My Sister's Keeper

" she says woodenly, before I can ask the question. "She was put under general anesthesia because she was so young, and needles were put into the crests of her hips to draw out the marrow."

"Was it one needle stick, like the other procedures?"

"No," Sara says quietly. "It was about fifteen."

"Into the bone?"

"Yes."

"What were the side effects for Anna this time around?"

"She had some pain, and was given some analgesics."

"So this time, Anna had to be hospitalized overnight . . . and she needed medication herself?"

Sara takes a minute to compose herself. "I was told that donating marrow isn't considered a particularly invasive procedure for a donor. Maybe I was just waiting to hear those words; maybe I needed to hear them at that time. And maybe I was not thinking as much of Anna as I should have been, because I was so focused on Kate. But I know beyond a doubt that--like everyone else in our family--Anna wanted nothing more than for her sister to be cured."

"Well, sure," I reply, "so that you'd stop sticking needles in her."

"Enough, Mr. Alexander," Judge DeSalvo interjects.

"Wait," Sara interrupts. "I have something to say." She turns to me. "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 this 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?"





ANNA




WHEN YOU ARE A KID you have your own language, and unlike French or Spanish or whatever you start learning in fourth grade, this one you're born with, and eventually lose. Everyone under the age of seven is fluent in Ifspeak; go hang around with someone under three feet tall and you'll see. What if a giant funnelweb spider crawled out of that hole over your head and bit you on the neck? What if the only antidote for venom was locked up in a vault on the top of a mountain? What if you lived through the bite, but could only move your eyelids and blink out an alphabet? 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.

*

During the first recess, Campbell takes me to a conference room for privacy and buys me a Coke that isn't cold. "So," he says. "What do you think so far?"

Being in the courtroom is weird. It's like I've turned into a ghost--I can watch what's going on, but even if I felt like speaking no one would be able to hear me. Add to that the very bizarre way I have to listen to everyone talk about my life as if they can't see me sitting right there, and you've landed in my surreal little corner of earth.

Campbell pops open his 7 UP and sits down across from me. He pours a little into a paper cup for Judge, and then takes a good long drink. "Comments?" he says. "Questions? Unadulterated praise for my skillful litigation?"

I shrug. "It's not like I expected."

"What do you mean?"

"I guess I figured when it started, I'd know for sure that I was doing the right thing. But when my mom was up there, and you were asking her all those questions . . . " I glance up at him. "That part about it not being simple. She's right."

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 these, which is how I know that whether I'm ready or not, I'm growing up.

"Anna." Campbell gets up and comes around to my side of the table. "Now is not the time to start changing your mind."

"I'm not changing my mind." I roll the can between my palms. "I think I'm just saying that even if we win, we don't."

*

When I was twelve I started baby-sitting for twins who live down the street. They're only six, and they don't like the dark, so I usually wind up sitting between them on a stool that's shaped like the stubby foot of an elephant, toenails and all. It never fails to amaze me how quickly a kid can shut off an energy switch--they'll be climbing the curtains and bam, five minutes later, they're conked out. Was I ever like that? I can't remember, and it makes me feel ancient.

Every now and then one of the twins will fall asleep before the other one. "Anna," his brother will say, "how many years till I can drive?"

"Ten," I tell him.

"How many years till you can drive?"

"Three."

Then the talk will split off like the spokes of a spiderweb--what kind of car will I buy; what will I be when I grow up; does it suck to get homework every night in middle school. It's totally a ploy to stay up a little bit later. Sometimes I fall for it, mostly I just make him go to sleep. See, I get a round hollow spot in my belly knowing I could tell him what's coming, but also knowing it would come out sounding like a warning.

*

The second witness Campbell calls is Dr. Bergen, the head of the medical ethics committee at Providence Hospital. He has salt-and-pepper hair and a face dented in like a potato. He is smaller than you'd expect, too, given the fact that it takes him just short of a millennium to recite his credentials.

"Dr. Bergen," Campbell starts, "what's an ethics committee?"

"A diverse group of doctors, RNs, clergy, ethicists, and scientists, who are assigned to review individual cases to protect patients' rights. In Western Bioethics, there are six principles we try to follow." He ticks them off on his fingers. "Autonomy, or the idea that any patient over age eighteen has the right to refuse treatment; veracity, which is basically informed consent; fidelity--that is, a health-care provider fulfilling his duties; beneficence, or doing what's in the best interests of the patient; nonmaleficence--when you can no longer do good, you shouldn't do harm . . . like performing major surgery on a terminal patient who's 102 years old; and finally, justice--that no patient should be discriminated against in receiving treatment."

"What does an ethics committee do?"

"Generally, we're called to convene when there's a discrepancy about patient care. For example, if a physician feels it's in the patient's best interests to go on with extraordinary measures, and the family doesn't--or vice versa."

