Themes
Key
LitCharts assigns a color and icon to each theme in My Sister’s Keeper, which you can use to track the themes throughout the work.
Bodily Autonomy
Siblinghood
Parenthood
Control
Illness and Isolation
Summary
Analysis
Brian rushes Anna, who has blood running down her face, into the emergency room. She has injured herself going over the handlebars of her bike. When a resident comes to check on her, Sara succinctly describes the situation and Anna’s injury—a scalp laceration with no signs of concussion—using medical terminology. The doctor asks her if she’s a doctor or a nurse, and Sara responds that she’s just used to this. Anna gets 82 stitches and pediatric Tylenol. When they walk back out to the rest of the family, Kate looks at her bandaged head and says that she likes it better when she gets to sit out in the waiting room.
Bringing Anna into the emergency room is, strangely, a welcome change for the Fitzgeralds. Although her injury is serious, it has a much simpler treatment than something as protracted as Kate’s cancer and Sara is easily able to handle the situation. Most notably, it’s a welcome change for Kate—who, for once in her life, gets to be the healthy kid waiting for her sister to leave the hospital, rather than the other way around.
Themes
Some time after this incident, Sara hears Kate scream from the bathroom and enters to discover her legs and underwear covered in blood; she has begun bleeding rectally, a clear sign that her APL has returned. Sara calmly helps her clean up and helps her put a sanitary pad in her underwear. She thinks about how this moment should have been for Kate’s first period, and she wonders if Kate will live long enough to have one. Sara and Brian take Kate to Dr. Chance, who tells them that Kate is in clinical relapse and recommends a bone marrow transplant. When Brian points out that Dr. Chance previously called such a procedure dangerous, Dr. Chance agrees, but says that Kate will die without it.
Kate’s condition continues to worsen despite the treatments she’s undergone. The parallel between her rectal bleeding and the period she has not gotten yet highlights just how young she is; Kate has not yet reached one of the major milestones for growing up. Furthermore, as the conversation with Dr. Chance shows, the worse Kate’s condition get, the riskier procedures the Fitzgeralds try in order to save her—with most of these including Anna acting as a donor.
Themes
A week later, Sara is on the phone with their health insurance company, having been on hold for 20 minutes. She is trying to get a straight answer as to whether Kate’s bone marrow transplant has been approved for coverage. The transplant will cost over $100,000, but just because Dr. Chance has deemed it necessary doesn’t mean the insurance company will cover it. Sara explains to the first representative she gets that she first called a week ago but hasn’t heard back yet, which gets her put on hold again, then hung up on. She swears loudly (prompting a scolding from Anna), then redials. This time, the representative informs her that the insurance company has decided the procedure is not in Kate’s best interests. Sara asks them if dying is.
Sara’s phone call with their insurance illustrates another difficult aspect to having a child with cancer: the financial burden of it. The company’s decision that Kate does not need her bone marrow transplant, even though her own doctor has decided that she does, is an example of how dehumanizing it is to be a cancer patient in a system where companies that don’t know you can essentially decide your fate. The callousness of this interaction casts Sara in a sympathetic light by showing the multiple types of battles she has to fight for Kate.
Themes
In order to prepare for the bone marrow extraction, Anna has to receive growth factor shots twice a day. Anna has been told about the reasoning behind this, but as a six-year-old, all she really understands is that she’s being subjected to a painful shot. Although Sara uses a topical anesthetic, Anna still screams out in pain. Sara wonders if the shot hurts as much as having your young daughter tell you that she hates you.
Although Sara has learned to inform Anna about what’s going to happen to her, she has still come to dread and resent the painful procedures she must undergo on behalf of Kate. The growth factor shots are one more example of her having to suffer on Kate’s behalf.
Themes
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Some time later, Sara is once again on the phone with the insurance company, attempting to get them to change their mind about their ruling. The representative tells her that the company understands where Sara’s coming from, which Sara says she finds hard to believe. The representative informs her that they will cover 90 percent for a donor lymphocyte infusion, but only 10 percent of a bone marrow transplant. Sara says that the review board clearly doesn’t have an APL specialist, since one would know that a donor lymphocyte infusion is useless, meaning that the insurance is choosing to cover a procedure that won’t help Kate and refusing the one that would. The representative responds formulaically that the company will cover the Fitzgeralds if they follow insurance protocol. Sara tells them that such protocol will kill Kate and calls the representative inhuman, which gets her hung up on.
The contrast between Sara’s intense concern for Kate and the insurance company’s penchant to treat her as just another case number once again illustrates just how much heartlessness Sara has to endure in fighting for Kate. These experiences are important in understanding why Sara is so protective of Kate: she’s seen that Kate is not only suffering from her cancer but is victimized by the medical and insurance systems. With this in mind, Anna’s legal battle in the present might not feel terribly different from an insurance company using technicalities to deny Kate the care that she needs.
