Doctors resigning and demoralised by forces ranging from heavy workloads to indemnity woes . . . A society conditioned to instant gratification, soaring expectations of modern medicine and technology, often fuelled by media hype (Ooi, page 639; Daniels, page 637) and increasingly cynical about doctors’ true priorities . . . A lucky country that’s materially better off than ever before . . . The latter observation comes from one of our foremost playwrights David Williamson (page 594), yet, as sociologist Hugh Mackay comments, we are “. . . neglecting the most vulnerable people in our society — the aged, the frail, the sick, the disadvantaged, the bewildered”.1 Meanwhile, internationally, the rift between rich and poor nations grows, and the lack of compassion of nations who “have” toward those who “have not” is seen as one of the antecedents to current international insecurity.

Is compassion in its death throes two millennia after one man in Jerusalem advocated loving others as oneself, and another in Mecca described “a person’s true wealth [as] the good he or she does in the world”?

A qualified “no” is the answer to this question from contributors to the 2003 Christmas issue of the Journal. Perspectives by emergency physicians O’Reilly et al (page 649) and Fulde (page 651), who make space in their hearts and lives for homeless people visiting their emergency departments, and by Sutton (page 591) and Taylor (page 617), who have worked in developing nations, indicate that many doctors are still motivated by compassion. Furthermore, a recent forum on globalisation, aid and foreign policies, and their impact on health brought together diverse Australian and international experts (Zwi and Reid, page 573) and showed that many of us want to engage in compassionate “big picture” action. Yet all acknowledge the difficulties of practising compassion in an environment that does not seem conducive to it.

Certainly not. There are sound, even pragmatic, reasons for healthcare workers to act compassionately. Firstly, it benefits patients. While the benefits of a compassionate approach may be difficult to measure, a systematic review suggests that patients have less pain and recover faster if their doctors show empathy and reassurance.2 Furthermore, homeless patients presenting to a Canadian emergency department, and randomly allocated to receive “compassionate” care (a chat and a snack with a volunteer) re-presented less frequently than those receiving standard care.3

Secondly, doctors are well placed to join informed debate about sociopolitical issues that may impact on health. This is also crucial if our profession is to regain the trust of a sceptical community. The Royal Australasian College of Physicians (RACP) gives its rationale for taking physicians’ views on health and social policy to Canberra: “What doctors must do is show the community that medicine and consumers have overwhelmingly common imperatives and that doctors stand with the community before self interest. . . . lack of trust [that doctors act from concern for their patients] . . . most seriously threatens medicine’s continuance as a profession bound up in ethical values rather than commercial ones”.4

Thirdly, a modicum of compassion would not go astray in medical workforce planning. Part of the remedy for our workforce crises lies in regarding it as “more than a numbers game and . . . [with more] explicit attention to working conditions, incentives and rewards”.5

While compassion might begin at home, a global perspective is also vital. At the inescapable altar of evidence, even certain humanitarian medical interventions (such as vaccination, providing food and safe water) have gained sanction for efficacy, although alternative types of evidence and outcome measures should also be pursued.6 Smith’s editorial in this issue (page 571) argues that the impact of climate change on the health and economies of all in our global village offers rich countries ample incentive to act now for a win–win solution.

Ultimately, however, to provide or enable healthcare of any ilk is a moral endeavour7 — we do so because we value human life.

Paradoxically, we believe that self-care (as opposed to self-centredness) is one of the keys. Reciprocity (or “getting something back”) is a motivation for altruism,5 and contributors to this issue of the Journal highlight their need for personal and external supports to prevent distress and the erosion of compassion (Smart, page 587; Edwards, page 647).

Like it or not, role models are integral to medical training, and medical students and young doctors value attributes such as compassion in their role models, as eminent neurologist Lance attests (page 620). Yet good role models are not plentiful in our hospitals,8 and all of us need both to be and to emulate such models (see Box). Indeed, the World Health Organization has outlined the social accountability of medical schools, which have an obligation to direct their education, research and services toward the community’s priority health concerns.9 Medical schools must be responsive to, and proactive about, societal needs. Our initial and ongoing education should also seek to actively instil a recognition of the social determinants of health, and the place of humane values and ethics.10

The imposition of mechanistic guidelines, audits and regulations on clinical practice, with increasing commercialisation, have contributed not only to de-professionalism, but also to compassion fatigue. Our practice and research should embrace and refine such outcome measures as quality of life and the doctor–patient relationship.

Compassionate action may also mean becoming advocates and agents of change for a variety of public health issues, such as more equitable healthcare access. We can do so as individuals by enthusing colleagues, engaging with others in the community and petitioning parliamentarians. We can do so as members of professional bodies (eg, the Australian Medical Association stance on Indigenous health [www.ama.com.au/web.nsf/doc/WEEN-5N5UHZ] and the joint statement by the RACP and the Royal Australian and New Zealand College of Psychiatrists on the health of children in immigration detention centres [www.racp.edu.au/hpu/policy/asylumseekers/detention.htm]). We can do so by supporting national and international coalitions of health, development, social justice and human rights, rather than coalitions of conflict or commercial interests. Examples of the former include Healthy Skepticism (Mansfield, page 644), the Medical Association for Prevention of War (www.mapw.org.au/about.html), and Médecins Sans Frontières. Surely medical involvement in some of these fields represents the ultimate preventive healthcare!

Hugh Mackay also observed in his commentary, “Who could have predicted that, at the turn of the century, Australia would become a less tolerant, less hospitable and less compassionate society?”1 This issue of the Journal celebrates the survival of compassion in medicine, in the face of bewildering societal changes. But we need much more. We need our policymakers to develop evidence-based, targeted strategies against health inequities. We need continued leadership and advocacy from our professional bodies. Above all, we need political leaders who champion compassion and unity rather than fear and division.