Show and slow codes: A historical analysis of clinicians' adaptations to ethical overreach

After briefly reviewing the historical development and ethical regulation of resuscitative technologies, this study probes why clinicians engage in the morally problematic practice of show and slow coding and why hospitals tolerate it? Studies conducted in 1995 and 2020 indicate that conscientious clinicians engage in these practices to protect their patients from abusive or futile resuscitation. And hospitals' clinical cultures tolerate these practices to protect conscientious clinicians from censure, dismissal, delicensing, or legal prosecution for withholding or withdrawing abusive or futile resuscitative technologies without prior patient or surrogate consent. Show and slow coding evolved in American clinical cultures in the second half of the 20th century when closed-chest cardiac massage, defibrillators, ventilators, and other resuscitative technologies raised seemingly novel ethical questions. To address these questions, bioethics commissions, healthcare societies, lawmakers, and a Roman Catholic Pope developed ethics standards requiring clinicians to obtain patient or surrogate consent before withholding or withdrawing resuscitative technologies. They thus conferred on patients an implicit right of resuscitation even if it was abusive and/or futile. Conscientious clinicians circumvented this implicit right by show and slow coding to protect patients from abusive resuscitation. Recognizing clinicians' benign intent, hospitals' clinical cultures tolerate show and slow coding as acts of conscience, akin to civil disobedience. Thus, rescinding ethics standards and laws requiring prior patient/surrogate consent for non-resuscitation or for cessation of resuscitative technologies decisions should end show/slow coding. Such a reform should also recognize clinicians' right of conscientious refusal to perform CPR.