is destroyed by the fire and how Kate's illness affects the Fitzgerald family is a strong parallel, but this point has been made many times already
More Fitzgerald family reminiscences as we approach the novel's climax.
Brian reveals that he is going to take Anna's side in the lawsuit.
  • pg. 259. "'I'm going to speak on Anna's behalf.' . . . 'If you testify for Anna, the judge is going to say that at least one of her parents is capable of supporting this petition, and he's going to rule in her favor.' 'I know that,' I say. 'Why else would I do it?' We stare at each other, speechless, unwilling to admit what lies at the end of each of these roads. 'Sara,' I ask finally, 'what do you want from me?' 'I want to look at you and remember what is used to be like,' she says thickly. 'I want to go back, Brian. I want you to take me back.' But she is not the woman I used to know . . . To be fair, I am not the same man. The one who listened. The one who believed her."

SARA, 2001
Anna becomes a hockey goaltender, her parents do not seem to be clued in.
Kate's illness becomes more serious and the parents face the decision of whether to let Kate die at home or in the hospital.
  • pg. 265. "'Maybe we should bring Kate home,' Brian says . . . 'I mean now.' He steeples his hands. 'I think she'd want to die in her own bed.' That word, between us, explodes like a grenade. 'She isn't going to-' 'Yes, she is.' He looks at me, his face carved by pain. 'She is dying, Sara. She will die, either tonight or tomorrow or maybe a year from now if we're really lucky. You heard what Dr. Chance said. Arsenic's not a cure. It just postpones what's coming.' My eyes fill up with tears. 'But I love her,' I say, because that is reason enough. 'So do I, Too much to keep doing this.'
It is difficult for families to make the final decision of when is enough, and this is why most of the costs of medical care come in the last few months of life. One survey reported that most families regret doing too much and wished they had allowed their loved one to die without heroic medical interventions.
Brian's list of Kate's qualities is a reminder of what makes us, us, not our physical bodies, per se, but our likes, dislikes, talents, etc., that can be robbed by disease. When we can no longer do them, we may lose who we are.
Another Jesse cry for attention, blowing up the school's septic tank with metallic sodium and H2O. Sara and Jesse finally have a confrontation of their respective stresses created by Kate's illness.
  • pg. 266-7. "You know what, Jess? The world's full of them. You will always be up against some. Something. He glares at me. 'You could take a conversation about the frigging Red Sox and somehow turn it back to Kate.' . . . 'We're all pretty gifted at that. Or were you blowing up the septic tank for some other reason?' 'You don't know what it's like being the kid whose sister is dying of cancer.' 'I have a fairly good idea. Since I'm the mother of the kid who is dying of cancer. You're absolutely right, it does suck. And sometimes I feel like blowing something up, too, just to get rid of that feeling that I'm going to explode any minute.'"
Anna does not get to go to hockey camp because of Kate's illness. Another brick in the wall of how an illness in the family can upset your life. The family says their "good-byes" to Kate and Sara explains why it is difficult,
  • pg. 271. "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."

I found Anna's discussion of "what age will we be in heaven?" incredibly saccharine and beside the point. This is where the book loses its way, in my opinion, and jumps the shark and becomes a lifetime movie.
The deal is for Anna to give her kidney in exchange for no further treatments or donations. It seems like this story will end "happily" for all (but, of course, there are still 150 pages left, so that can't be it), but Anna replies, "I can't." (pg. 275).

Nothing particularly valuable in this section. Romance Mush.

