Authors: Jodi Picoult
I sat back down, opening the questioning to Guy Booker. “You’ve been treating this child since she was six months old, correct?”
“Yes. I was working at Shriners in Omaha at the time, and Willow was part of our pamidronate trials there. When I moved to Children’s in Boston, it made more sense to treat her closer to home.”
“Now how often do you see her, Dr. Rosenblad?”
“Twice a year, unless there’s a break in between. And let’s just say I’ve never seen Willow only twice a year.”
“How long have you been using pamidronate to treat children with OI?”
“Since the early nineties.”
“And you said that, prior to the advent of pamidronate for OI, these children had a much more limited life in terms of mobility, correct?”
“Absolutely.”
“So would you say that the medical technology in your field has increased Willow’s health potential?”
“Dramatically,” Dr. Rosenblad said. “She’s able to do things now that kids with OI couldn’t do fifteen years ago.”
“So if this trial were taking place fifteen years ago, the picture
you’d be painting for us of Willow’s life might be even more grim, wouldn’t you agree?”
Dr. Rosenblad nodded. “That’s correct.”
“Given that we live in America, where medical research is blooming in laboratories and hospitals like yours on a daily basis, isn’t it likely that Willow might see even more medical advances in her lifetime?”
“Objection,” I said. “Speculative.”
“He’s an expert in his field, Judge,” Booker countered.
“He can give his opinion,” Judge Gellar said, “based on his knowledge as to what medical research is currently being done.”
“It’s possible,” Dr. Rosenblad replied. “But like I also pointed out, the wonder drugs that we thought bisphosphonates were might, over the long term, reveal some other problems we hadn’t counted on for OI patients. We just don’t know yet.”
“Conceivably, however, Willow could grow to adulthood?” Booker asked.
“Absolutely.”
“Could she fall in love?”
“Of course.”
“Could she have a baby?”
“Possibly.”
“Could she work outside the home?”
“Yes.”
“Could she live independently of her parents?”
“Maybe,” Dr. Rosenblad said.
Guy Booker spread his hands across the railing of the jury box. “Doctor, you treat illness, don’t you?”
“Sure.”
“Would you ever treat a broken finger by amputating the arm?”
“That would be a bit extreme.”
“Isn’t it extreme to treat OI then by preventing the patient from being born?”
“Objection,” I called out.
“Sustained.” The judge glared at Guy Booker. “I won’t have my courtroom turned into a pro-life rally, Counselor.”
“I’ll rephrase. Have you ever encountered a parent whose child is diagnosed with OI in utero who chooses to terminate the pregnancy?”
Rosenblad nodded. “Yes, often in cases where you’re talking about the lethal form of OI, Type II.”
“What about the severe form?”
“Objection,” I said. “What does this have to do with the plaintiff?”
“I want to hear this,” Judge Gellar said. “You may answer the question, Doctor.”
Rosenblad stepped through the minefield of his response. “Terminating a wanted pregnancy is no one’s first choice,” he said, “but when faced with a fetus who will become a severely disabled child, different families have different levels of tolerance. Some families know they’ll be able to provide enough support for a child with disabilities, some are smart enough to know, in advance, they won’t.”
“Doctor,” Booker said, “would you call Willow O’Keefe’s birth a wrongful one?”
I felt something at my side and realized that Charlotte was trembling.
“I am not in a position to make that decision,” Rosenblad said. “I’m just the physician.”
“My point exactly,” Booker answered.
Piper
I had not seen my ultrasound technician Janine Weissbach since she left my practice four years ago and went to work at a hospital in Chicago. Her hair, which had been blond, was now a sleek chestnut, and there were fine lines bracketing her mouth. I wondered if I looked the same to her, or if betrayal had aged me beyond recognition.
Janine had been allergic to nuts, and once there had been a minor war between her and a nurse on staff who’d brewed hazelnut coffee. Janine broke out in hives just from the smell that permeated our little lounge; the nurse swore she didn’t realize that liquefied nuts counted when it came to allergy; Janine asked how she’d ever passed her nursing exam. In fact, the brouhaha had been the biggest upset in my practice…until, of course, this.
“How is it that you came to know the plaintiff in this case?” Charlotte’s lawyer asked.
