My Sister's Keeper (2009)

Anna Fitzgerald was conceived as a genetic match for her older sister Kate, who has acute promyelocytic leukemia. Since birth she has provided blood, marrow and tissue.

At thirteen she hires a lawyer and sues her parents for medical emancipation, rather than donate a kidney. Her mother, a former attorney, takes the other side of the case. The household has organized itself around Kate for years, and the trial forces every unspoken arrangement into the open.

Spoilers throughout. This page says how My Sister's Keeper ends.

Children conceived as tissue matches for a sibling exist. Transplant teams do weigh a donor child's interests against a recipient's need. Whether a minor can meaningfully consent to a procedure that benefits someone else is a live question, not a screenwriter's invention.

The film is also good on the well sibling. Anna is simultaneously essential and invisible. Their brother Jesse drifts almost entirely out of the family's attention. That is a documented pattern in families with a seriously ill child, and it is rarely dramatized this directly.

The film names Kate's disease. That naming is what breaks it.

Acute promyelocytic leukemia is a distinct subtype of acute myeloid leukemia, making up about 7% of childhood AML. Its defining feature is not resistance to treatment. It is sensitivity to two drugs: tretinoin, a differentiating agent, and arsenic trioxide.

The results are among the best in oncology. In the Children's Oncology Group AAML1331 trial, 154 children aged 1 to 21 received tretinoin and arsenic trioxide with aggressive supportive care. Conventional chemotherapy was removed almost entirely. Standard-risk children had a 2-year event-free survival rate of 98% and an overall survival rate of 99%. High-risk children did better than in the previous trial, with 2-year event-free survival of 96.4% against 82.9%, and overall survival of 100% against 85.7%. Across the whole trial there was 1 death and 3 relapses.

Every standard-risk and high-risk child who completed induction achieved a complete remission before day 70.

The film's entire premise is a sibling donating tissue to keep Kate alive. Two facts dismantle it.

First, NCI states directly that because of the favorable outcomes with tretinoin and arsenic trioxide, hematopoietic stem cell transplant is not recommended for APL in first complete remission. The transplant Anna exists to supply is not what this leukemia calls for.

Second, kidney donation has no role in leukemia treatment at all. Leukemia is a disease of blood-forming marrow. A kidney does not make blood cells. Kidney failure in a child with leukemia would be a complication of treatment or of the illness, and its treatment is not a sibling transplant during active disease.

None of that makes the ethical question fictional. Sibling stem cell donation is real, and NCI notes that the best match for an allogeneic transplant is most often a brother or sister, judged by human leukocyte antigen typing. The film simply attached that real dilemma to a leukemia that does not generate it.

There is a genuine crisis in APL, and it happens in the first days rather than years later.

APL blasts trigger disseminated intravascular coagulation, a state in which blood clots and bleeds at the same time. NCI describes this coagulopathy as typically present at diagnosis. It shows as low platelets, prolonged clotting times, raised d-dimers and low fibrinogen.

The consequence is early death from bleeding. In a multicooperative group analysis of children with APL, coagulopathic deaths during induction occurred in 25 of 683 children, or 3.7%. Twenty-three were from hemorrhage, 19 of those in the central nervous system.

This is why tretinoin is started as soon as APL is suspected, on clinical and morphological grounds, before confirmation. A retrospective analysis found more early deaths from hemorrhage when tretinoin was delayed. It is also why a lumbar puncture is not performed until the coagulopathy has resolved.

That first week is the real drama in this disease. The film spends its tension on a courtroom instead.

Leukemia announces itself vaguely. Fatigue that does not lift. Repeated infections. Easy bruising or bleeding. Tiny red spots under the skin. Bone or joint pain. Night sweats. Unexplained fever.

In children these are routinely read as a run of ordinary viruses, which is reasonable most of the time. What should prompt evaluation is the combination and the persistence: bruising without cause alongside exhaustion and repeated infections. A blood count is a simple first test.

Bleeding that seems out of proportion, such as nosebleeds that will not stop or bruising with no injury, deserves same-day attention rather than a scheduled appointment.

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My Sister's Keeper is worth watching for the family it draws and the question it asks. It is not a guide to leukemia, and the specific leukemia it names is now one of the most curable there is.

A change that persists is worth a conversation, whatever a story led anyone to expect. My Sister's Keeper cannot tell you what to watch for, but screening and possible warning signs can.

This page discusses My Sister's Keeper for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email [email protected].

• NCI PDQ — Childhood Acute Promyelocytic Leukemia Treatment (Health Professional Version)
• NCI PDQ — Childhood Acute Myeloid Leukemia Treatment (Health Professional Version)
• NCI — Stem Cell Transplants in Cancer Treatment