Milk yield per cow has more than doubled in the previous 40 years and many cows now produce more than 20,000 kg of milk per lactation. The increase in production should be viewed with concern because: i) the increase in milk yield has been accompanied by declining fertility, increasing leg and metabolic problems and declining longevity; ii) there are unfavourable genetic correlations between milk yield and fertility, mastitis and other production diseases, indicating that deterioration in fertility and health is largely a consequence of selection for increased milk yield; and iii) high disease incidence, reduced fertility, decreased longevity and modification of normal behaviour are indicative of substantial decline in cow welfare. Improving welfare is important as good welfare is regarded by the public as indicative of sustainable systems and good product quality and may also be economically beneficial. Expansion of the Profitable Lifetime Index used in the UK to include mastitis resistance and fertility could increase economic response to selection by up to 80%, compared with selection for milk production alone. In the last 10 years, several breeding organisations in Europe and North America followed the example of Nordic Countries and have included improving fertility and reducing incidence of mastitis in their breeding objectives, but these efforts are still timid. A multi-trait selection programme in which improving health, fertility and other welfare traits are included in the breeding objective, and appropriately weighted relative to production traits, should be adopted by all breeding organisations motivated in their goal of improving welfare.