Themes
Suzanne comes over to watch Jesse the night before the Fitzgeralds leave for the hospital for Kate’s transplant. Sara gives her instructions for babysitting and housekeeping, with Suzanne paying close attention. When she’s done, Brian asks if there’s anything else, and Suzanne says yes: she takes out a check for $100,000. Sara, stunned, declines, but Suzanne insists. Brian also declines, but for a different reason: his colleagues ran a nationwide fundraiser for Kate and managed to raise the money, something he just found out about today. Sara hugs Suzanne, thanking her for even offering. Suzanne tells them the money is still there if they need it. Sara feels relief that she and Brian can take care of Kate themselves.
Suzanne’s generous offer to the Fitzgeralds once again emphasizes how important she is to Sara and the family at large as a source of support. However, the revelation that Brian was able to raise the money for Kate’s treatment allows both he and Sara to take pride in their ability to take care of their own children, highlighting how both of them value their ability to retain agency and control over Kate’s fate.
Themes
The next morning, Sara calls for Kate, who is running late and has not yet come downstairs. Eventually, Sara grows frustrated and goes up to get her. She finds Kate making her bed; her entire room has been cleaned, with all of her things neatly organized. Sara is shocked, since she hasn’t even asked Kate to clean up. Kate explains that she’s cleaned her room in case she doesn’t come back.
Kate’s decision to leave her bedroom neat in case she doesn’t return suggests that, unlike Sara, she has come to terms with the fact that she might die soon. Rather than her death being an abstract fear of hers, it is something she feels the need to prepare for in a very material way.
Themes
Sara reminisces about how, when she first became a parent, she used to lie awake at night and think of every possible terrible situation that could harm her children, from poisonous berries to diving into a shallow pool. As her children got older, these fears changed with them into things like drugs and playing with matches. Now that she’s been faced with a lethal situation, she feels that a parent in such a situation will either collapse or “take the blow” of their child’s illness. She does this for Kate at the hospital, who has vomited over 30 times and has debilitating mucositis. Sara uses the suction tube to clear out her throat, promising to do this while Kate rests. In this way, she comes to “breathe for [Kate].”
In a parallel to Sara repeatedly disposing of Kate’s vomit during her first chemotherapy, she continues to care for her in preparation of her bone marrow transplant. Unlike most mothers, who have the luxury of entertaining abstract fears of their children coming to harm, Sara’s fears have come true—and, once again, the only real way for her to face it is to do her best to make the situation better from moment to moment, since there is only so much control she has over the long term.
Themes
Sara compares the oncology ward to a battlefield: the patients are the soldiers, the doctors are the strategic heroes, but the nurses are the seasoned sergeants who know the patients well. In turn, Sara has gotten to know many of the nurses well, including one named Donna. One night at the hospital, Sara turns on the TV and watches a show featuring the ornate house of a wealthy person. She thinks about how she could never imagine such a life for herself, then realizes she once never imagined this life for herself. This makes her start to cry. Donna comes in and finds her like this. She takes Sara to the break room and brews her some coffee. Sara vents to her for an hour, then realizes how long it’s been and apologizes, since Donna surely has somewhere else she wants to be. Donna hugs her and responds: “Don’t we all?”
Donna’s support of Sara is another example of how, even though having a child with cancer can alienate one from the rest of the world, those within the world of cancer are often important sources of support for each other, since they understand what it’s like and do not shy away from the worst parts of cancer treatment. As Sara points out, the nurses are especially important to this support; unlike distant medical systems like ethics boards or insurance companies, they are the boots on the ground that witness the most emotional moments of battling cancer.
Themes
The day of Anna’s bone marrow extraction, Anna expresses second thoughts, asking Sara what happens if she changes her mind. Sara tells her that she doesn’t have to do this if she doesn’t want to, but that she, Brian, and Kate are all counting on her. Anna relents. The nurses guide Anna onto the exam table, doing their best to make it comfortable for her. Anna holds onto Sara’s hand until the anesthesiologist puts her under, at which point her grip slackens. Sara gives her a kiss and thanks her, then leaves the room, where she watches through a window as the doctors begin to prepare a massive needle. Then, she goes upstairs to be with Kate.
The day of Anna’s bone marrow donation is significant in that it is the first instance in which Anna explicitly expresses reluctance to donate to Kate. While previous procedures have clearly caused her pain, she has never before raised the possibility of backing out. Just as importantly, although Sara technically affirms Anna’s right to choose, the pressure she puts on Anna essentially coerces her into consenting to the procedure.
Themes
Some time after Anna’s procedure is complete, Sara is in Kate’s room helping to catch her vomit when Brian comes in to tell her that Anna is asking for her. Sara initially refuses, but Brian simply repeats that Anna is asking for her. Sara goes to Anna’s room to find her crying in pain. She asks Sara if she’ll stay with her, but Sara tells her she’ll have to go back to Kate, which upsets Anna. Sara learns from Brian that Anna’s been given very little pain medication, so she goes to find a nurse, who tells her that Anna has already had Tylenol. Sara argues with her that this isn’t enough, eventually obtaining a pediatric dose of Roxicet. When she returns, she finds Brian giving Anna a locket as a thank-you gift for her donation. Anna happily shows her locket to Sara, who holds out the medication, “a poor second-best.”
