Professor Megan-Jane Johnstone AO wrote a powerful article that was published online on 10 November 2023 in the ANMJ: “Bombing hospitals, destroying ambulances and the ethics of (un)just war”.¹

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Johnstone examined ‘just war theory’ and made a clarion call for nurses to take a stand and speak out about the injustices of war. There are daily stories of human suffering that cause us to feel distress and anguish, ie. humanitarian crises involving innocent hostages, civilians, and children in war zones.

We may feel empathy toward others who are suffering, but our inability to make a difference can activate our own emotions of distress, anger and suffering. We feel powerless. It’s easier to turn away, to stop listening, to disengage, and to stop witnessing the brutality.

But Johnstone calls us to do better. So how can we regulate (manage) our emotions so we can empathise with others’ suffering and act with compassion in ways identified by Johnstone?¹

This paper explains empathy and compassion and clarifies how self-compassion is a strategy to regulate emotions² and strengthen our resolve to act. We then learn how a successful blueprint for peace³ could be applied in one current crisis in our war-torn world – the Israeli-Gaza conflict.

Empathy

Empathy and compassion activate different neural pathways in the brain⁴. Functional magnetic resonance imaging (fMRI) brain scans show that empathy activates neural networks that confirm we share the positive and negative emotions of others. This means if we ‘feel’ distress when we see someone in pain, that response activates the same neural pain pathways in our brain as in the suffering person. This tells us that we must learn to regulate our emotions in ways to minimise our distress and keep us safe. So, when we witness others’ distress, we must be clear that the distress belongs to the other person, not to ourselves. This distinction is called the self-other boundary.If we blur this boundary, we risk being overwhelmed by others’ suffering and feel empathic distress fatigue; thus eroding our ability to comfort.² This critical process to maintain a boundary is called regulating (managing) our emotions.  A key strategy in regulating our emotions is self-compassion.

Compassion

Compassion is being sensitive to pain and suffering in others and in ourselves and acting to ease it. Brain scans (using fMRI) show that compassion activates neural reward pathways in our brain related to warmth, kindness, concern, and connection.⁴ This means compassion can positively affect our emotions, immune system, cardiovascular system, brain and nervous system. Being compassionate does not cause fatigue. Rather, it boosts our health and wellbeing. Compassion is directed outward toward others and self-compassion is turning the practice inwards to ourselves.⁵

Self-compassion is being supportive toward ourselves when suffering – be it caused by personal mistakes and inadequacies or external life challenges⁵. It consists of tender and fierce aspects. Tender compassion is about treating ourselves with the same warmth, kindness, and understanding when we are struggling, as we would treat a good friend. Mindfulness helps us understand our struggles and imperfections are part of the shared human experience and explore ‘what do I need right now’?⁵

Fierce compassion helps us cultivate strength and courage to confront social injustice and oppression. This strength depends on our ability to regulate our emotions (ie. anger) and maintain boundaries to protect ourselves.⁵ Anger can mask emotions such as fear, sadness or powerlessness. It may be easier to feel anger than sadness. Learning to manage our anger constructively is critical because it may lead to problem-solving. It is tempting to minimise overload and distress by avoiding the news cycles as protective regulation and boundary strategies. We can only deal with so much. But a more ethical approach is the intentional consumption of news, rather than turning away.

Rage, disrespect, violence and riots are examples of revenge, not fierce compassion. To discern whether our anger will be put to compassionate use, we need to distinguish whether we are angry at the injustice, or the person. Compassionate action focuses on the problem rather than hostility toward individuals.⁵ When tender and fierce compassion are both present, it creates a powerful, caring force that can be used to transform ourselves and the world around us.⁵

We can rely on fierce self-compassion to provide energy and focus our efforts, and tender self-compassion to nourish us on our journey⁵. It is time to act with courage and fierce self-compassion about current global conflicts, human suffering, and to speak up.

