My Sister's Keeper by Jodi Picoult | Summary and Analysis


23 Mar 2015 14 Dec 2017

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Anna Transplant Kidney


Anna Fitzgerald

Anna is a 13-year-old girl from a middle-class family in Rhode Island. Her father, Brian, is a firefighter, and her mother, Sara, is a housewife who used to be a lawyer. Her two older siblings are Jesse and Kate. Jesse is an adult who has had a troubled past and lives in an apartment at the family house. Kate is 16 and has recuperated from leukemia, but the treatments have hurt her kidneys, and she needs a kidney transplant. Anna is a natural choice for the donor because she was conceived to help Kate medically and has made donations to her throughout her life. Anna seeks help from a lawyer, Campbell Alexander, to gain control over her body so she can stop being a donor to Kate. Anna is more mature than her age and often ponders deep questions about her sister's illness and her role in it. Anna struggles with her decisions, and even though she has her outbursts, she is very close to her sister, and at the hearing, she admits that it was Kate who made her decide to instigate the suit.

What seemed to be a selfish act of a child was really the love of a sister. Although Kate's illness has prevented her from having a normal life, Anna is close to Kate and the rest of her family. She is on the opposite side from her mother in the case, but they are still a close mother and daughter. Her father tries to look after her as well as Kate, and she bonds with Jesse because they both feel like they don't fit in. Anna's business relationship with Campbell grows into a more personal one. She is with him in the wreck that ultimately kills her. She does donate the kidney while dying and at Campbell's request. At the hearing, she stood up for herself and her sister and ended up saving her sister's life, anyway. Anna, who had always felt invisible in her family, ends up being a heroine.

Campbell Alexander

Campbell is the lawyer Anna Fitzgerald asks to represent her in her lawsuit against her parents. He seems cold and calculating at first by being single-minded about Anna's case and pandering to the media. He has a guide dog, but he will not explain the animal's purpose. He makes jokes when people ask him about it. His softer side is revealed through Julia, Anna's guardian ad litem, and the flashbacks to their teen romance. He is the product of a wealthy background with parents who are shallow. His epilepsy and, therefore, the reason for the dog, is revealed in court. Although he wins the case, he feels for both sides and when faced with deciding to donate Anna's organs, he makes sure Kate is the kidney recipient. He left Julia all those years ago because he did not want her to have to deal with his condition, but Julia chooses to stay with him. He marries her.

Sara Fitzgerald

Sara is a lawyer turned housewife. As Brian's wife and Kate, Jesse, and Anna's mother, she does everything she can to keep her family together. She is close to her sister, Suzanne, who is a career woman. She wants Suzanne to be her rescuer, and she wants Anna to be Kate's rescuer. She is totally focused on Kate's illness and wants to try every treatment possible. She either ignores Jesse or gets angry with him. It is her idea to get pregnant with Anna and for Anna to make donations. She is shocked when Anna sues her and Brian. Her temper and devotion to Kate make her a worthy adversary to Campbell in the courtroom. At first, Sara can not understand why Anna is doing this and estranges herself from Brian, but after all the facts are revealed at the hearing, she understands the conflicts involved and how Anna is her own person who can make her own choices and that Kate can make her own choices, too. She and Brian become a stronger couple, and she makes peace with Anna before her death. She was shattered by Anna's death and hoped for her return. Through her family, she healed.

Brian Fitzgerald

Brian is a dependable husband to Sara and father to Kate, Jesse, and Anna. He is a firefighter who loves his job. His hobby is astronomy, and he makes astronomical references that can relate to his own life. When Anna sues him and his wife, he is surprised but wants to support Anna. He moves her into the fire station so she can have some distance from the home situation. This puts a strain on Brian and Sara's marriage, and they just talk about the medical issues. His decision to testify for Anna at the hearing does not help matters. At the hearing, however, he changes his mind and wants Anna to donate. Brian is really conflicted on the matter. He is not only a rescue worker; he likes to rescue everyone around him, and in this case, he cannot. Even though his sister-in-law Suzanne can help the family financially, he wants to be the provider. He is the only one who learns Jesse is the arsonist and sets him on the right path. He grows closer to his wife as they learn how the medical issues have overshadowed their marriage. He develops a drinking problem after Anna's death but conquers it.

Jesse Fitzgerald

Jesse is the oldest child in the Fitzgerald family. After his sister is diagnosed with leukemia as a toddler, he is still a child himself and often has to give up events for Kate. After Anna's birth, he feels useless because he is the sibling that cannot help. He acts out in school and is on a downward spiral into drugs, alcohol, stealing, and arson as he grows up. He tries to project the rebel image around his family, Julia, and Campbell, but his actions show his softer side. He donates platelets to Kate anonymously. He helps Anna out by taking her to the lawyer's office and when visiting Kate. Brian finds out Jesse is the arsonist, and Jesse has a breakthrough. He plays with fire because he can control it. Fire is a theme in the book, and Jesse shows the negative side of fire. He becomes a police officer and wins an award. He transforms himself from a destroyer to a rescuer.

Julia Romano

Julia is the guardian ad litem assigned to represent Anna in the hearing. She has to make a report about which side she supports. She was a rebel as a teenager from a large, poor family and has turned into a responsible adult. She is close to her twin sister. Close sisterly relationships permeate the book, including Anna and Kate's and Sara and Suzanne's. She had a romance with Anna's lawyer, Campbell Alexander, as a teenager despite their class differences. She was hurt when Campbell abandoned her. As she works with him on Anna's case, she is attracted to him even though she tries to resist it. She is good with Anna and Kate because she talks to them like they are real teenagers. At the hearing, she is unable to pick a side. She finally learns why Campbell left her after he has a seizure at the hearing. When she finds out he has epilepsy, she refuses to abandon him. They get married.

Kate Fitzgerald

Kate is diagnosed with leukemia as a toddler. When her brother, Jesse, does not match her for bone marrow donation, their mother Sara has the idea to get pregnant with a baby who is a genetic match for Kate. Anna is born, and she donates to Kate on several occasions. Kate struggles with being a normal teenager and having cancer because her appearance is affected, and her first boyfriend had cancer and died. At 16, Kate is cancer free, but the treatments have affected her kidneys, and she needs a kidney transplant. It is assumed Anna will be the donor, but she files a lawsuit to gain control over her body so she can stop donating. Anna reveals at the hearing that Kate was suicidal and urged her not to donate a kidney. Kate wanted her sister to be free of obligations to her. The judge rules for Anna, but after Anna dies in a wreck, Kate gets Anna's kidney. She recovers and becomes a dance teacher. She had told Julia she wanted to be a ballerina because she could have control over her body.

