Slow codes as ethical disobedience

KEY: Patients or families sometimes demand interventions that are of no benefit or are even harmful. Even in cases where cardiopulmonary resuscitation is futile or medically inappropriate, instituting a do not attempt resuscitation order requires either consent of the patient or family, or working through a cumbersome and conflictual institutional process to change code status over their objection. Sometimes they contest these decisions in court and sometimes they win. Avoiding such conflicts gave rise to the practice of “slow codes,” a situation in which the healthcare team responds to cardiac arrest in a patient in a deliberately slow or perfunctory manner, with the intention of not resuscitating the patient at all. Slow codes have been nearly universally decried as unethical in the literature, at least over the last three decades. After all, a slow code is fundamentally dishonest. But critics tend to avoid the socio-political and clinical realities that motivate the use of slow codes in the first place. In this article, I argue that in the context of judicial and legislative overreach into medical decision-making, the slow code serves a distinctly moral purpose beyond promoting the welfare of the patient: It is an act of disobedience against an unethical system.