“They sat me down and told me all the usual stuff, of course—but they also explained that they chose little embryonic me, specifically, because I could save my sister, Kate. ‘We loved you even more,’ my mother made sure to say, ‘because we knew what exactly we were getting.’”

From an early age, Anna knew she was born as a savior sibling for her older sister Kate—which inevitably has a psychological impact on her. The way in which Jodi Picoult introduces this information, by having Anna tell it in context of the “accidents” that led to the conception of many of her schoolmates, frames Anna’s upbringing as harmful to her. However, as the novel progresses and Anna’s character is further developed, it becomes clear that although the nature of her birth complicates relationships within the Fitzgerald family, Anna doesn’t resent helping Kate. In fact, her desire to help Kate is what leads to the novel’s conflict.

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

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