Duracell Dan

He is the homeless man Jesse bribes to keep his arson materials. He is with Jesse at one of his fires and tells Jesse a homeless man is in the burning building. This forces Jesse to save the man.

Suzanne Crofton

Suzanne is Sara's older sister. She is a single, career woman who lives a different life than Sara. She is a support during Kate's illness and even tries to help financially.

Vern Stackhouse

Vern is a sheriff and friend of the Fitzgerald family. He serves Sara with papers related to Anna's lawsuit. He is around during the hearing and provides assistance to the family and Campbell.

Isobel Romano

Isobel is Julia's identical twin sister and roommate. She had a bad breakup and cautions Julia against Campbell. Toward the end, Isobel and Campbell seem to come to an understanding.


Providence Hospital

This is where Kate is diagnosed and has her treatments and other stays. Anna is also a patient here as a donor. Her birth and death occur here.

The Fitzgerald House

This is the home of the Fitzgeralds where Brian, Sara, Kate, and Anna live. Jesse lives in an adjoining apartment.

The Fire Station

This is where Brian works and where he and Anna live to give Anna some distance from her mother and the case. The rooftop is a favorite place to watch the stars.

The Locket

Brian gives the locket to Anna as a child after one of her donations. It is a thank you present for helping Kate. Thirteen-year-old Anna sells it at a pawnshop to raise money for attorney fees.

The Courthouse

This is where the hearing is. Campbell and Anna's secrets are revealed here.

Campbell Alexander's Office

Anna first meets Campbell here to initiate the lawsuit.

Dr. Chance's Office

This is the office of the oncologist that diagnoses and treats Kate. The idea for Anna's conception begins here. It is also where Anna's donations are suggested.

Duracell Dan's Hideaway

It is an underpass where a homeless man lives. He stashes the materials Jesse uses for arson.

Jesse's Apartment

The apartment is part of the Fitzgerald house. From items in the apartment and other clues, Brian figures out that Jesse is the arsonist. This is where he confronts his son.

The Wheeler School

The Wheeler School is the private high school where Campbell and Julia met.

Julia's Apartment

Julia lives here with her twin sister, Isobel. This is where she and her sister talk about Campbell.

Campbell's Apartment

Campbell's apartment is very sterile and high tech. It seems to reflect his personality. Julia reveals she does not like it, and he agrees.

Shakespeare's Cat

Julia goes to the gay bar Shakespeare's Cat to forget Campbell.

Hercules the Goldfish

A pet Kate got for her birthday. Sara saves him from near death a couple of times.



Fire is a common theme in the book, and it ties much of the plot together. The passages that preface each section concern fire. Brian is a firefighter. Jesse sets fires. Kate's illness can be compared to a fire because it is out of control and destroys everything in its path. Anna compares her initiating the lawsuit to fire. Brian says a fire should be allowed to burn unchecked. He is referring to Kate's illness in that they should let it run its course without interference. He uses fire to make points in conversations with his coworkers. Brain connects fire to the story of Pandora 's Box and hope. Hope is what he has left as Kate's father. He is trying to put out the home fires, which include Kate's illness, Anna's lawsuit, Sara's stubbornness, and Jesse's troubles. Julia puts out the fire Brian starts in the kitchen; and in her role as guardian ad litem, she tries to put out fires. She also rescues Campbell.

People that put out fires are rescuers. Characters in the book fill the rescuer roles. Brian is a rescuer on the job and in his family. Anna is Kate's medical rescuer. Campbell points out at the hearing that people are not obligated to rescue by sharing a story of a homeless woman who let people die in a fire. Suzanne is Sara's rescuer. Jesse goes from arsonist to rescuer. At the hearing, it is revealed that Kate wanted to be Anna's rescuer for once.

At the end of the book, it rains, and this puts out the fires of the characters burning throughout the book. Jesse's inner fire is put out with Brian's help, and he redeems himself. Kate's fire is stopped, and she becomes healthy because of the kidney transplant. Campbell and Julia's fire is contained because they reunite. Sara and Brian's fire from Kate's illness and Anna's lawsuit and death is also contained, and they become a stronger couple.


Brian's hobby is used to make points throughout the book. Some of the passages preceding the sections make astronomical references. Anna's real name comes from a constellation named Andromeda, whose story is she is punished because of her mother, but she is rescued. The constellation resembles arms tied together. This can be applied to Anna's story because her mother is pressuring her to donate, but with the hearing and the wreck, Anna is rescued. Brian's talking about watching supernovas dies is comparable to the family and others watching Kate die. The story of Orpheus illustrates how death is inevitable. Sara continues the theme by comparing Kate's sick face to the moons Brian likes, moons that are "still, remote, cold."(118) Anna refers to the pleasant memory of catching stars after learning she can stay at the fire station. The punctuation of meteor showers during Brian and Anna's conversation symbolizes what is hard for them to say. Anna compares astronomy maps to trying to find direction in her own life. Anna talks about astronomy to Campbell during the hearing. She talks about how stars are there even if one cannot see them. This applies to how oblivious parents, especially Anna and Campbell's, can be to their children.

Brian feels he lives on a different planet because of the situations of Anna and Jesse. He talks about cultures looking between the stars and realizes he has been looking at the wrong things. While rescuing Campbell from his seizure, he thinks about how astronomy of the past makes astronomy today inaccurate and says it is because the earth's axis shakes. This tells the reader the life-shaking events of the book such as Kate's illness and Campbell's condition affects the perceptions of the people involved. After Anna's death, Brian thinks about how the brightness of a star can overshadow another star, and when the other star is seen, it is too late. This applies to how Kate overshadowed Anna, and when Anna finally asserts herself, she dies. After Anna's death, Kate reveals that her father said he could see Anna reincarnated in the stars.