Sara’s response to Anna’s struggle clearly illustrates that Kate is her first priority. Initially, she is reluctant to even visit Anna despite the fact that Anna is asking for her, viewing Kate’s support as more treatment. Once she actually sees Anna, she refuses to stay with her in favor of Kate. Even so, Sara is the one who is able to get Anna the pain relief she needs by arguing with a nurse—but the fact that she feels this is a “poor second-best” to Brian’s locket gift suggests that, although Sara is good at getting things done, she has lost the ability to emotionally connect with and support Anna.
Themes
Three weeks after Kate’s bone marrow transplant, an increase in white blood cell count shows it was a success. Brian takes Sara out to dinner to celebrate. Brian orders wine and toasts to their family. They talk briefly about the menu before Sara attempts to talk about Kate’s illness; Brian responds by saying he’d hoped they could get away from all of that. Sara agrees, but the two of them struggle to think of topics they have in common besides Kate. Sara looks around and notices that most of the couples talking are young, while the older couples are quieter. She wonders if this is because they’re comfortable with each other or if they have nothing to say. When the waiter comes, both Sara and Brian are relieved to have someone break the uncomfortable silence.
The Fitzgeralds struggle with isolation not only from the outside world but also isolation from one another—a fact clearly illustrated by Brian and Sara’s uncomfortable date. Kate’s illness and treatment has consumed so much of their life that they can no longer remember what they had in common at the beginning of their marriage. The implicit comparison between them and the silent elderly couples suggests that their ordeal has metaphorically aged them and affected their relationship in turn.
Themes
After her transplant succeeds, Kate is discharged from the hospital. She moves cautiously and has lost a significant amount of weight since her intake, to the point that Sara has to fashion a makeshift belt for her. Kate’s head is completely bare, and now that she’s leaving the hospital, she has to wear a mask and gloves to protect her compromised immune system. The nurses come up to say goodbye, with one, Willie, jokingly telling her not to come back and see them. When it’s time to leave, Kate is too nervous to step out of the hospital. Sara takes her hand and promises that they’ll do it together.
Although the road to Kate’s transplant has been a difficult one, Kate’s discharge from the hospital serves as a reminder of what all of the struggle was for. Even so, the fact that Kate is still incredibly fragile underscores the fact that she is still on borrowed time, implicitly raising the question of how much more the Fitzgeralds will risk in order to keep her alive. Still, Sara reassuring Kate reaffirms her commitment to fighting for Kate.
Themes
At home, Sara rifles through hospital bills. She happens to open a letter from their mutual fund, which she doesn’t usually do, and finds a notification that the total balance from Kate’s educational fund, $8,369.56, has been withdrawn and the account has been closed. Sara brings it to Brian, assuming that the bank has made a major error—but it isn’t. Brian admits that, although his colleagues did raise money, it was only $10,000. That, plus the money from Kate’s fund, was enough for the hospital to work out a payment plan. Sara reminds him that Suzanne offered to cover the full balance, but Brian insists that he takes care of Kate. He then tells Sara that Kate won’t live long enough for college, anyway, prompting Sara to run away and lock herself in the bathroom.
The illusion of control that Sara has over Kate’s treatment and the Fitzgeralds’ finances collapses when she discovers that Brian has lied to her. On the surface, his deception is completely illogical; after all, as Sara points out, Suzanne offered to cover Kate’s treatment in full, meaning Brian has needlessly tightened the family’s finances. However, Brian, too, wishes to retain control over Kate’s treatment—but, unlike Sara, he feels a responsibility to oversee her inevitable death, rather than her unlikely survival.
Themes
During Kate’s recovery, everyone wears masks so that Kate doesn’t have to. She receives growth factor shots twice a day and cannot yet go back to school. She rarely leaves the house, and when she does, she refuses to leave the car. One morning, Sara asks her if she wants to go to the mall, but she refuses. Sara tells her it’ll be good to get out of the house, but Kate responds that she doesn’t want everyone looking at her in public and calls herself a freak. In response, Sara goes into the bathroom, where Kate and Anna follow her, and shaves her head. Kate smiles. Anna volunteers next, and the three of them go to the mall together, bareheaded.
Sara’s decision to shave her head, as well as Anna’s decision to follow her lead, highlights a rare moment where Sara is on the same page as both of her daughters. Both she and Anna are moved by their love to Kate to make her feel less alone, even though it means going bald themselves. In other words, this scene shows what Sara and Anna have in common despite their differences: they both truly want Kate to be happy.
Themes