Anna does not show up on time for her court date. She is at the hospital with Kate. She and Campbell have a confrontation that leads to some false "true" confessions about why Campbell has a service dog and Anna filed her lawsuit. However, at least they are giving reasons. (pg. 291)
  • pg. 293. "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. It's for both of these reasons that I give Anna this answer. 'Well,' I say, 'I doubt it.'"
The details of the legal proceedings is not that important, except the distinction that Campbell makes between "legality" and "morality." The does not require one to behave ethically or morally, it determines legal responsibility based on sets of legal rights and responsibilities. In his opening statement he notes:
  • pg. 294. "'We're here today because there's a difference in our system of justice between what's legal and what's moral. Sometimes it's easy to tell them apart. But every now and then, especially when they rub up against each other, right sometimes looks wrong, and wrong sometimes look right.' . . . We're here today . . . so that this court can help us all see a little more clearly.'"
The purpose of Campbell's testimony is to show that Anna never gave permission for the procedures performed on her, that she was an appendage to Kate's health needs, and that consistently Kate's welfare was favored over Anna's. The key transformation that occurs during the testimony is how Sara responds while hearing the cumulative effect of all the treatments. They are no longer individual, "emergency" decisions, but a pattern of treatment. The climax comes at the end of the section when Sara states
  • pg. 298. "'Wait,' Sara interrupts. 'I have something to say . . . You think you can lay it all out in words, black-and-white, as if it's that easy. But you only represent one of my daughters, Mr. Alexander, and only in the courtroom. I represent both of them equally, everywhere, every place. I love both of them equally, everywhere, every place.' 'But you admitted that you've always considered Kate's health, not Anna's, in making these choices,' I point out. 'So how can you claim to love both of them equally? How can you say that you haven't been favoring one child in your decisions?' 'Aren't you asking me to do that very thing?' Sara asks. 'Only this time, to favor the other child?'

  • pg. 299. "When you are a kid you have your own language . . . It doesn't really matter how far you go; the point is that it's a world of possibility. Kids think with their brains cracked wide open; becoming an adult, I've decided is only a slow sewing shut."
Anna provides her perspective on the conflicts, internal and external.
  • pg. 300. "What if I was the one who was sick? What if Kate had been asked to do what I've done? What if one of these days, some marrow or blood or whatever actually worked, and that was the end? What if I could look back on all this one day and feel good about what I did, instead of feeling guilty? What if the judge doesn't think I'm right? What if he does? I can't answer a single one of thes, which is how I know that whether I'm ready or not, I'm growing up. 'Anna . . .now is not the time to start changing your mind.' 'I'm not changing my mind . . .I think I'm just saying that even if we win, we don't. PROVES SHE STILL FEEELS GUILTY AND NOT DOING IT FOR HER SELF BENEFIT ONLTY'"
pg. 301-302 describe the function, standards, and procedures of hospital "ethics" committees. In addition, the issue of parental vs. minor control over health decisiosn is discussed. The point of Campbell's line of questioning is that the donor's interests were not considered by medical decisionmakers in their deliberations. No one represented Anna's interests. Dr. Bergen weighs in to the cost-benefit of Anna donating her kidney to Kate.
  • pg. 304. "'Quite frankly, even before I knew that Anna didn't want to be a participant, I voted against her donating a kidney to her sister. I don't believe Kate would live through the transplant, and therefore Anna would undergo a serious operation for no reason at all. Up until this point, however, I think that the risk of the procedures was small, compared to the benefit the family as a whole received, and I suppport the choices the Fitzgeralds made for Anna."
Sara's questioning presents the other side:
  • pg. 307. "'If you were me . . . and the medical ethics committee handed you back a piece of papaer with a suggested course of action that would save our son's life, would you question them further . . . or would you just jump at the chance?'"
As they leave the courtroom, Sara makes a motherly manuever to adjust what her daughter is wearing and this makes a big impression on Anna.
  • pg. 307. "'. . . people you love can surprise you every day. That maybe who we are isn't so much about what we do, but rather what we're capable of when we least expect it.'"

SARA, 2002
This section introduces Taylor Ambrose, Kate's boyfriend. It foreshadows the possibility of Kate's demise and suggests one reason for Kate's role in the surprise ending. It also shows that suffering loves company and how having someone know what stresses and strains you are under can be therapeutic.
  • pg. 310. "'When you care more if someone else lives than you do about yourself . . . is that what love's like?'"
In many ways, this ordinary scene of teenage romance (with a big wrinkle) is to make the impending death of Kate more real. It is a dry run for the climax the reader is expecting.

