Fire symbolizes the relationships within the Fitzgerald family, evidenced by Picoult’s choice of Carl Sandburg’s poem “Kin” as the epigraph for the opening chapters. The poem describes fire’s ability to warm as well as to consume, just as the relationships seen in the family, can both nourish and destroy. Anna and Kate emotionally keep each other going, even as Anna undergoes painful medical procedures in order for Kate to survive. Kate feels increasingly wasted and consumed by her struggle to remain alive. Anna even compares her decision to file the lawsuit for medical emancipation with giving fuel to a fire. Another of the epigraphs Picoult chooses, the poem “First Fig” by Edna St. Vincent Millay, talks about a candle burning at both ends. The family, like that candle, is metaphorically burning itself out.
More than any of the other characters, Jesse and Brian display particular preoccupations with fire. Jesse turns out to be the arsonist setting fires around the city, while Brian, who is a firefighter, earns his living by putting fires out. A bit of irony in the book. Although Jesse and Brian approach fire in different ways, fire means basically the same thing to them. They view it as a destructive and uncontrollable force. Fire serves as a symbol of Kate’s cancer and the effect that cancer is having on their family, which is figuratively burning out. Just as Brian puts out actual fires at work, he tries at home to put out figurative fires, such as the emotional problems Anna has in response to Kate’s health and Jesse’s negative behavior in reaction to Kate. Jesse's arsonic acts come from his overwhelming sense of guilt from not being able to save Kate, a feeling that he, his dad, and his mom have. His feeling of powerlessness about Kate’s cancer turns into rage, which he releases by burning down buildings. For Jesse, fire also serves as a way to get his father’s attention. Jesse feels neglected because his parents focus so much on Kate and Anna but by setting fires he can get his father’s attention any time he wants because as a fire fighter his dad has to come and put it out.