The characters in the book play different roles. Anna is in the donor role for her sister when she would rather be in the role of a teenager who has friends and plays hockey. The lawsuit is Anna's way of resisting her lifelong role. Throughout the book, she imagines herself in outlandish adventure roles, and after winning the hearing, Campbell thinks she will have fantastic roles in 10 years. Anna concludes that that the role she wants most is to be Kate's sister.

In the hearing, it is revealed that Anna does not mind playing the donor role, but Kate is tired of being the recipient. By getting Anna not to donate a kidney, Kate can be Anna's savior, and they would have reversed roles for once.

Jesse point out to Anna before she begins the lawsuit that the siblings have their own roles in the family--he as the troublemaker, Kate as the martyr, and Anna as the peacemaker. Jesse changes roles by the end of the book. At first, he does not see himself as a rescuer because he cannot rescue Kate. After he has a breakthrough with his father, he goes from arsonist to police officer or savior.

Sara and Brian's roles go beyond being parents. Sara wants to play the savior role for Kate, but she has to get Anna to play that role. She demonstrates that she expects sisters to help each other as her sister, Suzanne, helps her. Sara has conflicts with the mother/lawyer role. After the lawsuit begins, Sara tries to balance being a mother to Anna and a lawyer on the opposing side of the lawsuit. This is a constant struggle until Sara realizes she is a good mother, and she should not try to save her children from themselves. Brian is the savior and mediator as he tries to save everybody in the family and acts as a buffer between Anna and Sara.

Campbell has the lawyer role as he panders to the media and questions the witnesses at the hearing. He could be seen in a rescuer role as he rescues Anna from donating to Kate. He also has the romantic role with Julia, but this does not come to fruition until the end of the book after his secret is revealed. Julia has a mediator role as Anna's guardian ad litem and a romantic role with Campbell after she learns the truth. Julia's role as a sister is shown with her twin, Isobel.

Ethical Dilemmas

At the heart of My Sister's Keeper is an ethical dilemma: Should thirteen-year-old Anna be forced to give her kidney to her dying sister? Through much of the novel, it seems like Anna does not want to give Kate her kidney because she is tired of being a store of spare parts for Kate. Since she was born, Anna has undergone a number of painful procedures to save Kate's life. Kate suffers from cancer and conditions related to the illness and its treatment. Her family's life has been focused on Kate's illness and its potential recurrence during times of remission, since before Anna was born.

Indeed, Anna was created to be a perfect sibling match for Kate. The Fitzgeralds went to a geneticist who created several embryos with the couple's sperm and eggs, then figured out which one matched Kate. That embryo was implanted in Sara and became Anna. At the time, there was public controversy over their decision because Anna was seen as a "designer baby." The ethical debate led to a talk show appearance for the couple, as well as hate mail.

More than anyone else in the family, Sara sees no ethical dilemmas, neither in how Anna was created nor in making Anna suffer to try to keep Kate alive. Sara only responds to the latest crisis and the best solution at hand. When necessary, taking from Anna to give to Kate is no dilemma for her. The result is that Kate has lived longer than her doctor ever expected, but at the cost of a balanced family. The needs of Kate and her illness are put above all else, with Sara diligently guarding those interests at the expense of her husband and other children. Even Julia, the court-appointed guardian of Anna's interests, cannot make a decision on what should be done.

Anna's lawsuit brings all these issues and the ethical dilemma to the forefront. With Campbell acting as her lawyer, she seeks the right to decide whether she gives up a kidney. Anna's true motivation in her quest for medical emancipation is yet another ethical dilemma. As she reveals on the stand during the hearing, the reason that Anna has brought the lawsuit was for Kate's benefit. Kate cannot tell her mother that she does not want to have the transplant. Kate is aware of the toll her illness has had on everyone and she seems tired of fighting. In fact, she has tried to kill herself before. This situation brings up the ethical dilemma: Should Kate be allowed to die when a measure can be taken to save her life?

None of these ethical dilemmas is allowed to reach its full conclusion in the story. The novel ends with Anna suffering an injury that leads to brain death. As executor of her medical rights, Campbell authorizes the kidney transplant. Kate's cancer goes into remission, and she has a normal life. But she knows that she is alive because Anna died. She believes that one sister had to die for the other to survive, another ethical conundrum.


One issue that shapes many of the characters and situations in the novel is that of control. Nearly every major character in My Sister's Keeper is looking for control over some part of their existence in the face of disease. Anna, for example, seems to want to control her body and what is taken from it as evinced by her lawsuit. While it is later revealed that she actually filed the suit at Kate's behest, Anna is still looking to control the situation to give her sister what she wants. Anna knows she cannot control her mother, her family, or her sister's illness, but she seeks control of her own destiny.

Kate and Sara would like control of the opposite sides of the same coin. Kate wants to control her existence and the toll she puts on her family. She would like to become a ballerina if she grows up because she believes they have control over their bodies. Sara has spent her life since the diagnosis of Kate's cancer trying to control the disease as well as Kate's life. Sara has done everything in her power, including creating Anna, in an attempt to control Kate's destiny. Sara has controlled all she could to keep Kate alive, without truly examining the consequences to herself and her family.

One of the costs of Sara's focused assault on Kate's disease is the loss of closeness with Jesse. Both Brian and Sara have given up on Jesse, who repeatedly acts out. He loves his sisters and has done what he can to keep Kate alive, most notably giving his blood regularly to boost her platelets. But he has also moved into an apartment over the family garage to be separate from, yet still part of, his family. He sets fires to get attention and to feel a sense of control over something. Jesse knows the fires, car theft, and substance abuse are all masks for his pain, but he needs a parent to care about him. Brian reclaims control over his son when he finds evidence that Jesse set fires.

Anna's lawyer, Campbell, is also obsessed with control. He has suffered from epileptic seizures since the age of eighteen, but he keeps his condition a secret. Whenever someone asks why he has a service dog, he gives an obviously untrue answer. He allowed his condition to end his high school romance with Julia without telling her why. He controlled the situation because he believed she should be free of the burden of caring for someone with his condition.

Familial Bonds

The importance of familial, especially sibling, relationships is another underlying theme of My Sister's Keeper. Despite all the problems created by Kate's illness and Sara's quest to keep Kate alive, the Fitzgeralds remain a family. Though Brian and Sara have their problems, they work together to keep the family together amidst the disruptive force of Kate's illness. Even Jesse, the delinquent son, still lives at home and is there to help out when Kate is ill or Anna needs his support.