Preparing ourselves to act

Poet and author Ben Okri says “To listen is to suffer.” We need courage to listen, to witness, and to act with compassion. To prepare ourselves, we need to:

1. Regulate our emotions (self-awareness, mindfulness) without either ignoring or being overwhelmed, and manage boundaries.
2. Compassion is listening and acting to alleviate suffering – in others and ourselves (self-compassion). It has tender and fierce elements, both required for well-being.
3. Identify compassionate actions toward people with whom we disagree.
4. Understand how anger and moral outrage can be a strategy to ease powerlessness.
5. Find ways to remain hopeful and be at peace with what is out of our hands.

The current Israeli-Gaza conflict is just one of any number of conflicts in our war-torn world that could be chosen to apply these lessons of compassion toward the suffering of strangers.

Suffering of civilians

Hamas is an Islamist political and paramilitary group that conducted the brutal attack on southern Israel on 7 October 2023. The attack killed at least 1,200 Israelis, many were seriously injured, and 253 Israelis were kidnapped. A ferocious retaliation was launched by the Israeli government in Gaza that has killed tens of thousands of Palestinians. Although Israel had a right to respond, the “dramatic lack of proportionality of the response” is questioned.⁶

In March 2024, Gaza’s Ministry of Health said at least 28,000 Palestinians have been killed – including 11,500 children. More than 68,000 Palestinians in Gaza have been injured – of which 18,000 are children.

Notably, 47.3% of the population in Gaza is under 18 years.⁶ Israel claims high civilian deaths (due to their attacks) are inevitable because Hamas militants are deliberately using civilians as human shields and hiding in civilian communities such as hospitals.⁶

In February 2024, Israel claims 130 hostages remain unaccounted for. Their relatives and friends are suffering deeply. Israel faces strong international pressure to stop its bombardment, but the Israeli prime minister continues to pursue ‘total victory’. A growing number of Israelis are calling for the government to make a deal with Hamas to release the hostages whatever the cost, even if it means ending the war without defeating Hamas.⁶

More than half of Gaza’s population of 2.3 million is now crammed into the small town of Rafah, the southernmost town on the border with Egypt, where only 250,000 people lived before this conflict. The United Nations estimates that 80% of the population (1.75 million people) have nowhere to live because at least 61% of all buildings have so far been destroyed⁶. Israel continues to threaten a military invasion into Rafah. But there are no plans to protect or evacuate displaced Palestinian civilians currently sheltering in Rafah.

Human Rights Watch (HRW) refugee researcher Nadia Hardman forewarned about the consequences saying: “forcing over one million displaced Palestinians in Rafah to again evacuate without a safe place to go in Gaza would be unlawful and have catastrophic consequences. The international community should take action to prevent further atrocities”.

The conflict in Gaza transcends faith, race, and nationality, and we need to have the moral courage to rise above divisive identity politics.⁷

Plight of children in Gaza

In February 2024, UNICEF said that children are now bearing the brunt of the horrors in Gaza: hunger, no clean water, severe malnutrition, diarrhoea, disease, homelessness, famine, grief and psychological suffering. They cannot access humanitarian aid. Families with no connections to Hamas militants have been harmed.

John Lyons said UNICEF’s James Elder noted “The Gaza Strip is the most dangerous place in the world to be a child. In my 20 years with UNICEF travelling the world from humanitarian crisis to the next, from famines to floods and war zones to refugee camps, I’ve simply never seen such devastation and despair as is happening in Gaza”.⁶

According to UNICEF, there are now at least 19,000 orphans in Gaza. Caesareans are performed without anaesthetic. Save the Children staff report that children are having bullets removed and limbs amputated without anaesthetic. This is the deadliest conflict for children in modern times. UNICEF says all children in Gaza need mental health support.⁶

Dr Dorit Nitzan told The Lancet “It’s important that we as Israelis doctors don’t lose our humanity. It is important to differentiate between civilians and Hamas in Gaza”.⁸ Gaza has 36 hospitals and at least 24 have closed. The others have run out of medicines, water, food, generators and critical supplies due to blockades of delivery trucks.

Just war theory

Johnstone¹ said ‘just war theory’ provides an ethical framework for deciding when and to what extent it is morally permissible to go to war. Just war theory was attributed to Aristotle (384-322BC), and the ethics of war were developed by moral philosophers over the centuries.¹ Just war theory has three components:

1. Decision-makers are required to show that their decision to go to war was made for a “just cause” (right intention) – in response to serious aggression or in self-defence;
2. “Conduct” during the war should show that every effort was made to reduce suffering. That actions were proportionate and only legitimate targets were attacked (not civilians, aid workers or hospitals); 
3. “Just action” after the war ends and transition to peace, ie., restoration of damaged infrastructure, homes, health care, and the natural environment.