Janine leaned closer to the microphone on the witness stand. She used to sing karaoke, I remembered, at a local nightclub. She had referred to herself as pathologically single. Now, though, she wore a wedding band.
People changed. Even the people you thought you knew as well as you knew yourself.
“She was a patient at the office where I was working,” Janine said. “Piper Reece’s ob-gyn practice.”
“You’re employed by the defendant?”
“I was for three years, but now I work at Northwestern Memorial Hospital.”
The lawyer was staring off at a wall, as if she wasn’t even listening. “Ms. Gates,” the judge prompted.
“Sorry,” she said, snapping to attention. “You’re employed by the defendant?”
“You just asked me that.”
“Right. Um, can you tell us the circumstances under which you met Charlotte O’Keefe?”
“She came in for an eighteen-week ultrasound.”
“Who else was there?”
“Her husband,” Janine said.
“Was the defendant there?”
For the first time, Janine met my eye. “Not at first. The way we did it, I’d perform the ultrasound and discuss it with her; and she’d read the results and talk to the patient.”
“What happened during Charlotte O’Keefe’s ultrasound, Ms. Weissbach?”
“Piper had told me to be on the lookout for anything that might signify Down syndrome. The patient’s quad screen had shown a slightly elevated risk. I was excited to be working with a new machine—it had only just arrived, and was state of the art. I got Mrs. O’Keefe settled on the table, put some gel onto her abdomen, and then moved the transducer around to get several clear views of the fetus.”
“What did you see?” the lawyer asked.
“The femurs were measuring on the small side, which can sometimes be a flag for Down syndrome, but none of the other indicators were present.”
“Anything else?”
“Yes,” Janine said. “Some of the images were incredibly clear. Particularly the one of the fetal brain.”
“Did you mention these findings to the defendant?”
“Yes. She said that the femur wasn’t off the charts, that it could simply be because the mother was short,” Janine answered.
“What about the clarity of the images? Did the defendant have anything to say about that?”
“No,” Janine said. “She didn’t.”
The night I’d driven Charlotte home from her twenty-seven-week ultrasound, the one with all the broken bones visible, I’d stopped being her friend and started being a doctor. I sat at the kitchen table and used medical terminology, which almost acted like a sedative itself: the pain in Char
lotte’s and Sean’s eyes dulled as I heaped them with information they could not understand. I talked to them about the physician I’d already called for a consultation.
At one point, Amelia had flitted into the kitchen. Charlotte hastily wiped her eyes. “Hey, sweetie,” she said.
“I came to say good night to the baby,” Amelia said, and she ran up to Charlotte where she sat and wrapped her arms as best as she could around her mother’s belly.
Charlotte made a tiny sound, a mewling. “Not so tight,” she managed, and I knew what she was thinking: had this eager love broken some of your bones?
“But I want her to come out,” Amelia said. “I’m sick of waiting.”
Charlotte stood up. “I think I might go lie down, too.” She held out her hand for Amelia, and they walked out of the kitchen.
Sean sank into the seat she’d vacated. “It’s me, right?” He looked up at me, haunted. “I’m the reason the baby’s like this.”
“No—”
“Charlotte had one kid who was perfectly fine,” he said. “Do the math.”
“This is probably a spontaneous mutation. There’s nothing you could have done to prevent it.” I couldn’t have prevented it, either. But that didn’t keep me from feeling guilty, just like Sean. “You have to take care of her, because she can’t fall apart right now. Don’t let her look this up on the Internet before you see the doctor tomorrow; don’t tell her you’re worried.”
“I can’t lie,” Sean said.
“Well, you will, if you love her.”
Now, all these years later, I wondered why I could not forgive Charlotte for following this very same advice.
I didn’t like Guy Booker, but then again, when you choose malpractice insurance providers, you’re not going for the folks you want to have over for Christmas dinner. He was good at making someone squirm on the witness stand, like an insect being pinned by a collector who wanted to scrutinize it more closely. “Ms. Weissbach,” Booker said, standing up to do his cross-examination, “have you ever seen another fetus that had a similar finding in the measurement of the femur?”
“Of course.”
“Do you happen to know the outcome?”