In turn, Anna helps her brother get out of jail when he is arrested for stealing the judge's vehicle. Anna also does all she can to help her sister. While the pair squabble as sisters do when they share a room, Anna files the lawsuit to give Kate what she wants. All the siblings resent what has happened to them, but respond to the needs of the others in their family when the situation calls for it. After Anna's unexpected death, the family grieves separately but eventually grows closer again.

Like Kate and Anna, Julia and her twin sister, Izzy, are close. Julia allows her to move in after a painful breakup. Izzy wants to protect her from Campbell. While Campbell's relationship with his parents is not close at all, it serves as an illuminating contrast to the Fitzgeralds and the Romanos.


Point of View

Each chapter in the book is told from the first person point of view. All the main characters narrate a chapter. They even have their own fonts. Picoult could have made this Kate's story since it is the central issue, but she allows the characters to share their own stories. Kate has one chapter, and it is the final one. The other characters have more than one chapter each. The reader can see the effects of Kate's illness on the Fitzgerald family. Everyone in the family despairs about Kate's illness and Anna's lawsuit, but they have different perspectives. The reader sees Campbell and Julia's thoughts on the lawsuit and also their feelings about each other. By viewing Anna's thoughts, the reader can see she does not take her decision to sue her parents lightly and that she is smart and perceptive. Jesse seems like an unlikable person, but his thoughts and actions show his pain over Kate's illness and his helplessness.

The reader sees Sara's desperation to heal Kate at all costs and the epiphany she has during the hearing. The author shows Brian's conflict over supporting his children when the family is in a divisive crisis. Campbell's tough side as a lawyer and softer side with Julia are in his chapters. His growing friendship with Anna is shown. Because of the mystery of the guide dog, the reader wonders what Campbell's medical problem is. Julia is able to see the Fitzgeralds objectively, so the reader gets an unbiased stranger's view. After the intertwining of the character's viewpoints, the chapter from Kate's point of view is surprising and enlightening. Up until her chapter, she was always a character seen by everyone else.


The book is set in Providence, Rhode Island. The medical settings are Kate's hospital room and Dr. Chance's office, which are both located in Providence hospital. Although Kate goes through tough times in her hospital room, Anna goes there to visit her sister despite the lawsuit. It is in Dr. Chance's office that Sara gets the idea of having another child. His suggestions of how Anna can donate to Kate start there. The hospital is where Sara finds out about the lawsuit. The Fitzgerald house, which includes Jesse's apartment, is another setting. It is in the house where Kate's leukemia signs begin, and she has other medical problems there. The house is where family arguments such as between Kate and Sara take place. Brian finds materials around the apartment that make him realize Jesse is the arsonist. The homeless man, Duracell Dan's, place at the underpass is where the rest of Jesse's materials are kept.

Campbell and Julia's flashbacks are at the Wheeler School, which is a private high school in Rhode Island where they met. The class differences between Campbell and Julia and the other students' reactions to their relationship occur at the school. Campbell's apartment is part of the story because it is described as being modern and up-to-date but not warm like Campbell at first. Julia tells Campbell after they reconcile that she does not like his apartment. Julia's apartment is where she and her sister discuss Campbell. Julia goes to a bar called Shakespeare's Cat to try to escape Campbell.

The fire station is a setting where Brian works, and he and Anna live to get away from the lawsuit at home. The fire station is a rescue place in different ways. Not only does it house the firefighters, but it also gives Brian an escape from the house and medical drama. On the rooftop, he can practice his astronomy hobby. Anna escapes there to get away from the pressures of her mother and the lawsuit.

The courthouse is where the hearing is held. Campbell's secret is revealed there, and the truth behind the lawsuit is also revealed there.

Some settings serve as places that save the characters. The hospital obviously saves Kate's life. The fire station saves Brian and Anna. The courthouse saves the Fitzgerald family and Campbell and Julia's relationship.

Language and Meaning

At the beginning of each section, the language of passages from famous works refer to the book's situations and themes. Anna's first memory story's language sets the tone for the rest of the book.

The language in the main part of the book is simple, but medical terms are used often. They are well explained. Sara, Kate, and Anna have as much medical knowledge about Kate's condition as anyone else. Sara uses medical language to try to save Kate. Kate uses it, along with the language of a frustrated teenager, who is concerned about appearance and dating. Anna also mixes it with her own concerns about her life outside Kate. Legal language is used in the petition and in the hearing. The medical language helps Kate, but the legal language helps Anna. Sara analyzes words as she ponders situations. For example, she talks about how there is no word for a parent whose child dies. (703) Anna tries to figure out language, too. Brian and Anna use the language of astronomy and legends in an attempt to figure the world out. Brian uses his firefighter language to demonstrate situations.

There is a combination of characters' thoughts and dialogue. Because of his medical knowledge as a rescue worker, Brian's thoughts let the reader know what is wrong with Campbell. Julia's language with the Fitzgeralds is that of the mediator, which is part of her role as guardian ad litem even though she is not as conciliatory toward Campbell. The characters' thoughts allow the readers to understand them; their dialogue does not sufficiently describe the characters. For example, Anna's thoughts reveal her maturity beyond her 13 years. Jesse projects a tough-guy image to everyone with crude language, but his thoughts reveal his softer feelings about his family. Campbell is similar in that he acts like the tough lawyer, but his flashbacks to Julia and his present-day thoughts unveil his romantic side.

Getting ready for the last day of the trial, Campbell, Brian, Jesse, Anna, and Sara note that it is raining at the beginnings of their chapters. These words quench the fires that have been raging in the book.


The chapters are not numbered. They are titled by the character's names. There is a prologue with a quote and then a short story by Anna. The sections are started by a day of the week and a passage. Sara's chapters are flashbacks titled by years until her chapter called Present Day where she joins the present. She begins with Kate's diagnosis and goes through the milestones of Kate's illness. Campbell and Julia's chapters are in the present, but they have flashbacks to their time together in high school. There is an epilogue by Kate set in a time in the future.