Reconstruction of homes and other facilities is essential before Gazans are able to reconstruct their lives. A comprehensive approach akin to the historic Marshall Plan that reconstructed Europe after World War 2 is proposed.

Opinions will vary about what are justifiable acts of self-defence and proportionate responses.¹ Richard Horton⁹ reported that Paul Wise and colleagues set out three ‘just war principles’ to guide hostile conduct and civilian protection in war:

1. principle of discrimination: exclude all non-combatants.
2. principle of proportionality: harm to civilians or civilian structures (ie. hospitals) must not be excessive compared with any anticipated military advantage.
3. principle of military necessity: to protect non-combatants, the least harmful means of attack must be chosen.⁹

There is ample evidence and photographs to confirm that both Israel and Hamas are breeching each ‘just war’ principle. The atrocities and indiscriminate killing committed against both Israeli and Palestinian civilians is condemned.⁷

Johnstone said, “War is not OK and is never the best course of action despite just war theory advocates arguing to the contrary. War is always horrendous and inhumane, not morally just or morally beneficial”.¹

The condition of the hostages still hidden by Hamas militants in underground tunnels in Gaza remains unknown and tragic. UNICEF’s Tess Ingram said humanity cannot allow this warped version of normal to persist any longer.⁶

Going forward – A blueprint for peace negotiations

The brutality and violence must stop. It is time for open dialogue, mediation and negotiation⁷. It is easy to feel hate when we see injustices and feel empathy for the suffering on one’s own’s side. However, it is morally flawed and indeed counterproductive if we only call out atrocities based on our biased support or rejection of an issue¹⁰. Compassion must be inclusive. Decades of distrust, mutual grievances, and tit-for-tat violence will erode any capacity to see the other viewpoint.¹⁰

Dr Colin Irwin, a Research Fellow at the University of Liverpool in the UK, led a method called ‘peace polling’ that was successfully used in Northern Ireland to pave the way to a peace deal and the 1998 Good Friday Agreement.³

He explained that peace negotiations involve open dialogue about all issues. All parties require trust, good will, and cooperation to find enough common ground. There needs to be accord in terms of concessions to reach agreement. Negotiators must be empathic and fair when mediating between representatives of all groups.³ The Northern Ireland 1998 Good Friday Agreement is irrefutable evidence that a blueprint to achieve and sustain peace exists³. Current political leaders must learn the lessons of history. Why not apply the Northern Ireland blueprint for peace in Israel-Gaza?

The Troubles was a term used to describe a 30-year period of assassinations, horrific conflict, and acts of terrorism in Northern Ireland from the late 1960s. Violence was carried out by both the unionist and republican paramilitary groups. The origins of The Troubles can be traced back to the 17^th century. Catholics considered themselves Irish, held nationalist views and wanted an independent Ireland free from British control. Protestants largely identified as British and unionist, so wanted to remain linked to Britian. The Good Friday Agreement was signed on 10 April, 1998. It was a culmination of formal negotiations between eight political parties from all sides in the conflict. Notably, “the legitimacy of the Good Friday agreement was ensured by the full democratic participation of all parties to the agreement and the people of Northern Ireland. Through public opinion polls the general public gained a seat at the negotiating table, and through a referendum the deal was made”.³

The Agreement created a plan for peace and power-sharing in the Northern Ireland Assembly and future relationships between Ireland and Britain. The Good Friday Agreement was approved in May 1998 by a referendum passed with 71% majority.³ Irwin has used peace polling in other global conflicts. It can work in any context. Irwin said “peace polls aim to fairly and objectively measure the public’s support, from both sides, for every possible option. The aim is to determine the precise points of common ground, where they existed, or effective compromise where it was needed for peacemaking”.³ This is about identifying what people can live with. Peace polling offers a blueprint for how an agreement could be reached in the Israeli-Palestinian conflict.^3,11

