Intended for healthcare professionals

Opinion

Are children more accepting of death than adults?

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o2020 (Published 12 August 2022) Cite this as: BMJ 2022;378:o2020
  1. Richard Smith, chair
  1. UK Health Alliance on climate change

The death of a child is for most parents the worst thing that could happen to them. It is against the natural order for the child to die before the parents. But could it be that children are more accepting of death than adults?

In Waiting for the Last Bus: Reflections on Life and Death, Richard Holloway, former Bishop of Edinburgh, describes his debate with Richard Dawkins, the “militant atheist,” in which he asks Dawkins what he would say to a dying child. Holloway, the most bookish of priests, quoted from The Last of the Just, by André Schwarz-Bart, a novel about the Holocaust. A child asks what death will be like, and an adult tells him it will be like a dream. A woman criticises the man for not being truthful, and he responds, “Madame, there is no room for truth here.” Holloway says that this must be the case for children who are dying, telling them perhaps that they will be in Heaven and see again all those that they love. He challenges Dawkins about what he would say, and Dawkins answers “the same.”

Holloway, who has spoken with children who are dying, concludes: “It turns out that there are times when it is impossible to accept the utter finality of death. A child’s death is one of them. There is no room for truth here. There is only room for the impossible act of consolation.”

But M R Rajagopal (known to all as Raj), the internationally-acclaimed palliative care physician who has spoken with many children who are dying, would disagree. In his book Walk with the Weary: Lessons in humanity in health care (which I have already written about1) he writes: “Paradoxically, children seem to accept incurability or death much more easily than adults….Children have amazing resilience. In my experience, they can process bad news much more easily than adults.”

Raj tells the story of Joseph, a dying child, who asked his mother, “Will I die before you?” His mother couldn’t answer, but asked Raj to talk to him. Raj and his team had realised that dying children usually knew that they were dying even though their parents had not told them and that they had many irrational fears about death that could be dispelled. Joseph was worried that he would suffocate when he was buried. Raj told him that there was no discomfort once somebody was dead. Raj asked if he had any other questions, but Joseph said no and went to play on his computer.

“Children,” writes Raj, “have short attention spans. They don’t want lectures; they ask straight questions and want straight answers. That is enough to reassure them. They need to be given the opportunity to ask those intense, and at times profound, questions. Without honest answers, their misery and loneliness cannot be imagined by you or me.”

Eight year old Abdul, for example, was worried that God would punish him when he died because he had pulled his sister’s hair and once stolen her pen. Raj consulted with the religious authorities who said that wrongs committed by children under 15 were not punished. Abdul could be reassured. (I found myself wondering what Raj would have said to a 16 year old.)

Raj also tells the story 11 year old Thasleena, who “taught us more than most, about love, endurance, courage, hope and above all, the fragility of life.” She had a large tumour in her leg that gave her severe pain and had metastasised to her lungs. Her doctors had advised amputation. Thasleena didn’t want to be “half a person” and refused. Raj talked with her and encouraged her to see a popular film that had a hero with one leg. After watching the film she agreed to an amputation.

After the amputation she had some months of pain-free life, and it was her who cut the ribbon to open the new palliative care unit. But her cancer returned, and she died. Raj concludes: “This 11 year old ‘guru’ taught us lessons in resilience, acceptance, and endurance. She taught us how one can enjoy life even when in pain and with death staring in the face.”

There are few things in life more difficult than to talk honestly about death with a child who is dying, and the conversation may be avoided not for the benefit of the child but for the benefit of the adult.

Footnotes

  • Competing interest: RS and M R Rajagopal worked together on the Lancet Commission on the Value of Death.

  • Provenance and peer review: not commissioned, not peer reviewed.

References