"So you don't see every case that passes through a hospital?"

"No. Only when there are complaints, or if the attending physician asks for a consultation. We review the situation and make recommendations."

"Not decisions?"

"No," Dr. Bergen says.

"What if the patient complaining is a minor?" Campbell asks.

"Consent isn't necessary until age thirteen. We rely on parents to make informed choices for their children until that point."

"What if they can't?"

He blinks. "You mean if they're not physically present?"

"No. I mean if there's another agenda they're adhering to, that in some way keeps them from making choices in the best interests of that child?"

My mother stands up. "Objection," she says. "He's speculating."

"Sustained," Judge DeSalvo replies.

Without missing a beat, Campbell turns back to his witness. "Do parents control their children's health-care decisions until age eighteen?"

Well, I could answer that. Parents control everything, unless you're like Jesse and you do enough to upset them that they'd rather ignore you than pretend you actually exist.

"Legally," Dr. Bergen says. "However, once a child reaches adolescence, although they can't give formal consent, they have to agree to any hospital procedure--even if their parents have already signed off on it."

This rule, if you ask me, is like the law against jaywalking. Everyone knows you're not supposed to do it, but that doesn't actually stop you.

Dr. Bergen is still talking. "In the rare instance where a parent and an adolescent patient disagree, the ethics committee weighs several factors: whether the procedure is in the adolescent's best interests, the risk/benefit scenario, the age and maturity of the adolescent, and the argument he or she presents."

"Has the ethics committee at Providence Hospital ever met regarding the care of Kate Fitzgerald?" Campbell asks.

"On two occasions," Dr. Bergen says. "The first involved allowing her to enter a trial for peripheral blood stem cell transplant in 2002, when her bone marrow transplant and several other options had failed. The second, more recently, involved whether or not it would be in her best interests to receive a donor kidney."

"What was the outcome, Dr. Bergen?"

"We recommended that Kate Fitzgerald receive a peripheral blood stem cell transplant. As for the kidney, our group was split on that decision."

"Can you explain?"

"Several of us felt that, at this point, the patient's health care had deteriorated to a point where major invasive transplant surgery was going to do more harm than good. Others believed that without a transplant, she would still die, and therefore the benefits outweighed the risk."

"If your team was split, then who gets to decide what will ultimately happen?"

"In Kate's case, because she is still a minor, her parents."

"During either of the times that your committee met regarding Kate's medical treatment, did you discuss the risks and benefits to the donor?"

"That wasn't the issue at stake--"

"What about the consent of the donor, Anna Fitzgerald?"

Dr. Bergen looks right at me, sympathetic, which it turns out is worse even than him thinking I'm a horrible person for filing this petition in the first place. He shakes his head. "It goes without saying that no hospital in the country is going to take a kidney out of a child who doesn't want to donate it."

"So, theoretically, if Anna was fighting this decision, the case would most likely land on your desk?"

"Well--"

"Has Anna's case landed on your desk, Doctor?"

"No."

Campbell advances toward him. "Can you tell us why?"

"Because she isn't a patient."

"Really?" He pulls a stack of papers out from his briefcase, and hands them to the judge, and then to Dr. Bergen. "These are Anna Fitzgerald's hospital records at Providence Hospital for the past thirteen years. Why would there be records for her, if she wasn't a patient?"

Dr. Bergen flips through them. "She's had several invasive procedures," he admits.

Go, Campbell, I think. I am not one to believe in knights who ride in to rescue damsels in distress, but I bet it feels a little like this. "Doesn't it strike you as odd that in thirteen years, given the thickness of this file and the fact it exists in the first place, the medical ethics committee never once convened to discuss what was being done to Anna?"

"We were under the impression that donation was her wish."

"Are you telling me that if Anna had previously said she didn't want to give up lymphocytes or granulocytes or cord blood or even a bee sting kit in her backpack--the ethics committee would have acted differently?"

"I know where you're going with this, Mr. Alexander," the psychiatrist says coldly. "The problem is that this kind of medical situation hasn't existed before. There is no precedent. We're trying to feel our way as best we can."

"Isn't your job as an ethics committee to look at situations that haven't existed before?"

"Well. Yes."

"Dr. Bergen, in your expert opinion, is it ethically right for Anna Fitzgerald to have been asked to donate parts of her own body repeatedly for thirteen years?"

"Objection!" my mother calls out.

The judge strokes his chin. "I want to hear this."

Dr. Bergen glances at me again. "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 support the choices the Fitzgeralds made for Anna."

Campbell pretends to consider this. "Dr. Bergen, what kind of car do you drive?"

"A Porsche."

"Bet you like it."

"I do," he says guardedly.