It is interesting that Jesse's tale of midwifing the sheep's birth - a story that usually is filed under the "wonder of life" - used to set-up Kate's impending death. However, like many of the wrinkles in Jesse's biography, it is to remind us that he is not a "bad" person. He has heroic instincts, whether it is helping his sister, delivering the sheep, or saving the homeless person from the warehouse. His bad behavior is due to his need for love and attention deprived from him because of Kate's illness.
His conversation with Kate shows that Kate is dealing much better with her impending death than her family is = acceptance. Jesse gives an example of bargaining.
  • pg. 325. "I suddenly remember an old game I used to play when I was nine or ten, and was allowed to ride my bike until it got dark. I used to make little bets with myself as I watched the sun getting lower and lower on the horizon: if I hold my breath to twenty seconds, the night won't come. If I don't blink. If I stand so still a fly lands on my cheek. Now, I find myself doing the same thing, bargaining to keep Kate, even though that isn't the way it works."
followed by anger . . .
  • pg. 326. "I stand up, with that lightning bolt branding the lining of my throat, which makes it impossible to swallow, so everything gets backed up like a dammed river. I hurry out of Kate's room and far enough down the hall where I won't disturb her, and then I lift my fist and punch a hole in the thick white wall and still this isn't enough."

  • pg. 327. "It's hard to be the one always waiting. I mean there's something to be said for the hero who charges off to battle, but when you get right down to it there's a whole story in who's left behind."
An example of resignation . . .
  • pg. 328. "There was a time when Jesse disappointed me regularly; eventually, I told myself not to expect anything from him, and as a result, it has gotten easier for me to take what comes."
Brian figures out what he should have known, and has been in denial about: Jesse is the arson who has been setting the fires and he puts it all together when he first visits his garage apartment. A confrontation ensues. It should be clear that this is not only an intervention for Jesse, but for Brian, too. Their problems are symmetrical.
  • pg. 331. "He is asking to be punished. So I do what I now 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 wasn't a genetic match, to the man he is now, and I guess this 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 toldhim otherwise? . . . Maybe it's because Jesse isn't all that different from me, choosing fire as his medium, needing to know that he could command at least one uncontrollable thing"

Above, I mentioned that lawyers are often portrayed in a negative light, but doctors in a positive light. I am not sure that this is fair and Campbell's delaying tactics while examining Dr. Chance reveals some of the tension and resentment.
  • pg. 333. "Doctors have this thing about being subpoenaed: they let you know, with every syllable of every word, that no moment of this testimony will make up for the fact that while they were sitting on the witness stand under duress, patients were waiting, people were dying. Frankly, it pisses me off. And before I know it, I can't help myself . . . whatever it takes to keep them cooling their heels just a few seconds more. Dr. Chance is no exception to the rule. From the onset he's anxious to leave. he checks his watch so often you'd think he was about to miss a train."
I think that when Campbell has Dr. Chance read the standard release form, the legal framework and protections that doctors take is more clear. On one hand, doctors render judgments that there is almost "no risk," but at the same time they want freedom from liability from all these "small risks." There is a debate about "defensive medicine" where doctors argue they overprescribe and overtreat because they are afraid of beign sued. Doctors often ignore the "market" dimension to their work - as if costs do not matter - and the legal aspect of their work - as if the law is unimportant, or just a technicality, when one is saving lives.
  • pg. 335. "'That's exactly why we have a consent form. It's to protect us from people like you,' he says. 'But realistically, the risk is extremely small. And the procedure of donating marrow is fairly simple.'"
The section wraps up with a discussion of parental influence on their children and we learn of one shared aspect of Anna and Campbell: they both grew up feeling "invisible" and that might be the link between the two in the novel and why they understand each other.

  • pg. 344. "'You don't know what it's like,' he says quietly, 'until your child is dying. You find yourself saying things and doing things you don't want to do or say. And you think it's something you have a choice about, but then you get up a little closer to it, and you see you had it all wrong . . . I didn't want to do that to Anna. But I couldn't lost Kate.'"
Campbell's legal strategy falls apart when Brian supports his wife, and not Anna, about the kidney transplant. Brian's breakdown on the stand is the first time he has cried about Kate's illness. There is a social norm that men are supposed to "be strong" in times such as these to reassure others, but they probably feel all the same emotions, strains, etc.
  • pg. 347. "'I've never seen my dad cry . . . My mom, she would lose it all the time over Kate. But Dad-well, if he tfell apart, he made sure to do it where we weren't wathcing.' 'Anna-' 'Do you think I did that to him?'"
Anna will have to testify, she is not keen on that idea.

