By Perri Klass

Random House. 284 pp. $19.95

Perri Klass, the former Harvard medical student whose 1987 book, "A Not Entirely Benign Procedure," described her early years of training at that institution, has taken on a real challenge this time. She has written a novel featuring the lives and deaths of children in a Boston teaching hospital, an unsentimentalized account describing little ones with illnesses like AIDS, which has evidently grown out of her own experiences as a pediatrician. It is a finely crafted, intelligent, engaging novel that seems on balance more truth than fiction. And despite the poignancy of much that Klass describes, "Other Women's Children" is anything but bleak.

Enhancing the sense of truth that suffuses her novel is Klass's increasingly more sophisticated use of writing technique. The novel concerns a pediatrician, Amelia, but the story is told from both third- and first-person points of view. Amelia moves through the action of the story in the third person. But what lends intensity to the novel is the voice of the speaker-author, who represents, of course, Amelia, but also represents someone else as well, the thoughtful conscience of the narration.

After poking fun as the story opens at Amelia and Matt's efforts to get their own precious 5-year-old admitted to the right schools, the speaker abruptly shifts voice. "This is not the story I was intending to write. ... How can anyone write about children who get sick, children who die? What is most heart-piercing in life can turn to bathos, melodrama, sentimental nonsense in fiction." She recollects the pithy comment of Oscar Wilde about Dickens's Little Nell -- "One must have a heart of stone to read the death of Little Nell without laughing" -- then concludes -- "And Dickens was a genius, and I am not."

Genius she may not be, but Klass is a persuasive writer whose emotional depth and capacity to engage have grown immensely since her earlier novel, "Recombinations." She moves comfortably from the hospital world of Amelia, the pediatrician caring for children whose disrupted and disruptive family lives interplay with their illnesses, to her framing story, a period in the life of Amelia herself in which her own nurturing becomes threatened.

Her concern for sick children is presented in poignant counterpoint with the silent bargain Amelia makes with God -- I'll take care of them, and please keep my own child well -- a bargain born perhaps out of the almost unavoidable sense of guilt that haunts more fortunate people who are exposed intimately to others' pain.

Ironically, that desire to protect her own child by devoting so much of herself to other children denies Amelia's husband and son some of what she might otherwise have given them in the way of nurturing in exchange for the warmth and security they have provided for her.

And so the family unity is fated to be disrupted, at least until a new balance is achieved.

In the way that people know uneasily that things are not right long before trouble occurs, Klass foreshadows events with wit and intelligence. Chapter headings -- "The Moment Before the Crash" and "The Dumb Woman Builds Her House Upon the Sand" -- are humorous in the context of the novel. The first introduces Amelia's compulsive creation of a poem whenever she is on an airplane with her son; loose, disjointed, it describes in excruciating detail what each person is doing just before the plane ostensibly crashes. The latter is a song her 5-year-old son warbles as she cuddles him after nursery school, a hymn, she decides doubtfully. But they also presage what is to come, contributing irony and ambiguity.

Running through "Other Women's Children" as well, as if to lend gravity, are the author's attempts to reconcile the reality of death of young children with what has been written in fiction about such deaths by Dickens, Elizabeth Gaskell, Louisa May Alcott. Klass's speaker reads these death scenes, weighs the meanings assigned the deaths, and rages at those that shamelessly play upon the reader's sentimentality -- wondering why it was the privileged little Eva who was not permitted to survive in "Uncle Tom's Cabin" rather than Topsy, "the battered, beaten, overworked and undernourished child who statistically should not have lived past childhood."

Some of the underprivileged hospital children introduced in "Other Women's Children" are not as fortunate as Topsy was. Three-year-old Darren, for instance, whose mother has died of AIDS, is being consumed by the same illness as his grandmother struggles to bring a measure of sweetness and humanity into his painful, medicine-dominated existence.

The progression of Darren's illness -- Amelia says of him flatly, "Darren is one of the ones who have been cheated, now and forever" -- raises life and death issues which are very much part of the daily struggle in our hospitals. Just what is "heroic" treatment? Should such care be terminated? If so, at what point, and who has the right to decide?

Klass deals with the issues and the ironies realistically and with great empathy. Her protagonist is ultimately appealing both in her strength and for her imaginative foibles, and her story quite believable. At times it seems close enough to home to leave one with the uncomfortable feeling that "Other Women's Children" may be more a mirror of reality than a window into the author's imagination. But its conclusion reaches reassuringly toward epiphany, and the book is worthy of a long, thoughtful look.

The reviewer is a Washington physician and coauthor of the book "The Family Handbook of Medical Tests."