"What if I told you that you have to give up your Porsche before you leave this courtroom, because that action will save Judge DeSalvo's life?"

"That's ridiculous. You--"

Campbell leans in. "What if you had no choice? What if, today, psychiatrists simply have to do whatever lawyers decide is in the best interests of others?"

He rolls his eyes. "In spite of the high drama you're alluding to, Mr. Alexander, there are basic donor rights, safeguards put into place in medicine, so that the greater good doesn't steamroll the pioneers who help create it. The United States has a long and nasty history of the abuse of informed consent, which is what led to laws relating to Human Subjects Research. It keeps people from being used as experimental lab rats."

"Then tell us," Campbell says, "how the hell did Anna Fitzgerald slip through the cracks?"

*

When I was only seven months old, there was a block party in our neighborhood. It's just as bad as you're thinking: Jell-O molds and towers of cheese cubes and dancing in the street to music piped out of someone's living room stereo. I, of course, have no personal recollection of any of this--I was plopped down in one of those walkers they made for babies before babies started overturning them and cracking their heads open.

At any rate, I was in my walker, tooling around between the tables and watching the other kids, so the story goes, when I sort of lost my footing. Our block is canted at an angle, and suddenly the wheels were moving faster than I could make them stop. I whizzed past adults, under the barricade the cops had put up at the end of the road to shut it off to traffic, and I was heading right for a main drag full of cars.

But Kate came out of nowhere and ran after me. She somehow managed to grab me by the back of my shirt moments before I got hit by a passing Toyota.

Every now and then, someone on the block brings this up. Me, I remember it as the time she saved me, instead of the other way around.

*

My mother gets her first chance to play lawyer. "Dr. Bergen," she says, "how long have you known of my family?"

"I've been at Providence Hospital for ten years now."

"In those ten years, when some aspect of Kate's treatment was presented to you, what did you do?"

"Come up with a plan of action that was recommended," he says. "Or an alternate, if possible."

"When you did, at any point in your report did you mention that Anna shouldn't be a part of it?"

"No."

"Did you ever say this would hurt Anna considerably?"

"No."

"Or put her in grave medical danger herself?"

"No."

Maybe it's not Campbell, after all, who will turn out to be my white knight. Maybe it's my mother.

"Dr. Bergen," she asks, "do you have kids?"

The doctor looks up. "I have a son. He's thirteen."

"Have you ever looked at these cases that come to the medical ethics committee and put yourself in a patient's shoes? Or better yet, a parent's shoes?"

"I have," he admits.

"If you were me," my mother says, "and the medical ethics committee handed you back a piece of paper with a suggested course of action that would save your son's life, would you question them further . . . or would you just jump at the chance?"

He doesn't answer. He doesn't have to.

*

Judge DeSalvo calls a second recess after that. Campbell says something about getting up and stretching my legs. So I start to follow him out, walking right past my mother. As I pass by, I feel her hand on my waist, tugging down my T-shirt, which is riding up in the back. She hates the spaghetti-strap girls, the ones who come to school in halters and low-riders, like they're trying out as dancers in a Britney Spears video instead of going to math class. I can almost hear her voice: Please tell me that shrank in the wash.

She seems to realize mid-tug that maybe she shouldn't have done this. I stop, and Campbell stops, too, and her face goes bright red. "Sorry," she says.

I put my hand over hers and tuck my shirt into the back of my jeans where it should be. I look at Campbell. "Meet you outside?"

He's giving me a look that has Bad Idea written all over it, but he nods and heads down the aisle. Then my mother and I are nearly alone in the courtroom. I lean forward and kiss her on the cheek. "You did really great up there," I tell her, because I don't know how to say what I really want to: that the 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

KATE MEETS TAYLOR AMBROSE when they are sitting side by side, hooked up to IVs. "What are you here for?" she asks, and I immediately look up from my book, because in all the years that Kate has been receiving outpatient treatment I cannot remember her initiating a conversation.

The boy she is talking to is not much older than she is, maybe sixteen to her fourteen. He has brown eyes that dance, and is wearing a Bruins cap over his bald head. "The free cocktails," he answers, and the dimples in his cheeks deepen.

Kate grins. "Happy hour," she says, and she looks up at the bag of platelets being infused into her.

"I'm Taylor." He holds out his hand. "AML."

"Kate. APL."

He whistles, and raises his brows. "Ooh," he says. "A rarity."

Kate tosses her cropped hair. "Aren't we all?"

I watch this, amazed. Who is this flirt, and what has she done with my little girl?

"Platelets," he says, scrutinizing the label on her IV bag. "You're in remission?"

"Today, anyway." Kate glances at his pole, the telltale black bag that covers the Cytoxan. "Chemo?"

"Yeah. Today, any