The plot zigzags back and forth between the present and the past; it depends on the speaker. The book chronicles the events of the Fitzgerald family out of order mainly after Kate's diagnosis: Anna's birth; Anna's donations; Anna, Kate, and Jesse's childhoods; and the hearing and its aftermath. Campbell and Julia's professional and personal stories and sections of the past about their teen relationship are mixed in.

Multiple Points of View

One striking feature of My Sister's Keeper is the way Picoult uses multiple first-person narrators to tell the story. A first-person point of view tells the story from one character's perspective in his or her own voice. Each section in the novel is made up of parts designated by the name of the character whose voice and perspective is being revealed. Picoult emphasizes the differences in these voices through the use of different fonts for different characters.

The use of multiple voices allows readers the ability to understand the situations from different standpoints. The way Sara sees Kate's cancer and Anna's lawsuit is quite different from Anna's viewpoint, Jesse's position, and Campbell's and Julia's judgment. The result is a rounded, dramatic narrative.


Several characters use flashbacks and flash-forwards as part of their narratives. Flashbacks look back in time, while flash-forwards describe future events. The only major character in the book who does not get a voice in the main chapters is Kate. She speaks only in the prologue and epilogue, eight years after the novel's end. In the prologue, she talks about how she imagined killing her sister and that she only existed in relation to Anna. In the epilogue, Kate describes what happens after Anna's death.

Most of Sara's chapters present flashbacks. In each chapter, she primarily describes Kate's illnesses and treatments, but she also includes some information about her family. She begins with when Kate was diagnosed with cancer, then goes through each relapse, until she reaches present day and the court case. These flashbacks show Sara's increasing tension and desperation to keep Kate alive.

Campbell also incorporates flashbacks in his sections. When describing his teenage relationship with Julia, his flashbacks are set in italics. In these memories, Campbell describes how the relationship got started, what kind of people he and Julia were as teens, and important events in their romance. The flashbacks emphasize the importance of the relationship for Campbell, while underscoring how remote it is in his everyday life.

Heroes and Anti-heroes

In My Sister's Keeper, Picoult contrasts the actions of heroes with those of anti-heroes. A hero is a primary character that displays commendable traits such as courage and integrity. Anna is a heroine because she takes action to give Kate what she wants. The whole point of her lawsuit is to bring her sister peace, though it costs Anna much in her life. Characters like Jesse and Campbell can be defined as anti-heroes. Anti-heroes have the reader's sympathy despite their flaws, and while not villains, see themselves as social outcasts, distrust the world, feel helpless, and lack courage and integrity. Jesse defines himself by his rebellious acts: arson, drug use, stealing cars, and supporting Anna's seemingly mutinous lawsuit. Though he does some good things, most of his time and energy is spent in self-destructive, self-serving acts.

Campbell is better adjusted than Jesse, but he bucks the system in his own way. He takes on Anna's case primarily because of the publicity it will bring him. Campbell wants to win the case, not necessarily because it is the best thing for Anna, but because it is a challenge. He also is dishonest about who he is to nearly everyone. Many people ask about the dog, but it is not until Campbell has a seizure in court that he admits to having epilepsy. Campbell also bowed out of his relationship with Julia years earlier, and he does not tell her why he ended it until she sees his seizure. Campbell keeps the world at a distance with cold and cowardly behavior.

Historical Context

Designer Babies and Genetic Planning

In interviews describing the origin of My Sister's Keeper, Picoult talks of a news story from 2000. On August 29, 2000, Adam Nash was born. He was considered the world's first "designer baby." Like Anna in the novel, Adam was conceived for a specific purpose. His six-year-old sister Molly had an uncommon type of anemia, a genetic disease called Fanconi anemia (FA), in which the body cannot make healthy bone marrow. Doctors gave the child only a year to live. Medical professionals recommended to her parents, Jack and Lisa Nash, that the best chance for Molly to survive was to receive stem cells from a genetic match. Though the couple could conceive naturally, fifteen embryos were created via in vitro fertilization (IVF) with the couple's sperm and egg in a laboratory. Two embryos were perfect matches, and one was implanted in Lisa Nash. It became Adam.

After Adam's birth, stem cells from his umbilical cord blood were transplanted into Molly. Doctors hoped the stem cells would become bone marrow inside Molly and give her a functioning immune system. Though the transplant worked and Molly recovered, the means of and reason for Adam's creation became an international controversy. There were two ethical issues involved: Should anyone be created just to provide assistance to someone else, and should embryos be screened for selected traits?

Critics saw such genetic planning as a new form of eugenics and a violation of natural law. Others believed it would lead to parents screening embryos for characteristics such as eye color and intelligence. Some medical professionals raised the question of how the family would feel about the child if his donation did not have the desired effect. Lisa Nash was certain she did the right thing, telling Josephine Marcotty of the Minneapolis Star Tribune, "This technology had to be brought to the forefront so people with Fanconi anemia or any other [genetic] disease know there is a way to have a healthy child."

Because of the success of Molly's transplant, some experts believed that more and more embryos would be subject to pre-transplant genetic diagnosis (PGD). PGD was developed in the early 1990s by scientists working in Great Britain and refined over the next decade. In this procedure, "cell clusters" created by in vitro fertilization are examined for genetic markers. In 2000, about twenty-five genetic diseases could be identified by PGD. Between August and October 2000 alone, at least three hundred babies conceived with IVF in the United States underwent PGD. However, there have only been a few cases worldwide similar to the Nash family's. For example, in 2002, a couple in Leeds, England, was given permission by the British government to screen an embryo to be free of the faulty gene which cause thalassaemia, a disease of the red blood cells, so that the resulting infant could be used to help an older sibling.

Not all parents are using genetic planning for the interests of other children. A 2002 article in Washington Monthly cites a deaf lesbian couple who only wanted a congenitally deaf sperm donor so they could have deaf children. Both of their children were born deaf. Their choice contributed to the debate over genetic planning for children. Observers worry that parents will want to control their children's appearance using such genetic testing, as well as gender, personality, interests, and sexual orientation. Genetic enhancement is also another possibility as PGD and similar techniques are refined and enhanced.

In an editorial piece in the British publication the Spectator, Bryan Appleyard brings up a central issue to the debate over designer babies, one touched on in My Sister's Keeper. He writes,

We will ... design our babies. They will certainly be no better than us and, with luck, no worse. The best we can hope for is that, having designed them, we can still find it in our hearts to love them. But that, I think, may turn out to be the real problem.