Failing to learn the lessons

In early 2009, Irwin and colleagues conducted a peace poll in Israel and Palestine, meeting with political parties from most sides, including Hamas. The one key interlocutor who refused to meet with Irwin was Netanyahu. Non-participation of any group from negotiations will result in failure. Irwin argues that Israel continues to fail to learn lessons from the Northern Ireland peace process conducted a quarter of a century ago and remains operational today.³

Conclusion

The sheer scale of misery and desperation must end. History shows that inclusive negotiations are key in any peace settlement, but tragically the lessons of the Good Friday Agreement have been ignored. Irwin said, “over centuries, the cost of war has often been measured in “blood and treasure”. It’s fair to say that since 2009 in the Middle East and elsewhere we’ve seen “blood” in thousands of lives lost and “treasure” in billions of dollars wasted, again and again”.³ As Johnstone¹ summarised:

“Tragically, so long as authoritarian leaders, driven by their own personal ideologies, psychology, and vested interests use war as a means to shape the world in their own image, there can never be peace. What war mongering fails to consider is that without peace, there can be no prosperity. Without prosperity there can be no progress. And without progress, there can be no prospect of achieving an enduring habitable world in which we can all live and flourish.”

The International Committee of the Red Cross is demanding protection of aid workers, civilians, and critical infrastructure. Doctors Without Borders/Médecins Sans Frontières said the situation is “horrific,” in Gaza and urges restraint as medical facilities continue to be destroyed. Let us join Johnstone in speaking in a collective voice against terror and inhumanity. It is time to demand peace and pressure leaders to become humane¹. We need leaders with intellectual humility, wisdom, and moral courage to act with fierce compassion to confront social injustice, oppression, and violence. Only then, will it be possible to understand perceived injustices and grievances and to negotiate justice and fairness. To that end, the Northern Ireland blueprint for peace offers a genuine way forward for peace in Israel and Gaza.

References

1. Johnstone, M. J. 2023. Bombing hospitals, destroying ambulances and the ethics of (un)just war. Available at:  Bombing hospitals, destroying ambulances and the ethics of (un)just war – ANMJ
2. Hofmeyer, A., Kennedy, K. Taylor, R. 2020. Contesting the term ‘compassion fatigue’. Integrating findings from social neuroscience. Collegian 27(2), 232-237.DOI: https://doi.org/10.1016/j.colegn.2019.07.001
3. Irwin, C. J. 2024. How Israel failed to learn from the Northern Ireland peace process. The Conversation, January 4, Available at: How Israel failed to learn from the Northern Ireland peace process (theconversation.com)
4. Singer, T. & Klimecki, O. M. 2014. Empathy and compassion. Current Biology, 24, R875–R878. Available at: https://doi.org/10.1016/j.cub.2014.06.054
5. Neff K. D. 2024. The Yin and Yang of Self-Compassion. http://self-compassion.org/  
6. Lyons, J. 2024. Children are bearing the brunt of the horrors in Gaza. How can this go on? Available at: Children are bearing the brunt of the horrors in Gaza. How can this go on? – ABC News
7. Shahid, H.J. & Wallace, P.G. 2023. The healthcare community must approach the violence in Israel and Gaza with inclusive compassion BMJ 383:p.2645 Available at:  http://dx.doi.org/10.1136/bmj.p2645
8. Devi, S. 2023. Israeli and Palestinian doctors speak out. The Lancet, vol 402, 146-7. Available at: DOI:https://doi.org/10.1016/S0140-6736(23)02345-0
9. Horton, R. 2021. Israel-Gaza – what comes next? vol 402, 1511 Available at:  Offline: Israel–Gaza—what comes next? – The Lancet
10. Mayroz, E. 2024. Why do Israelis and the rest of the world view the Gaza conflict so differently? And can this disconnect be overcome? 16 February, Available at:  Why do Israelis and the rest of the world view the Gaza conflict so differently? And can this disconnect be overcome? (theconversation.com)
11. Ware, G. & Irwin, C.J. 2024. Israel-Gaza: how opinion polls used in Northern Ireland could pave a way to peace. 22, February. Available at: Israel-Gaza: how opinion polls used in Northern Ireland could pave a way to peace (theconversation.com)