SARA, Present Day
In her cross-examination of Brian, her husband, Sara and Brian have one of the first honest dialogues in a long while. They recreate themselves as people and not simply the mutual parents of a sick child.
  • pg. 352. "And in that moment, the strangest thing happens. Brian and I, facing each other and poles apart, flip like magnets sometimes can; and instead of pushing each other away we suddenly seem to be on the same side. We are young and pulse-to-pulse for the first time; we are old and wondering how we have walked this enormous distance in so short a period of time . . . Suddenly it does not matter that he has moved out with Anna, that he questioned some of the decisions about Kate. He did what he thougth was right, just the same as me, and I can't fault him for it. Life sometimes gets so bogged down in the details, you forget you are living it."
The estrangement of Brian and Sara seems to be resolved, and perhaps their estrangement from Anna, but there are other loose ends to tie up . . .

Julia notes another similarity between Campbell and Anna: they are both running away
    • pg. 361. "'You're cowards. You're both hell-bent on running away from yourself,' I say. 'I know what the consequences Anna's afraid of. What about you? . . . Where's the one-liner? Or is it too hard to joke about somethign that hits so close to the bone? You back away every time someone gets close to you. It's okay if Anna's just a client, but the minute she becomes someone you care about, you're in trouble. Me, well, a quick fk's just fine, but makign an emotional attachment, that's out of the question. The only relationship you have is with your dog, and even that's some enormous State secret.'"
For the first time, it seems that Campbell is going to tell us about the dog, but . . .

The testimony of Dr. Neaux is the first to really introduce the psychological benefits and harms beyond the physical benefits of the transplant. I tend to share Campbell's assessment of the testimony -- "psychobabble bullst," but there are ample examples of how the illness has psychological effects on each of the Fitzgeralds because of their illness and the disempowering effects of not being able to help Kate in her need.

A nod at Picoult's decision to use a "multiple perspectives" framework to tell this story through the metaphor of Julia's Guatemalan weave knapsack . . .
  • pg. 368. "Anna turns away, then reach down to pick up my knapsack for me. 'I like this. All the colors.' 'I saw old women weaving them, when I was in South America. It takes twenty spools of thread to make this pattern.' 'Truth's like that,' Anna says . . ."
Julia summarizes her recommendation to the court . . .
  • pg. 370-1. "'When I first was given this assignment two weeks ago . . . and I started to look at the dynamics of the family, it seemed to me that medical emanciapation was in Anna's best interests. But then I realized I was guilty of making judgments the way everyone else in this family does-based solely on physiological effects, instead of psychological ones. The easy part of this decsision is to figure out what's medically right for Anna. Bottom line: it is not in her best interests to donate organs and blood that has no medical benefit for Anna herself but prolongs her sister's life . . . It's harder to comep up with a solution, thoguh-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 withotu figuring out the best way to bring this into thte 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 . . I see no one in the Fitzgerald family who can make unbiased decisions about Anna's health care . . . Not her parents, and not Anna herself.'"

Julia cannot provide a recommendation, which does not move the plot along except that it prods Anna to testify for herself.

Anna does not like public speaking, she is "afraid of saying too much." So, what could Anna be hiding? Campbell is also not well, we are building to a climax where both their secrets will be revealed. Anna recounts how the original idea for the kidney transplant was broached. The key fact here is not Anna's or Brian's resistance, but Kate's
  • pg. 377. "'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 ting. Just leave me alone, will you?' My mother's face went white. 'Fine, Kate. Go ahead and commit suicide!' . . ."It's not suicide,' she said, 'if you're already dying.'" MAKES HER SEEM EGOCNETRIC AND HEARTLESS
As Campbell's dog is acting up, Anna reveals that it is Kate who convinced Anna to file the lawsuit, which is a surprise to everyone, and down goes Campbell . . .