Guardian Ad Litem

In the novel, Julia acts as a Guardian Ad Litem (GAL) for Anna in her case against her parents. The Latin term means "guardian at law." GALs are appointed by the court and ensure their clients receive due process and have their feelings and opinions known in court. A GAL is usually a lawyer, but can be any adult who has received special training. The latter are usually called Court Appointed Special Advocates (CASA) or Volunteer GALs. In Rhode Island, the setting of My Sister's Keeper, the GAL speaks on behalf of the interests of a minor child or adult with special needs in court cases.

The use of GALs became widespread in the United State after the federal Child Abuse Prevention and Treatment Act was passed in 1974. This law requires the use of GALs in court cases involving abuse or neglect of a child. States will not receive federal funding for child abuse and neglect prevention and treatment programs unless they provide GALs for such children. It took several years for the use of GALs to be widespread in the United States, though the level of compliance from state to state is inconsistent.

Critical Overview

Like many of Picoult's novels, My Sister's Keeper was generally embraced by critics for its gripping exploration of emotionally complicated issues. For example, Tom Jackson of the Tampa Tribune represented the sentiments of many reviewers, declaring "My Sister's Keeper is a gut-wrenching, melancholic work designed to linger in the minds of its readers long after they have finished it." Others, such as Kim Uden Rutter of the Library Journal, called it "timely and compelling."

Many critics praised the way Picoult presents the story's dilemmas. Jennifer Reese of Entertainment Weekly commented, "My Sister's Keeper crackles when the characters wrestle with unanswerable moral questions." Similar sentiments were expressed on the Picoult's construction of the novel. While Andrea L. Sachs of People Weekly commented, "Picoult's style borders on the poetic," Robin Vidimos of the Denver Post noted, "It's a busy story, but Picoult keeps all the balls in the air and the story moving at a good clip. This book may be Picoult's breakout book, moving her from a book-group favorite to a wider audience."

A number of reviewers took issue with the number of narrators used. For example, Tamira Surprenant of Capital Times (Madison, Wisconsin) wrote:

The device is effective to a certain degree, and My Sister's Keeper is a quick and enjoyable read, but there are almost too many narrators. The story would not have missed a beat if the romantic interests of Anna's attorney had been left out.

Some critics, like Katherine Arie of the Washington Post, were also critical of the novel's pacing, though she felt multiple narrators were necessary to fully understand the story, noting:

The novel's shifting points of view also help to add depth to a cast of characters who would otherwise seem rather thinly drawn. Without this device, Anna's mother could become a one-sided study in shrill desperation, and Anna's lawyer, Campbell, could be mistaken for a base egomaniac.

Reviewers were divided about the effectiveness of the subplot involving Campbell and Julia. Some found the storyline out of place. Echoing such sentiments, Sara Kuhl in the Wisconsin State Journal noted, "The relationship is distracting." Entertainment Weekly's Reese added, "Soapy discursions like this dilute the effect of Picoult's sharp central narrative." Still, several critics found Campbell to be necessary to the balance of the whole novel. For example, Jeanne Ray of the Boston Herald noted, "Some much-needed comic relief arrives with Campbell."

A few critics dismissed My Sister's Keeper outright. Meredith Blum of the New York Times Book Review saw the book as a "soap opera," and as "some awkward combination of a sci-fi novel and a movie on the Lifetime Channel." However, most reviewers agreed with the point of view expressed in the Kirkus Review: "The author vividly evokes the physical and psychic toll a desperately sick child imposes on a family." The review concluded, "There can be no easy outcomes in a talk about individual autonomy clashing with a sibling's right to life, but Picoult thwarts our expectations in unexpected ways."

Critical Essay #1

Petrusso is a history and screenwriting scholar and freelance writer and editor. In this essay, Petrusso argues that while the surprise ending to My Sister's Keeper is controversial among critics and readers, it is logical to the story and underscores major ideas and themes in the novel.

In many reviews of Jodi Picoult's My Sister's Keeper, critics object to the way the novel ends. The last fifty pages or so feature a somewhat unexpected climax and a most stunning conclusion. The climax nears when Anna finally agrees to take the stand and explain why she filed the lawsuit. Throughout the text, it seems like the thirteen-year-old has taken her parents to court to win control over her own body because she does not want to donate a kidney to her sister, Kate. Anna testifies that she filed for medical emancipation as a favor to Kate, so that the cancer patient can end the many treatments that have extended her life. Kate wants be allowed to die of the renal failure already so close to taking her life. After the drama temporarily increases because of Campbell's seizure in the courtroom, there are a few pages of calm as Julia and Campbell's subplot is resolved.

Back on the stand, Anna reveals that Kate did not want to live and why. Though their mother, Sara, can barely fathom Anna's explanation, Kate does not want the kidney that Anna is prepared to donate. On the stand, Anna says, "It was so she wouldn't have to go through this anymore. I thought it was what she wanted." A few lines later, Anna adds, "It was ... it was what I wanted, too." Anna also comes to terms with her feelings, thinking, "in addition to the piece of me that's always wanted Kate to live, there's another, horrible piece of me that sometimes wishes I were free." Anna is ashamed of her thoughts, but Campbell helps her realize that perhaps Kate understood that Anna needed to be free, too, and that was one reason why she was prepared to die.

After Judge DeSalvo talks to Kate, he grants Anna's medical emancipation in the climax of the novel. The aftermath of this decision, however, turns the novel on its head and defies readers' expectations with a plot twist at the novel's resolution. While riding in a car with Campbell after signing the necessary paperwork, Anna ponders her future and hopes that Kate will be a part of it. Readers then learn that a car accident takes Anna's life and injures Campbell and his service dog, Judge. Because Campbell holds Anna's medical power of attorney, he donates the brain-dead girl's kidney to her sister. Readers then learn in the epilogue that Kate survived and her cancer went into long-term remission. Readers also realize that it was Kate's unlabeled voice in the beginning saying, "In the end, though, I did not kill my sister. She did it all on her own. Or at least this is what I tell myself."