Charlotte’s lawyer stood up. “Objection, Your Honor. The witness is just a technologist, not a physician.”
“She sees this every day,” Booker countered. “She’s specially trained to read sonograms.”
“Sustained.”
“Well,” Janine said, miffed. “For your information, it’s not so easy to read the results of an ultrasound. I may just be a technologist, but I’m also supposed to point out things that might be problematic.” She jerked her chin toward me. “Piper Reece was my boss. I was just doing my job.”
She did not say anything more, but I could hear it all the same: Unlike you.
Charlotte
Something was wrong with my lawyer. She was fidgeting; she kept missing questions and forgetting answers. It got me wondering: Was doubt contagious? Had Marin sat next to me all day while I fought the urge to stand up and put an end to all this, and then awakened this morning with the same gut instincts?
She had called in a witness I did not know—Dr. Thurber, who was British but had become the head of radiology at Lucile Packard Children’s Hospital at Stanford before moving to Shriners in Omaha and applying his knowledge as a radiologist to OI kids. According to the endless list of credentials Marin had led him through, Dr. Thurber had read thousands of ultrasounds during his career, had lectured throughout the world, and donated two weeks of his vacation every year to provide care to expectant mothers in impoverished countries.
Basically, he was a saint. A really smart one.
“Dr. Thurber,” Marin said, “for those of us who aren’t familiar with ultrasounds, can you explain the technology?”
“It’s a diagnostic tool, in terms of obstetrics,” the radiologist said. “The equipment is a real-time scanner. Sound waves get emitted from a transducer, which is placed against the mother’s abdomen and moved around to reflect the contents of the uterus. The image gets projected onto a monitor—a sonogram.”
“What are ultrasounds used for?”
“To diagnose and confirm pregnancy, to assess fetal heartbeat and fetal malformations, to measure the fetus in order to assess the gestational age and growth, to see the location of the placenta, to determine the amount of amniotic fluid—among other things.”
“When are ultrasounds traditionally performed during pregnancy?” Marin asked.
“There’s no hard-and-fast rule, but sometimes scans can be done at about seven weeks to confirm pregnancy and rule out ectopic or molar pregnancies. Most women have at least one ultrasound performed between eighteen and twenty weeks.”
“What happens during that ultrasound?”
“By then, the fetus is large enough to check out the anatomy and to look for congenital malformations,” Dr. Thurber said. “Certain bones will be measured, to make sure the baby is the right size based on the date of conception. They’ll make sure organs are in the right place, and that the spine’s intact. Basically, it’s a confirmation that everything’s where it’s supposed to be. And of course, you get to go home with a picture that stays taped to your fridge for the next six months.”
There were a few laughs on the jury. Had I had a picture of you, from your ultrasound? I couldn’t remember. When I think back to that day, I only feel this great tidal wash of relief, from the moment Piper told me you were healthy.
“Dr. Thurber,” Marin asked, “did you have an opportunity to review the eighteen-week ultrasound that was performed on Charlotte O’Keefe?”
“I did.”
“And what did you see?”
He glanced at the jury. “Based on the ultrasound, there was definite cause for concern. Normally when you do an ultrasound, you’re looking at the brain through the skull, so it’s usually a little fuzzy, a little bit muddy and gray, because of reverberation artifacts from the side of the skull that the ultrasound beam first hits. In Mrs. O’Keefe’s sonogram, however, the intracranial contents were crystal clear—even that near field of the cerebral hemisphere, which is normally obscured. This suggests a demineralized calvarium. There are several conditions in which the skull presents undermineralized, including skeletal dysplasia, and OI. One then has the obligation to look at the long bones, and in fact femur length is a part of every obstetric ultrasound. In Mrs. O’Keefe’s case, the femur was also measuring a bit short. The combination of the short femur and the demineralized skull is strongly suggestive of osteogenesis imperfecta.” He let the words hang in the courtroom. “In fact, had the technologist pushed down on Mrs. O’Keefe’s belly as she was
doing the ultrasound, she would have been able to watch the screen and see the skull of the fetus being squashed out of shape.”
I folded my hands over my stomach, as if you were still inside.
“If Mrs. O’Keefe had been your patient, Doctor, what would you have done?”