A point that has been alluded to all along is that the dark, empty spaces might be the real drivers of the action, like the empty eye of a hurricane around which all the chaos revolves. That eye is Kate and Brian makes the connection first and at the same moment his instincts as a first responder kick into gear as he tries to help Campbell who is suffering from a grand mal seizure.
A key point here is how ashamed people can be of illness and how patients take their sickeness as a personal failure and hide it from those who may help them and therefore not getting the help they need. Campbell's dog is a "seizure dog" and his secret is out of the bag.

Campbell and Julia have their moment of truth; another thread is tied up.
  • pg. 384. "'You don't love someone because they're perfect . . . You love them in spit of the fact that they're not.'"
I don't think this is quite right. I would write tha we love others because they are imperfect, not in spite of their imperfections. It is impossible to love a perfect person or be loved by one.

Anna suggests another parallel between Campbell and Anna: they both know what it is like to not have control over their own body. Campbell's display also strengthens Anna's resolve to finish her testimony. She also realizes how he uses humor to call attention away from her illness as Campbell does to his own.
Kate's suicide attempts are detailed and Anna cries,
  • pg. 389. "'I don't want her to die, but I know she doesn't want to live like this, and I'm the one who can give her what she wants . . .I've always been the one who can give her what she wants.'" NOT EGO INTERNAL CONFLICT
There is guilt felt by those who suffer from chronic illnesses because they become aware of all the sacrifices made by their loved ones. As much as they want to live, they do not want their loved ones to suffer indefinitely. Understanding that death is inevitable is the stage of acceptance: it is going to happen, and one can die a "good death," as Anna notes
  • pg. 391. "'Anna,' Campbell says quietly, 'what made you think that Kate wanted to die?' 'She said she was ready.'

Many threads are tied for Kate, Sara, Anna, even Jesse, as he jokes with his sister. The truth is out in the open, this should be the end, but there are twenty more pages . . .

This is just a clam before the storm scene . . . The key point here is that Campbell reflects on how Anna has matured and grown through the process. Given what is about to happen, we know that Anna has had her own problems resolved.
  • pg. 400. "She doesn't look like an indecisive kid anymore, that much is true. She doesn't look selfish. She just looks like the rest of us-trying to figure out exactly who she is, and what to make of it. The truth is, as Anna once told me, nobody's going to win. We are going to give our closing arguments and hear the hudge's opinion and even then, it won't be over."

Foreshadows a plot "lighting bolt"

It's raining. As all the major characters are tied together by their common focus on the rain. All have a different perspective on a common experience


Probably the fullest statement of Sara's perspective, now fully aware. Too long to quote, but deep insight into her character, the perspective of mothers, and why they sometimes do crazy things.
Sara returns to the "burning building" metaphor Campbell laid out at the beginning.
  • pg. 406. ". . . you said none of us is obligated to go into a fire and save someone else from a burning building. But that all changes if you're a parent and the person in that burning building is your child. If that's the case, nott only would everyone understand if you ran in to get your child-they'd practically expect it of you.'"

Campbell is tempted to give an honest answer about his dog after his closing statement, but falls back into a wisecrack, but he is no longer hiding anything, and that is all the difference.

Judge DeSalvo: Quality of Life vs. Sanctity of Life.
  • pg. 409. "'The answer is that there is no good answer. So as parents, as doctors, as judges, and as a society, we fumble through and make decisions that allow us to to sleep at night-because morals are more important than ethics, and love is more important than the law."
While this may be true, it is beside the point and a cop out in my opinion by Judge DeSalvo, but he decides to give Anna her medical emancipation.

  • pg. 412. "'Ten years from now, ' I say, 'I'd like to be Kate's sister.'" NOT EGO-INTERNAL CONFLICT

And Campbell, Julia, and Anna are in a car accident, how deus ex machina. No spoilers.

Anna dies, but she saves her sister.

Kate reflects and wraps up the story and gives a glimpse of each person's future. THE END.