Critics are divided on the effectiveness of this ending. A number of reviewers see it as unsatisfying and a cop-out on Picoult's part. The critic in the Kirkus Review calls it a "too-neat twist," while Andrea L. Sachs of People Weekly states, "The ending could be a bit more courageous." Other critics regard the twist as a plus. Sara Kuhl of the Wisconsin State Journal writes, "the book's ending is satisfying and most importantly, makes the reader think about the delicate web of life."

Two reviewers in particular raise interesting points on both sides of the issue. In the New York Daily News, Sherryl Connelly notes, "It's only at the story's close that [Picoult] skirts the very issues she's raised." In contrast, Tom Jackson of the Tampa Tribune writes:

Some have called the shocking twist of an ending an avoidance of the very issues Picoult raises, but the author herself claims it was inevitable and "fictionally necessary." Besides, it is the rare conclusion that causes a reader to revisit the prologue, and this one does precisely that.

Connelly has missed the point of My Sister's Keeper. The ethical and moral medical dilemmas are important to the story, but they are not its primary theme. While the novel is ostensibly about Anna fighting against being forced to give Kate a kidney, Picoult focuses most of her attention on the Fitzgerald family itself. Kate's illnesses are only a conduit for Picoult to explore the emotions in and dynamics of the family. Family is at the core of the book, not cancer. Numerous choices that Picoult made in the novel's construction, characterizations, and plot lines underscore this position.

For example, mother Sara has essentially missed the point of having a family. She has moved from crisis to crisis with Kate, without seeing how to spread her love and creating togetherness among the rest of the family. Even though times that Kate's cancer is in remission are presented as less stressful, Sara is constantly on guard for any recurrence. Not only does Sara know little about Jesse and Anna, but she does not even know much about the child she is trying to save because she never asks Kate what she wants. Sara has kept Kate alive for the next medical crisis, creating her own constant worry, and continually alienating both her husband and other children in small, but significant, ways. Yes, Sara has done the best she can under impossible circumstances, but she has an epiphany in the courtroom listening to Anna. Sara later apologizes to Kate, but still believes what she did was right.

To make certain that Sara, especially, truly understands the fragility of life, one of her daughters had to die by novel's end. Picoult foreshadows this scenario in the prologue. Readers know one of the sisters will die, and it seems logical that it would be Kate. However, the prologue makes it clear that it is not. When reading the book for the first time, a reader might note that there is no label on who is speaking in the prologue after noticing every part of each section begins with a name of whose voice and perspective is therein. Being drawn into the action of the novel, it is easy to forget that the person in the prologue is anonymous until the end. The epilogue is labeled "Kate: 2010," about eight years after the novel ends. Only then does the prologue become key to fully understanding what happened in the book, as Jackson notes.

The prologue and epilogue are also important because they are the only times that Kate speaks, and then only after Anna has been long gone. Kate is the only major character without a first-person voice and perspective in the main section of the novel. As in her family, everything in the novel revolves around Kate, but she is not heard. Her words are filtered through everyone else's opinions, wants, needs, desires, and expectations. While Anna listens to Kate, and Jesse helps her in his own, sometimes sly, way, Brian does not really seem to know his daughter. Because he cannot save her, he focuses on his job as a fire captain to save everyone else.

Sara has so intertwined keeping Kate alive with her own identity that she does not see Kate as a person. Sara believes that if Kate dies, she will, too, in some way. The family psychiatrist testifying on Sara's behalf, Dr. Neaux, agrees with Campbell when he states, "You might say that [Sara] defines her own ability to be a good mother by keeping Kate healthy. In fact, if her actions keep Kate alive, she herself benefits psychologically." Though it is natural for parents feel this way about their children, Sara takes it to a dysfunctional level. When Anna is testifying that Kate has tried to kill herself, Sara interjects. Sara believes that Anna misunderstood Kate. Anna tells her mother, "She couldn't tell you. She was too afraid if she killed herself she'd be killing you, too."

Though Sara denies it throughout My Sister's Keeper, Anna has always existed to keep Kate alive, and Sara's affection for Anna has been measured in those terms. Sara's actions and decisions in her narrative sections of the story clearly show her motivations. Anna was created and screened in a laboratory to help Kate's cancer, an idea that came from Sara, not from her husband. While pregnant with Anna, Sara did not even think of a name but focused on what the infant would provide Kate once it was born. Brian named Anna after a constellationher full first name is Andromeda. When Anna was born, Sara did not show interest in her new baby, but only in preserving her cord blood and getting it to Kate as soon as possible.

Anna reports that there are next to no pictures of her childhood around the family home, while Jesse and Kate are depicted in many more photographs. When Sara outlines every procedure in her chapters, she only thinks of Kate, not dealing with the pain or hurt Anna might feel as she is involved in painful procedures over and over again. Brian tends to his youngest child at these times. Jesse is ignored completely as he plays only an occasional small part in keeping Kate alive; Sara gave up on her son long before. While Brian went along with that, before the end of the novel, the father is determined to reconnect with his son.

Thus, Anna, like Kate, wants to live and die on her own terms. Kate understands this, and says so in the prologue. Anna knew she had to be sacrificed; it was why she was created. Anna also had to die to make Sara understand what losing a child really means. Kate cannot die because Sara could not handle that loss; the mother would cease to function if her life's purpose vanished. Losing Anna, though unexpected and emotionally devastating, is easier for Sara than losing Kate would have been. Anna has served her purpose in the family. She has kept Kate alive for many years, made Sara and the rest see what they were missing, and, in death, given Kate a new lease on life. Kate also thrives after Anna's death because Kate has the freedom Anna won for her in court.

Anna's death also adds to the moral and ethical dilemmas highlighted in My Sister's Keeper. On this point, Katherine Arie of the Washington Post muses, "Can a child born to save another ever really be free? Babies selected for certain characteristics, like Anna, are predestined to be tied indefinitely to the circumstances of their birth, and their parents and siblings in need." Just when Anna thinks she has finally won choices and understanding for herself, Kate, and even Jesse by winning medical emancipation, her life is taken from her and given to Kate. The only solace in the novel's end is that Kate says that she has treasured Anna's sacrifice every day of her life.

Source: A. Petrusso, Critical Essay on My Sister's Keeper, in Literary Newsmakers for Students, Thomson Gale, 2007.

The Kite Runner (2004), written by Khaled Hosseini, is a novel that also takes a first-person perspective on life-changing childhood events. The novel is set in Afghanistan and the United States, and features several significant plot twists.

The Tenth Circle (2006), by Jodi Picoult, focuses on a family dealing a problematic teenager as well as parents who must face problems in their own lives. Trixie is suffering from emotional issues, while her father, Daniel, has not fully dealt with his own teen years as well as difficulties in his marriage to Laura.

Vanishing Acts (2003), another novel by Picoult, deals with a dramatic family situation. Delia Hopkins learns that the respected father who raised her had kidnapped her from her mother when she was a young child, gave her a new identity, and told her that her mother was dead. He is jailed while Delia deals with the emotional and legal fallout from the situation, including her still-living mother.

The Adolescent Alone: Decision Making in Health Care in the United States (1999), edited by Jeffrey Blustein, Carol Levine, and Nancy Dubler, is a collection of essays about the issues surrounding teens in terms of medicine and how choices should be made for their health care.

Critical Essay #2

In the following essay, Newhart describes the usefulness of My Sister's Keeper in a health and biomedical ethics course.

In The Fiction of Bioethics (reviewed by Carol Quinn in Teaching Philosophy 25:2 [June 2002]), Tod Chambers discusses what has come to be known as the distinction between the use of "thin" and "thick" case studies in bioethics. Thin case studies give only the skeletal outline of a moral dilemma, emphasize clear-cut clashes between fundamental bioethical principles, and usually take place within the public dimension of the practice of medicine, e.g., emergency rooms, clinics, etc. Chambers's conclusion is that thin case studies lend themselves to being used by their presenters to compel students (and others) to take a particular position on the ethical dilemma presented by the case. Thick case studies, on the other hand, immerse the student in the issue being presented by the case. Thick case studies contain a lot of details concerning both the public and private dimensions of health care in order to situate the dilemma in a rich contextual background. Thus, they enable the student to confront the issue in all of its complexity and preclude the possibility of an easy and/or "obvious" conclusion.

While I do make use of thin case studies to elucidate simpler concepts quickly, as a teacher of biomedical ethics, I am always in search of effective thick case studies to bring the issues to life for students. I have used journalistic narratives, documentaries, and even full-length feature films for this purpose. This summer, I stumbled upon a contemporary novel entitled My Sister's Keeper that I am very much looking forward to using as a thick case study in my Health and Biomedical Ethics course next spring.

My Sister's Keeper is about a thirteen-year-old girl named Anna, who was conceived through in vitro fertilization and selected through preimplantation genetic diagnosis to be a perfectly matched donor for her older sister Kate, who has leukemia. Kate was diagnosed with acute promyelocytic leukemia at the age of three. She was not expected to live past the age of five, but with Anna's help she has lived to be sixteen. After numerous medical procedures including cord blood donation and bone marrow transplantation, and in spite of the fact that Anna is closer to Kate than anyone else in the world, Anna is suing her parents for medical emancipation. Kate is now in need of a kidney, and this is where Anna draws the line. Anna's decision to take legal action against her parents comes at a crucial point in the history of Kate's illness and catapults the family into a situation where they have to account morally for the decisions they've made throughout the course of Kate's illness.

The novel is especially suited as a thick case study because of the stylistic decisions made by the author. There are seven main characters. Brian and Sara Fitzgerald are the parents of Kate, Anna, and Jesse, who is the sisters' older brother. In addition to the five Fitzgeralds, there are Campbell Alexander, Anna's attorney; and Julia Romano, Anna's guardian ad litem. Each chapter is narrated by a different character, and each character is limited to his or her own perspective or point of view. The effect of these stylistic decisions is an understanding on the part of the reader that all of the characters truly believe they are doing the right thing in spite of the fact that their actions clash, sometimes violently, with the interests of other characters. In the absence of a transcendent, omniscient narrator, there is less danger that the reader will be tempted to jump to an easy or obvious conclusion.

Given current popular and scientific interest in embryological issues, the specific issues explored in my bioethics course have shifted over time to deal predominantly with ethical controversies concerning the beginning of life. The specific issues planned for next spring are research on human subjects, euthanasia, abortion, research on embryonic stem cells, prenatal and preimplantation genetic diagnosis, gene therapy, alternative reproductive technologies, gamete donation and surrogacy, and human cloning. Clearly, and happily, My Sister's Keeper presents a rich and complex case study in which almost all of these issues can be explored.

What is more surprising, and pleasing, is how My Sister's Keeper brings into play so many other biomedical ethical topics discussed in the class and even some that are not. In terms of general normative ethical theories, the plot of the novel presents an implicit opposition between Utilitarian measurements of relative suffering and the high premium placed on an almost Kantian sense of autonomy. There is no attempt to conceal or deny the amount of suffering Kate's death will bring to the entire family, including Anna; yet, as Julia, Anna's guardian ad litem, tells us, Anna is in a no-win situation: "Either this girl loses her sister ... or she's going to lose herself." The most important good at stake in Anna's lawsuit against her parents for medical emancipation appears to be Anna's autonomy. Both JesseAnna's brotherand Julia stress that up to this point the medical procedures Anna has been subjected to have not been a result of her choice.

However, even once the ethical primacy of autonomy is granted, the issue of the interdependence of the family members complicates the possibility of an autonomousin the sense of independentdecision on Anna's part. Echoing the criticisms of modern Western ethical theories that have been made from the perspective of an ethics of care, Sara (Anna and Kate's mother) tells us, "[N]obody ever really makes decisions entirely by themselves, not even if a judge gives them the right to do so." Sara is implying that we take into account the interests of those with whom we are in morally significant relationships, and one of Anna's primary relationships is with her sister, Kate. Anna describes this relationship: "Kate and I are Siamese twins; you just can't see the spot where we're connected. Which makes separation that much more difficult."

The specifically biomedical ethical issues that arise in My Sister's Keeper from the application of these general ethical theories and perspectives include the value of informed consent to medical procedures, the role of the family in individual patient medical decision-making, and the extent to which parents are justified in making medical decisions for minors. Moreover, My Sister's Keeper contains even more specific references to biomedical ethics such as a description of how the medical ethics committee works at Providence Hospital, where Kate and Anna have been patients, and an account of the "six principles" of "Weste


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